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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___
Coronary artery bypass grafting x 4; left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to first marginal branch, second marginal branch to
posterior descending
artery.
History of Present Illness:
___ yo M with no significant PMH presenting with NSTEMI from
___ w/ new onset chest pain while watching TV. Cardiac cath
___ at ___ found to have multi-vessel disease, with
recommendation for C-surg evaluation.
Cardiac Catheterization: ___ ___:
2 lesions in the RCA (mid 70% and distal 90%, the latter was
thought to be culprit, with associated thrombus). Distal LMCA
was
angiographically equivocal, per ___ IVUS which showed a
cross-sectional area of <5mm2 in an 18mm2 vessel. There was also
an OM1 with an ostial 90% lesion
Past Medical History:
Past Medical History: Tonsillectomy many years ago
Broken ribs, clavicle in the past
Social History:
___
Family History:
No history of premature coronary disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: 97.6 144/91 79 17 93% RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No elevation of JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Exam:
Vital Signs I/O
24 HR Data (last updated ___ @ 1000)
Temp: 97.5 (Tm 97.5), BP: 104/64 (91-104/61-67), HR: 66
(57-68), RR: 20, O2 sat: 97% (97-98)
Fluid Balance (last updated ___ @ 952)
Last 8 hours Total cumulative -46ml
IN: Total 180ml, PO Amt 180ml
OUT: Total 226ml, Urine Amt 226ml
Last 24 hours Total cumulative -46ml
IN: Total 180ml, PO Amt 180ml
OUT: Total 226ml, Urine Amt 226ml
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: CTA [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema ____
Left Upper extremity Warm [x] Edema_____
Right Lower extremity Warm [x] Edema _tr____
Left Lower extremity Warm [x] Edema __tr___
Pulses:
DP Right: 2+ Left: 2+
___ Right: palp Left: palp
Radial Right: 2+ Left: 2+
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena []
Lower extremity: Right [] Left [] CDI [x]
Upper extremity: Right [] Left [] CDI [x]
Other:
Pertinent Results:
ADMISSION
___ 02:46AM BLOOD WBC-10.4* RBC-5.11 Hgb-15.0 Hct-43.5
MCV-85 MCH-29.4 MCHC-34.5 RDW-12.5 RDWSD-38.4 Plt ___
___ 02:46AM BLOOD Neuts-68.5 ___ Monos-7.4 Eos-0.0*
Baso-0.6 Im ___ AbsNeut-7.12* AbsLymp-2.38 AbsMono-0.77
AbsEos-0.00* AbsBaso-0.06
___ 02:46AM BLOOD Glucose-114* UreaN-18 Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-25 AnGap-12
___ 02:46AM BLOOD CK-MB-18* MB Indx-5.9
___ 02:46AM BLOOD cTropnT-0.24*
PERTINENT STUDIES
___ TTE
The left atrium is mildly dilated. The interatrial septum is
dynamic, but not frankly aneurysmal. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
62 %. There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size, and regional/global systolic function. Mild
pulmonary artery systolic hypertension. No valvular pathology or
pathologic flow identified.
___ CATH
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is angiographiacally appears to be 50-60%, CSA by IVUS
at tightest segment in distal left main is < 5mm2
* Left Anterior Descending
The LAD is has mild proximal disease, 20%
* Circumflex
The Circumflex is has minimal luminal irregularities
The ___ Marginal is has an ostial 90% stenosis
* Ramus
The Ramus is moderate in size and has mild 30% mid vessel
stenosis
* Right Coronary Artery
The RCA is large, dominant. There is a mid RFCA 70% stenosis and
distal RCA 90% stenosis (associated with thrombus) just proximal
to the bifurcation into the R-PDA and RPL branches
The Right PDA has mild luminal irregularities
Impressions:
1. Significant left main, RCA and branch vessel disease in this
right dominant coronary system
2. IVUS of the left main (CSA < 5mm2, normal left main segment
CSA of 18mm2)
Recommendations
1. Resume heparin 2 hours after radial sheath pull
2. CT surgery consultation to eval for CABG
3. Further recommendations as per inpatient Cardiology service
___ 02:46AM BLOOD CK-MB-18* MB Indx-5.9
___ 02:46AM BLOOD cTropnT-0.24*
___ 08:00AM BLOOD CK-MB-31*
___ 08:00AM BLOOD cTropnT-0.39*
___ 03:05PM BLOOD CK-MB-27*
___ 03:05PM BLOOD cTropnT-0.42*
___ 08:00PM BLOOD CK-MB-19* cTropnT-0.47*
___ 06:10AM BLOOD CK-MB-12* cTropnT-0.40*
___ 06:10AM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.9 Mg-1.9
Cholest-181
___ 06:10AM BLOOD Triglyc-103 HDL-49 CHOL/HD-3.7
LDLcalc-111
___ 08:00PM BLOOD %HbA1c-5.4 eAG-108
___ 05:03AM BLOOD WBC-12.5* RBC-4.15* Hgb-12.4* Hct-36.7*
MCV-88 MCH-29.9 MCHC-33.8 RDW-12.7 RDWSD-41.2 Plt ___
___ 08:45AM BLOOD WBC-15.2* RBC-3.97* Hgb-12.0* Hct-35.5*
MCV-89 MCH-30.2 MCHC-33.8 RDW-12.9 RDWSD-42.1 Plt ___
___ 02:02AM BLOOD WBC-18.7* RBC-4.12* Hgb-12.1* Hct-36.0*
MCV-87 MCH-29.4 MCHC-33.6 RDW-12.6 RDWSD-39.9 Plt ___
___ 01:48AM BLOOD WBC-17.8* RBC-4.06* Hgb-12.2* Hct-35.3*
MCV-87 MCH-30.0 MCHC-34.6 RDW-12.7 RDWSD-39.9 Plt ___
___ 08:45AM BLOOD Glucose-150* UreaN-29* Creat-0.9 Na-138
K-4.2 Cl-98 HCO3-30 AnGap-10
___ 02:02AM BLOOD Glucose-115* UreaN-26* Creat-0.9 Na-139
K-4.4 Cl-99 HCO3-29 AnGap-11
___ 02:15PM BLOOD UreaN-20 Creat-0.9 K-4.3
___ 01:48AM BLOOD Glucose-128* UreaN-15 Creat-0.9 Na-135
K-4.4 Cl-100 HCO3-27 AnGap-8*
___ 05:00PM BLOOD UreaN-16 Creat-1.0 K-4.4
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Q ___ Disp #*30
Tablet Refills:*2
4. Docusate Sodium 100 mg PO BID
5. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q 4 hours Disp #*60
Tablet Refills:*0
7. Metoprolol Tartrate 12.5 mg PO TID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
three times a day Disp #*60 Tablet Refills:*2
8. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*5 Tablet Refills:*0
9. Ranitidine 150 mg PO BID
RX *ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s)
by mouth twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p NSTEMI
Secondary diagnosis
Tonsillectomy many years ago
Broken ribs, clavicle in the past
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
Trace Edema
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with NSTEMI pending evaluation for CABG// preop
Surg: ___ (CABG)
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. There is mild unfolding of the thoracic aorta. Hilar
contours are preserved. Lungs are clear. Pleural surfaces are clear without
effusion or pneumothorax. There are deformities from old left-sided rib
fractures. There is no acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ year old man with CAD s/p CABG. Please ___ at
___ with abnormalities.// FAST TRACK EXTUBATION CARDIAC SURGERY, ?line
placement, r/o PTX/Effusion Contact name: ___: ___
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Patient is status post cardiac surgery in the interim. Support lines and
tubes are in acceptable position. There are small bilateral effusions. No
pneumothorax is seen
Radiology Report
INDICATION: ___ year old man with s/p CABG// s/p ct removal ? ptx
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right internal jugular central venous catheter projects over the
cavoatrial junction. The endotracheal tube, chest tubes an enteric tube have
been removed. The sternal wires are well aligned. There is mild left basilar
atelectasis. No pneumothorax or large pleural effusion. Left lateral rib
deformities are again noted. The size of the cardiomediastinal silhouette is
within normal limits.
IMPRESSION:
No pneumothorax post removal of the chest tubes.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with CABG// r/o inf, eff r/o inf, eff
IMPRESSION:
Heart size and mediastinum are stable. Minimal left pleural effusion is
demonstrated. No appreciable right pleural effusion. No pneumothorax. Mild
vascular congestion
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Elevated troponin, Transfer
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.0
heartrate: 70.0
resprate: 17.0
o2sat: 96.0
sbp: 160.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
The pt is a ___ woman with a history of PCOS on OCP's
who
presents with headache x 5 days. She states that the headache
started last ___ while she was taking her Step 3 exam. It
was
located over her right temple, constant, not throbbing. She
tried
some tylenol without relief; did experience some temporary
improvement with ibuprofen. However the headache remained
constant, present throughout the day and not relieved by sleep.
She does not typically get headaches (other than occasional
self-resolving tension headaches) so this was unusual for her.
She also notes that the headache worsened with coughing,
sneezing, bending over, lying down, or straining. It also
worsened with turning her head toward the left. She denies any
associated photo- or photophobia, vision changes,
nausea/vomiting, numbness/tingling, or weakness. She has had no
recent neck trauma.
She spoke with a friend who is a neurology resident who advised
her to come into the ED, but she had a vacation planned to
___ and as her headache was relatively well-controlled
with
ibuprofen she decided to go. The headache continued while she
was
there and remained about the same quality and severity. When she
returned today the headache was getting somewhat worse, still
located over her R temple but seemed to be expanding to involve
a
greater area of her head. She also had some mild nausea today
but
no vomiting. She decided to come into the ED for evaluation.
Neuro ROS is positive for headache as above. The pt denies loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. +Mild nausea today, denies vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
PCOS - has been on OCP's for last ___ years
Social History:
___
Family History:
There is no family history of blood clots, strokes, or
miscarriages.
Physical Exam:
Physical Exam:
Vitals: 98.3 97 145/76 16 100% RA
General: Awake, pleasant and cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. The pt had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm 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 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: Deferred
********************
Physical Exam on Discharge:
No neurologic deficits, gait steady.
Pertinent Results:
___ 09:20PM PTT-57.9*
___ 02:47PM PTT-49.0*
___ 08:05AM GLUCOSE-95 UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15
___ 08:05AM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.7
___ 08:05AM WBC-6.6 RBC-4.87 HGB-12.1 HCT-39.4 MCV-81*
MCH-24.8* MCHC-30.7* RDW-13.4
___ 08:05AM PLT COUNT-221
___ 08:05AM ___ PTT-50.8* ___
___ 12:53AM ___ PTT-24.6* ___
___ 09:00PM GLUCOSE-130* UREA N-12 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
___ 09:00PM estGFR-Using this
___ 09:00PM URINE HOURS-RANDOM
___ 09:00PM URINE UCG-NEGATIVE
___ 09:00PM WBC-6.8 RBC-4.98 HGB-12.5 HCT-40.5 MCV-81*
MCH-25.1* MCHC-30.8* RDW-13.4
___ 09:00PM NEUTS-59.6 ___ MONOS-3.5 EOS-2.1
BASOS-0.4
___ 09:00PM PLT COUNT-248
___ 09:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
___ 09:00PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 09:00PM URINE MUCOUS-RARE
CT head ___:
IMPRESSION: No acute intracranial process.
MR/MRV ___:
1. Occlusion of right transverse and sigmoid sinuses extending
into the upper right internal jugular vein. The right vertebral
artery appears to be diminutive in size and not well seen
intracranially. Consider MR angiogram for better assessment of
the vertebral arteries.D/w ___ by ___ on ___ at
6pm.
Venous US RUE ___:
IMPRESSION: No thrombus involving the imaged portion of the
right internal jugular through subclavian veins.
Medications on Admission:
Yaz
Discharge Medications:
1. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. zolpidem 5 mg Tablet Sig: One (1) Tablet PO qhs ().
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) MG Subcutaneous
every twelve (12) hours for 6 months.
Disp:*60 syringes* Refills:*6*
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Venous Sinus Thrombosis, likely secondary to oral contraception
use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
.
There are no clear neurological abnormalities at the time of
discharge.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with headache and venous sinus thrombosis.
STUDY: Right upper extremity venous ultrasound, limited involving the right
IJ and right subclavian vein.
COMPARISON: Head MRI/MRV from ___.
FINDINGS: Grayscale and color Doppler sonographic imaging was performed of a
right internal jugular vein and subclavian veins. The right jugular vein
demonstrates normal compressibility, flow, and augmentation. The right
subclavian vein demonstrates normal flow.
IMPRESSION: No thrombus involving the imaged portion of the right internal
jugular through subclavian veins.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: H/A
Diagnosed with PHLEBITIS & THROMBOPHLEBITIS OF INTRACRANIAL SINUS, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS, POLYCYSTIC OVARIES
temperature: 98.3
heartrate: 97.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 76.0
level of pain: 5
level of acuity: 3.0 | Dear Dr. ___,
.
It has been a pleasure to care for you at the ___. You
presented to the ED with a 5 day history of headache. Imaging
revealed evidence of venous sinus thrombosis, for which
anticoagulation has been started. Although the most likely
source of the thrombosis is use of oral contraception, a
hypercoaguability evaluation has also been initiated.
.
As you know, a heparin drip was transitioned to therapeutic
lovenox dosing prior to your discharge. You will likely need to
continue the anticoagulation for ___ months.
.
Since it works, we agree with continuing ibuprofen to treat the
headaches. Please use famotidine or another agent to protect
your stomach while taking NSAIDs on a regular basis. Please
avoid taking Yaz for now pending a discussion about alternative
contraceptive options with your OB-GYN.
.
We recommend the performance of an MRV in about three months to
determine if the lovenox can be discontinued or should be
continued for a total of 6 months. We have ordered this scan to
be performed on ___, prior to your appointment with Dr. ___.
.
With your doctors, please follow the results of pending studies
(hypercoagulability panel) as well.
.
MEDICATION CHANGES
- Yaz was discontinued
- Started famotidine 20 mg po bid
- Started Lovenox (1mg/kg) sc q12 h |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ Y/o male with hx of HIV (last CD4 333 down
from >600), treated syphilis in ___, and who presents with 5
days of fever, chills and sweats. Went to the ___ over the
weekend, no known insect bites. no sick contacts. He reports
first noting penile lesion on ___ with generalized malaise,
joint/muscle aches. ___ he had low grade temp of 99.0 for
which he took aleve. ___ myalgias and joint pains
resolved, saw ID who started infectious w/u. ___ evening
temp to 101.2 and noted spreading erythematous lesions on
extremity and trunk. On ___ seen at ___ with temp 102.5,
declined ED. CXR negative but labs notable for elevated D-dimer.
This morning he has a glass of milk, following which he had a
few episodes of non-bilious emesis followed by emesis w/ note of
blood streak ( 2 tablespoons of red blood ). No coffee ground
emesis. Had one loose non-bloody BM. In light of ongoing fever
and hematemesis he presented to ED as advised by ___ MD.
In the ED, initial vs were: 08:50 0 97.0 95 120/80 20 95% .
Recent labs remarkable for decline in CD4 to 333 from 606. CT
chest w/ no PE. Vitals on Transfer:13:16 0 99.5 79 107/67 16 95%
RA.
On the floor, patient reports feeling relatively well. ROS
essentially negative with the exception of subjective dyspnea
associated with fevers.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
1. Low testosterone. (on clomiphene)
2. Hypothyroidism.
3. Obesity.
4. Chronic constipation and chronic abdominal bloating.
5. Sleep disorder. He has mixed sleep-disordered breathing,
circadian rhythm disorder. On acetazolamide and Nuvigil.
6. molluscum contagiosum
7. Anal dysplasia.
8. Allergic rhinitis and allergic cough.
9. Ependymoma.
10. Asymptomatic HIV infection.
11. Chronic foot pain.
12. Depression
Social History:
___
Family History:
-Father is deceased.
-Mother with coronary artery disease, hypertension, and
depression.
- uncle with prostate cancer
- maternal aunt died of brain tumor at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98 121/85 82 20 98ra 209.8lbs
General: well appearing, pleasant man in NAD
HEENT: MMM, slcear non-icteric, PERRLA, EOMI, OP clear
Neck: supple, few, mobile anterior cervial LAD with mild TTP on
left
Lungs: CTABL
CV: RRR,normal S1/s2, no mrg
Abdomen: soft, NT, ND, NABS, no organomegaly
Ext: no edema, 2+ distal pulses
Skin: ulcer on dorsum of penis w/o drainage; Few scattered
raised, round, erytematous lesions not involving palms/soles,
some with central white tip
Lymph: + right inguinal mildly tender LAD, no axillary LAD
Neuro: Grossly intact, no menismus
DISCHARGE PHYSICAL EXAM
VS: T: 98.4 BP: 120/90 HR: ___ R: 20 O2: 99RA
GENL: pleasant, NAD, comfortable
EENT: NC/AT, PERRL, EOMI, sclerae anicteric, moist mucous
membranes, no ulcers / lesions / thrush
NECK: supple, few, mobile anterior cervial LAD with mild TTP on
left
CARD: RRR, normal S1, S2, no murmurs / rubs / gallops
PULM: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
ABDM: non-distended, normoactive bowel sounds, soft, non-tender,
no hepatosplenomegaly
MSK: no joint swelling or erythema
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally
SKIN: diffuse papular erythematous rash, some with central white
tip.
No vesicles noted. located diffusely over the face, front of
scalp, chest, back and legs.
NEURO: awake, alert and oriented x3, CN ___ intact, ___
strength
bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect
Pertinent Results:
ADMISSION LABS
___ 09:25AM BLOOD WBC-5.1 RBC-5.04 Hgb-15.6 Hct-44.5 MCV-88
MCH-31.1 MCHC-35.2* RDW-13.0 Plt ___
___ 09:25AM BLOOD Neuts-68.7 ___ Monos-6.8 Eos-0
Baso-0.8
___ 09:39AM BLOOD ___ PTT-25.8 ___
___ 09:25AM BLOOD Glucose-107* UreaN-15 Creat-1.1 Na-139
K-4.4 Cl-105 HCO3-26 AnGap-12
DISCHARGE LABS
___ 04:54AM BLOOD WBC-4.8 RBC-4.99 Hgb-15.4 Hct-44.3 MCV-89
MCH-30.9 MCHC-34.8 RDW-13.5 Plt ___
___ 04:54AM BLOOD Neuts-48* Bands-0 ___ Monos-10
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 04:54AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 04:54AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:30AM BLOOD Parst S-NEGATIVE
___ 04:54AM BLOOD Glucose-113* UreaN-13 Creat-1.0 Na-135
K-4.3 Cl-104 HCO3-25 AnGap-10
___ 04:54AM BLOOD ALT-67* AST-68* AlkPhos-81 TotBili-0.3
___ 04:54AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.4
RELEVANT LABS/MICRO
___ 04:54AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 04:54AM BLOOD HCV Ab-PND
___ 04:27PM BLOOD Lactate-1.3
___ 09:29AM BLOOD Lactate-1.0
___ 03:10PM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE
ANTIBODIES, IGG AND IGM-PND
___ 08:00PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 08:00PM BLOOD ARBOVIRUS ANTIBODY IGM AND IGG-PND
___ 3:10 pm Blood (Toxo)
TOXOPLASMA IgG ANTIBODY (Pending):
TOXOPLASMA IgM ANTIBODY (Pending):
___ 8:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
___ SEROLOGY-PENDING
___ CULTUREBlood Culture,
Routine-PENDING
___ CULTUREBlood Culture, Routine-PENDING
___ 11:30 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
___ 11:30 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:2.
Reference Range: Non-Reactive.
___ 11:45 am THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
___ 11:30 am URINE
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis by ___ System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
Microbiology
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___:
Negative for Neisseria gonorrhoeae by PANTHER System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
Microbiology
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
URINE
___ 01:43PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:43PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 01:43PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
IMAGING
___ CTA CHEST
IMPRESSION:
1. No evidence of acute aortic abnormality or pulmonary
embolus.
2. Hepatic steatosis.
___ CXR
IMPRESSION: Stable right middle lobe opacity likely represents
epicardial fat pad and is unchanged. No pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
2. Clindamycin 1 Appl TP BID
3. Ketoconazole Shampoo 1 Appl TP ASDIR
4. ClonazePAM 1 mg PO QHS Sleep Aid
5. AcetaZOLamide 125 mg PO Q24H
6. Fluticasone Propionate NASAL ___ SPRY NU BID
7. ClomiPRAMINE 50 mg PO 3X/WEEK (___)
8. Efavirenz 600 mg PO DAILY
9. Emtricitabine 200 mg PO Q24H
10. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO PRN Pain
12. albuterol sulfate 90 mcg/actuation Inhalation ___ puffs
every ___ hours Cough/wheezing
13. Levothyroxine Sodium 75 mcg PO DAILY
14. Liothyronine Sodium 5 mcg PO DAILY
Discharge Medications:
1. AcetaZOLamide 125 mg PO Q24H
2. ClomiPRAMINE 50 mg PO 3X/WEEK (___)
3. ClonazePAM 1 mg PO QHS Sleep Aid
4. Efavirenz 600 mg PO DAILY
5. Emtricitabine 200 mg PO Q24H
6. Fluticasone Propionate NASAL ___ SPRY NU BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Liothyronine Sodium 5 mcg PO DAILY
9. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO PRN Pain
11. albuterol sulfate 90 mcg/actuation INHALATION ___ PUFFS
EVERY ___ HOURS Cough/wheezing
12. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
13. Clindamycin 1 Appl TP BID
14. Ketoconazole Shampoo 1 Appl TP ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Suspected syphilis
-febrile illness
SECONDARY:
-HIV
-hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: HIV, dyspnea, elevated D-dimer, and hematemesis.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained of the chest after the
administration of IV contrast in the arterial phase. Multiplanar reformatted
images were generated in the coronal and sagittal planes as well as maximum
intensity projection oblique images.
DLP: 725.51 mGy-cm.
FINDINGS: The heart size is normal without significant pericardial effusion.
The thoracic aortic arch is normal in caliber without aneurysmal segments or
dissection. The main pulmonary artery is normal in caliber, and there is no
pulmonary embolus to the segmental level. There is no supraclavicular,
axillary, hilar, or mediastinal lymphadenopathy by CT size criterion.
The airways are patent to the subsegmental level. There is mild posterior
dependent atelectasis bilaterally. Minimal mosaic parenchymal attenuation is
likely due to submaximal inspiration. Lungs are otherwise clear without focal
nodule or consolidation. A small subpleural bulla is noted anteriorly in the
left upper lobe. Pleural surfaces are clear without thickening, effusion, or
pneumothorax.
This study is not tailored for subdiaphragmatic diagnosis; however, within
those limitations, the liver is globally hypodense suggestive of steatosis.
The remainder of the visualized upper abdomen is grossly unremarkable.
OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. No evidence of acute aortic abnormality or pulmonary embolus.
2. Hepatic steatosis.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Dyspnea, Hemoptysis
Diagnosed with FEVER, UNSPECIFIED, NONSPECIF SKIN ERUPT NEC, ASYMPTOMATIC HIV INFECTION
temperature: 97.0
heartrate: 95.0
resprate: 20.0
o2sat: 95.0
sbp: 120.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of fevers, malaise, and a rash. Your penile
lesion was concerning for possible syphilis and as a result you
were treated with penicillin. You will need two more doses of
penicillin (one dose per week). Please make sure to follow up
with Dr. ___ to arrange for these doses.
Your rash and fevers may be secondary to a viral illness; so far
all your blood tests have been negative. Since you appear to be
feeling better, you can return home but will need close follow
up with Dr. ___ Dr. ___. Please make sure to call to
arrange appointments for next week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin / Lyrica / amitriptyline / honey
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ESRD, currently well controlled HIV on fluc suppression
for
recurrent esophageal candiasis and viral suppression for zoster
who
has chronic hypotension (frequently 70 ot 80/palp in clinic) and
poor extremity access (failed fistulas on each side, right lower
amputation and left groin HD access) who comes in to for
outpatient EGD for odynophagia but then was found to have right
sided abdominal pain and was referred to the ED. GI plans to do
inpatient EGD to rule out fluc resistant candidiasis.
Patient has BP's reading as 66-84/30-40's in the GI clinic but
she is mentating, not light headed, no chest
pain. She has new tachycardia compared to previous clinic
visits
and she has had ___ right sided abdominal pain since last
night. She was tender in the RLQ with guarding.
Denies fevers, chills, nausea, vomiting. Last BM yesterday
morning.
She was found to be hyperkalemic which was addressed with a
section of HD in the emergency department. During dialysis she
was noted to enter atrial fibrillation that was treated with
diltiazem. IV access was obtained and after repeated
conversations patient now consents to admission for likely EGD
and continued treatment.
In the ED, initial VS were:
97.7 99 68/39 16 98% RA
Exam notable for: Tender RLQ
Labs showed: AP: 379 and K+ up to 8.2
Imaging showed:
CT ABD/PELVIS WITH CONTRAST:
1. No evidence of acute intra-abdominal process.
2. Re-demonstration of atrophic kidneys with numerous bilateral
cysts, several
of which appear to contain peripheral hyperdensities and
calcifications. For
further characterization, MRI or ultrasound could be considered.
CXR
Left basilar subsegmental atelectasis. No acute cardiopulmonary
abnormality otherwise identified.
Patient received:
___ 11:31 IVF NS
___ 15:01 IVF NS 500 mL
___ 21:30 IV BOLUS Diltiazem 5 mg
___ 21:30 PO/NG Diltiazem 15 mg
___ 00:23 PO/NG OxyCODONE (Immediate Release) 5 mg
___ 00:59 IV Diltiazem 10 mg
___ 01:09 IV Calcium Gluconate (1 gm ordered)
Transfer VS were:
98 92/31 16 98% RA
On arrival to the floor, patient reports still having RLQ pain
that has improved. She is worried that it is constipation even
though her last BM was yesterday.
Past Medical History:
HIV since ___, PCP PNAx3
ESRD secondary to HIV/AIDS nephropathy on HD (___) since ___
Currently dialyzed via L common femoral HD catheter
C.diff
Paroxysmal afib
Eight V1 herpes zoster ___ complicated by post-herpetic
neuralgia and decreased vision in the right eye
Cervical dysplasia
Fibroids
Secondary hyperparathyroidism
Chronic headaches
Warfarin associated calciphylaxis c/b bilateral transmetatarsal
amps requiring revisions, ___ left third finger dry gangrene,
___
MRSA bacteremia and R HD tunneled line infection, ___
PAST SURGICAL HISTORY
___: Right above-knee amputation
___: Right AT angioplasty
___ Angioplasty of the left interosseous artery occlusion
___ UE angio: Occluded left radial and ulnar arteries
___ TMA revision left
___ TMA revision right
___ Bilateral open transmetatarsal amputation for b/l
gangrene
multiple AV fistulas and grafts
R femoral graft,
IVC balloon plasty for 90% stenosis (___)
right lower extremity angiogram and balloon angioplasty of the
right anterior tibial artery (___)
Social History:
___
Family History:
Sister- DM, CVD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Afebrile 52 / dopp HR 100's
GENERAL: NAD. Chronically ill appearing
HEENT: Sclera anicteric, MMM, R eye with significant
whitening/clouding
Neck: supple
Lungs: breathing comfortably on room air
CV: RRR, normal S1 + S2, II/VI systolic murmur
Abdomen: Soft, ND, Mild RLQ pain.
EXTREMITIES: R AKA incision site is clean/dry/intact with no
purulence or associated erythema, R leg is swollen but not
erythematous/tender compared to the left, L lower extremity
without edema but distal
pulses difficult to palpate. Middle finger amputation
NEURO: Face grossly symmetric, A&Ox3, moving all limbs with
purpose
DISCHARGE PHYSICAL EXAM:
========================
VITALS: Reviewed in ___ confirms SBP often in
___, difficult to accurately measure due to severe vascular
disease
GENERAL: Chronically ill appearing, lying in bed, NAD
HEENT: Sclera anicteric, MMM w/o thrush, R eye with significant
whitening/clouding
Neck: supple
PULM: breathing comfortably on room air
CV: RRR, normal S1 + S2, II/VI systolic murmur
GI: Soft, ND, Mild RLQ pain.
EXTREMITIES: R AKA incision site is clean/dry/intact with no
purulence or associated erythema, R leg is swollen but not
erythematous/tender compared to the left, L lower extremity
without edema but distal pulses difficult to palpate. Middle
finger amputation
NEURO: Face grossly symmetric, A&Ox3, moving all limbs with
purpose
Pertinent Results:
PERTINENT LABS:
===============
___ 09:29AM BLOOD WBC-9.8 RBC-3.80* Hgb-11.5 Hct-36.6
MCV-96 MCH-30.3 MCHC-31.4* RDW-17.4* RDWSD-60.4* Plt ___
___ 09:29AM BLOOD Glucose-84 UreaN-37* Creat-3.5* Na-138
K-6.5* Cl-93* HCO3-22 AnGap-23*
___ 11:10AM BLOOD ALT-26 AST-70* CK(CPK)-59 AlkPhos-379*
TotBili-0.3
___ 08:30PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:30PM BLOOD HCV Ab-NEG
___ 04:33PM BLOOD HIV1 VL-NOT DETECT
DISCHARGE LABS
==============
___ 02:30AM BLOOD WBC-9.0 RBC-4.04 Hgb-12.0 Hct-39.1 MCV-97
MCH-29.7 MCHC-30.7* RDW-17.2* RDWSD-60.4* Plt ___
___ 02:30AM BLOOD Glucose-89 UreaN-28* Creat-2.9* Na-140
K-4.8 Cl-91* HCO3-20* AnGap-29*
___ 02:30AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.8
IMAGING/STUDIES:
================
1. No evidence of acute intra-abdominal process.
2. Re-demonstration of atrophic kidneys with numerous bilateral
cysts likely related to chronic hemodialysis, several of which
appear to contain peripheral hyperdensities and calcifications.
For further characterization, MRI or ultrasound could be
considered.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Acyclovir 400 mg PO Q24H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Cilostazol 50 mg PO BID
7. Cinacalcet 60 mg PO QPM
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Dolutegravir 50 mg PO QPM
10. DULoxetine 30 mg PO DAILY
11. Emtricitabine 200 mg PO 2X/WEEK (MO,FR)
12. Fluconazole 200 mg PO QHS
13. Fludrocortisone Acetate 0.1 mg PO BID
14. Midodrine 10 mg PO MWF
15. Nephrocaps 1 CAP PO QHS
16. Omeprazole 20 mg PO BID
17. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Severe
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Senna 17.2 mg PO BID:PRN constipation
20. Sertraline 50 mg PO QAM
21. sevelamer CARBONATE 1600 mg PO TID W/MEALS
22. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (SA)
23. Ondansetron 4 mg PO Q6H:PRN nausea
24. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
2. Omeprazole 40 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Acyclovir 400 mg PO Q24H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Cilostazol 50 mg PO BID
9. Cinacalcet 60 mg PO QPM
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Dolutegravir 50 mg PO QPM
12. DULoxetine 30 mg PO DAILY
13. Emtricitabine 200 mg PO 2X/WEEK (MO,FR)
14. Fluconazole 200 mg PO QHS
15. Fludrocortisone Acetate 0.1 mg PO BID
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. Midodrine 10 mg PO MWF
18. Nephrocaps 1 CAP PO QHS
19. Ondansetron 4 mg PO Q6H:PRN nausea
20. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ capsule(s) by mouth every 8 hours as
needed for pain Disp #*12 Capsule Refills:*0
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Senna 17.2 mg PO BID:PRN constipation
23. Sertraline 50 mg PO QAM
24. sevelamer CARBONATE 1600 mg PO TID W/MEALS
25. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (SA)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Constipation
Odynophagia
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with abdominal pain and hypotension// ?pneumonia
(XRay), ?intrab-abdominal process such as SBO (CT)
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest CT ___, chest radiograph ___
FINDINGS:
Cardiac silhouette size appears normal. Mediastinal and hilar contours are
unchanged with enlargement of the azygous and left superior intercostal vein
again noted, the sequela of chronic right brachiocephalic venous occlusion,
better assessed on previous CT. Pulmonary vasculature is not engorged.
Linear opacity in the left lung base likely reflects an area of atelectasis.
No focal consolidation, pleural effusion, or pneumothorax is seen. Extensive
calcifications are noted within the right upper extremity arterial
vasculature. Central venous catheter is noted within the inferior vena cava,
coursing through a stent within the IVC and terminating in the region of the
right atrium.
IMPRESSION:
Left basilar subsegmental atelectasis. No acute cardiopulmonary abnormality
otherwise identified.
Radiology Report
EXAMINATION: CT abdomen/pelvis with contrast.
INDICATION: History: ___ with abdominal pain and hypotension. Evaluation for
intra-abdominal process such as SBO.
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 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 18.2 mGy (Body) DLP = 946.7
mGy-cm.
Total DLP (Body) = 958 mGy-cm.
COMPARISON: Multiple prior studies, most recently CTA torso from ___,
and CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout. There are
two distinct 1.0 cm hypodensities noted in the posterior periphery, unchanged
from prior study and likely represent cysts.
ADRENALS: There is mild thickening of the right and left adrenal glands,
however no evidence of focal mass.
URINARY: Bilateral kidneys appear severely atrophic and demonstrate
innumerable cysts, several of which appear to contain peripheral
hyperdensities and calcifications. The most prominent cysts include a 4.0 cm
exophytic cyst at the right lower pole and a 2.8 cm exophytic cyst at the left
interpolar region. There is a nonobstructing renal calculi within the right
lower pole measuring approximately 6 mm. There is no hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
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. A vascular stent is seen within the intrahepatic IVC.
There is a left femoral dialysis catheter terminating in the right atrium.
BONES: Diffuse sclerosis along the vertebral body endplates is compatible with
renal osteodystrophy. There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Re-demonstration of atrophic kidneys with numerous bilateral cysts likely
related to chronic hemodialysis, several of which appear to contain peripheral
hyperdensities and calcifications. For further characterization, MRI or
ultrasound could be considered.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: nan
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: nan
dbp: nan
level of pain: Unable
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure caring for at ___
___!
WHY YOU WERE ADMITTED:
-You were having abdominal pain
-Your potassium level was high from having missed dialysis
WHAT HAPPENED IN THE HOSPITAL:
-A CT scan did not show any acute problems that could cause your
pain
-The scan you were likely constipated which we believe was
causing your pain
-The GI doctors ___ able to perform an EGD and recommended
medicines to help improve your pain with swallowing
-You received dialysis
-Your heart rate increased at times but improved without any
medication.
WHAT YOU SHOULD AT HOME:
-Continue taking your medications as prescribed
-Follow-up with your scheduled doctor appointments
Thank you for allowing us to be involved in your care, we wish
you the best!
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Fever, hand swelling
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ who presents with a 1-week history of
objective fevers (to 101.3), chills and swelling/stiffness in
her fingers/toes. The patient's ___ called her PCP today and
relayed T 99.5, HR 90, BP 110/60, O2 sat 96% RA and persistent
pain in multiple joints of hands bilaterally. Her PCP advised
her to come to ED for further evaluation. The patient had
complained of fever since ___, up to 101.3, for which she was
taking Tylenol with some relief. The pain in her finger/toe
joints is worse with extension/flexion. She denies any headache,
cough, shortness of breath, chest pain, abdominal pain, back
pain, dysuria, or change in color of urine/stool. No recent
travel.
In the ED initial vitals were: 97.6 88 130/71 18 98% RA. Labs
were significant for WBC 5.7 w/ 56% PMNs, Hgb 11.8, plts 188,
Chem7 WNL, Lactate 1.6, UA bland, CXR showed possible PNA vs.
mass. CT chest was done and showed "subtle consolidations in the
right middle and left lower lobe may be secondary to an
infectious process." Other relevant recent outpatient work-up
(from ___ included CRP 81.9 and ESR 100. Patient was given
Ceftriaxone and was admitted. Vitals prior to transfer were:
98.4 89 162/69 14 98% RA.
On the floor, initial VS were 98.0 141/63 96 18 94% RA. The
patient was comfortable and had no complaints.
Past Medical History:
HTN
DM2
HLD
Diverticulosis
Social History:
___
Family History:
No family hx of RA or other autoimmune d/o. Cousin died in her
___ No FHx of lung CA
Physical Exam:
ADMISSION
Vitals - 97.6 88 130/71 18 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. No effusions of finger joints.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
Vitals - 98.0 138/64 90 18 97%RA
GENERAL: WDWN woman laying hospital bed comfortably
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. No effusions of finger joints.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength throughout upper and lower
ext
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS
ADMISSION
___ 09:21PM BLOOD WBC-5.7 RBC-3.87* Hgb-11.8* Hct-36.1
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.5 Plt ___
___ 09:21PM BLOOD Neuts-55.8 ___ Monos-8.7 Eos-2.0
Baso-0.7
___ 09:21PM BLOOD Plt ___
___ 09:21PM BLOOD Glucose-151* UreaN-14 Creat-0.8 Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
___ 09:39PM BLOOD Lactate-1.6
DISCHARGE
___ 06:20AM BLOOD WBC-5.2 RBC-3.60* Hgb-10.8* Hct-32.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.2 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-157* UreaN-11 Creat-0.6 Na-142
K-3.4 Cl-105 HCO3-25 AnGap-15
___ 06:20AM BLOOD ALT-17 AST-22 LD(LDH)-197 AlkPhos-83
TotBili-0.3
___ 06:20AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.0
___ 06:20AM BLOOD RheuFac-11
___ 09:39PM BLOOD Lactate-1.6
MICROBIOLOGY
___ 10:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:40PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:40PM URINE Mucous-RARE
BCx x2 pending
IMAGING
___
CXR IMPRESSION (PRELIM):
1. Bibasilar opacities may be secondary to atelectasis given low
lung volumes, however acute infectious process cannot be
excluded.
2. Opacity overlying the right upper lung, along the
mediastinum, may be
secondary to tortuosity of the great vessels, or superimposition
of
structures, however a CT is recommended for further evaluation
to exclude malignancy.
CT CHEST W/ CON IMPRESSION (PRELIM):
1. Tubular opacities at the upper lungs bilaterally is likely
secondary to bronchial impaction, consistent with patient's
history of granulomatous disease.
2. Consolidation seen in the right middle lobe and left lower
lobe is
concerning for an infectious process.
3. Nodules are seen in the lungs bilaterally measuring up to 0.9
cm. A
three-month followup is recommended for further evaluation to
exclude malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO QAM
4. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. GlipiZIDE 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO QAM
4. Simvastatin 10 mg PO DAILY
5. Azithromycin 250 mg PO DAILY
Please take two pills today, followed 1 pill a day for the next
4 days (up to and on ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical respiratory illness,
Sub-centimeter pulmonary nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of fevers. Please evaluate.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: ___ MDCT images were obtained through the chest after the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axis were generated and reviewed.
FINDINGS: The thyroid is normal. There is no axillary, supraclavicular,
mediastinal or hilar lymphadenopathy. The heart size is normal. The
pericardium is intact without evidence of an effusion. The esophagus does not
demonstrate any evidence of wall thickening; however, note is made of a
moderate hiatal hernia. The aorta is normal in caliber without evidence of
aneurysm or dissection.
The airways are patent to the subsegmental levels. In the upper right lung,
there is a tubular opacity with calcification. An additional tubular opacity
is seen in the upper left lung. In the right lower lobe, there is a nodule
with an eccentric calcification, which measures approximately 0.9 cm x 0.8 cm,
(series 4, image 102). An additional 0.5-cm nodule is seen in the right lower
lobe (series 4, image 102). There is a subtle focus of consolidation in the
right middle lobe, (series 4, image 121). A second focus of consolidation is
seen in the right middle lobe, (series 4, image 130). There is mild bibasilar
peribronchial thickening, which could be secondary to an infectious process.
A 6-mm nodule is seen at the left lower lobe as well as a second 5-mm nodule
(series 4, image 149 and series 4, image 143). There is no pleural effusion
or pneumothorax.
This study is not tailored for the evaluation of subdiaphragmatic structures;
however, areas of enhancement are noted in segment VIII (series 4, image 145
and series 4, image 148), which may be secondary to a hemangioma. There is
evidence of fatty liver.
No lytic or blastic lesions concerning for malignancy are identified.
IMPRESSION:
1. Tubular opacities at the upper lungs bilaterally likely secondary to
bronchial mucus plugging, consistent with patient's history of granulomatous
disease.
2. Small airspace disease in the right middle lobe and left lower lobe is
concerning for an infectious process.
3. Nodules are seen in the lungs bilaterally measuring up to 0.9 cm in the
right lower lobe, with a calcification. A 3 month follow up is recommended
for further evaluation to exclude malignancy.
Updated findings were d/w Dr. ___ by Dr. ___ by phone at 9:50A on the
day of the exam.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 97.6
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 130.0
dbp: 71.0
level of pain: 5
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure treating you at the ___
___. You were admitted for your recent fever, hand
swelling, and possible lung infection. While you were admitted,
you had an x-ray and CT scan of your lung which showed us some
findings that will need to be followed up on by your PCP. Your
fever is likely a result of an atypical bacterial infection and
we've prescribed a short course of antibiotics. Beyond this,
we've set up an appointment with rheumatology to discuss your
recent hand swelling. It's important that you follow-up with
your primary care physician following discharge to ensure
resolution and/or further workup of your symptoms.
As we discussed, the CT scan found several small lung nodules.
These could be benign, but we recommend follow up CT scan in 3
months to make sure these are not something serious, like
cancer.
START:
-- Azithromycin once per day for 5 days
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Pepto-Bismol / Penicillins
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a ___ man with a history of right
frontoparietal hemorrhage in ___ thought to be
secondary to amyloid angiopathy, CAD s/p MI, HTN,
hyperlipidemia,
afib not on anticoagulation, remote nasopharyngeal carcinoma,
cardiomyopathy
with inactive defibrillator in place who presents with
left-sided
weakness and found to have right frontal hemorrhage on CT.
The patient was in his usual state of health until last
___. In the morning when he woke up his family noticed
that he was weaker than normal, and that he was having a hard
time using his walker to get around the house. They said that
he
seemed very stiff on the left side, and so this made it hard for
him to use his walker with his arms, and hard for him to lift
his
leg to take a step. He has had weakness before when he has been
dehydrated, so the family assumed that this was the case. They
gave him lots of fluid over the weekend, but they noticed that
he
was not getting any better. The weakness progressed from
___ to ___, and has been stable since ___. The
patient went to a cardiology appointment today at twice daily
___, and while he was there at the family decided to bring
him to the emergency room there to have his weakness evaluated.
A CT head was performed, which showed a right frontal bleed with
surrounding edema. He was then transferred to ___ for further
management.
Other than the weakness, he reports no new symptoms. He has
never
had a seizure, and is on Keppra for prophylaxis since he is high
risk for seizure. He was found to have atrial fibrillation last
___, but was not started on anticoagulation or aspirin given
his high risk for bleeding that was thought to outweigh the risk
of ischemic infarct.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion worse than baseline. Denies
difficulty with producing speech or comprehending speech. Denies
loss of vision, blurred vision, diplopia, vertigo, tinnitus,
hearing difficulty, dysarthria worse than baseline, or
dysphagia.
Endorses left-sided upper and lower extremity weakness. Denies
numbness, parasthesia. Denies loss of sensation. No recent
trauma no falls, patient has not been dropping things. There
has
been no change in his confusion, or speech.
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. Has not had a bowel movement since ___.
Past Medical History:
CAD status post MI
Cardiomyopathy with deactivated defibrillator in place
Nasopharyngeal carcinoma status post chemo and radiation ___
years
ago
Hypothyroidism
Hypertension
Hyperlipidemia
Atrial fibrillation not on anticoagulation
Social History:
___
Family History:
Brother who had a stroke
Physical Exam:
Vitals:
T 98.5 HR 76 BP 101/67 RR 17 SaO2 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Good peripheral perfusion
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurological Examination:
Mental Status: Alert and oriented to self, ___, ___
but not date (baseline per family). Intact fluency,
comprehension, naming and repetition. Follows three-step
commands. Days of week backwards intact.
Cranial Nerves:
Pupils were equal, round and reactive 3-->2 bilaterally.
Extraocular movements intact. Visual fields were intact to
confrontation bilaterally. He has slurred speech, which is at
baseline per family. Reports symmetric sensation in bilateral
face. Left facial droop at baseline. Decreased hearing 70% left
ear compared to right (long term, damaged in surgery). Right
shoulder shrug intact, no movement on the left.
Motor Examination: No adventitious movements. Significantly
increased tone of the left arm and leg. Normal bulk of all four
limbs. Strength for the left arm was 1 deltoid, 1 biceps, 1
triceps, 1 for finger extensors. For the left leg, strength
was 1 for the iliopsoas, 0 hamstrings, 1 quadriceps, ___
strength for the left dorsiflexion and ___ strength for
plantarflexion. ___ strength of the right arm and leg, both
proximally and distally.
Sensory Examination:
Reports symmetric sensation to light touch in bilateral arms and
legs. He has extinction to double light touch stimulation of the
left
side of the body. Able to identify pen with eyes closed, but not
battery when placed in his hand. Agraphesthesia bilaterally.
Coordination: Unable to assess the left arm or leg due to
weakness. Coordination was intact to finger-nose-finger with
the
right arm.
Unable to assess gait as paitent's left side is so weak he has
been unable to walk.
DISCHARGE PHYSICAL EXAM
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty.Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was dysarthric but understandable. 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.
V: Facial sensation intact to light touch.
VII: Facial droop on left side at baseline, facial
musculature
asymmetric (asymmetric smile).
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 throughout; increased tone on left side. No
pronator drift on right side. Unable to assess on left side due
to weakness. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ 1 ___ 2 2 1 2 1
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to pinprick and cold sensation. Left leg
and foot has decreased sensation throughout. Extinction noted to
DSS. Vibratory sense, and proprioception preserved.
-DTRs:
deferred
___ response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on right FNF or HKS bilaterally. Unable to assess
on
left side.
-Gait: walks with walker, circumducts weak leg with rigid foot
brace on.
Coordination: Unable to assess the left arm or leg due to
weakness. Coordination was intact to finger-nose-finger with the
right arm.
Pertinent Results:
___ 11:10PM BLOOD WBC-6.4 RBC-4.02* Hgb-12.4* Hct-36.8*
MCV-92 MCH-30.8 MCHC-33.7 RDW-14.0 RDWSD-47.9* Plt ___
___ 09:49AM BLOOD ___ PTT-31.4 ___
___ 06:40AM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-142
K-4.5 Cl-102 HCO3-28 AnGap-12
___ 11:10PM BLOOD ALT-23 AST-31 CK(CPK)-234 AlkPhos-66
TotBili-0.8
___ 09:49AM BLOOD %HbA1c-5.7 eAG-117
___ 09:49AM BLOOD Triglyc-105 HDL-49 CHOL/HD-2.1 LDLcalc-34
___ 09:49AM BLOOD TSH-1.3
___ 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA Head and Neck ___
IMPRESSION:
1. Evidence of large right MCA and ACA territory late acute to
subacute
infarction.
2. Diffuse hyper attenuation of the anterior right frontal
cortex likely
represents areas of petechial hemorrhage.
3. Regions of volume loss in the right posterior temporal, right
frontoparietal and left occipital lobes as well as the left
cerebellar
hemisphere likely represent sequela of old infarcts.
4. Several outpouchings of the bilateral ICAs as above, most
likely
infundibula.
5. Possible 2 mm aneurysm at the left MCA M2 bifurcation.
6. No evidence of dissection or occlusion of the head and neck.
No
significant ICA stenosis by NASCET criteria.
7. Evidence of prior left-sided neck dissection. "
CT head ___
"IMPRESSION:
1. Hyperdensities in the anterior right frontal lobe are
re-demonstrated,
similar in appearance to the prior study. Hemorrhage cannot be
excluded,
however further evaluation with MRI is recommended.
2. Extensive chronic encephalomalacia re-demonstrated. "
Video swallow study ___
FINDINGS:
Aspiration was noted with thin liquids. Improved with ___ tuck
and head
tilt, however there was still trace penetration. Pooling of
nectar liquids. Putting residue was noted after 3 swallows.
IMPRESSION:
Aspiration noted with thin liquids, improved with ___ tuck and
head tilt with residual trace penetration. "
======================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - (x) No (had hemorrhagic conversion)
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x ] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No had hemorrhagic
transformation
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A had hemorrhagic
transformation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. LevETIRAcetam 500 mg PO BID
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
3. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin 10 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*4
4. Senna 8.6 mg PO BID:PRN Constipation
5. LevETIRAcetam 500 mg PO BID
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic infarct with hemorrhagic conversion
Discharge Condition:
Mental Status: Mr. ___ reports feeling continued weakness
along his left side, though improvement in his speech.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty.Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was mildly dysarthric-lingual, palatal, facial (much improved
from days prior). Able to follow both midline and appendicular
commands. There was no evidence of apraxia.
Ambulatory Status:Able to ambulate with the help of family and
hemi walker. Still exhibits gait instability and left sided
weakness.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ with weakness, recent IPH // eval for bleed
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: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.9 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,303.2 mGy-cm.
Total DLP (Head) = 2,236 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a large territory of hypoattenuation involving the right
frontoparietal and right temporal lobes i right MCA and ACA distributions
likely representing late acute to subacute infarction. There is diffuse
hypoattenuation of the anterior right frontal cortex, which likely represents
areas of petechial hemorrhage.
Areas of volume loss within the right posterior temporal, frontal parietal and
left occipital lobes are compatible sequela of old infarcts.
Focal hyperdense areas along the right anterior frontal lobe cortex,
concerning for acute hemorrhages, are again noted and unchanged. Left
cerebellar hypodensity is also likely sequela of prior infarct.
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is mild mucosal thickening of the ethmoid air cells and right sphenoid
sinus. The mastoid air cells and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
CTA HEAD:
There is a possible 2 mm inferiorly oriented aneurysm at the supraclinoid
segment of the right internal carotid artery (601:33) though this is more
likely an infundibulum of the anterior choroidal artery. 1-2 mm tiny
infundibulum versus aneurysm is arising from the supraclinoid segment of the
left internal carotid artery (3:274, 276). There is a possible 2 mm aneurysm
at the left MCA M2 bifurcation (601:30). There are calcifications of the
carotid siphons. There is a fetal type configuration of the right PCA from
the ICA. The remainder of the vessels of the circle of ___ and their
principal intracranial branches appear normal without stenosis, occlusion, or
aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
There is a right dominant vertebrobasilar system with the left intracranial
vertebral artery nearly terminates into the left ___. Partially calcified
atherosclerotic plaque seen in the common carotid and bilateral proximal ICAs.
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs demonstrate mild centrilobular emphysema
and scarring at the right lung apex, potentially radiation induced. Patient
is status post left neck dissection with absence of the submandibular gland,
sternocleidomastoid muscle and internal jugular vein. The visualized portion
of the thyroid is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Evidence of large right MCA and ACA territory late acute to subacute
infarction.
2. Diffuse hyper attenuation of the anterior right frontal cortex likely
represents areas of petechial hemorrhage.
3. Regions of volume loss in the right posterior temporal, right
frontoparietal and left occipital lobes as well as the left cerebellar
hemisphere likely represent sequela of old infarcts.
4. Several outpouchings of the bilateral ICAs as above, most likely
infundibula.
5. Possible 2 mm aneurysm at the left MCA M2 bifurcation.
6. No evidence of dissection or occlusion of the head and neck. No
significant ICA stenosis by NASCET criteria.
7. Evidence of prior left-sided neck dissection.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with right frontal IPH// evaluate for interval
change
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain
windows.
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 frontoparietal craniotomy changes are again noted. Re-demonstrated are
hyperdense foci along the anterior right frontal gyri, similar in appearance
to the prior study. Extensive chronic encephalomalacia is also seen along the
right frontoparietal lobe and left occipital lobe, unchanged. Chronic left
cerebellar infarct again noted. Ex vacuo dilation of the occipital horn of
the right lateral ventricle again noted. The imaged paranasal sinuses are
clear. Mastoid air cells and middle ear cavities are well aerated.
IMPRESSION:
1. Hyperdensities in the anterior right frontal lobe are re-demonstrated,
similar in appearance to the prior study. Hemorrhage cannot be excluded,
however further evaluation with MRI is recommended.
2. Extensive chronic encephalomalacia re-demonstrated.
Radiology Report
EXAMINATION: Video oropharyngeal swallow study
INDICATION: ___ year old man with stroke// Dysphagia
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 5: 23 min.
COMPARISON: None available.
FINDINGS:
Aspiration was noted with thin liquids. Improved with chin tuck and head
tilt, however there was still trace penetration. Pooling of nectar liquids.
Putting residue was noted after 3 swallows.
IMPRESSION:
Aspiration noted with thin liquids, improved with chin tuck and head tilt with
residual trace penetration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: L Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: 97.9
heartrate: 71.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness
most likely resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. We believe that this brain tissue then
developed bleeding. It is possible that this was caused by a
clot from your heart from atrial fibrillation. However, because
of your current and past bleeding, you are at high risk to be on
anticoagulation, which would be the way to prevent strokes from
atrial fibrillation from happening. After imaging your brain
and monitoring you closely, we have found that you are no longer
bleeding and are in stable condition. In order to reduce the
risk of this happening in the future, you should closely monitor
your blood pressures, minimize your cholesterol intake, and
continue to take your prescribed medications. For your blood
pressure, please continue to exercise, minimize sodium intake,
and take your prescribed metoprolol succinate ER 25 mg tablet,
extended release 24 hr (0.5 tablet per day). For your
cholesterol, please eat a diet high in fiber and low in
cholesterol, and take the statin medication that has been
prescribed for you: Crestor 10 mg daily. Also, be sure to attend
your follow-up appointment with your outside neurologist, Dr.
___.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
atrial fibrillation
high cholesterol
prediabetes
high blood pressure
We are changing your medications as follows:
stop taking atorvastatin, starting taking rosuvastatin 10 mg
nightly
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
For discharge diet, please follow the recommendations of the
swallow study team as outlined below:
Please see ___ for the international dysphagia diet
framework and testing methods.
Food TESTING METHODS:
1. SPOON TILT TEST: trained wife to make sure her foods are
adequately smooth, moist and slippery to make sure the puree is
safe. Scooping up the puree, the puree should slip off the spoon
without sticking (as this would stick to the walls of his
pharynx
as well). Her ___ fish/rice porridge passed this test well.
He had no difficulty with this texture.
2. FORK PRESSURE TEST:
Used the banana she brought to teach the fork pressure test with
pressing fork into the banana to show how it squashes easily and
can be made into a puree. We pureed the banana and added his
preferred whipped cream. He had no difficulty with this pureed
texture.
Testing soaked cheerios with the fork pressure test: these did
NOT pass. The cheerios did NOT deform with pressure from fork,
and are NOT safe for him to eat. High risk for these to be
aspirated, as they could get stuck in pharynx and fall to
airway.
Analyzed clam chowder, and this is NOT safe, as the liquid is
thin. The liquid from the clam chowder could be added to the
mashed potatoes to smooth them out.
Similar thin liquid issue with the ice cream and Ensure - these
are thin liquids and cannot be eaten at this time. They could
make a nectar thick frappe with ice cream and Ensure with
thickening by banana and yogurt.
It was a pleasure meeting you,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abnormal MRI finding, ?mass vs. infarct
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Mr. ___ is a ___ right-handed man with a history of
paroxysmal atrial fibrillation, hyperlipidemia, and a prior L
pontine infarct in ___ who presents with a 2 week history of
numbness in his lower lip and right arm along with some
clumsiness in his right hand and foot. He reports that he first
noticed some numbness along his lower lip, he thinks both sides,
about 2 weeks ago. He was eating a lot of cayenne pepper at the
time and at first attributed it to this. However over the next
few days he also began to notice numbness along the inner
surface
of his right arm and some difficulty using his hand. He noticed
that his hand felt somewhat clumsy and his handwriting was
messier. He then began to notice some numbness in the toes on
his
R foot and felt that it was harder to move his ankle. He felt
that his gait was somewhat more unsteady with occasional
"stumbling" due to this.
These symptoms have been continuing over the last 2 weeks but he
does not think they have progressed or gotten any worse. He
denies any associated headaches, visual changes, difficulty
speaking, dizziness/lightheadedness, nausea/vomiting. His wife
says she has noticed a couple of instances in the last few weeks
in which he didn't remember something she would have expected
him
to - such as the location of items around the house. He denies
any difficulties with his memory however and says he feels he is
thinking clearly. He has otherwise been feeling well with no
recent illnesses.
He does report an instance about a month ago while he was
working
with some equipment on a ___ farm and cut his right hand on a
piece of metal. He sustained a relatively deep cut between his
first and second digits but did not seek medical care; he taped
his fingers together and the wound healed without complications.
Last tetanus shot ___ years ago. He says he did decrease his
coumadin from 11mg to 5mg daily for 2 weeks after the injury to
avoid excessive bleeding. He is now back up to his prescribed
dose of 11mg daily and thinks his most recent INR was at goal.
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.
On general review of systems, the pt denies recent fever or
chills. He does report a 20 lb weight loss over the last year,
which he says was not entirely intentional - he has been
decreasing his consumption of beer and carbohydrates but was
still somewhat surprised he had lost that much weight. 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:
Hyperlipidemia
Prior stroke in ___ - presented with left facial numbness in
setting of a fib with RVR, found to have L pontine infarct. He
was on aspirin + coumadin with an INR of 2.6 at the time.
Paroxysmal a fib - on aspirin and coumadin
Prostate CA - diagnosed in ___ (adenocarcinoma on biopsy),
declined TURP, being followed by urology. Last PSA in ___
elevated at 7.96.
Anaplasmosis (___) - per ___ records, "anaplasmosis
IgM
was positive at 1:1280 and IgG positive at 1:1280, consistent
with acute anaplasmosis confirmed by serology. Of note his
other
studies for Lyme, ehrlichia and babesia were negative."
Last colonoscopy ___ - normal except for sigmoid
diverticulosis,
recommended f/u in ___ years
Social History:
___
Family History:
Father died at age ___ of bone cancer
Mother died at age ___ with colon cancer and CHF
Brother with prostate cancer s/p resection and skin cancer
Physical Exam:
Vitals: 98.4 56 155/82 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to date, ___, president. Able
to relate history without difficulty. Attentive, able to name
___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick, and cold in
all three distributions.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Slight R pronator drift.
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: Reports somewhat different/tingly sensation to
pinprick
over R arm circumferentially. Pinprick mildly decreased over R
leg.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: Fine finger movements and foot tapping slightly
slower on the R. No intention tremor, no dysdiadochokinesia
noted. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
ADMISSION LABS:
___ 08:20AM BLOOD WBC-12.4* RBC-4.38* Hgb-14.6 Hct-44.2
MCV-101* MCH-33.3* MCHC-33.0 RDW-13.5 Plt ___
___ 08:20AM BLOOD Neuts-80.6* Lymphs-11.6* Monos-5.3
Eos-2.1 Baso-0.3
___ 08:20AM BLOOD ___ PTT-43.2* ___
___ 08:20AM BLOOD Glucose-114* UreaN-20 Creat-0.9 Na-140
K-4.0 Cl-104 HCO3-31 AnGap-9
___ 08:20AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1
___ 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:20AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-Test
CSF STUDIES (___):
- WBC-0 RBC-1* Polys-16 ___ Monos-12
-TotProt-39 Glucose-62
- MS Profile: PENDING
- Cytology: PENDING
- Flow Cytometry: PENDING
MRI/MR SPECT HEAD (___):
1. The rim-enhancing lesion with abnormal diffusion in the left
parietal white matter demonstrates abnormal MR spectroscopy, as
detailed above, but no evidence of increased perfusion. These
findings are compatible with a subacute infarction and
tumefactive demyelination. MR spectroscopy is also compatible
with a neoplasm, and absence of hyperperfusion does not
definitively exclude a neoplasm. Short-interval followup MRI
with intravenous contrast would be helpful, as contrast
enhancement associated with infarction
and demyelination would be expected to improve.
2. Scattered nonspecific foci of high T2 signal in the
bifrontal and biparietal white matter, without contrast
enhancement or abnormal diffusion, which are compatible with
sequelae of chronic microvascular infarcts in a patient of this
age, though demyelinating lesions could have a similar
appearance.
3. Faint small focus of high T2 signal in the left pons, which
may correspond to the chronic pontine infarct described in the
history.
Medications on Admission:
Coumadin 11mg daily
Aspirin 81mg daily
Sotalol 120mg BID
Diltiazem 120mg XR daily
Vitamin D supplements
Fish oil
Flax seed oil
Discharge Medications:
1. Outpatient Lab Work
Please check INR on ___ and fax to cardiologist Dr.
___ ___.
2. Outpatient Lab Work
Please check INR on ___ and fax to cardiologist Dr.
___ ___.
3. Outpatient Lab Work
Please check INR on ___ and fax to cardiologist Dr.
___ ___.
4. Outpatient Lab Work
Please check INR on ___ and fax to cardiologist Dr.
___ ___.
5. Warfarin 11 mg PO DAILY16
6. Aspirin 81 mg PO DAILY
7. Enoxaparin Sodium 100 mg SC BID
Please continue taking this medication until your INR is between
___ (when instructed to stop taking it by your cardiologist).
RX *enoxaparin 100 mg/mL 100mg subcutaneous injection twice a
day Disp #*60 Syringe Refills:*0
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Sotalol 120 mg PO BID
10. Vitamin D 800 UNIT PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. flaxseed oil *NF* 1,000 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left subcortical white matter lesion: stroke vs. tumor vs.
demyelinating lesion
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 PA and lateral.
INDICATION: ___ male patient with new brain lesion, evaluate for
cardiopulmonary process.
FINDINGS: PA and lateral chest views were obtained with patient in upright
position. The heart size is within normal limits. No typical configurational
abnormality is seen. Thoracic aorta and mediastinal structures are
unremarkable. The pulmonary vasculature is not congested. No signs of acute
or chronic parenchymal infiltrates are present and the lateral and posterior
pleural sinuses are free. No evidence of pneumothorax in the apical area on
frontal view. Mildly accentuated kyphotic curvature in the thoracic spine as
seen on the lateral view with mild degree of degenerative spurs at vertebral
body edges, but no evidence of vertebral body compression fracture. No other
skeletal abnormalities identified on PA and lateral chest views.
Our records do not include a previous chest examination available for
comparison.
IMPRESSION: No evidence of cardiovascular or pulmonary abnormalities on PA
and lateral chest examination.
Radiology Report
HEAD MRI WITH AND WITHOUT CONTRAST, MR PERFUSION, MR SPECTROSCOPY
INDICATION: ___ man with atrial fibrillation, on anticoagulation,
history of small pontine stroke, now with two weeks of mild right sensory and
motor deficits. Outside MRI showed a left white matter lesion, with diagnostic
possibilities including infarct, tumor, tumefactive multiple sclerosis,
unlikely infection. Please evaluate.
COMPARISON: Head MRI with and without contrast performed at ___
___ on ___.
TECHNIQUE: Sagittal T1-weighted, and axial T1-weighted, T2-weighted, FLAIR,
gradient echo, and diffusion-weighted images of the head were obtained.
Arterial spin labeling MR perfusion was obtained. Dynamic susceptibility
contrast MR perfusion was performed during intravenous gadolinium
administration. Following additional intravenous gadolinium administration,
multiplanar T1-weighted images of the head were obtained. Multivoxel MR
spectroscopy was obtained in the region of interest in the left hemisphere.
FINDINGS: Again seen is a lesion with high T2 signal and a thick peripheral
rim of contrast enhancement in the left parietal periventricular white matter,
posterior and superior to the thalamus. There is mild surrounding edema
without significant mass effect. The enhancing rim of the lesion demonstrates
slow diffusion, with high signal on the diffusion tracer and low signal on the
ADC map. No change in the appearance of the lesion is seen compared to two
days earlier.
There is an unchanged 9 mm non-enhancing, T2 hyperintense lesion in the right
frontal centrum semiovale (image 10:26), and scattered unchanged punctate
non-enhancing foci of high T2 signal in the frontal and parietal
supratentorial white matter, which are nonspecific. There is a faint focus of
a high T2 signal in the left pons, image 6:12, more conspicuous than on the
outside study. This may correspond to the chronic pontine infarct described
in the history, as there is no associated diffusion abnormality or contrast
enhancement.
There is mild cerebral atrophy with mild prominence of the sulci. The
ventricles are normal in size for age. The major arterial flow voids are
grossly preserved.
There is mild mucosal thickening throughout the imaged paranasal sinuses, and
a small mucous retention cyst in the left maxillary sinus.
MR PERFUSION. Neither the arterial spin labeling technique nor the dynamic
susceptibility contrast technique demonstrates evidence of increased perfusion
within the left parietal lesion.
MR SPECTROSCOPY: The lesion is included in voxel #8, which demonstrates an
abnormal spectrum, including increased choline, decreased NAA, and increased
choline/NAA ratio. These findings may be seen in either tumor or tumefactive
demyelination. Increased NAA is also compatible with subacute infarction, and
choline levels may be variable in subacute infarction. A lactate peak is also
noted within the lesion, but this does not help differentiate between the
diagnostic possibilities.
IMPRESSION:
1. The rim-enhancing lesion with abnormal diffusion in the left parietal
white matter demonstrates abnormal MR spectroscopy, as detailed above, but no
evidence of increased perfusion. These findings are compatible with a
subacute infarction and tumefactive demyelination. MR spectroscopy is also
compatible with a neoplasm, and absence of hyperperfusion does not
definitively exclude a neoplasm. Short-interval followup MRI with intravenous
contrast would be helpful, as contrast enhancement associated with infarction
and demyelination would be expected to improve.
2. Scattered nonspecific foci of high T2 signal in the bifrontal and
biparietal white matter, without contrast enhancement or abnormal diffusion,
which are compatible with sequelae of chronic microvascular infarcts in a
patient of this age, though demyelinating lesions could have a similar
appearance.
3. Faint small focus of high T2 signal in the left pons, which may correspond
to the chronic pontine infarct described in the history.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL CT
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, SKIN SENSATION DISTURB
temperature: 98.4
heartrate: 54.0
resprate: 18.0
o2sat: 100.0
sbp: 170.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital with two weeks of numbness in
your lower lip and right arm and clumsiness in your right hand
and foot. You had an MRI which showed a lesion on the left side
of your brain. We performed a lumbar puncture (spinal tap) and
sent off several studies looking for cancer cells or multiple
sclerosis: these are still pending. We believe your brain lesion
is either an old stroke, a tumor or a demyelinating lesion (loss
of the fat cells insulating your neurons) which can be seen in
diseases like multiple sclerosis. You will need a repeat MRI in
2 weeks to follow this up, and an appointment with Dr. ___
___ of ___ to discuss the findings and plans for
the next steps in your treatment.
We made the following changes to your medications:
1. STARTED enoxaparin (Lovenox) ___ subcutaneous twice daily
(to be taken until your Coumadin dose is again therapeutic at
INR ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Laryngoscopy and tracheostomy placement (___)
Laryngeal mass biopsy (___)
Gastric tube placement (___)
History of Present Illness:
___ yo male with 120pk yrs tobacco presenting with dyspnea,
difficulty swallowing, change in voice and 40 lb weight loss x
___ months.
He began experiencing dysphagia 6 months ago, which worsened
acutely over the past ___ weeks. He is tolerating liquids and
soft solids (cake, bread, cookies), though liquids have been
more difficult and associated with more coughing. He has no pain
in his throat or odynophagia, just the sensation of something
there. He denies fever, chills, night sweats, any bony pain or
pain anywhere else.
He also developed DOE 1.5 weeks ago. He has had a chronic cough
for years, which has remained stable but his phlegm production
has increased. Over the past week, he has occasionally had blood
streaked sputum but no frank or large volume hemoptysis. He has
also had trouble coughing and difficulty with drooling and
handling his secretions for ___ weeks.
He has a 120 pack-year smoking history, though quit smoking 3
days ago and had cut down to ___ cigarettes/day for the past
several months.
Other than the symptoms above, review of systems was negative
for headaches, vision changes, issues with balance, falling,
syncope, dizziness, weakness, changes in sensation, chest pain,
nausea/vomiting, abdominal pain, hematuria, dysuria,
hematochezia, myalgias, arthralgias.
In the ED his
VS: 97.8 F (36.6 C). Pulse: 133. Respiratory Rate: 26.
Blood-pressure: 136/88. Oxygen Saturation: 99%.
EKG: Sinus tachycardia.
Exam notable for: Speaking ___ word sentences, tolerating
secretions, no stridor. No respiratory distress.
Labs notable for: Lactate 4.3. WBC 14. Dirty UA - got 1g CTX
Imaging:
CT/SOFT TISSUE NECK W/CONTRAST @ ___
1. Large bulky lobulated heterogeneous solid mass occupying a
significant portion of the pharynx beginning at the base of the
tongue extending down both right and left lateral pharyngeal
walls involving the epiglottis, larynx, and arytenoids. Airway
is severely compromised and narrowed to 3 x 4 mm.
2. Extensive necrotic adenopathy along the right carotid and
jugular chain.
3. Question involvement of significant compression of the right
jugular vein.
CTA @ ___
1. Multiple metastatic nodules throughout the chest as described
above.
2. Multiple bilateral nonobstructing renal calculi.
3. No PE
Patient received:
___ 03:12 IVF LR ___ Started 150 mL/hr
___ 03:12 IV Dexamethasone 10 mg ___
___ 07:13 IVF LR ___ Confirmed No Change in
Rate, rate continued at 150 mL/hr
___ 09:15 IVF LR ___ Stopped (6h ___
___ 10:43 IV Dexamethasone 10 mg ___
Consults: ENT
Vitals on transfer:
T 97.9, P 78, BP 143/74, RR 30, Sat 92% RA
Upon arrival to ___, patient reports feeling fine. He has no
complaints, other than difficulty coughing.
Past Medical History:
No known PMH: has not seen doctor in ___
Social History:
___
Family History:
Adopted so unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 97.9, P 78, BP 143/74, RR 30, Sat 92% RA
GENERAL: NAD, sitting up in bed
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear, no teeth
NECK: No stridor, JVP not elevated,
LUNGS: Normal work of breathing. Poor air movement throughout,
rhonchi b/l.
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
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: Well demarcated erythematous plaques with overlying scale,
two on left lower extremity and 1 on right lower extremity, no
pain or pruritis
NEURO: CN III-XII intact. Strength ___ in b/l upper and lower
extremities, no pronator drift, sensation intact throughout, FNF
and rapid alternating movement intact
ACCESS: PIV
DISCHARGE PHYSICAL EXAM
=======================
VS: 97.9 103/64 64 18 100 TM
GEN: NAD. Thin-appearing.
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple with trach in
place, well seated without surrounding erythema or discharge.
Cards: RRR. S1/S2 normal. no murmurs/gallops/rubs.
Pulm: Diffuse, coarse breath sounds bilaterally. No wheezes or
rales.
Abd: BS+, soft, NT, no rebound/guarding, PEG tube in place
without surrounding drainage
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: AOx3, CNs II-XII intact, moves all extremities with
purpose
Pertinent Results:
ADMISSION LABS
==============
___ 12:10AM BLOOD WBC-10.3* RBC-5.06 Hgb-14.6 Hct-44.8
MCV-89 MCH-28.9 MCHC-32.6 RDW-14.9 RDWSD-47.3* Plt ___
___ 12:10AM BLOOD Neuts-76.4* Lymphs-17.6* Monos-5.0
Eos-0.1* Baso-0.5 Im ___ AbsNeut-7.88* AbsLymp-1.82
AbsMono-0.52 AbsEos-0.01* AbsBaso-0.05
___ 12:10AM BLOOD ___ PTT-30.9 ___
___ 12:10AM BLOOD Glucose-133* UreaN-24* Creat-0.6 Na-143
K-5.2* Cl-102 HCO3-20* AnGap-21*
___ 12:10AM BLOOD ALT-11 AST-36 AlkPhos-88 TotBili-0.4
___ 12:10AM BLOOD Lipase-13
___ 12:10AM BLOOD proBNP-322*
___ 12:10AM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD Albumin-3.7
___ 04:03PM BLOOD Calcium-10.1 Phos-3.4 Mg-2.0
___ 12:51AM BLOOD Lactate-1.9
RADIOLOGIC STUDIES
==================
CT Neck (___):
1. Large bulky lobulated heterogeneous solid mass occupying a
significant portion of the pharynx beginning at the base of the
tongue extending down both right and left lateral pharyngeal
walls involving the epiglottis, larynx, and arytenoids. Airway
is severely compromised and narrowed to 3 x 4 mm.
2. Extensive necrotic adenopathy along the right carotid and
jugular chain.
3. Question involvement of significant compression of the right
jugular vein.
CTA Chest (___):
1. Multiple metastatic nodules throughout the chest as described
above.
2. Multiple bilateral nonobstructing renal calculi.
3. No PE
TTE (___):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a small to moderate sized
pericardial effusion slightly more prominent around RA. There
are no obvious echocardiographic signs of tamponade.
CT ABD/PELVIS W/ W/O CONTRAST (___):
1. Again seen are multiple large, solid pulmonary nodules in the
bilateral
lower lung fields measuring up to 1.6 cm, concerning for
metastatic disease.
There is background moderate paraseptal and centrilobular
emphysema.
Unchanged innumerable centrilobular and ___ nodules in
both lungs.
Differential includes atypical infection, drug reaction, or
respiratory
bronchiolitis.
2. Multiple liver hypodensities, measuring up to 1.1 cm, are
noted. 1.1 cm
hypodensity measures simple fluid and likely represent cyst
versus biliary
hamartoma. Remaining hypodensities are too small to
characterize, but
statistically likely to also represent cysts. Recommend
attention on
follow-up. There is nodular contour of the liver with atrophy
parenchyma in
the gallbladder fossa and hypertrophy of the caudate lobe
suggestive of early
cirrhotic changes.
3. No convincing evidence for metastatic disease in the abdomen
or pelvis.
4. Nonobstructing bilateral renal stones, measuring up to 2.0 cm
in the right
interpolar region.
Video Swallow Study (___):
Complex abnormal anatomy is noted in the larynx and subglottic
larynx
secondary to known tumor. There is significant restriction of
normal
movements of structures in this area. This is appreciated via
significant
impairment palpable cyst flow throughout swallowing. Gross
aspiration was
noted during and after swallow with thins and nectar consistency
liquid which
acute cough. There was significant pharyngeal residue.
DISCHARGE LABS:
==============
___ 05:06AM BLOOD WBC-10.8* RBC-4.47* Hgb-13.0* Hct-39.2*
MCV-88 MCH-29.1 MCHC-33.2 RDW-15.0 RDWSD-47.5* Plt ___
___ 05:45AM BLOOD ___ PTT-30.9 ___
___ 05:06AM BLOOD Glucose-139* UreaN-12 Creat-0.4* Na-139
K-4.5 Cl-98 HCO3-30 AnGap-11
___ 05:06AM BLOOD ALT-14 AST-22 LD(LDH)-353* AlkPhos-78
TotBili-0.4
___ 05:06AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.5* Mg-1.8
Medications on Admission:
None
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
On ___, take 2 pills in the morning and 2 at night. Starting on
___, take 1 pill daily.
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*34
Tablet Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by g tube daily Disp #*30
Capsule Refills:*0
3.Oxygen
5L via tracheostomy mask at all times
ICD:10 J96.12
4.Humidifier
Coolmist aerosol with supplies
ICD:10 Z93.0
5.Suction
Suction machine with supplies
-___ suction catheter
Trach: Portex #5 cuffless trach
ICD ___- ___
6.Hospital Bed
Semi Electric Hospital Bed
ICD- 10: ___.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Basaloid squamous cell carcinoma of the tongue
Upper airway obstruction s/p tracheostomy and gastric tube
placement
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 new pharyngeal mass now s/p trach// r/o PTX,
confirm trach placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT scan dated ___
FINDINGS:
A tracheostomy is suboptimally evaluated. There is no evidence of
pneumothorax, pleural effusion or focal consolidation. Multiple pulmonary
nodules seen on yesterday's CT scan are not evident radiographically. The
size of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach, new leukocytosis// consolidation
IMPRESSION:
In comparison with the study of ___, the tracheostomy tube remains in
place. Cardiomediastinal silhouette is stable and there is no evidence of
acute pneumonia or appreciable vascular congestion.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old man with new line// new left PICC 49 cm ___ ___
Contact name: ___: ___
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___
FINDINGS:
The study is compromised secondary to patient obliquity. The tracheostomy
tube is grossly unchanged imposition. There is no evidence of focal
consolidation or large pleural effusion. The heart is normal in size. The
aorta is atherosclerotic.
The left PICC doubles back upon itself
IMPRESSION:
No focal consolidation. The left PICC tip doubles back upon itself.
Repositioning is advised.
RECOMMENDATION(S): Repositioning of the left PICC is advised.
NOTIFICATION: The findings were discussed with the nurse ___, by
___, M.D. on the telephone on ___ at 4:49 pm, within 5
minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with new line// recheck PICC tip power flushed
___ ___ Contact name: ___: ___
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from approximately 1 hour prior
FINDINGS:
The tip of the left PICC remains doubled back upon itself. Heart and lungs
are unchanged in appearance. Tracheostomy tube grossly stable in position.
IMPRESSION:
Tip of the left PICC remains doubled back upon itself. Consider
repositioning.
RECOMMENDATION(S): PICC repositioning is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recent tracheostomy. Worsening
secretions/leukocytosis// ?PNA
IMPRESSION:
In comparison with the study of ___, the left subclavian PICC line no
longer is coiled and the tip is in the region of the cavoatrial junction.
Small areas of opacification are seen at the bases. Although this could
merely represent atelectasis, in the appropriate clinical setting,
superimposed early aspiration/pneumonia should be considered.
Radiology Report
INDICATION: ___ year old man with pharyngeal cancer, needs PEG placement;
unable to tolerate PO and unable to have endoscopic placement of PEG// eval
for PEG placement
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ attending, performed the procedure.
ANESTHESIA: Procedure was performed with general anesthesia.
MEDICATIONS: 1 mg of intravenous glucagon.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4.1 min, 8 mGy
PROCEDURE: 1. Placement of a ___ ___ gastrostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. General anesthesia was induced. A ___ glide catheter was placed
under fluoroscopic guidance as an NG tube.
The tube site was prepped and draped in the usual sterile fashion. A scout
image of the abdomen was obtained. The stomach was insufflated through the
catheter / nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Under fluoroscopic guidance, 3 T fastener buttons were
sequentially deployed in a triangular position elevating the stomach to the
anterior abdominal wall. Intra-gastric position was confirmed with aspiration
of air and injection of contrast. A 19 gauge needle was introduced under
fluoroscopic guidance and position confirmed using an injection of dilute
contrast. The needle trajectory was directed towards the pylorus. A ___
wire was introduced and coiled within the stomach. A small skin incision was
made along the needle and the needle was removed.
The tract was dilated witha ___ dilator. A ___
gastrostomy catheter was advanced over the wire into position. The catheter
was locked by forming the retaining loop in the stomach after confirming the
position of the catheter with a contrast injection. The catheter was then
flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings
were applied. The patient tolerated the procedure well and there were no
immediate complications.
FINDINGS:
1. Successful placement of a ___ gastrostomy tube with its
tip in the distal stomach.
IMPRESSION:
Successful placement of a 12 ___ ___ gastrostomy tube with its
tip in the stomach. The gastrostomy can be used for medications, but should
not be used for feeding for 24 hours.
RECOMMENDATION(S): Please see POE for post-procedure orders.
Radiology Report
EXAMINATION: SECOND OPINION CT NEURO PSO1 CT
INDICATION: ___ 120pk yr tobacco history p/w dyspnea, difficulty swallowing,
and 40 lb weight loss with CT demonstrating pharyngeal mass// second opinion
read
TECHNIQUE: Imaging was performed after administration of 80 ml of
Omnipaque350 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: Accumulated DLP: 182.09 mGy/cm
COMPARISON: CT chest dated same day.
FINDINGS:
There is no evidence of fracture or intracranial infarction, hemorrhage,
edema,or mass. The ventricles and sulci are unremarkable in size and
configuration. There is no abnormal enhancement on post contrast images.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
Evaluation of the aerodigestive tract demonstrates a large irregular
heterogeneously enhancing mass extending from the true vocal folds and cricoid
cartilage to the base of the tongue. There is circumferential laryngeal and
pharyngeal involvement, as well as left and possible right arytenoid cartilage
involvement. The airway is almost completely obliterated by the mass with
only approximately 3 mm patent area the level of the arytenoid cartilage
(3:97).
There is an associated conglomerate of necrotic lymph nodes along the right
internal jugular vein and internal carotid artery with compression of the
right internal jugular vein superior to the level of the thyroid cartilage.
Fat planes surrounding the right common carotid artery are preserved. There
is loss of fat plane surrounding the right submandibular gland (3:84).
The lymph node conglomerate contacts the right parotid gland (3:62). The
remaining salivary glands enhance normally and are without mass or adjacent
fat stranding. The thyroid gland appears normal.
Multilevel degenerative changes of the cervical spine are seen, notable for
mild anterolisthesis of C3 on C4, intervertebral disc space narrowing most
significant at C5-6, C6-7, C7-8, and anterior and posterior osteophyte
formation from C3 to C5, causing moderate canal narrowing at these levels.
Multilevel uncovertebral hypertrophy and facet arthropathy causes neural
foraminal narrowing, most significant at C4-5 on the left.
Please see separate report performed on the same day for detailed evaluation
of the chest.
IMPRESSION:
1. Large heterogeneously enhancing mass with circumferential laryngeal and
pharyngeal involvement, extending superiorly to the base of the tongue, with
severe narrowing of the airway. Large right conglomerate of necrotic lymph
nodes along the internal jugular vein results in severe compression of the
internal jugular vein. This likely represents a squamous cell carcinoma.
2. Please see separate report from CT chest performed same day for
description of intrathoracic findings.
Radiology Report
EXAMINATION: Second opinion CTA of the chest
INDICATION: ___ w/ 120pk yr tobacco history p/w dyspnea, difficulty
swallowing, and 40 lb weight loss with CT demonstrating pharyngeal mass//
second opinion osh read
TECHNIQUE: A second opinion read is provided for CTA of the chest performed
at an outside hospital ___ dated ___.
DOSE: None available
COMPARISON: None.
FINDINGS:
There is no pulmonary embolism through the level of the segmental arteries.
There are mild scattered atherosclerotic calcifications of the thoracic aorta
without aneurysmal dilatation. The main pulmonary artery is normal in caliber,
measuring 2.6 cm.
There is masslike thickening of the pharynx, partially imaged. The thyroid
gland is unremarkable. There is no axillary lymphadenopathy.
Mediastinal lymph nodes are non-enlarged by size criteria. The largest lower
left paratracheal lymph node measures 0.8 cm in short axis (5:88). There is
no hilar lymphadenopathy.
The heart is normal in size. There is a small, focal anterior pericardial
effusion, measuring up to 11 mm in thickness.
Small amount of secretions are noted in the left mainstem bronchus and left
upper lobar bronchus. The central airways are otherwise patent.
There is moderate paraseptal and centrilobular emphysema, most pronounced in
the bilateral upper lobes. There are multiple solid pulmonary nodules with
lobulated margins in both lungs, with representative nodules as follows: 1.8
cm nodule in the right middle lobe (5:154), 1.4 cm nodule more inferiorly in
the right middle lobe (5:175), 1.5 cm nodule in the left lower lobe (5:163),
and 0.7 cm nodule in the right lower lobe (5:165). Findings are concerning
for pulmonary metastases.
There are innumerable tiny centrilobular and ___ nodules in both
lungs, most pronounced in the bilateral lower lobes. There are also
ground-glass opacities in the bilateral upper lobes, right greater than left.
Differential considerations include atypical infection, drug reaction, or
respiratory bronchiolitis.
Limited evaluation of the upper abdomen is notable for nonobstructing stones
in bilateral kidneys, largest measuring 2.1 x 1.5 cm in a right interpolar
calyx. 1.2 cm hypodense lesion in hepatic segment VIII measures simple fluid
density and is consistent with a cyst or biliary hamartoma. There are a few
other subcentimeter scattered hypodensities throughout the liver, too small to
characterize. The caudate lobe is enlarged, suggestive of cirrhotic change.
Mild thickening of the left adrenal gland is noted, without a discrete nodule.
There is a punctate stone in the gallbladder (5:247).
No suspicious osseous lesion is identified. There are mild multilevel
endplate degenerative changes of the thoracic spine.
IMPRESSION:
1. No pulmonary embolism through the level of the segmental arteries.
2. Multiple solid pulmonary nodules with lobulated margins in bilateral lungs,
measuring up to 1.8 cm, concerning for metastases.
3. Background moderate paraseptal and centrilobular emphysema. Innumerable
tiny centrilobular and ___ nodules in both lungs, most pronounced in
the bilateral lower lobes. Ground-glass opacities in the bilateral upper
lobes, right greater than left. Differential considerations include atypical
infection, drug reaction, or respiratory bronchiolitis.
4. Partially imaged masslike thickening of the pharynx. Of note, laryngoscopy
demonstrated a large mass at the base of the tongue, for which biopsies were
obtained, pathology pending.
5. Nonobstructing stones in the bilateral kidneys.
6. Enlarged caudate lobe, suggestive of cirrhotic change.
Radiology Report
EXAMINATION: Baseline oncology abdomen pelvis
INDICATION: ___ year old man with new pharyngeal mass with e/o lung mets on CT
chest.// staging CT
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done without and with IV contrast. Initially the abdomen was scanned without
IV contrast. Subsequently a single bolus of IV contrast was injected and the
abdomen and pelvis were scanned in the portal venous phase, followed by a scan
of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 31.4 cm; CTDIvol = 6.7 mGy (Body) DLP = 205.6
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 12.2 s, 0.2 cm; CTDIvol = 208.1 mGy (Body) DLP =
41.6 mGy-cm.
4) Spiral Acquisition 8.1 s, 52.4 cm; CTDIvol = 6.5 mGy (Body) DLP = 336.7
mGy-cm.
5) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 6.7 mGy (Body) DLP = 203.7
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: Second opinion CT torso from ___
FINDINGS:
LOWER CHEST: There are multiple large, solid pulmonary nodules in the
bilateral lower lung fields, measuring up to 1.6 cm in size (series 3; image
7) (additional examples include series 3; images 4, 7, 8, 10, 11). There is
background paraseptal and centrilobular emphysema. Again seen are innumerable
centrilobular and ___ nodules in both lungs, most pronounced in
bilateral lower lobes.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are multiple liver hypodensities measuring up to 1.1 cm in the dome of
the liver (series 8; image 27), which measure simple fluid and likely
represents cyst versus biliary hamartoma. The additional subcentimeter
hypodensities in the right and left lobes of the liver are appreciated (for
example series 8; image 15), which are too small to characterize. The liver
is slightly irregular in contour with evidence of widening of the gallbladder
fossa and caudate lobe hypertrophy, which may be suggestive of early cirrhotic
changes. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The 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 adrenal gland is normal. There is mild thickening of the
left adrenal gland without discrete nodule.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis. There are subcentimeter hypodensities, which are
cortically based, which are too small to characterize, but likely represent
simple cysts. Again seen are bilateral renal calculi measuring up to 2.0 cm
in the right interpolar region and 0.9 cm in the left lower pole. There is no
perinephric abnormality.
GASTROINTESTINAL: Gastrostomy tube appears to enter in the body of the
stomach, loop just distal to the antrum, and terminate with tip back in the
body of the stomach. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. There is extensive colonic
diverticulosis without surrounding inflammation or wall thickening to suggest
diverticulitis. 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 is enlarged and the seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. Mild
stranding at the umbilicus is nonspecific.
IMPRESSION:
1. Again seen are multiple large, solid pulmonary nodules in the bilateral
lower lung fields measuring up to 1.6 cm, concerning for metastatic disease.
There is background moderate paraseptal and centrilobular emphysema.
Unchanged innumerable centrilobular and ___ nodules in both lungs.
Differential includes atypical infection, drug reaction, or respiratory
bronchiolitis.
2. Multiple liver hypodensities, measuring up to 1.1 cm, are noted. 1.1 cm
hypodensity measures simple fluid and likely represent cyst versus biliary
hamartoma. Remaining hypodensities are too small to characterize, but
statistically likely to also represent cysts. Recommend attention on
follow-up. There is nodular contour of the liver with atrophy parenchyma in
the gallbladder fossa and hypertrophy of the caudate lobe suggestive of early
cirrhotic changes.
3. No convincing evidence for metastatic disease in the abdomen or pelvis.
4. Nonobstructing bilateral renal stones, measuring up to 2.0 cm in the right
interpolar region.
Radiology Report
EXAMINATION: Video swallow
INDICATION: ___ year old man with laryngeal CA// eval aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2 minutes 23 seconds min.
COMPARISON: No relevant comparison.
FINDINGS:
Complex abnormal anatomy is noted in the larynx and subglottic larynx
secondary to known tumor. There is significant restriction of normal
movements of structures in this area. This is appreciated via significant
impairment palpable cyst flow throughout swallowing. Gross aspiration was
noted during and after swallow with thins and nectar consistency liquid which
acute cough. There was significant pharyngeal residue.
IMPRESSION:
Abnormal anatomy due to known tumor. Restricted movement of laryngeal
structures. Gross aspiration during and after swallow with thins and nectar.
Significant pharyngeal residue.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Other diseases of larynx
temperature: 97.7
heartrate: 72.0
resprate: 18.0
o2sat: 94.0
sbp: 154.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were feeling
nauseous, had lost a lot of weight, and were having trouble
swallowing.
WHAT HAPPENED WHILE I WAS HERE?
You were found to have a large mass at the base of your tongue.
We took a sample of this mass and found that this was a cancer
of your tongue called a squamous cell carcinoma. Since your
breathing tube had a blockage because of this cancer, you
underwent a procedure called a tracheostomy, to bypass this
blockage (connecting your breathing tube to your neck). You also
had a feeding tube placed in your stomach because of your
problems swallowing.
We performed a study to test your ability to swallow. This study
showed that you cannot safely swallow, so we highly recommend
that you avoid eating or drinking anything by mouth.
We wanted you to spend some more time in the hospital in order
to set you up with the services you needed to safely go home. We
also recommended that you spend some time at a rehabilitation
facility before going home to get help with caring for your new
tracheostomy and your new PEG feeding tube, as well as to help
you get stronger. However, you made it clear that you wanted to
go home right away, and you did not want to spend any more time
in the hospital. You showed us that you understood the dangers
of going home right away, and you were willing to accept these
risks.
WHAT SHOULD I DO WHEN I GET HOME?
You should go to all of your doctor's appointments, as it will
be important to start treating your cancer as soon as possible.
You should care for your new tracheostomy tube and your new PEG
tube and keep them clean. You will have visiting nurses to help
you with this. Since we found that you cannot safely swallow,
please do not eat or drink anything by mouth. Instead of taking
your pills by mouth, you should crush them and put them through
your G tube. You are at high risk of choking or catching an
infection in your lungs because of your problems swallowing.
We wish you the best!
Sincerely,
Your ___ Cancer Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Urinary retention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ ___ speaking M with DM2 presents 3d s/p cataract
surgery w/ urinary retention. The patient had dysuria, urgency,
frequency, and only able to urinate a small amount at a time.
Also developed painful ab'l distention until his Foley was
placed. Denies fevers, hematuria. This has never happened
before,
never had sensation of incomplete emptying until his eye
surgery.
Also, the pt complains of blood in his stool. Referral notes a
large hemorrhoid with an abnormal appearance. His last BM was
this morning. Has never had blood in the stool in the past.
Denies straining to have BM.
Has been able to eat and drink. Has not been taking any pain
medicines, denies NSAID use. No new medications aside from eye
drops.
Denies palpitations, chest pain, light-headedness/dizziness.
Past Medical History:
Diabetes mellitus c/b retinopathy
Elevated PSA
Social History:
___
Family History:
No family history of kidney disease
Physical Exam:
VS: 98.1 127/74 69 1898RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, S4 gallop, no r/g
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: slightly distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
GU: Foley in place draining clear yellow urine
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Pertinent Results:
=============================
ADMISSION LABS
=============================
___ 05:20PM BLOOD WBC-13.3*# RBC-4.70 Hgb-12.2* Hct-38.7*
MCV-82 MCH-26.0 MCHC-31.5* RDW-15.3 RDWSD-45.8 Plt ___
___ 05:20PM BLOOD Neuts-83.9* Lymphs-4.7* Monos-10.7
Eos-0.1* Baso-0.1 Im ___ AbsNeut-11.19* AbsLymp-0.62*
AbsMono-1.43* AbsEos-0.01* AbsBaso-0.01
___ 05:20PM BLOOD Plt ___
___ 05:20PM BLOOD Glucose-113* UreaN-85* Creat-5.2*# Na-137
K-5.5* Cl-95* HCO3-16* AnGap-26*
___ 02:43AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
=============================
DISCHARGE LABS
=============================
___ 07:20AM BLOOD WBC-7.1 RBC-4.78 Hgb-12.4* Hct-38.5*
MCV-81* MCH-25.9* MCHC-32.2 RDW-14.8 RDWSD-43.5 Plt ___
___ 07:20AM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-242* UreaN-25* Creat-1.2 Na-141
K-4.5 Cl-101 HCO3-28 AnGap-12
___ 12:45PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
=============================
PERTINENT INTERVAL LABS
=============================
___ 03:10PM BLOOD WBC-9.9 RBC-4.26* Hgb-11.7* Hct-35.2*
MCV-83 MCH-27.5 MCHC-33.2 RDW-15.4 RDWSD-46.3 Plt ___
___ 07:23AM BLOOD Plt ___
___ 03:10PM BLOOD Glucose-61* UreaN-45* Creat-1.6* Na-148*
K-4.7 Cl-109* HCO3-22 AnGap-17*
___ 07:23AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
=============================
IMAGING
=============================
Renal US ___
IMPRESSION:
No evidence of hydronephrosis.
=============================
PROCEDURES
=============================
none
=============================
MICRO
=============================
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
2. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
4. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE QID
5. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE BID
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth every day
Disp #*14 Capsule Refills:*0
2. ___ 50% Pad ___SDIR
RX *___ [Hemorrhoidal (witch ___ 50 % apply daily
Disp #*14 Pad Refills:*0
3. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE QID
4. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE BID
5. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
6. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis/es
1. Urinary retention
2. Acute kidney injury
3. Elevated PSA
4. Leukocytosis
5. Hyperkalemia
6. Anion gap metabolic acidosis
7. Hemorrhoids
Secondary diagnosis/es
1. Diabetes Mellitus
2. Arteriosclerotic Cardiovascular Disease risk
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with urinary retention, ___// eval for
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 9.3 cm. The left kidney measures 9.2 cm. There is no
hydronephrosis, stones, or masses bilaterally. There is a punctate cortical
calcification noted in the right lower pole. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is decompressed with a Foley catheter.
IMPRESSION:
No evidence of hydronephrosis.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Urinary retention
Diagnosed with Acute kidney failure, unspecified, Retention of urine, unspecified
temperature: 98.3
heartrate: 100.0
resprate: 20.0
o2sat: 97.0
sbp: 134.0
dbp: 79.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
==========================================
WHY WERE YOU ADMITTED TO THE HOSPITAL?
==========================================
You had urinary retention following your cataract surgery.
==========================================
WHAT HAPPENED AT THE HOSPITAL?
==========================================
-We believed the cause of the urinary retention to be a pain
medication used during your cataract removal procedure known as
remifentanil, but an enlarged prostate might be playing a role
as well.
-A foley catheter was used to help drain urine. This alleviated
your symptoms of distention and discomfort due to the retention.
-We tried and discontinue the use of the foley catheter and
allow you to try and urinate on your own, however you were
unfortunately unable to do so.
-We discharged you home with the Foley catheter in place with
the plan to follow up with the urology team for further
management.
-We set up an appointment with colorectal surgery for hemorrhoid
care.
===================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
===================================================
-Make all of your follow up appointments (see below)
-Care for your Foley as you were instructed prior to leaving the
hospital.
-Call your primary care doctor if the Foley stops draining urine
or you have fever, nausea, vomiting, or abdominal pain.
-Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ped struck by auto C/o L sided
abd/chest/arm pain, and neck pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ RHD F who was crossing the street in her
usual state of health when she was struck by a vehicle, with
associated left upper extremity and left ankle injuries.
She was brought in by EMS with GCS 15 at the scene, complainig
of
neck pain, extremities, but otherwise intact, communicative, no
other complains.
Past Medical History:
PAST MEDICAL HISTORY:
Allergies (seasonal)
Anemia
Anxiety/Depression
h/o low back pain ___ herniated disc
Depression- remote hx of suicide attempt in ___, overdose,
went to ED had stomach pumped but never admitted to hosp or inpt
psych in past.
Diabetes since ___
Hypertension
High Cholesterol
GERD
Thyroid Nodule noted on MRI - she has bx scheduled in ___
Social History:
___
Family History:
mother with diabetes, died of an MI at age ___. Four siblings
with diabetes.
Physical Exam:
Constitutional: tearful
HEENT: Normocephalic, atraumatic, pupils ___ bilaterally,
no midface ttp
ccollar in place
Chest: bs=b/l, left chest wall ttp
Cardiovascular: Regular Rate and Rhythm, ___ ext pulses
Abdominal: Soft, ttp, fast neg
Extr/Back: ttp over L wrist, L tib/fib, compartments soft
diffuse back ttp
Skin: No lacerations/abrasions/ecchymosis
Neuro: strength intact ___ ext
Psych: Normal mentation
Pertinent Results:
___ 12:43PM GLUCOSE-389* NA+-143 K+-5.0 CL--102 TCO2-27
___ 12:30PM UREA N-17 CREAT-1.2*
___ 12:30PM estGFR-Using this
___ 12:30PM LIPASE-271*
___ 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:30PM WBC-6.3 RBC-3.95* HGB-10.7* HCT-35.3* MCV-89
MCH-27.1 MCHC-30.3* RDW-14.2
___ 12:30PM PLT COUNT-216
___ 12:30PM ___ PTT-29.4 ___
___ 12:30PM ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Venlafaxine XR 75 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Simvastatin 20 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral BID
Discharge Medications:
1. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral BID
2. Aspirin EC 81 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Simvastatin 20 mg PO DAILY
7. Venlafaxine XR 75 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
10. Glargine 28 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
11. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 100 capsule(s) by mouth
twice a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Left distal radius fracture
- Left ankle with an intra-articular tibial pilon fracture
- Concussion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TRAUMA CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest radiograph from ___.
CLINICAL HISTORY: Pedestrian struck with chest pain.
FINDINGS: Portable AP supine chest radiograph was provided. Underlying
trauma board is in place. There is a mild levoscoliosis of the T-spine. The
lungs are clear without focal consolidation or supine signs of effusion or
pneumothorax. The cardiomediastinal silhouette appears normal. No bony
abnormalities are seen.
IMPRESSION: No signs of traumatic injury. Please refer to subsequent CT of
the torso for further details.
Radiology Report
HISTORY: Pedestrian struck with left-sided pain and tenderness.
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
the administration of IV contrast. Reformatted coronal and sagittal and
thin-section bone algorithm reconstructed images were acquired.
DLP 1025.72 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent, and there is preservation of gray-white
matter differentiation.
No fractures are identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Pedestrian struck.
TECHNIQUE: Axial MDCT images were taken from the skull base through the T2
level. Coronal and sagittal reformats were also examined.
DLP: 649.51 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. Multilevel degenerative changes are also
seen with anterior osteophyte formation at C4-6. Posterior disk bulges are
seen at C4-5, C5-6, and C6-7. The lung apices are clear. Again seen are
multiple nodules in the thyroid. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
LEFT ARM RADIOGRAPHIC SERIES PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Pedestrian struck with left arm pain.
FINDINGS: Thirteen images were provided including views of the left hand,
wrist, elbow, and shoulder. AP, lateral, and oblique views of the left hand
and left wrist were provided. There is impacted dorsally angulated fracture
of the distal radius, possibly involving the distal articular surface. There
is deformity of the distal ulna which could reflect old injury and no
convincing evidence of an acute fracture at the level of the distal ulna is
seen. Overlying soft tissue swelling is noted. Carpal alignment is
preserved. Degenerative triscaphe arthritis and basal joint arthritis noted.
The bones of the left hand appear intact. The left elbow is intact. There is
no joint effusion. The left shoulder is intact.
IMPRESSION: Acute fracture of the distal radius with slight dorsal angulation
and impaction. Deformed distal ulna, likely chronic and without acute injury.
Radiology Report
INDICATION: Left-sided pain and tenderness.
COMPARISON: CT abdomen and pelvis ___, thyroid ultrasound
___.
TECHNIQUE: Contiguous axial MDCT images were taken through the torso after the
administration of 130 cc of Omnipaque intravenous contrast material. Coronal
and sagittal reformats were also examined.
DLP: 934.85 mGy-cm.
FINDINGS: Again seen are multiple hypodense nodules in both lobes of the
thyroid, better assessed on prior ultrasound. The aorta is unremarkable
without any evidence of acute aortic syndrome. The heart size is normal. The
great vessels are unremarkable. Again seen is a calcified right hilar node,
stable since the prior study. There is no mediastinal or hilar
lymphadenopathy. The lungs are clear without nodule, pleural effusion, or
pneumothorax.
Again seen are multiple hypodensities in the liver, stable since the prior
study. The spleen is homogeneous and normal in size. The pancreas is
unremarkable, without peripancreatic stranding or fluid collection. The
gallbladder is distended but otherwise unremarkable. The portal vein is
patent. The adrenal glands are unremarkable. The kidneys present symmetric
nephrograms and excretion of contrast. Note is made of a left peripelvic
cyst.
Fluid is seen in the esophagus, and there is mild thickening of the distal
esophagus, compatible with GERD and possible esophagitis. The stomach and
duodenum are unremarkable without any evidence of wall thickening or
obstruction. Diverticulosis is present in the colon without signs of
diverticulitis. There is no mesenteric or retroperitoneal lymphadenopathy.
There is no free air or free fluid. There are no abdominal wall hernias. The
intra-abdominal vasculature is unremarkable.
The bladder and terminal ureters are unremarkable. Again seen is a calcified
lesion within the uterus, stable and likely a fibroid. A second calcified
exophytic uterine lesion is also seen, also likely representing an exophytic
fibroid and stable since the prior study. The adnexa are unremarkable. There
is no pelvic sidewall or inguinal lymphadenopathy.
No fractures or suspicious lesions are seen in the visualized osseous
structures.
IMPRESSION:
1. No acute abnormalities.
2. Stable findings including small hypodense lesions in the liver, probable
uterine fibroids, and multiple hypodense nodules in the thyroid.
Radiology Report
LEFT LOWER EXTREMITY RADIOGRAPHIC SERIES PERFORMED ON ___
COMPARISON: Left foot radiographs dated ___.
CLINICAL HISTORY: Pedestrian struck with injury to the left lower extremity,
assess for fracture.
FINDINGS: Nine views were provided including AP, lateral, oblique views of
the left ankle, AP and lateral views of the left femur and tibia/fibula.
There is an acute fracture involving the distal tibia, oblique in orientation,
likely extending to the distal articular surface. An oblique fracture of the
distal fibula is also noted extending to the level of the syndesmosis, likely
a Weber B fracture. Slight widening of the lateral mortise space is noted.
The left femur, hip, and left knee appear intact.
IMPRESSION: Distal tibial and fibular fractures with mild associated widening
of the lateral ankle mortise. Of note, the distal tibial fracture extends to
the articular surface.
Radiology Report
LEFT WRIST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior wrist radiograph from earlier today.
CLINICAL HISTORY: Distal radius fracture, post-reduction films.
FINDINGS: Three views of the left wrist were provided. There has been
application of a plaster splint. There is unchanged alignment at the
radiocarpal joint. The impacted fracture of the distal radius is again
visualized. No significant change since prior.
Radiology Report
LEFT ANKLE RADIOGRAPH PERFORMED ON ___
Comparison with a prior radiograph from earlier same day.
CLINICAL HISTORY: Tibia/fibula fractures, post-reduction views.
FINDINGS: Three views of the left ankle were provided. Again noted are
fractures involving the distal tibia and distal fibula with intra-articular
extension. There has been no change in alignment with mild persistent
widening of the lateral mortise space.
Radiology Report
HISTORY: ___ woman with midline tenderness to palpation after trauma.
Evaluate for ligamentous injury.
TECHNIQUE: Multiplanar multisequence MRI of the cervical spine was obtained
without IV contrast.
COMPARISON: MRI of the cervical spine of ___ and CT of ___.
FINDINGS:
The alignment is maintained. The vertebral body heights are maintained.
Similar to the prior examination, a hemangioma is noted at T2 vertebral body.
There is no evidence of abnormal STIR signal that could indicate ligamentous
injury.
At C3-C4, there is a small central disc protrusion indenting the anterior
thecal sac resulting mild spinal canal narrowing. There are uncovertebral
osteophytes resulting in moderate right and mild left neural foraminal
narrowing.
At C4-C5, there is a central disc protrusion contacting the ventral aspect of
the cord and resulting in mild spinal canal narrowing. There is no evidence
of abnormal signal within the cord. There are uncovertebral and facet joint
osteophytes resulting in moderate to severe right and moderate left neural
foraminal narrowing.
At C5-C6, there is a broad-based disc protrusion with superimposed endplate
osteophytes indenting the anterior aspect of the cord resulting in moderate
spinal canal narrowing. There are uncovertebral and facet joint osteophytes
resulting in moderate right and severe left neural foraminal narrowing.
At C6-C7, there is a broad-based disc protrusion and posterior endplate
osteophytes flattening the anterior thecal sac and contacting the cord
resulting in moderate spinal canal narrowing. There is mild right and
moderate left neural foraminal narrowing due to uncovertebral and facet joint
osteophytes. The spinal canal is mildly progressed since the prior
examination.
The thyroid gland is enlarged and multinodular, with a dominant nodule in the
left lobe measuring 2.5 cm x 3.1 cm. This nodule was previously assessed by
sonography and sampled by FNA on ___.
IMPRESSION:
1. No evidence of ligamentous injury.
2. Multilevel degenerative changes of the cervical spine, mildly progressed
since the prior examination at C6-C7 level, and unchanged at other levels
allowing for motion artifacts.
3. Enlarged heterogeneous multinodular thyroid gland with a dominant nodule
in the left lobe, previously assessed by sonography and FNA.
Radiology Report
HISTORY: Left ankle pain. Operative planning.
TECHNIQUE: Contiguous helical MDCT images were obtained through the left
lower extremity without IV contrast. Multiplanar axial, coronal and sagittal
images were generated.
Title body DLP: ___ mGy-cm
COMPARISON: Radiographs of the left ankle ___.
FINDINGS:
There is soft tissue edema about the ankle more prominent laterally. The
anterior tibiofibular ligament is torn. The posterior tibiofibular ligament
is grossly intact. The anterior and posterior talofibular ligaments are
grossly intact. The calcaneofibular ligament is not well seen but likely
intact. Well corticated ossific densities adjacent to the inferior aspect of
the medial malleolus suggest prior deltoid ligament injury or tear with
associated avulsion fracture. The spring ligament is grossly intact.
There is no tendon entrapment about the ankle. The plantar fascia and
Achilles tendon are intact.
There is no dislocation. There is an old medial malleolar avulsion fracture
evidenced by well corticated ossific densities inferior to the medial
malleolus. There is no fracture in the foot. The subtalar joint is intact.
There is an obliquely oriented comminuted fracture of the distal fibula
emerging at the tibiotalar joint. There is also a comminuted fracture of the
distal tibia beginning in the distal diaphysis, emerging at the joint, and
also involving the posterior malleolus. There is fracture of the medial
malleolus. At the lateral aspect of the tibia there is avulsion fracture with
associated disruption of the anterior tibiofibular ligament as described
above. There is no significant displacement or angulation. Step-off
posteriorly at the posterior malleolar fracture is minimal.
IMPRESSION:
1. Comminuted minimally displaced intra-articular distal fibular fracture.
2. Comminuted minimally displaced intra-articular distal tibial fracture also
involving the medial and posterior malleoli.
3. Disruption of the anterior tibiofibular ligament. The remaining
ligamentous structures about the ankle appear grossly intact and can be more
definitively evaluated by MRI if clinically indicated.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with FX DISTAL RADIUS NEC-CL, FX TIBIA W FIBULA NOS-CL, MV COLL W PEDEST-PEDEST, ABN BLOOD CHEMISTRY NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | You were admitted to ___ after
you were hit by a car. On further evaluation, you were found to
have a left distal radius fracture and left tibia fracture. You
were seen by the orthopedics service. Your wrist fracture was
reduced and placed in a splint. Your ankle (tibia) fracture was
placed in ankle splint.
You were seen by Physical and Occupational therapy. Physical
Therapy has recommended that you be discharged to a
rehabilitation facility for further physical rehabilitation.
Occupational Therapy felt that, due to your trauma, you had
concussive symptoms and will require follow-up with Cognitive
Neurology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / eggs
Attending: ___.
Chief Complaint:
Leg pain; confusion; unable to pee
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with CAD, heart failure with reduced
ejection fraction with AICD, diabetes, nephropathy,
hypothyroidism, anemia, and depression who presents with leg
pain
and dysuria. When asked why the patient is here today, she
responds "My
daughter is worried about me. Also my leg hurts."
She woke up with leg pain this morning, acute onset which feels
"like ___ horse." She has not had trauma. She says she can
feel a hard spot on her leg where it hurts. She was recently
treated for UTI when she presented with dysuria and urinary
frequency. She was treated with ciprofloxacin 250 mg BID for 3
days on ___. She did not leave a urine sample for culture.
Since then she says the dysuria has improved, but she still has
urinary frequency and hesitancy. She denies fevers and back
pain.
She says her daughter is worried about her being confused and
about her memory. The patient doesn't think she is confused, but
she does admit that her memory isn't as strong as it used to be.
She says this has been going on for the last year. She was seen
by her PCP for this, at the request of her daughter. PCP note
says:
"Patient has become irritable, irascible and has somehow changed
her personality. Also they have noticed that she has had
tremors, mostly in her left hand for about a year. She has
episodes of brief absences when her pupils get pinned." She was
referred to neurology after this visit. She had a CT which
revealed chronic microangiopathy.
She was found to have urinary retention on CT scan, so was
straight cathed for several hundred milliliters, and felt better
afterwards.
Past Medical History:
CAD: s/p STEMI ___ with DES to LAD
Diabetes ___ Type 2
Hyperlipidemia
Hypertension
Diabetic Neuropathy
CKD Stage 3 -- eGFR ___ ml/min
Hypothyroidism
MRSA Cellulitis History
Obesity
Anxiety
Social History:
___
Family History:
Father -- cancer, alcoholism, died at age ___
Mother -- glaucoma
Brother -- died from prostate cancer
Sister -- stoke at age ___ still living
Daughters -- diabetes ___ type 2--> now resolved after
bypasss surgery.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.1 BP 158/79 HR78 RR18 99% Ra
GENERAL: Alert and interactive. Alert and oriented x3, although
repeats the same questions within the conversation.
HEENT: slight anisocoria with L > R which the patient pointed
out
prior to exam. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
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.
BACK: NO CVA tenderness.
ABDOMEN: Normal bowels sounds, mildly distended with palpable
bladder. Non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE EXAM:
Discharge weight: 95.3kg
GENERAL: Alert and oriented x2-3, appropriate, conversational
CARDIAC: Regular rhythm & rate, no m/r/g
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, mildly distended with palpable
bladder. Slightl suprapubic tenderness. Non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx2-3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout.
Pertinent Results:
ADMISSION RESULTS:
___ 02:00PM BLOOD WBC-5.9 RBC-4.12 Hgb-11.9 Hct-35.8 MCV-87
MCH-28.9 MCHC-33.2 RDW-13.7 RDWSD-43.4 Plt ___
___ 02:00PM BLOOD Glucose-338* UreaN-17 Creat-1.2* Na-138
K-4.4 Cl-101 HCO3-25 AnGap-12
___ 06:15AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9
RELEVANT RESULTS:
___ 08:35AM BLOOD VitB12-506
___ 08:35AM BLOOD Trep Ab-NEG
RELEVANT IMAGING:
___ MR HEAD w/ and w/o CONTRAST:
1. No acute infarct or acute intracranial hemorrhage.
Postcontrast images are mildly to moderately motion degraded.
Within this confine: No abnormal enhancement.
2. Confluent and severe periventricular and subcortical T2/FLAIR
white matter hyperintensities, nonspecific, but commonly seen
with chronic microangiopathy in a patient of this age.
3. Scattered multiple punctate foci of gradient echo
susceptibility
hypointensities, predominantly involving the right much greater
than left
frontoparietal lobes, potentially representing amyloid
angiopathy.
___ MR THIGH:
1. No enhancing mass or cyst lesion seen in the visualized
right hip or right thigh. Evidence for osteomyelitis.
2. Findings consistent with mild right greater trochanteric
bursitis.
3. Enhancing edema about the distal insertion of the gluteus
minimus,
consistent with mild tendinosis with possible partial thickness
tearing.
4. Moderate proximal hamstring tendinosis with interspersed
fluid consistent with partial-thickness tearing.
DISCHARGE RESULTS:
___ 06:15AM BLOOD WBC-5.9 RBC-3.61* Hgb-10.3* Hct-31.8*
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-45.3 Plt ___
___ 06:15AM BLOOD Glucose-172* UreaN-22* Creat-1.4* Na-137
K-5.0 Cl-105 HCO3-25 AnGap-7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terbinafine 1% Cream 1 Appl TP BID
2. Lisinopril 5 mg PO DAILY
3. Gabapentin 1200 mg PO BID
4. Ketoconazole 2% 1 Appl TP DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
8. amLODIPine 10 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Torsemide 10 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Clopidogrel 150 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Levothyroxine Sodium 100 mcg PO DAILY
15. NPH 37 Units Breakfast
NPH 37 Units Dinner
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
4. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 3 Days
5. Tamsulosin 0.4 mg PO QHS
6. NPH 37 Units Breakfast
NPH 37 Units Dinner
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
10. Gabapentin 1200 mg PO BID
11. Ketoconazole 2% 1 Appl TP DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
14. Metoprolol Succinate XL 200 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Terbinafine 1% Cream 1 Appl TP BID
17. Torsemide 10 mg PO DAILY
18. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until instructed by your PCP
19. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your doctors
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary retention
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 RLQ pain, weakness, AMS, hip pain// CT scan:
?kidney stone, diverticulitis, appendicitis Pelvis, hip xray: ?fx, CXR: ?PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Single lead left-sided AICD is seen with lead extending SPECT position of the
right ventricle. No focal consolidation, pleural effusion, evidence of
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process. No significant change from the prior study.
Radiology Report
INDICATION: History: ___ with RLQ pain, weakness, AMS, hip pain// CT scan:
?kidney stone, diverticulitis, appendicitis Pelvis, hip xray: ?fx, CXR: ?PNA
TECHNIQUE: AP view of the pelvis and AP and lateral views of the right hip
COMPARISON: None.
FINDINGS:
There are moderate to severe right hip degenerative changes with joint space
narrowing and marginal sclerosis. There also moderate left hip degenerative
changes. No acute fracture or dislocation is seen. Degenerative changes seen
on the partially imaged lower lumbar spine.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: History: ___ with RLQ pain, weakness, AMS, hip pain// CT scan:
?kidney stone, diverticulitis, appendicitis Pelvis, hip xray: ?fx, CXR: ?PNA
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 7.0 s, 55.1 cm; CTDIvol = 21.4 mGy (Body) DLP =
1,177.7 mGy-cm.
Total DLP (Body) = 1,189 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
pancreatic ductal dilatation. At the head of the pancreas, there is a 1.0 cm
round circumscribed hypodense lesion (series 2, image 34). 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 is normal.
PELVIS: The urinary bladder is largely distended, measuring 14.4 x 13.2 x 14.9
cm with equivocal slight haziness of the adjacent fat. The distal ureters are
prominent. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Multilevel degenerative changes with joint space narrowing and
osteophyte formation. Moderate degenerative changes of the bilateral hips.
The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Largely distended urinary bladder and prominent distal ureters without
obvious source obstruction. Recommend correlation with urinalysis and
patient's ability to voluntarily void.
2. Within the head of the pancreas, there is a 1.0 cm circumscribed hypodense
lesion, which may represent an IPMN. Recommend MRCP for further evaluation.
RECOMMENDATION(S): Recommend MRCP for further evaluation of the pancreatic
head lesion.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman with R lateral upper thigh nodule// eval R
lateral thigh nodule
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the -.
COMPARISON: None
FINDINGS:
Note is made that the patient indicated the area of concern is the superficial
tissues of the right lower quadrant of the abdomen. Transverse and sagittal
images were obtained. No suspicious soft tissue mass is visualized. No fluid
collection is seen. Several tiny superficial cysts are incidentally noted
within this region measuring up to 4 mm. None of the cysts demonstrates
suspicious vascularity.
IMPRESSION:
No suspicious soft tissue mass or fluid collection seen in the right lower
quadrant, at the site of interest indicated by the patient.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with CAD, heart failure with reduced ejection
fraction with AICD, diabetes, nephropathy,hypothyroidism, anemia, and
depression who presents with acute urinary retention on background of subtle
confusion, worsening gait.// structural abnormality
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head without contrast of ___.
FINDINGS:
Postcontrast images are mildly to moderately motion degraded. Within this
confine:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The
sulci, ventricles and cisterns are within expected limits for the degree of
mild senescent related global cerebral and loss. There are severe
periventricular and subcortical T2/FLAIR white matter confluent
hyperintensities, nonspecific, but compatible with chronic microangiopathy in
a patient this age. Multiple scattered punctate foci of gradient echo
susceptibility hypointensity predominantly involving the right much greater
than left frontoparietal lobes is noted, which may represent sequela of
amyloid angiopathy.
The major intracranial flow voids are preserved. The dural venous sinuses are
patent. The orbits are unremarkable. The paranasal sinuses are essentially
clear noting a metopic suture. Fluid signal opacifies the right mastoid tip,
similar to prior examination.
IMPRESSION:
1. No acute infarct or acute intracranial hemorrhage. Postcontrast images are
mildly to moderately motion degraded. Within this confine: No abnormal
enhancement.
2. Confluent and severe periventricular and subcortical T2/FLAIR white matter
hyperintensities, nonspecific, but commonly seen with chronic microangiopathy
in a patient of this age.
3. Scattered multiple punctate foci of gradient echo susceptibility
hypointensities, predominantly involving the right much greater than left
frontoparietal lobes, potentially representing amyloid angiopathy.
4. Additional findings described above.
Radiology Report
EXAMINATION: MR THIGH ___ CONTRAST RIGHT
INDICATION: ___ year old woman with persistent R hip/upper thigh pain// please
assess source of pain, firmness in upper R hip
TECHNIQUE: Multiplanar images of the right hip/thigh were performed before
and after the administration of intravenous contrast using a musculoskeletal
mass/infection MR protocol.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
There is no acute fracture or dislocation seen. Right hip joint and knee
joint are suboptimally evaluated due to large field-of-view, however there is
intermediate to high signal within the anterior superior, superior and
posterior superior labrum, consistent with degenerative changes. The hyaline
cartilage is suboptimally evaluated on this large field of view. There are
mild subchondral cyst-like changes and bone marrow edema seen in the posterior
acetabulum, secondary to degenerative changes.
There is a Foley catheter in place. The bladder is decompressed.
Muscle bulk is likely within normal limits for patient's age.
There is no enhancing mass or cyst lesion seen.
There are moderate degenerative changes of the patellofemoral joint.
There is moderate thickening of the proximal hamstring tendons with
interspersed fluid signal consistent with tendinosis and possible
partial-thickness tearing. There is fluid signal deep to the anterior gluteus
maximus, consistent with greater trochanteric bursitis. There is also edema
in stranding within the distal anterior detachment of the gluteus minimus,
consistent with tendinosis with possible partial-thickness tearing and
subgluteus minimus bursitis.
IMPRESSION:
1. No enhancing mass or cyst lesion seen in the visualized right hip or right
thigh. Evidence for osteomyelitis.
2. Findings consistent with mild right greater trochanteric bursitis.
3. Enhancing edema about the distal insertion of the gluteus minimus,
consistent with mild tendinosis with possible partial thickness tearing.
4. Moderate proximal hamstring tendinosis with interspersed fluid consistent
with partial-thickness tearing.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 97.3
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 161.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for confusion and urinary
retention
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You had an MRI which showed some disease in the brain
- You were seen by the neurologists and had some medication
adjustments
- You had a foley catheter placed
- You were treated for a possible UTI
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headaches, nausea, vomiting
Major Surgical or Invasive Procedure:
___ transphenoidal hypophysectomy
___ Lumbar Drain
___ Transsphenoidal endoscopic craniotomy and resection of
residual pituitary tumor.
___ Lumbar blood patch
History of Present Illness:
___ y/o M with no significant past medical history was
recently diagnosed with a pituitary adenoma after visual
disturbances discovered on eye exam who presents today with
severe headaches and vomiting. Patient states that at 4am this
morning, he woke up with a severe headache and vomiting. At
approximately 6am, patient ate a small meal and then took pain
medication with no relief. He went to ___
where a head CT was performed which showed question of pituitary
apoplexy. He was then transferred to ___ for further
evaluation.
Patient reports headache and vomiting, but denies any changes in
his vision since his ophthalmology exam, dizziness, dysarthria,
or weakness.
Past Medical History:
Pituitary adenoma
Social History:
___
Family History:
NC
Physical Exam:
O: T:96 BP:116/78 HR: 68 R: 18 O2Sats: 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils: 3-2mm bilaterally EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
a&ox3, PERRL, no appreciable field cult, no pronator drift, MAE
___ strength
Pertinent Results:
MRI Pituitary ___:
Large sellar/suprasellar mass elevating the optic nerves and
optic chiasm, and demonstrating patchy enhancement with possible
areas of blood products. Findings may represent a pituitary
macroadenoma
CT Head ___:
Large sellar and suprasellar mass that elevates the optic chiasm
and optic
nerves. There is no evidence of hemorrhage or infarction. The
appearance similar compared to the outside hospital study from
yesterday. MRI would provide far more detail.
CTA Abdomen/Pelvis ___:
1. No evidence of abdominal aortic aneurysm or acute
intraabdominal
pathology.
2. Epidural catheter, correlate clinically.
3. 2 mm non-obstructing left renal stone.
4. Trace amount of pelvic ascites.
MRI Pituitary Post-op ___ total resection of suprasellar
mass, there is soft tissue vs. residual tumor posteriorly with
mild compression on optic chiasm. Post operative changes.
CXR ___:
Negative for acute process.
CT Head ___:
1. No evidence of acute intracranial process.
2. Interval transsphenoidal resection of a pituitary
macroadenoma with
resultant expected postsurgical changes and pneumocephalus, as
above.
___. Apparent extensive anterior epidural air from the
craniocervical junction through the C5-6 level, with
interspersed small foci of blood, as well as epidural air
extending into the posterior fossa along the dorsal clivus.
Presence of air could be confirmed by CT.
2. Compression of the thecal sac from C2 through C4 with mild
deformation of the ventral spinal cord, but no evidence for
abnormal cord signal.
3. Mild degenerative disease.
___ CT head
Increased hyperdensity in the suprasellar resection cavity
extending into the sphenoid sinus; this could be postoperative,
but new small acute hemorrhage cannot be excluded in the absence
of interval postoperative imaging
___ MRI brain
Status post transsphenoidal resection of a presumed pituitary
adenoma. There is a minimal amount of hemorrhage at the
surgical resection site.
Subarachnoid and subdural pneumocephalus is similar to the
recent head CT, but has increased compared to the previous
examinations.
Significant interval debulking of the tumor with a thin shell of
enhancement surrounding the surgical site.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headaches
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*60 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
4. Hydrocortisone 20 mg PO QAM
RX *hydrocortisone 10 mg per instructions tablet(s) by mouth per
instructions Disp #*60 Tablet Refills:*0
5. Outpatient Lab Work
Please draw Complete metabolic panel
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Lesion
Diabetes insipidus
Acute visual field loss
Hyponatremia
Vasovagal syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ year old man with headache, vomiting, pituitary tumor.
TECHNIQUE: Multiplanar multisequence MR images of the pituitary/sella were
obtained before and after the administration of intravenous contrast.
COMPARISON: Non contrast CT head ___.
FINDINGS:
Patient motion artifact degrades image quality rendering suboptimal
evaluation. Within these confines:
Once again noted is a 2.9 SI x 3.6 TV x 2.2 AP cm sellar/suprasellar mass
extending superiorly into the suprasellar cistern where it mildly splays the
bilateral A1 segments and abuts the region of the anterior communicating
artery. There appears to be elevation of the optic nerves and optic chiasm
although not well delineated secondary to patient motion. The mass
demonstrates patchy enhancement, and areas of blooming susceptibility on the
gradient images possibly related to blood products. The pituitary infundibulum
is not identified. The mass abuts the cavernous carotid arteries which appear
to maintain their flow flow voids.
The remainder of the brain demonstrates no abnormal enhancement or restricted
diffusion to indicate of acute infarction. The ventricles and sulci are age
appropriate. Again noted is ___ cisterna magna.
IMPRESSION: Large sellar/suprasellar mass elevating the optic nerves and optic
chiasm, and demonstrating patchy enhancement with possible areas of blood
products. Findings may represent a pituitary macroadenoma.
Radiology Report
HISTORY: ___ male with acute vision loss and history of pituitary
lesion.
COMPARISON: Outside hospital head CT dated ___ at approximately
10:00 a.m.
TECHNIQUE: Head CT was performed without intravenous contrast. Multiplanar
reformatted images were reviewed.
FINDINGS:
There is no evidence of hemorrhage, edema, or infarction. There is
preservation of the gray-white matter differentiation. A large seppar and
suprasellar mass measuring approximately 2.5 cm appears similar compared to
prior exam with expansion and remodeling of the sella. Although poorly
characterized on CT, this elevates the optic chiasm and optic nerves. ___
cisterna magna appears similar compared to prior exam. Mild mucosal
thickening is seen in the left maxillary sinus, left sphenoid ethmoidal
recess, and ethmoid air cells. The remainder of the visualized portions of
the paranasal sinuses and mastoid air cells appear well aerated.
IMPRESSION:
Large sellar and suprasellar mass that elevates the optic chiasm and optic
nerves. There is no evidence of hemorrhage or infarction. The appearance
similar compared to the outside hospital study from yesterday. MRI would
provide far more detail.
Discussed with ___ by phone at 1:51 a.m. on ___.
Radiology Report
HISTORY: Postoperative evaluation status post transsphenoidal resection of a
sellar/suprasellar mass.
TECHNIQUE: Multiplanar multisequence MR images of the pituitary/sella were
obtained before and after the administration of intravenous contrast.
COMPARISON: MR pituitary ___.
FINDINGS:
The patient is status post transsphenoidal debulking of a sellar/suprasellar
mass. The bulk of the prior described mildly heterogeneous enhancing mass
appears to have been resected. Intrinsic T1 hyperintensity within the region
of the prior mass may related to fat packing, postoperative hemorrhage,
surgical material, or combination thereof. There is persistent nonenhancing
soft tissue density superiorly superior displacing the optic chiasm the, which
is the more well-defined compared to the preoperative study. There is
complete opacification of the sphenoid sinuses. The cavernous carotid
arteries appear to maintain their flow voids. The remainder of the brain
demonstrates no abnormal enhancement. Ventricles and sulci are age
appropriate. Again noted is ___ cisterna magna.
IMPRESSION: Status post transsphenoidal debulking of a sellar/suprasellar mass
with postoperative changes including fat packing and/or postoperative
hemorrhage. Although the bulk of the mass appears to have been resected,
there is persistent nonenhancing soft tissue abutting and superiorly
displacing the optic chiasm.
Radiology Report
INDICATION: History of pulsatile abdomen. Assess for abnormality.
COMPARISONS: None.
TECHNIQUE: MDCT axial imaging was obtained from the lung bases through the
pubic symphysis prior to and following the administration of intravenous
contrast material. Coronal and sagittal reformats were completed.
DLP: 1184.8 mGy-cm.
FINDINGS: There is bibasilar atelectasis. The visualized heart and
pericardium are unremarkable. The liver enhances homogenously without any
focal lesions or intra- or extra-hepatic biliary dilatation. The main portal
vein is patent. The gallbladder, pancreas, spleen and adrenal glands are
unremarkable. The kidneys enhance and excrete contrast symmetrically without
any hydronephrosis. A 2.2 x 2.4 cm cyst is present arising from the
interpolar region of the left kidney. The stomach is distended. The stomach,
small and intra-abdominal large bowel are unremarkable. There is no free
fluid, free air or lymphadenopathy within the abdomen.
CTA: Due to contrast timing, the aorta is not optimally opacified in the
arterial phase; however, there is no evidence of aneurysm and the major
vessels are patent. The aorta measures 1.9 cm in maximal dimension.
CT PELVIS: There is a small amount of pelvic ascites. The rectum and sigmoid
colon are unremarkable. The prostate gland is unremarkable. A Foley catheter
is present within the bladder. An epidural catheter is noted with small
locules of air likely within the epidural space. There is a small locule of
air within the right lateral abdomen wall (3:20).
OSSEOUS STRUCTURES: There are no concerning osseous lesions.
IMPRESSION:
1. No evidence of abdominal aortic aneurysm or acute intraabdominal
pathology.
2. Epidural catheter, correlate clinically.
3. 2 mm non-obstructing left renal stone.
4. Trace amount of pelvic ascites.
Radiology Report
AP CHEST, 4:36 P.M., ___
HISTORY: ___ man after transsphenoidal resection. Fever.
IMPRESSION: AP chest reviewed in the absence of prior chest imaging:
Normal heart, lungs, hila, mediastinum and pleural surfaces. No pneumonia.
Radiology Report
HISTORY: Status post transsphenoidal resection of a pituitary adenoma, now
with near syncope.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
CTDIvol: 53.45
DLP: ___
COMPARISON: Comparison is made with head CT dated ___, and MR
pituitary dated ___.
FINDINGS:
There has been interval transsphenoidal resection of a previously identified
pituitary macroadenoma, now with postsurgical changes included a small degree
of sellar fat, blood, and air. The basal cisterns are mildly effaced, and
there is a small degree of adjacent SAH, within expected post-surgical levels.
Air-fluid levels are seen within the left maxillary and bilateral sphenoid
sinuses. There is no evidence of acute intracranial hemorrhage, mass effect,
edema, or large territorial infarction. The ventricles and sulci are normal
in size and configuration. ___ cisterna magna is redemonstrated, unchanged
from prior examinations. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. Mucosal thickening is seen within the bilateral
ethmoid air cells. The visualized mastoid air cells and middle ear cavities
are clear. The globes are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Interval transsphenoidal resection of a pituitary macroadenoma with
resultant expected postsurgical changes and pneumocephalus, as above.
Radiology Report
SKULL FILMS ON ___.
HISTORY: Transsphenoidal surgery.
FINDINGS: Two views from the OR obtained with skull in lateral position. An
endotracheal tube is seen. Material seen within the oropharynx. Hardware
overlies the orbits and skull. See operative note for full description.
Radiology Report
CERVICAL SPINE MRI WITHOUT CONTRAST, ___
INDICATION: Status post transsphenoidal hypophysectomy for pituitary
macroadenoma on ___ and additional resection. There are intraoperative
fluoroscopic images from ___ as well, suggesting additional
transsphenoidal surgery on that date. Continued pain in the head and neck.
Evaluate for hemorrhage.
COMPARISON: Intraoperative fluoroscopic images from ___. Post-operative
pituitary MRI from ___. Post-operative non-contrast head CT
from ___.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, fat-suppressed T2-weighted, and
water-suppressed T2-weighted images of the cervical spine, and axial gradient
echo and T2-weighted images of the cervical spine.
FINDINGS: There is material with low signal on all sequences conforming to
the shape of the anterior epidural space from the craniocervical junction to
the C5-6 level, and also extending superiorly into the posterior fossa along
the dorsal clivus, suggesting air, new compared to the ___ MRI. Small
amount of intermediate-signal material on T1- and T2-weighted images is also
seen in the anterior epidural space at the level of the odontoid process and
at the level of C3, suggesting small amount of blood products. From C2 to the
C5-6 level, the thecal sac is compressed. Ventral surface of the spinal cord
is mildly deformed at C4 and C5. Spinal cord signal remains within normal
limits. Cerebellar tonsils are normally positioned.
Vertebral body heights are preserved. Alignment is normal. ___ type 2
discogenic bone marrow changes are present in the endplates at multiple
levels, most extensive at C6-7.
At C2-3, there is no significant neural foraminal narrowing.
At C3-4, there is mild-to-moderate left neural foraminal narrowing by
uncovertebral and facet osteophytes.
At C4-5, there is no significant neural foraminal narrowing.
At C5-6, there is a small shallow central disc osteophyte complex which
slightly indents the ventral thecal sac, as well as mild bilateral neural
foraminal narrowing by uncovertebral osteophytes.
At C6-7, there is a shallow central disc osteophyte complex which mildly
indents the ventral thecal sac, and moderate left neural foraminal narrowing
by uncovertebral osteophytes.
IMPRESSION:
1. Apparent extensive anterior epidural air from the craniocervical junction
through the C5-6 level, with interspersed small foci of blood, as well as
epidural air extending into the posterior fossa along the dorsal clivus.
Presence of air could be confirmed by CT.
2. Compression of the thecal sac from C2 through C4 with mild deformation of
the ventral spinal cord, but no evidence for abnormal cord signal.
3. Mild degenerative disease.
Results discussed by Dr. ___ from neurosurgery via
telephone at approximately 2:30 pm on ___.
Radiology Report
EXAM: MR brain and pituitary with and without contrast.
INDICATION: ___ male who is status post transsphenoidal
hypophysectomy with continued pain in the head and neck. This examination is
performed to assess for hemorrhage in the presence of worsening symptoms.
TECHNIQUE: Multiplanar, multisequence MR images of the head and sella were
obtained before and after the administration of intravenous contrast.
COMPARISON: CT head without contrast ___ and MR ___ with and
without contrast ___ and ___.
FINDINGS: There is relatively extensive subdural and subarachnoid air
including within and overlying the tumor which is similar to the head CT from
the previous day, but increased from the prior MRI dated ___.
Small amounts of intrinsic T1 hyperintensity within the surgical resection
cavity are consistent with hemorrhage, but have decreased in the interval.
There is susceptibility artifact from pneumocephalus, but no hemorrhage
outside the surgical site is identified.
There are changes related to transsphenoidal resection of the pituitary
adenoma, with significant debulking of the tumor. A thin shell of enhancement
surrounds the surgical site. Compared to the initial examination, there has
been interval decompression of the optic chiasm.
Small, thin bilateral subdural fluid collections are present. There is
pachymeningeal enhancement diffusely, and leptomeningeal enhancement adjacent
to the surgical resection site which are likely post-operative in nature. The
cavernous internal carotid arteries are displaced laterally, as seen on the
previous examinations.
There are fluid levels within both maxillary sinuses, left greater than right,
and there is near complete opacification of the ethmoid sinuses.
IMPRESSION:
Status post transsphenoidal resection of a presumed pituitary adenoma. There
is a minimal amount of hemorrhage at the surgical resection site.
Subarachnoid and subdural pneumocephalus is similar to the recent head CT, but
has increased compared to the previous examinations.
Significant interval debulking of the tumor with a thin shell of enhancement
surrounding the surgical site.
Radiology Report
HISTORY: Mid-anterior old male status post recent transsphenoidal pituitary
excision with return to the OR on ___, now with epistaxis and
headaches.
COMPARISON: ___.
TECHNIQUE: Head CT was performed without intravenous contrast. Multiplanar
reformatted images were reviewed.
FINDINGS:
Compared to the prior exam, there is slight increased hyperdensity in the
suprasellar resection cavity extending into the sphenoid sinus.
Post-operative air in the resection cavity has slightly increased. There is
markedly increased pneumocephalus. Small bifrontal subdural collections have
increased compared to prior. There is no shift of normally midline structures
or hydrocephalus. There is extensive opacification of the paranasal sinuses
with layering fluid in the frontal air cells. The mastoid air cells appear
well aerated. No acute bony abnormality is detected.
IMPRESSION:
Increased hyperdensity in the suprasellar resection cavity extending into the
sphenoid sinus; this could be postoperative, but new small acute hemorrhage
cannot be excluded in the absence of interval postoperative imaging.
Discussed with ___ by ___ by phone at 21:51 on ___ at the time of initial review of the study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, N/V
Diagnosed with HEADACHE, VISUAL DISTURBANCES NEC
temperature: 96.0
heartrate: 68.0
resprate: 18.0
o2sat: 99.0
sbp: 116.0
dbp: 78.0
level of pain: 9
level of acuity: 2.0 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
If you are required to take hydrocortisone, an oral steroid,
make sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a dripping
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
Fever greater than or equal to 101° F.
If you notice your urine output to be increasing, and/or
excessive, and you are unable to quench your thirst, please call
your endocrinologist. |
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 | You were admitted to the hospital for cellulitis on your left
foot. We gave you antibiotics and the infection improved. We are
sending you home on two oral antibiotics. Please see your
primary care doctor in the next week to make sure the infection
is getting better.
We also heard some fluid in your lungs. Please follow up with
Dr. ___ to see if she would like to prescribe a diuretic to
help with this. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pink grapefruit / Ultram
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Ex Lap ___
History of Present Illness:
Mr. ___ is a ___ y/o man with dilated cardiomyopathy (EF
<20%) s/p BiV-ICD, mitral regurgitation, paroxysmal atrial
fibrillation on warfarin, CKD (baseline Cr 3.7), presenting as a
transfer from ___ for acute on chronic renal failure and
hyperkalemia.
Patient states that he was in his usual state of health until 2
weeks ago. 2 weeks ago his cardiologist changed his lisinopril
from 30 mg daily to 40 mg daily. Since that time patient has had
orthostatic hypotension as well as nausea. The symptoms are
intermittent throughout the day. He denies chest pain, denies
shortness of breath denies fevers, denies chills, denies
complete review of systems otherwise. Patient had routine lab
work today that revealed the new ___, subsequently went to ___
___, subsequently transferred here. Patient had 9.5 mEq of
calcium gluconate, 10 of insulin, glucose, and one nebulizer
treatment for temporizing measures for his hyperkalemia at OSH.
In the ___, initial vitals: 96.5 60 88/46 18 94% RA
Labs notable for: Na 135, K 5.4, Cl 95, HCO3 21, BUN/Cr
134/14.0; WBC 9.4 H/H 8.0/24.9 plt 279
Exam notable for: Clear lungs, no leg swelling, no JVD
Imaging:
- EKG: Paced at 60, no peaked T waves
- US: no pericardial effusion, concentric squeeze, bladder with
475cc, no hydronephrosis
- CXR: No significant pulmonary edema.
Consults:
- Renal: Place Foley. Treat K medically. No urgent need for
dialysis.
- Cardiology: No recs.
Patient was given:
___ 21:44 IVF 1000 mL NS 500 mL
On transfer, vitals were: 94 103/68 18 98% RA
On arrival to the MICU, Pt is awake, alert, oriented and
ambulatory in NAD. He states that 2 weeks ago after increased
lisinopril dose from 30mg daily to 20mg BID he has had
lightheadedness and dizziness. This was in the setting of
increased exercise (treadmill 15mins multiple times a day)
without increase in fluid intake. He denies recent illness,
orthopnea, PND and ___ swelling. He went to PCP for lab work,
post med change, found to have elevated Cr and K. Sent to ___
___. He is currently comfortable. Denies f/c/cp/sob/abd
pain, change in bowel habits.
Past Medical History:
PAST MEDICAL HISTORY:
- idiopathic dilated cardiomyopathy (LVEF 20%) s/p BiV ICD
(___)
- ICD shocks in ___ for atrial flutter, ___ for VFib (shock
x2), ___ for AFib w/ RVR
- mitral regurgitation (3+)
- paroxysmal atrial fibrillation
- pulmonary hypertension
- morbid obesity
- history of LV thrombus (s/p 12 months of warfarin in ___
- psoriasis
- chronic knee pain
- pneumonia (___)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: T: 96.2 HR: 60 BP: ___ RR:100%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: 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
SKIN: erythematous psoriasis rash on all four distal
extremities
NEURO: CN ___ intact.
DISCHARGE PHYSICAL EXAM:
=============================
Vital Signs: 98.5 96/51 90 16 96|RA
I/O: 8h: 240/550 24h: 1200/2325
Weight: 141.2 <- 141.6 <- 142.1 <- NR <-140.8 <- 144.2
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, dry. neck supple, JVP not
elevated, no LAD
Lungs: Lungs clear bilaterally. No wheezes or rhonchi.
CV: RRR, S1, S2. ___ systolic murmur heard, no radiation.
Abdomen: Large midline incision from umbilicus to bottom of
sternum. Incision C/D/I with staples in place. BS+.
Ext: Warm, well perfused, 2+ pulses, no clubbing, mild edema.
Skin: Without rashes or lesions
Neuro: CN II-XII grossly intact.
Pertinent Results:
Admission Labs
============
___ 09:20PM BLOOD WBC-9.4 RBC-2.70* Hgb-8.0* Hct-24.9*
MCV-92 MCH-29.6 MCHC-32.1 RDW-15.5 RDWSD-52.0* Plt ___
___ 09:20PM BLOOD Neuts-80.3* Lymphs-9.2* Monos-9.1
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.54* AbsLymp-0.86*
AbsMono-0.85* AbsEos-0.07 AbsBaso-0.02
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-107* UreaN-134* Creat-14.0*#
Na-135 K-5.4* Cl-95* HCO3-21* AnGap-24*
___ 04:11AM BLOOD ALT-22 AST-16 AlkPhos-62 TotBili-0.5
___ 01:12AM BLOOD Calcium-8.6 Phos-10.3* Mg-2.4
___ 09:35PM BLOOD Lactate-1.1 K-5.5*
___ 04:31AM BLOOD freeCa-0.90*
Pertinent Interval Labs
=================
___ 01:00PM BLOOD Neuts-93.7* Lymphs-1.5* Monos-3.7*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-23.84*# AbsLymp-0.39*
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.04
___ 12:03PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:10PM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:31AM BLOOD ___ pO2-166* pCO2-40 pH-7.34*
calTCO2-23 Base XS--3
___ 01:03PM BLOOD ___ Temp-36.3 pO2-63* pCO2-38
pH-7.40 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
___ 05:03PM BLOOD Type-ART Temp-37.7 Tidal V-1012 PEEP-5
FiO2-100 pO2-100 pCO2-40 pH-7.38 calTCO2-25 Base XS-0 AADO2-573
REQ O2-94 As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 11:33PM BLOOD Type-ART Temp-36.7 pO2-67* pCO2-43
pH-7.33* calTCO2-24 Base XS--3
___ 04:45AM BLOOD Type-ART Temp-36.8 pO2-134* pCO2-47*
pH-7.32* calTCO2-25 Base XS--2
___ 07:40AM BLOOD Type-ART pO2-115* pCO2-42 pH-7.42
calTCO2-28 Base XS-3
___ 09:35PM BLOOD Lactate-1.1 K-5.5*
___ 04:31AM BLOOD Glucose-181* Lactate-2.2* K-4.6
___ 01:03PM BLOOD Lactate-1.13
___ 12:54AM BLOOD Lactate-1.6
___ 07:40AM BLOOD Lactate-0.6
Discharge Labs
===========
___ 06:46AM BLOOD WBC-11.4* RBC-2.99* Hgb-8.9* Hct-27.7*
MCV-93 MCH-29.8 MCHC-32.1 RDW-15.0 RDWSD-50.7* Plt ___
___ 06:46AM BLOOD Plt ___
___ 06:46AM BLOOD Glucose-97 UreaN-18 Creat-1.3* Na-136
K-4.8 Cl-101 HCO3-27 AnGap-13
___ 06:46AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
Imaging & Studies
=============
CXR ___
FINDINGS:
The endotracheal tube is difficult to visualize but may lie near
the carina.
Cardiac pacemaker. Shallow inspiration accentuates pulmonary
vascularity. No
definite pleural effusion. Increased ___ size, more
prominent.
IMPRESSION:
Endotracheal tube tip difficult to visualize but may lie near
the carina. The
patient was extubated per the nurse ___.
CT Abd/Pelvis w/out contrast ___
IMPRESSION:
Wall thickening, surrounding fat stranding, and pneumatosis of
the ascending
colon extending through the proximal transverse colon,
concerning for
necrotizing colitis. The differential diagnosis is broad,
including
infectious, inflammatory, and ischemic etiologies.
CXR ___
FINDINGS:
Cardiac size is enlarged as before. Pacer leads are in standard
position. .
The lungs are clear. There is no pneumothorax or pleural
effusion.
IMPRESSION:
No evidence of pneumonia or pulmonary edema
Renal US ___
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 11.7
cm. Images
of the kidneys are somewhat limited due to reduced acoustic
penetration.
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is poorly distended and appears to contain a Foley
catheter, which
is not well evaluated due to bladder collapse and reduced
acoustic access.
IMPRESSION:
No evidence of hydronephrosis. Collapsed urinary bladder which
cannot be
further assessed.
Microbiology
==========
__________________________________________________________
___ 4:47 am BLOOD CULTURE Source: Line-ART.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:12 pm BLOOD CULTURE Source: Line-art.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
2. Amiodarone 300 mg PO DAILY
3. Lisinopril 20 mg PO QAM
4. Lisinopril 10 mg PO QPM
5. Metoprolol Succinate XL 125 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
7. Spironolactone 12.5 mg PO DAILY
8. Torsemide 40 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Warfarin 7.5 mg PO 5X/WEEK (___)
11. Warfarin 10 mg PO 2X/WEEK (___)
12. Halobetasol Propionate 0.05 % topical BID:PRN
Discharge Medications:
1. Lidocaine 5% Patch 2 PTCH TD QAM
RX *lidocaine [LC-5] 5 % apply once daily apply once daily
Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hrs Disp #*5 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Torsemide 10 mg PO ONCE Duration: 1 Dose
Take on ___.
Also take any day you have > 2 lb weight gain
RX *torsemide [Demadex] 10 mg 1 tablet(s) by mouth take each day
you have > 2 lb weight change Disp #*10 Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every 6
hrs Disp #*6 Capsule Refills:*0
6. Lisinopril 30 mg PO DAILY
RX *lisinopril 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Warfarin 6 mg PO DAILY16
RX *warfarin [Coumadin] 6 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
10. Amiodarone 300 mg PO DAILY
RX *amiodarone 100 mg 3 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Halobetasol Propionate 0.05 % topical BID:PRN
12. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every 6 hrs Disp #*24
Tablet Refills:*0
13. Spironolactone 12.5 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C Diff colitis
Acute Renal Failure
Congestive ___ Failure
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: ___ w/CHF please assess for volume status, volume overload.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The lungs are well inflated and clear. No pulmonary edema. No pleural
effusion or pneumothorax. Stable mild to moderate cardiomegaly. Mediastinal
contour and hila are unremarkable.
A left pacer device is seen with lead tips in the right atrium, right
ventricle and coronary sinus.
IMPRESSION:
1. No acute cardiopulmonary process. Specifically no pulmonary edema.
2. Stable cardiomegaly.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with heart failure and CKD presents with Acute on
chronic Kidney disease // Eval for Kidney pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Ultrasound ___
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 11.7 cm. Images
of the kidneys are somewhat limited due to reduced acoustic penetration.
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is poorly distended and appears to contain a Foley catheter, which
is not well evaluated due to bladder collapse and reduced acoustic access.
IMPRESSION:
No evidence of hydronephrosis. Collapsed urinary bladder which cannot be
further assessed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ no with elevated WBC // Eval for PNA
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
FINDINGS:
Cardiac size is enlarged as before. Pacer leads are in standard position. .
The lungs are clear. There is no pneumothorax or pleural effusion.
IMPRESSION:
No evidence of pneumonia or pulmonary edema
Radiology Report
INDICATION: Abdominal pain.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 63.9 cm; CTDIvol =
17.1 mGy (Body) DLP = 1,091.2 mGy-cm. Total DLP (Body) = 1,091 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: The visualized lung bases are clear, with only a punctate
calcified granuloma noted in the left lung base. There is no pleural
effusion. A trace pericardial effusion is likely physiologic. Cardiac leads
are noted.
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.
No portal venous gas is visualized. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no ductal
dilation or peripancreatic stranding or fluid collection.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally. In the lateral limb of the left adrenal gland is a 2.4 cm
myelolipoma.
URINARY: The kidneys are symmetric and normal in size, without stone or
hydronephrosis. There is no evidence of focal renal lesions within the
limitations of an unenhanced scan. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed, without obvious focal wall
thickening or mass. Small bowel loops are normal in caliber, without wall
thickening or evidence of obstruction. There is wall thickening of the
ascending colon with surrounding fat stranding and trace adjacent free fluid.
Locules of air within the wall are compatible with pneumatosis. There may be
an additional tiny locule of subserosal gas(2:59, 601b:44). The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate gland is unremarkable.
LYMPH NODES: There is no retroperitoneal lymph node enlargement by CT size
criteria. Mesenteric lymph nodes in the right abdomen are prominent. There is
no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is
noted.
BONES: There is no focal lytic or sclerotic osseous lesion to suggest neoplasm
or infection.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
Wall thickening, surrounding fat stranding, and pneumatosis of the ascending
colon extending through the proximal transverse colon, concerning for
necrotizing colitis. The differential diagnosis is broad, including
infectious, inflammatory, and ischemic etiologies.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF, severe c. diff now s/p abdominal
washout, intubated s/p OR. // tube placement, pleural effusion or pulmonary
edema
TECHNIQUE: Chest single view
COMPARISON: ___ 05:11
FINDINGS:
The endotracheal tube is difficult to visualize but may lie near the carina.
Cardiac pacemaker. Shallow inspiration accentuates pulmonary vascularity. No
definite pleural effusion. Increased heart size, more prominent.
IMPRESSION:
Endotracheal tube tip difficult to visualize but may lie near the carina. The
patient was extubated per the nurse ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Acute renal failure, Hyperkalemia, Transfer
Diagnosed with Acute kidney failure, unspecified
temperature: 96.5
heartrate: 60.0
resprate: 18.0
o2sat: 94.0
sbp: 88.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You came to the hospital because of renal failure, thought to
occur because you had too much fluid taken off your body with
the water pills you were taking at home to control your ___
failure. While at the hospital, you were given fluid, and your
diuretics were held, and your kidney function improved.
Unfortunately, you were also noted to have a severe infection of
your colon (C difficile), and you were started on antibiotics.
With antibiotics, you improved, and ultimately your kidney
function improved as well and we started you on a much lower
dose of home diuretic (water pill).
We are sending you home with a plan to reduce your diuretic
dose, and to finish a course of antibiotics tomorrow. It is VERY
important that you hold your home torsemide, and only take 10 mg
on ___. However, if you weight on any day increases by > 2
lbs, please take an addition 10 mg of torsemide.
In addition, visiting nurses ___ visit you at home. They will
check your weight daily.
We wish you the best!
-Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Clogged feeding tube. Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ female status post Whipple
pancreatectomy who was recently discharged after a prolonged
course presenting with clogged GJ tube, and sepsis. The
patient's recent hospitalization was complicated by sepsis, PEA
arrest, intra-abdominal fluid collection peritoneal cutaneous
fistula formation, ___ infection, and blood cultures
positive for strep Aregenosis, who was recently discharged to
rehab on ___. Infectious disease discharge the patient on
Unasyn and fluconazole to treat her fluid collections that were
deemed undrainable at the time. The patient has been doing well
at
rehab, tolerating p.o. intake, and had been recovering
appropriately. However it was noted that her GJ tube was
clogged today by the rehab physician and it was also noted that
the patient had been having 24 hours of rigors and cold sweats.
Patient reports herself that she has been experiencing chills
and
cold sweats for the past ___ days. She and her husband deny a
recorded fever. The patient initially presented to an outside
hospital emergency department where her white count was found to
be 15.3. Given her complex history the patient was transferred
to ___ for evaluation. In the ED, the patient reports no
changes in her bowel habits, she does endorse some nausea,
denies vomiting,
reports that her pain is about the same. Her husband has notes
that her delirium has actually improved markedly since her
discharge from hospital.
Past Medical History:
Other allergic rhinitis
Anemia of chronic renal failure
Addison anemia
Mixed anxiety depressive disorder
Chronic kidney disease, stage III (moderate)
Unilateral hearing loss
Dizziness
Hyperlipidemia
Hypoactive thyroid
Osteoporosis, post-menopausal
Seizure disorder
Shoulder pain
Tremor
Vesicoureteral reflux
Unspecified vitamin D deficiency
s/p cholecystectomy in ___
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Prior To Discharge:
VS: 98.4, 85, 134/53, 18, 94% RA
GEN: Pleasant, somewhat confused without acute distress.
HEENT: PERRL, EOMI, no scleral icterus
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, NT/ND. Bilateral subcostal incision open to air and
c/d/I, medial part covered with dry gauze.
EXTR: LUE with bruise, RUE with double lumen PICC - dressing
c/d/I. Bilateral ___ - warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 06:33AM BLOOD WBC-12.3* RBC-2.89* Hgb-9.0* Hct-27.4*
MCV-95 MCH-31.1 MCHC-32.8 RDW-16.0* RDWSD-55.8* Plt ___
___ 06:33AM BLOOD Glucose-126* UreaN-10 Creat-1.1 Na-140
K-3.3* Cl-104 HCO3-21* AnGap-15
___ 06:42AM BLOOD ALT-25 AST-27 CK(CPK)-32 AlkPhos-290*
TotBili-0.3
___ 06:33AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5*
MICRO: BLOOD/URINE CX - negative
RADIOLOGY:
___ CT ABD:
FINDINGS:
LOWER CHEST: There is interval decrease in right basilar
atelectasis with
residual bibasilar linear atelectasis remaining. Prior pleural
effusions have resolved. 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 surgically absent.
PANCREAS: Patient is status post post pylorus preserving
pancreaticoduodenectomy with postsurgical changes. The fluid
collection in the operative bed is grossly stable in size and
volume considering differences in technique measuring 3.0 x 2.0
x 3.9 cm, previously measuring 3.0 x 2.0 x 3.0 cm on noncontrast
exam (2:29, 601:26). The perihepatic/periduodenal anterior
fluid collection has nearly resolved. No evidence of new fluid
collections or abscess. The remaining remnant pancreas has
normal attenuation and pancreatic duct measuring approximately 5
mm. No significant 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: Again demonstrated, is decreased excretion of contrast
from the left kidney with decreased degree and now mild
hydronephrosis. There are areas of relatively decreased
enhancement at both lower and upper poles of the left kidney
which demonstrated more normal enhancement on ___.
There is a 9 mm calcification just anterior to the left
ureterovesicular junction though this does not appear to be
within the ureter itself, however there is a 4 mm calcification
which does appear to be within the distal ureter at the
ureterovesicular junction(601:35, 2:78). The right kidney again
demonstrates a contrast containing caliceal diverticulum
(02:35). Otherwise, the right kidney enhances normally without
evidence of hydronephrosis. Areas of renal scarring noted
bilaterally. There is no perinephric abnormality.
GASTROINTESTINAL: Enteric tube is seen traversing the stomach in
entering the small-bowel. Otherwise, stomach is unremarkable.
Again visualized, is a thickened appearance of the bowel
adjacent to the operative bed, likely secondary inflammatory
reaction related to surgical manipulation (02:27, 601:25).
Remaining small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. Diverticulosis of the
colon is noted, without evidence of wall thickening or fat
stranding. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal
abnormality is seen.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted.
BONES: Redemonstration of a healing right anterior rib fracture
(2:4).
Otherwise, there is no additional evidence of worrisome osseous
lesions or
acute fracture.
SOFT TISSUES: Again demonstrated, is a fat containing incisional
hernia along the right abdominal wall (02:43). In addition,
there is postsurgical subcutaneous edema along the anterior
abdominal wall.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 2 mg PO QPM
2. Aspirin 325 mg PO DAILY
3. ClonazePAM 0.5 mg PO QHS
4. LamoTRIgine 100 mg PO BID
5. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 150 mcg PO 1X/WEEK (WE)
7. LOPERamide 2 mg PO DAILY:PRN diarrhea
8. Sertraline 250 mg PO DAILY
9. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID
11. Ampicillin-Sulbactam 3 g IV Q6H
12. Cholestyramine 4 gm PO BID
13. Creon 12 2 CAP PO TID W/MEALS
14. Fluconazole 200 mg PO Q24H
15. Heparin 5000 UNIT SC BID
16. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing
17. Multivitamins W/minerals Chewable 1 TAB PO DAILY
18. Ramelteon 8 mg PO QHS anxiety/insomnia
19. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
20. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush
21. Tamsulosin 0.4 mg PO DAILY
22. Calcium Carbonate 500 mg PO DAILY
23. Cyanocobalamin 1000 mcg PO DAILY
24. Denosumab (Prolia) 60 mg SC ASDIR
25. Ferrous Sulfate 325 mg PO DAILY
26. FoLIC Acid 1 mg PO DAILY
27. Simvastatin 40 mg PO QPM
28. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*14 Capsule Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. Ampicillin-Sulbactam 3 g IV Q6H
The end day for this medication will be determine by Infectious
Diseases during f/u on ___
4. ARIPiprazole 2 mg PO QPM
5. Aspirin 325 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. ClonazePAM 0.5 mg PO QHS
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
8. Creon 12 2 CAP PO TID W/MEALS
9. Cyanocobalamin 1000 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluconazole 200 mg PO Q24H
12. FoLIC Acid 1 mg PO DAILY
13. Heparin 5000 UNIT SC BID
14. LamoTRIgine 100 mg PO BID
15. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
16. Levothyroxine Sodium 150 mcg PO 1X/WEEK (WE)
17. LOPERamide 2 mg PO DAILY:PRN diarrhea
18. Multivitamins W/minerals Chewable 1 TAB PO DAILY
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID
20. Ramelteon 8 mg PO QHS anxiety/insomnia
21. Sertraline 250 mg PO DAILY
22. Simvastatin 40 mg PO QPM
23. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
24. Vitamin D 1000 UNIT PO DAILY
25. HELD- Denosumab (Prolia) 60 mg SC ASDIR This medication was
held. Do not restart Denosumab (Prolia) until follow up with Dr.
___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Pancreatic adenocarcinoma s/p Whipple procedure
2. Intra abdominal abscess
3. Clogged ___ feeding tube
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with Sepsis, recent whipple.// PICC position?
Pneumonia?
TECHNIQUE: Single AP view of the chest.
COMPARISON: Multiple prior chest radiographs, most recently dated ___.
FINDINGS:
New right PICC line terminates in the mid to distal SVC. NG tube is
unchanged. Lung volumes are persistently low. There is mild cardiomegaly
with pulmonary vascular congestion, slightly increased compared to prior. No
focal consolidation. No frank pulmonary edema. Likely small left pleural
effusion. No appreciable pneumothorax.
IMPRESSION:
Right PICC line terminates in the mid to distal SVC. Persistent low lung
volumes with cardiomegaly and pulmonary vascular congestion.
Radiology Report
INDICATION: ___ with Whipple, c/f sepsis, clogged NGT. NO_PO contrast//
Abscess? Intraabdominal infection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 741 mGy-cm.
COMPARISON: Noncontrast CT abdomen pelvis ___. Contrast-enhanced CT
abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is interval decrease in right basilar atelectasis with
residual bibasilar linear atelectasis remaining. Prior pleural effusions have
resolved. 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 surgically absent.
PANCREAS: Patient is status post post pylorus preserving
pancreaticoduodenectomy with postsurgical changes. The fluid collection in
the operative bed is grossly stable in size and volume considering differences
in technique measuring 3.0 x 2.0 x 3.9 cm, previously measuring 3.0 x 2.0 x
3.0 cm on noncontrast exam (2:29, 601:26). The perihepatic/periduodenal
anterior fluid collection has nearly resolved. No evidence of new fluid
collections or abscess. The remaining remnant pancreas has normal attenuation
and pancreatic duct measuring approximately 5 mm. No significant
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: Again demonstrated, is decreased excretion of contrast from the left
kidney with decreased degree and now mild hydronephrosis. There are areas of
relatively decreased enhancement at both lower and upper poles of the left
kidney which demonstrated more normal enhancement on ___. There is a
9 mm calcification just anterior to the left ureterovesicular junction though
this does not appear to be within the ureter itself, however there is a 4 mm
calcification which does appear to be within the distal ureter at the
ureterovesicular junction(601:35, 2:78). The right kidney again demonstrates
a contrast containing caliceal diverticulum (02:35). Otherwise, the right
kidney enhances normally without evidence of hydronephrosis. Areas of renal
scarring noted bilaterally. There is no perinephric abnormality.
GASTROINTESTINAL: Enteric tube is seen traversing the stomach in entering the
small-bowel. Otherwise, stomach is unremarkable. Again visualized, is a
thickened appearance of the bowel adjacent to the operative bed, likely
secondary inflammatory reaction related to surgical manipulation (02:27,
601:25). Remaining small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. Diverticulosis of the colon is noted,
without evidence of wall thickening or fat stranding. The appendix is not
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Redemonstration of a healing right anterior rib fracture (2:4).
Otherwise, there is no additional evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Again demonstrated, is a fat containing incisional hernia along
the right abdominal wall (02:43). In addition, there is postsurgical
subcutaneous edema along the anterior abdominal wall.
IMPRESSION:
1. No significant decrease in fluid collection in the operative bed. Near
complete resolution of previously seen perihepatic fluid collection.
2. No new fluid collections or evidence of abdominopelvic abscesses.
3. Asymmetric areas of hypoperfusion of the left kidney. Given the
heterogeneity of enhancement, underlying pyelonephritis should be considered.
4. Possible 4 mm left ureterovesicular junction calculus though decreased
degree of hydronephrosis compared to prior.
5. Interval decrease in right basilar atelectasis in resolution of right
pleural effusion.
NOTIFICATION: The findings, particularly impression #3, were discussed with
___, M.D. by ___, M.D. on the telephone on ___ at 6:37
pm, 5 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Sepsis, unspecified organism, Peritoneal abscess
temperature: 98.0
heartrate: 104.0
resprate: 20.0
o2sat: 98.0
sbp: 152.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Ms. ___,
You were admitted to the surgery service at ___ from
rehabilitation service with clogged feeding tube and question of
worsening infection. Your DHT was removed, and after swallow
evaluation your diet was advanced to regular. Your CT scan
demonstrated decrease size of known intra abdominal abscess and
current antibiotics and antifungal treatment was continued. You
are now safe to return in rehabilitationto complete your
recovery with the following instructions:
.
Please ___ Dr. ___ office at ___ or Office RNs at
___ if you have any questions or
concerns.
.
Incision Care:
*Your wound dressing will be changes daily in rehab by the
nurses.
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
Please weight yourself daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Tingling/numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo RH woman
Recent "viral illness" with raspy/hoarse voice, cough and
shortness of breath, empirically given penicillin as her
children
also had ear infection/strep at home. However, she had worsening
shortness of breath and d dimer was positive, so sent for CTA of
chest at ___ which was negative. Her PCP checked some
labs and found slightly elevated ESR and told her she might have
"inflammatory disease." She also had some episodes of
lightheadedness for the last week.
Today she was at work on conference call at 2pm, when she
noticed
tingling/numbness in her right upper arm. Then after 20 minutes
involved right leg, and then right hand and then into right
foot.
She decided to come to ED, and by the time she arrived, it had
involved the right side of her neck but not the face. Started
going away around 8 pm (having lasted about 6 hours or so),
starting from the right leg. Right arm felt heavy during this
episode but she was not clumsy. She had some mild headache when
she arrived at ED but describes as a tightness and not
migrainous
in nature. Never had an episode like this before.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness. No bowel or bladder incontinence
or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. + 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:
- anxiety
- asthma
- prolactinoma/pituitary microadenoma
Social History:
___
Family History:
Maternal grandmother: stroke
Father: HTN
Mother: hypertension, pacemaker, valvular issues
Siblings: healthy
Physical Exam:
ADMISSION EXAM
Vitals: 98.4 95 141/85 16 100% 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
without difficulty. Attentive to different parts of examination.
Language has good fluency and comprehension. Normal prosody.
There were no paraphasic errors. Pt was able to name both high
and low frequency objects. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch/pinprick.
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 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, cold sensation,
vibratory sense 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 bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
DISCHARGE EXAM
Normal neurologic exam
Pertinent Results:
___ 07:34PM URINE HOURS-RANDOM
___ 07:34PM URINE UCG-NEGATIVE
___ 07:34PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
___ 07:34PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:34PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 07:34PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-2
___ 07:15PM GLUCOSE-90 UREA N-9 CREAT-0.8 SODIUM-136
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 07:15PM ALT(SGPT)-44* AST(SGOT)-37 ALK PHOS-69 TOT
BILI-0.4
___ 07:15PM cTropnT-<0.01
___ 07:15PM ALBUMIN-4.5
___ 07:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:15PM WBC-8.5 RBC-4.38 HGB-12.9 HCT-39.6 MCV-90
MCH-29.4 MCHC-32.5 RDW-12.7
___ 07:15PM NEUTS-59.4 ___ MONOS-5.6 EOS-2.2
BASOS-0.7
___ 07:15PM PLT COUNT-282
___ 07:15PM ___ PTT-29.7 ___
___ 11:33AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:33AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:33AM URINE RBC-20* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-1
___ 11:33AM URINE MUCOUS-FEW
___ 09:50AM UREA N-12 CREAT-0.8 SODIUM-141 POTASSIUM-4.7
CHLORIDE-100 TOTAL CO2-27 ANION GAP-19
___ 09:50AM estGFR-Using this
___ 09:50AM CK(CPK)-67
___ 09:50AM RHEU FACT-9 CRP-3.7
___ 09:50AM WBC-7.8 RBC-4.60 HGB-13.4 HCT-42.7 MCV-93
MCH-29.2 MCHC-31.4 RDW-13.5
___ 09:50AM NEUTS-70.5* ___ MONOS-5.2 EOS-2.6
BASOS-0.5
___ 09:50AM PLT COUNT-268
___ 09:50AM SED RATE-39*
MRI BRAIN
There are two new foci of FLAIR hyperintensity in the right
temporal
periventricular white matter and the left lateral pons
(101:65,78). Neither of these lesions enhance. The ventricles
and extra-axial spaces are normal in size. There is no evidence
of midline shift, mass effect or hydrocephalus. The vascular
flow voids are maintained. The visualized paranasal sinuses are
clear. There is no evidence of abnormalparenchymal, vascular, or
meningeal enhancement.
IMPRESSION:
Two nonspecific FLAIR hyperintensities in the right temporal
white matter and pons, similar to previous studies when
accounting for differences in slice selection. Appearance not
typical for demyelinating disease but clinical correlation
recommended. Neoplasm is unlikely.
The study and the report were reviewed by the staff radiologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 150 mg PO DAILY
2. TraZODone 100 mg PO HS:PRN insomnia
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H prn wheezing
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. TraZODone 100 mg PO HS:PRN insomnia
3. Venlafaxine XR 150 mg PO DAILY
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H prn wheezing
5. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth QHS prn
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
NON-CONTRAST HEAD CT PERFORMED ON ___.
COMPARISON: MRI of the brain from ___ as well as a CT of the head from
___.
CLINICAL HISTORY: ___ female with right arm heaviness and numbness.
FINDINGS: Non-contrast head CT with axial, coronal, and sagittal
reformations. There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally midline structures, or evidence of acute major vascular
territorial infarction. The ventricles and sulci have a normal overall
pattern. The basilar cisterns are widely patent. The imaged paranasal
sinuses, mastoid air cells and middle ear cavities are widely patent. The
bony calvarium is intact.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: History of dyspnea. Please assess for pneumonia.
COMPARISONS: Chest radiographs dated back to ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: The heart size is normal. The hilar and mediastinal contours are
normal. No focal consolidations concerning for pneumonia identified. There
is no pleural effusion or pneumothorax. The visualized osseous structures are
unremarkable.
IMPRESSION: No pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman who presented with R hemibody tingling for 6
hours. // ?intracranial lesions to explain R hemibody tingling
TECHNIQUE: Multiplanar FLAIR images were obtained. After administration of
Gadavist intravenous contrast, axial imaging was performed with gradient echo,
FLAIR, and T1 technique. Sagittal MPRAGE imaging was performed and
re-formatted in axial and coronal orientations.
COMPARISON: MRI brain, ___, and ___.
FINDINGS:
There are two new foci of FLAIR hyperintensity in the right temporal
periventricular white matter and the left lateral pons (101:65,78). Neither of
these lesions enhance. The ventricles and extra-axial spaces are normal in
size. There is no evidence of midline shift, mass effect or hydrocephalus. The
vascular flow voids are maintained. The visualized paranasal sinuses are
clear. There is no evidence of abnormal parenchymal, vascular, or meningeal
enhancement.
IMPRESSION:
Two nonspecific FLAIR hyperintensities in the right temporal white matter and
pons, similar to previous studies when accounting for differences in slice
selection. Appearance not typical for demyelinating disease but clinical
correlation recommended. Neoplasm is unlikely.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: NEURO
Diagnosed with SKIN SENSATION DISTURB, RESPIRATORY ABNORM NEC
temperature: 98.4
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 85.0
level of pain: nan
level of acuity: 1.0 | Dear Ms. ___,
You were admitted with 6 hours of tingling and numbness. We did
an MRI which did not show anything. We think that your symptoms
are likely due to changes in respirations due to your cough,
which changes the level of CO2 in your blood. You should follow
up with neurology, and with your PCP, as listed below. We have
given you a cough syrup to use at night.
It was a pleasure taking care of you during this hospital day. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
found down, left ICH
Major Surgical or Invasive Procedure:
1. Endotracheal intubation
2. Left frontal external ventricular drain placement (___)
3. Right frontal external ventricular drain placement (___)
4. Tracheostomy and percutaneous gastrostomy tube placement
(___)
5. Right vocal cord injection (___)
History of Present Illness:
The pt is a ___ yo man with PMHx of HTN who presents after being
found down at work with possible seizure activity and was found
to have a large L ICH. The history was obtained from the
patient's wife and EMS. The patient was c/o a headache all
afternoon on ___. He took "3 Nyquil" for unclear reasons, but
his wife thinks it was to help with his headache. Then at
around 6pm the patient again c/o headache and thn started
profusely vomiting for the next 3 hours. The patient's wife
figured he had a stomach bug and left to go to sleep. The
patient continued to stay on to work at the family's liquor
store. His wife received a call because at 10pm the patient was
found on the floor unresponsive by a customer. The customer
called ___ and when they arrived the patient wasn't moving his
RUE and was possibly having some L-sided twitching/shaking,
although no first hand account of this is avalable at this time.
He was given ativan and brought to ___. In the ED, he was
intubated and given 1,000mg of IV phenytoin. Neurology and
Neurosurgery were consulted and neurosurgery felt there was no
medical intervention to be done, so deferred to neurology. The
patient was admitted to the neuro ICU for further evaluation.
Pt unable to complete ROS as he is intubated and minimally
responsive.
Past Medical History:
Hypertension
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.6 P: ___'s R: 16 BP: 260's/130's SaO2: 98% on ETT
General: intubated, unresponsive even with sedation off
HEENT: ETT in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: No response to noxious, voice or sternal rub.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils 1mm and unreactive (although perhaps too small to
react). No reaction to visual confrontation. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages. Weak corneal
on the L, no corneal on the R
III, IV, VI: Doll's showed some very subtle correction.
V:unable to test
VII: unable to assess given ETT
VIII: unable to assess.
IX, X: Gag intact
XI: unable to test
XII: unable to assess.
-Motor: No movement to noxious throughout. Pt spontaneously
moves his LUE and his LLE (but the LUE much more so).
-Sensory: no response to noxious as above
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was mute bilaterally.
-Coordination: unable to test
-Gait: deferred
Physical Exam on Discharge:
Pertinent Results:
Labs on Admission:
137 / 100 / 19
--------------< 158
3.5 / ___ / 0.7
10.5 >-----< 246
41.5
___: 10.3 PTT: 27.1 INR: 0.9
Lactate:2.3
Stox: negative
Utox: negative
UA: negative for UTI
EKG: sinus tachycardia with LVH and inferior lateral ST-T
changed may be secondary to hypertrophy and/or ischemia
Radiologic Data:
Non-Contrast CT of Head ___: large left basal ganglia
hemorrhage with intraventricular extension measuring 2.7 x 4.8 x
2.8cm with surrounding edema and mass effect with 8mm rightward
shift of midline structures. It is likely starting to extend
into the midbrain with edema in the pons. The left suprasellar
cistern is minimally
effaced (2:8) concerning for downward transtentorial herniation.
Ventricular nlargement out of proportion to sulci may indicate
early hydrocephalus.
CTA H&N: No occlusion, dissection or stenosis in the neck.
Calcifications in the proximal ICA just beyond the bifurcation
b/l without significant stenosis. No occlusion, stenosis or
aneurysm >3mm in the head.
NCHCT ___
Large left ___ ganglia hemorrhage with extension into the
bilateral lateral ventricles, ___ ventricle and ___ ventricle is
unchanged with interval placement of left frontal approach
ventriculostomy catheter in satisfactory position. No new
hemorrhage is seen with sliver of right frontal subarachnoid
hemorrhage again demonstrated. Basal cisterns remain patent.
IMPRESSION:
Status post ventriculostomy catheter placement with unchanged
left basilar
ganglia hemorrhage.
NCHCT ___. No significant interval change in the left basal ganglia
hemorrhage with
intraventricular extension, and associated mass effect.
2. The orogastric tube is coiled in the nasopharynx.
NCHCT ___
Unchanged left basal ganglia hemorrhage and effacement of local
sulci and the left lateral ventricle along with intraventricular
hemorrhage.
Ventriculostomy catheter is unchanged in appearance with slight
interval
increase in blood surrounding the catheter in the left frontal
lobe.
EEG ___
This is an abnormal continuous EEG recording due to asymmetric
background slowing on the left posterior temporal-occipital
region with a
relative attenuation of faster frequencies indicative of
moderate
encephalopathy with focal cortical dysfunction over the
corresponding
cortices consistent with the patient's history of left
intraparenchymal
hemorrhage. There are frequent runs lasting seconds to minutes
of diffuse
polymorphic delta activity suggestive of moderate encephalopathy
but non-
specific etiology. There is frequent focal slowing over the
right temporal
region with moderately high voltage delta/theta waves suggestive
of
subcortical dysfunction. There are no epileptiform discharges or
seizures
recorded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever, pain
RX *acetaminophen 500 mg/5 mL 5 ML by mouth three times daily as
needed Disp #*1 Bottle Refills:*11
2. Amantadine 100 mg PO BID
RX *amantadine 100 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*11
3. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*11
4. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*11
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*11
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 by mouth twice daily Disp
#*60 Tablet Refills:*11
7. Tucks Hemorrhoidal Oint 1% ___AILY
RX *pramoxine-mineral oil-zinc [Tucks] 1 %-12.5 % 1 Ointment(s)
rectally daily Disp #*30 Packet Refills:*11
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl [Acid Control] 150 mg 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*11
9. Nystatin Oral Suspension 5 mL PO QID:PRN oral thrush
RX *nystatin 100,000 unit/mL 5 ml by mouth 4 times daily Disp
#*1 Bottle Refills:*6
10. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*11
11. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*11
12. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Disp
#*1 Bottle Refills:*3
13. Enoxaparin Sodium 30 mg SC Q12H
RX *enoxaparin 30 mg/0.3 mL 1 syringe twice daily Disp #*60
Syringe Refills:*11
Discharge Disposition:
Home
Discharge Diagnosis:
Left intraparenchymal hemorrhage
hypertension
Discharge Condition:
Neuro exam:
He opens his eyes spontaneously and is able to fixate gaze, Does
not follow commands. Occassionally tries to speak. Leftward gaze
preference but can cross the midline. Left arm and leg moves
spontaneously at least antigravity. Right arm extends to noxious
and has increased tone. There triple flexion of the right leg to
noxious stimuli.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ male with possible endotracheal tube leak.
FINDINGS: Comparison is made to previous study from ___ at 2:59
a.m.
There is an endotracheal tube whose distal tip is 4.8 cm above the carina. No
mediastinal air is seen. There is a feeding tube and right-sided subclavian
catheter which appear appropriately sited and stable. There is mild elevation
of the right hemidiaphragm. There is minimal prominence of the pulmonary
vascular markings without pulmonary edema. There is atelectasis at the right
lung base. Heart size is upper limits of normal but stable.
Radiology Report
HISTORY: Intracranial hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast.
COMPARISON: ___.
FINDINGS:
Large left intraparenchymal hemorrhage centered in the basal ganglia with
extension into the left lateral ventricle and, to a lesser degree, the ___,
___ and right lateral ventricles is unchanged. Ventricular size is unchanged
without evidence of significant obstructive hydrocephalus persistent mild
ventricular enlargement out of proportion to sulcal size is noted. Minimal
surrounding edema is seen along with effacement of sulci within the left
cerebral cortex. The basal cisterns remain patent. No new sites of bleeding
are seen aside from minimal subarachnoid blood within the right frontotemporal
sulci (2:20 and 12) which might reflect redistribution given the presence of
significant intraventricular blood. Imaged paranasal sinuses and mastoid air
cells are unremarkable. Likely unchanged 7-8 mm rightward shift of midline
structures is noted. There is no fracture.
IMPRESSION:
Essentially unchanged large left basal ganglia hemorrhage with
intraventricular extension without change in the degree of ventricular size
and sulcal effacement. Likely unchanged 7-8 mm rightward shift of midline
structures. Trace right subarachnoid hemorrhage could be due to
redistribution.
Radiology Report
HISTORY: Left basal ganglia hemorrhage and intraventricular extension, assess
ventricular drainage placement.
TECHNIQUE: Contiguous axial images were obtained of the brain without
intravenous contrast.
COMPARISON: CT from 6 hours prior.
FINDINGS:
Large left ___ ganglia hemorrhage with extension into the bilateral lateral
ventricles, ___ ventricle and ___ ventricle is unchanged with interval
placement of left frontal approach ventriculostomy catheter in satisfactory
position. No new hemorrhage is seen with sliver of right frontal subarachnoid
hemorrhage again demonstrated. Basal cisterns remain patent.
IMPRESSION:
Status post ventriculostomy catheter placement with unchanged left basilar
ganglia hemorrhage.
Radiology Report
INDICATION: Left basal ganglia hemorrhage. Intubated. Assess for interval
change.
COMPARISON: Chest radiograph from ___.
FINDINGS: The endotracheal tube is appropriately positioned, ending 6 cm
above the level of the carina. A right subclavian central venous catheter
ends in the low SVC. An enteric catheter courses below the level of the
diaphragm and out of the field of view inferiorly. There is central pulmonary
vascular congestion without frank interstitial pulmonary edema. Subsegmental
left retrocardiac atelectasis is not significantly changed. Mild elevation of
the right hemidiaphragm is not significantly changed. Mild cardiomegaly is
similar in appearance. The mediastinal contours are unchanged. There are no
pleural effusions. No pneumothorax is seen.
IMPRESSION:
1. Appropriately positioned lines and tubes.
2. Unchanged subsegmental left retrocardiac atelectasis and mild
cardiomegaly.
Radiology Report
HISTORY: ___ male with ___ ganglia hemorrhage. Repeat evaluation.
TECHNIQUE: Contiguous axial images obtained from skullbase to vertex without
intravenous contrast.
COMPARISON: Head CT from ___.
FINDINGS:
When compared to most recent exam, there has been no significant interval
change. Again seen is a parenchymal hemorrhage centered in the left basal
ganglia. Component involving the left caudate head appears slightly smaller
compared to prior. The interventricular extension into the dependent portions
of the lateral ventricles and ___ ventricle. Less extensive component seen
within the aqueduct of Sylvius and ___ ventricle. Subarachnoid blood is seen
in the right frontal region region again seen, and potentially within the left
sylvian fissure as well unchanged. There is approximately 5 mm of rightward
shift of midline structures, not significantly changed. There is persistent
effacement of the sulci on the left. Basilar cisterns remain patent.
Ventriculostomy catheter is in unchanged position via left frontal burr hole.
The ventricles are stable in configuration. There is no evidence of new
hemorrhage or increased mass effect.
IMPRESSION:
No significant interval change of left basal ganglia hemorrhage extending into
the ventricles with additional foci of subarachnoid blood. Unchanged midline
shift to the right of approximately 5 mm.
Radiology Report
REASON FOR EXAMINATION: Basal ganglia hemorrhage, assessment for interval
change.
In comparison to prior radiograph from ___, the current AP
radiograph demonstrates interval development of pulmonary edema, interstitial,
mild as well as right lower lobe consolidation concerning for aspiration
versus interval development of infectious process. Tubes and lines are in
unchanged position. Small amount of pleural effusion cannot be excluded.
Radiology Report
HISTORY: Left basal ganglia hemorrhage.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
DLP: 113___.___ mGy-cm.
COMPARISON: Multiple NECT of the head studies dated ___ at 20:38 and 8:24, CTA of the head and neck ___.
FINDINGS:
Compared to the study from ___, there has been no significant
interval change. Again seen is an intraparenchymal hemorrhage centered in the
left basal ganglia and dissecting into the left lateral ventricle.
Intraventricular blood is stable in extent. A small amount of subarachnoid
blood is again seen in the left sylvian fissure. 5 mm rightward shift of
midline structures is unchanged. There is persistent effacement of the sulci
on the left. The basilar cisterns are not compressed. A left frontal
approach ventriculostomy catheter remains in place with its tip at the left
foramen of ___, unchanged. Small amount of blood along the course of the
cathether is stable. The ventricles are stable in size. There is no evidence
of new hemorrhage or increased mass effect.
There is mild bilateral mucosal thickening in the maxillary and ethmoid
sinuses, and fluid in the sphenoid sinuses, likely related to endotracheal
intubation and orogastric tube placement. The orogastric tube is coiled in
the nasopharynx.
IMPRESSION:
1. No significant interval change in the left basal ganglia hemorrhage with
intraventricular extension, and associated mass effect.
2. The orogastric tube is coiled in the nasopharynx.
The results were discussed with Dr. ___ the telephone by Dr. ___
___ on ___ at 15:08.
Radiology Report
TYPE OF EXAMINATION: Chest, AP portable single view.
INDICATION: ___ male patient with NG tube placed, evaluate position.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next preceding similar
study obtained 12 hours earlier during the same date. The patient remains
intubated, the ETT in unchanged position. The same holds for the right
subclavian central venous line terminating in the lower SVC. A newly placed
NG tube is seen to reach well into the stomach and terminates pointing towards
the pylorus just about to enter the duodenum. No other significant interval
changes can be identified. Comparison of the pulmonary vasculature suggests
that the episode of pulmonary congestion encountered 12 hours ago has again
normalized and is similar to that observed on the morning of ___.
Radiology Report
HISTORY: ___ male with left basal ganglia hemorrhage and fever.
COMPARISON: ___.
FINDINGS: Portable supine chest radiograph demonstrates superior migration of
the endotracheal tube which is now located at least 6.3 cm from the level of
the carina, with the change in position likely the result of the change in
neck extension. An NG tube is in place, its tip is not seen below the
inferior margin of the film. An esophageal temperature probe is in place. A
right subclavian central venous catheter tip is located at the cavoatrial
junction.
The lungs are clear, with somewhat low lung volumes. There is no pleural
effusion or pneumothorax. The cardiac silhouette and mediastinal contours are
unchanged.
IMPRESSION:
1. ETT tube now at least 6.3 cm from the carina, suggest advancement for more
optimal positioning.
2. No acute chest abnormality.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with left basal ganglia
hemorrhage, interval change.
AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is approximately 6.5 cm above the carina. The NG tube tip is
in the stomach. The right subclavian line tip is at the cavoatrial junction.
The heart size and mediastinum are unchanged in appearance, though there is
slight interval progression of interstitial pulmonary edema, mild. No
definitive increase in pleural effusion or pneumothorax demonstrated.
Radiology Report
INDICATION: Intracranial hemorrhage due to hypertension, with external
ventricular drain. Evaluate for ileus.
No prior examinations for comparison.
ABDOMEN, AP, SUPINE AND LEFT LATERAL DECUBITUS: Nasogastric tube terminates
in the stomach. There is relative paucity of gas in the abdomen. Moderate
retained fecal material throughout the colon. No free air.
IMPRESSION: Paucity of bowel gas, with moderate retained fecal material.
Radiology Report
HISTORY: Large left-sided basal ganglia hemorrhage with intraventricular
hemorrhage likely secondary to hypertension status post EVD placement.
TECHNIQUE: Contiguous axial helical MDCT images were obtained through the
brain without administration of IV contrast.
DLP: 936.6 T2 mGy-cm.
COMPARISON: Multiple nonenhanced CT head examinations dating back to ___, CTA head and neck ___.
FINDINGS:
There has been no significant change from the ___ study. Again
seen is a large intraparenchymal hemorrhage centered in the left basal ganglia
and dissecting into the left lateral ventricle and left temporal lobe.
Intraventricular blood is stable in extent. Unchanged small amounts of
subarachnoid blood is again seen in the left sylvian fissure and perhaps
slightly along the Rolandic fissure. 5 mm rightward shift of midline
structures is unchanged. There is persistent effacement of the sulci on the
left. The basilar cisterns are not compressed. A left frontal approach
ventriculostomy catheter remains in place with the tip at the left foramina of
___ unchanged. A small amount of blood along the catheter is unchanged.
The ventricles are stable in size. There is no evidence of new hemorrhage or
increased mass effect.
Again seen is mild mucosal thickening in the maxillary and ethmoid sinuses and
fluid layering in the sphenoid sinuses likely related to endotracheal tube
placement.
IMPRESSION:
No significant interval change in the left basal ganglia hemorrhage with
intraventricular extension and associated mass effect.
Radiology Report
AP CHEST, 4:42 A.M. ON ___
HISTORY: ___ man with cerebral hemorrhage.
IMPRESSION: AP chest compared to 9 and 11:
Lung volumes are lower today than on ___, exaggerating and interval
development of mild pulmonary edema. It also exaggerates mild cardiomegaly
and the increase in caliber of the mediastinal veins, but findings suggest
volume overload. Upper enteric drainage tube passes into the stomach and out
of view. Tip of an endotracheal tube is no less than 7 cm from the carina
with the chin partially flexed. It should be advanced at least 3 cm for more
secure seating. Dr. ___ was paged at 9:50 a.m. when the findings
were recognized.
Radiology Report
HISTORY: Large left basal ganglia hemorrhage with intraventricular extension
likely secondary to hypertension, status post ventriculostomy catheter.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast.
COMPARISON: ___.
FINDINGS:
Large left basal ganglia hemorrhage with extension into the left lateral
ventricle and surrounding edema are unchanged. A left frontal approach
ventriculostomy catheter terminates in the region of the ___ ventricle with
minimal interval increase in surrounding hemorrhage along the catheter tract
within the left frontal lobe (2:19). Local sulcal effacement and mass effect
upon the left lateral ventricle is unchanged with patent basal cisterns.
Persistent 5 mm rightward shift of the midline structures is noted. No new
foci of hemorrhage are identified with poor visualization of the right-sided
subarachnoid blood. The imaged paranasal sinuses and mastoid air cells
demonstrate fluid in the ethmoid and sphenoid air cells.
IMPRESSION:
Unchanged left basal ganglia hemorrhage and effacement of local sulci and the
left lateral ventricle along with intraventricular hemorrhage.
Ventriculostomy catheter is unchanged in appearance with slight interval
increase in blood surrounding the catheter in the left frontal lobe.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intracranial hemorrhage, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the endotracheal tube, the
nasogastric tube and the right subclavian catheter are in unchanged position.
The mild-to-moderate pulmonary edema is constant. Constant moderate
cardiomegaly. Bilateral basal areas of atelectasis. No larger pleural
effusions. No parenchymal opacities. No evidence of pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pulmonary edema, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices, including the very highly
positioned endotracheal tube, are constant. Consideration of advancing the
tube by 2-3 cm should be made.
Overall, low lung volumes. Moderate cardiomegaly with mild fluid overload and
retrocardiac atelectasis. No larger pleural effusions.
Radiology Report
INDICATION: ___ man with left basal ganglia hemorrhage, status post
EVD with increased intracranial pressure.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
DLP: 1131 mGy-cm.
CTDI VOLUME: 70.7 mGy.
COMPARISON: ___, and multiple prior CTs dating back to ___.
FINDINGS:
Large left basal ganglia hemorrhage with extension into the left lateral
ventricle is redemonstrated. Parenchymal hemorrhage shows decreased density,
however, surrounding edema and mass effect with 5.9 mm rightward shift of the
midline are relatively unchanged compared to the prior study. There is
interval enlargement of the verntricles. Left frontal approach ventriculostomy
catheter is unchanged in position with the tip remains in the region of the
foramen of ___. No new hemorrhage is seen. The basal cisterns are patent.
No fractures are identified. The visualized paranasal sinuses demonstrate
mild thickening within the maxillary sinuses as well as moderate opacification
of the ethmoid air cells and sphenoid sinuses, unchanged. Mastoid air cells
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Evolving left basal ganglia hemorrhage with unchanged edema and mass
effect.
2. Interval increase in the size of the ventricles, with unchanged position
of the ventriculostomy catheter.
Radiology Report
HISTORY: ___ male status post EVD placement evaluate for ileus
COMPARISON: ___.
FINDINGS:
The nasogastric tube terminates in the stomach with side port in the gastric
body. There is relative paucity of gas within the small bowel. Distended
air-filled loop of the transverse colon is noted. No free air.
Radiology Report
HISTORY: Large left basal ganglia hemorrhage, with interventricular
hemorrhage, likely secondary to hypertension, status post EVD placement.
Evaluate for interval change.
TECHNIQUE: Contiguous axial images CT images were obtained through the brain
without administration of IV contrast.
DLP: 990 mGy-cm.
CTDIvol: 70.7 mGy.
COMPARISON: NECT Head from ___ .
FINDINGS:
Again seen is a large left basal ganglia intraparenchymal hemorrhage with
extension into the ventricular system. Surrounding edema and mass-effect, with
approximately 10 mm rightward shift of midline structures, are unchanged
compared to the prior study. The third ventricle remains shifted to the right
and compressed. Enlargement of the lateral ventricles is stable compared to
___, though increased since ___. The left frontal approach
ventriculostomy catheter terminates near the left foramen of ___, as before,
with stable small amount of blood along its parenchymal course. No new
hemorrhage is seen. The basal cisterns are patent.
Mild mucosal thickening within the maxillary sinuses is unchanged. Complete
opacification of the left sphenoid sinus and moderate mucosal thickening with
aerosolized secretions within the right sphenoid sinus are relatively stable,
and probably related to prolonged supine positioning. Also noted are partial
opacification of the right mastoid air cells, complete opacification of the
left mastoid air cells, and partial opacification of the left middle ear
cavity, unchanged, likely also secondary to prolonged supine positioning.
IMPRESSION:
1. Stable left basal ganglia hemorrhage with intraventricular extension, and
stable associated mass effect.
2. Stable compression of the third ventricle. Enlargement of the lateral
ventricles is stable since ___ but increased since ___. Unchanged
position of the ventriculostomy catheter.
Radiology Report
HISTORY: ___ male with intracranial hemorrhage, now status post
external ventricular drain placement.
COMPARISON: ___ - ___.
FINDINGS: Portable upright chest radiograph demonstrates an endotracheal tube
with its tip at the level of the clavicular heads. An NG tube passes through
the stomach, and a right subclavian central venous catheter tip is at the
cavoatrial junction.
There is an interval decrease in lung volumes; small bilateral pleural
effusions and bibasilar atelectasis is mild and increased. The cardiac
silhouette is enlarged and unchanged. The mediastinal contours are little
changed. Pulmonary vasculature is normal and improved.
IMPRESSION:
1. Endotracheal tube projects just beyond the thoracic inlet, and might be
advanced 1.5 cm for more optimal seating.
2. Interval decrease in lung volumes with increase in bibasilar atelectasis
and small bilateral pleural effusions, although edema has improved.
Radiology Report
HISTORY: ___ man with basal ganglia hemorrhage, rising intracranial
pressure despite cooling, paralysis, hypertonic saline. Please evaluate for
interval change.
TECHNIQUE: Contiguous axial unenhanced CT images were obtained through the
brain without the administration of IV contrast.
DLP: 1373 mGy-cm.
CTDIvol: 70.7 mGy.
COMPARISON: ___.
FINDINGS:
Again seen is a large left basal ganglia hemorrhage with surrounding edema and
mass effect on the left lateral ventricle and the third ventricle and shift of
midline structures to the right, relatively unchanged compared to the prior
study. The hematoma extends into the ventricular system with blood seen
layering within the occipital horns of the lateral ventricles.
Ventriculostomy catheter through a left frontal burr hole with the tip to the
left of the foramen ___ and ___ along the parenchymal course of the
catheter remains unchanged. No new hemorrhage is seen. The basal cisterns are
patent.
No fracture is identified. Mild mucosal thickening within the maxillary
sinuses, complete opacification of the left sphenoid sinus, moderate mucosal
thickening of the right sphenoid sinus, partial opacification of the right
mastoid air cells, complete opacification of the left mastoid air cells, and
partial opacification of the left middle ear cavity are unchanged and likely
secondary to prolonged supine positioning and intubation. The orogastric tube
appears to have coiled in the oropharynx, however, a chest radiograph from the
same date demonstrates passage into the stomach.
IMPRESSION:
1. Left basal ganglia hemorrhage with intraventricular extension, surrounding
edema and mass effect with midline shift is virtually unchanged compared to
the prior study.
2. Enlargement of the lateral ventricles stable since ___ but increased
since ___. Unchanged position of the ventriculostomy catheter.
Radiology Report
REASON FOR EXAMINATION: Elevated intracranial pressure, assessment of the ET
tube placement.
AP radiograph of the chest was compared to ___.
The AP radiograph of the chest demonstrates the ET tip being 6.4 cm above the
carina. The right subclavian line tip is at the cavoatrial junction. The NG
tube tip passes below the diaphragm, most likely terminating in the stomach.
Heart size and mediastinum are unchanged, but there is interval development of
minimal interstitial edema. There is also increase in the right lower lobe
atelectasis.
Radiology Report
INDICATION: Patient with large left basal ganglia hemorrhage. Status post
ventriculostomy catheter placement. Assess for interval change.
COMPARISONS: ___ and ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained at
5 mm slice thickness without intravenous contrast.
FINDINGS:
There is interval removal of the preexisting ventriculostomy catheter with a
left frontal approach. There is stable hemorrhage along its course with new
locules of gas, which likely relate to its removal (2:18). There is interval
introduction of the new ventriculostomy catheter with right frontal approach
traversing the frontal horn of the right lateral ventricle, septum pellucidum,
its tip abutting the inferior aspect of the left basal ganglia hemorrhage
(2:13). Again noted a large intraparenchymal hemorrhage centered in the left
basal ganglia, which is essentially unchanged since ___ exam, now
measuring 2.9 x 2.1 cm (2:15). Small amount of blood products are seen
layering within the occipital horns of the lateral ventricles, unchanged
(2:19). No new intracranial hemorrhage is detected. There is extensive
vasogenic edema which surrounds the left basal ganglia hemorrhage with
associated mass effect. There is persistent rightward shift of normally
midline structures, measuring 8 mm, previously 11 mm. There is persistent
mass effect on the third ventricle, which appears compressed and deviated to
the right. There is no vascular territorial infarction. The basal cisterns
are minimally effaced. Sphenoid sinuses remain opacified. Moderate amount of
secretions are seen at the level of the nasopharynx, which likely relate to
patient's intubation. The frontal sinuses are clear. The left mastoid air
cells are under-pneumatized. The right mastoid air cells are well aerated.
No acute fracture is detected.
IMPRESSION:
Interval removal of the pre-existing left ventriculostomy catheter with left
frontal approach. Stable areas of hemorrhage and new locules of gas along its
course likely relate to its removal. Interval placement of the new
ventriculostomy catheter with right frontal approach with its tip abutting the
inferior aspect of the left basal ganglia hemorrhage (2:13). No significant
change in left basal ganglia, ventricular hemorrhage. No new intracranial
hemorrhage. Stable edema, mass effect and persistent rightward shift of
normally midline structures.
Radiology Report
HISTORY: Left subclavian placement.
FINDINGS: In comparison with the study of ___, there has been placement of a
left subclavian catheter that extends to the mid portion of the SVC. Other
monitoring and support devices are essentially unchanged. There is continued
enlargement of the cardiac silhouette with elevated pulmonary venous pressure.
The right hemidiaphragm is now sharply seen. However, there is continued
opacification at the left base with poor definition of the hemidiaphragm,
consistent with substantial volume loss in the left lower lobe with probable
associated effusion.
Radiology Report
EXAM: MRI BRAIN.
CLINICAL INFORMATION: Patient with right basal ganglia hemorrhage. Evaluate
for stroke.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial
images of the brain were acquired. Comparison was made with the CT of
___.
FINDINGS: There is a large left basal ganglia subacute hemorrhage identified.
The hemorrhage extends to the left lateral ventricle. There is edema in the
surrounding region. Extensive periventricular hyperintensities are seen.
Bilateral ventriculostomy catheters are identified, with a tract on the left
side and a catheter extending from the right. There are extensive areas of
slow diffusion seen within the areas of hemorrhage which could be due to blood
products. However, there are also adjacent areas of restricted diffusion
which could be secondary to infarcts. The restricted diffusion is seen within
the ventricles is due to blood products.
There are multiple areas of chronic microhemorrhages seen in both cerebral
hemispheres in the supratentorial region as well as in the brainstem and
cerebellum. There is no evidence of midline shift. There is no evidence of
transtentorial herniation. Soft tissue changes are seen in the mastoid air
cells and visualized sinuses.
IMPRESSION:
1. Left thalamic hemorrhage extending to the lateral ventricles with blood
products within the thalamus and in the ventricles showing restricted
diffusion. Additionally, there are areas of restricted diffusion adjacent to
the blood products which involve the left temporal lobe and left
frontoparietal region which are suggestive of associated infarcts in the
adjacent brain.
2. Multiple microhemorrhages in both cerebral and infratentorial brain.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Indwelling support and monitoring devices are remarkable for
removal of right subclavian catheter with no visible pneumothorax. Tip of
left subclavian catheter is directed towards the lateral wall of superior vena
cava, without change. Cardiac silhouette remains enlarged, and is accompanied
by pulmonary vascular congestion, slightly improved from the prior exam. Left
perihilar haziness probably reflects asymmetrical edema, but radiographic
followup would be helpful to exclude a developing pneumonia in the appropriate
clinical setting.
Radiology Report
PORTABLE CHEST ___.
COMPARISON: ___ radiograph.
FINDINGS: Indwelling support and monitoring devices are remarkable only for
slightly proximal location of the endotracheal tube, terminating 5.5 cm above
the carina with the neck in a flexed position. Persistent cardiomegaly and
pulmonary vascular congestion accompanied by interstitial edema. Worsening
left retrocardiac opacity is probably due to a combination of atelectasis and
effusion.
Radiology Report
AP CHEST, 2:59 A.M. ___
HISTORY: Basal ganglia hemorrhage. Check EVD placement.
IMPRESSION: AP chest compared to ___, 1:54 p.m.
Upper enteric drainage tube passes into the mid-portion of a nondistended
stomach. Left subclavian line ends in the upper SVC. Tracheostomy tube in
standard placement. Moderate cardiomegaly is longstanding. Lung volumes have
improved and bibasilar atelectasis has substantially decreased, but there is
still pulmonary vascular congestion. Pleural effusions are small. No
pneumothorax.
Radiology Report
TYPE OF EXAMINATION: Chest, AP portable single view.
INDICATION: ___ male patient with large left basal ganglia hemorrhage
with intravascular hemorrhage likely. Now status post EVD placement, status
post tracheostomy.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next preceding supine
chest examination of ___. The patient was intubated and has now
received a tracheostomy cannula which is seen to be in correct intratracheal
position with the tube lower point terminating some 3 cm above the level of
the carina. No pneumothorax has developed. A previously existing left
subclavian approach central venous line remains in unchanged position. Also,
a previously existing NG tube remains in unchanged position terminating in the
lower abdomen, probably in the expanded fundus of the stomach. No new
pulmonary parenchymal infiltrates can be identified in comparison with the
next preceding portable chest examination. No pneumothorax has developed.
Radiology Report
INDICATION: Post-tracheostomy tube and PEG placement.
COMPARISON: Radiographs available from ___.
FRONTAL ABDOMINAL RADIOGRAPHS: A PEG is appropriately positioned at the mid
abdomen, located next to the tip of a nasogastric tube. A non-obstructive
bowel gas pattern is demonstrated. No free air is appreciated, although
supine orientation with lower sensitivity for detection of pneumoperitoneum.
There is a small amount of ascites. Small bilateral pleural effusions are
better appreciated on the chest radiograph performed earlier.
IMPRESSION:
1. PEG and NG tubes in appropriate positions.
2. Small amount of ascites.
Radiology Report
HISTORY: Patient with basal ganglia hemorrhage without hydrocephalus.
TECHNIQUE: Axial images of the head were obtained without contrast.
COMPARISON: Comparison was made to the MRI of ___ and CT of ___.
FINDINGS:
Left-sided basal ganglia hemorrhage again identified with surrounding
hypodensity. There is further evolution of blood products. There remains
some mass effect on the ___ ventricle as well as on the left lateral ventricle
which is decreased compared to the prior study. There is slight prominence of
both temporal bones seen which is not significantly changed. The right frontal
ventricular drain tip remains in the left lateral ventricle and slightly
anteriorly as before. Small amount of blood is again seen in the left frontal
region, possibly at the site of previous placement of ventricular drain.
IMPRESSION:
Left basal ganglia hemorrhage and some intraventricular blood are again
identified. Although there remains slight prominence of temporal horns it is
not significantly changed since the previous MRI examination. The mass effect
on the left lateral ventricle has decreased. No new hemorrhage.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with left basal ganglia
hemorrhage.
Portable AP radiograph of the chest was compared to ___.
Tracheostomy is in place. The NG tube is not seen, potentially withdrawn.
Heart size and mediastinum are unchanged in appearance. Lung volumes are
slightly lower with overall no interval development of new consolidations in
addition to pre-existing left retrocardiac atelectasis is seen. There is no
pneumothorax.
Radiology Report
INDICATION: ___ male with a history of a left basal ganglia
hemorrhage, status post PICC line placement.
COMPARISONS: Chest radiographs from ___,
___, and ___.
TECHNIQUE: AP portable chest radiograph.
FINDINGS: There is a left-sided PICC line which terminates in the mid SVC.
The tracheostomy is in place. The heart size and mediastinum are unchanged in
appearance. Again, the lung volumes are low; however, there has been no
interval development of any consolidations. Again seen is pre-existing left
retrocardiac atelectasis. There is no pneumothorax or pleural effusions.
IMPRESSION:
Left-sided PICC line which terminates in the mid SVC.
These findings were discussed with ___ at 9:51am by Dr. ___ by
telephone on the day of the exam.
Radiology Report
AP CHEST, 7:53 A.M. ON ___.
HISTORY: ___ man with hemorrhagic stroke and fever, possible
pneumonia.
IMPRESSION: AP chest compared to ___ through ___:
Moderate cardiomegaly has been present throughout, though today, there is no
pulmonary edema. Consolidation in the left lower lobe has worsened, now
obscuring nearly the entire diaphragmatic interface. Whether this is
pneumonia or atelectasis is difficult to say since the appearance has been
similar on many of the chest radiographs over the past 10 days. Small left
pleural effusion may have developed, often seen with persistent lower lobe
collapse. Left PIC line ends in the mid SVC. Tracheostomy tube in standard
placement. No pneumothorax.
Radiology Report
INDICATION: ___ man with left intraparenchymal hemorrhage, who
presents for evaluation of aspiration.
COMPARISONS: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered. This was a limited exam secondary to patient's
difficulty in following instructions.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. There was no gross aspiration. There was evidence
of penetration with thin liquids. There is also delayed swallowing. For
further details, please refer to the speech and swallow division note in OMR.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with left basal ganglia hemorrhage.
FINDINGS: No prior studies for comparison.
There has been placement of an endotracheal tube whose distal tip is 4 cm
above the carina at the level of the aortic knob, appropriately sited. There
is a nasogastric tube whose distal tip and side port are below the GE
junction. There is some elevation of the right hemidiaphragm. There is mild
prominence of the pulmonary vascular markings without overt pulmonary edema.
No focal consolidation or pneumothoraces are present. Heart size is upper
limits of normal.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: UNRESPONSIVE
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You were admitted to the hospital
after being found unconscious at work. You were found to have a
cerebral hemorrhage (bleeding in the brain) that required tubes
to be placed for drainage for a period of time. The cause of
this bleed was likely uncontrolled high blood pressure. It is
important that you continue all blood pressure medications in
order to prevent future bleeding.
You were also found to have a right vocal cord partial
paralysis. Dr. ___ injected the cord which may
strengthen it. Your tracheostomy has been removed and will heal
gradually.
Please continue all medications as instructed and attend follow
up appointments as scheduled below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left pneumothorax
Major Surgical or Invasive Procedure:
VATS LUL blebectomy w/ mechanical pleurodesis
History of Present Illness:
___ is an otherwise healthy ___ old who presents with a
left-sided pneumothorax. He was walking home last night and had
acute onset left-sided chest pain. He did not take anything for
the pain, went to bed without difficulty, but the pain persisted
this AM and he presented to his ___ Health Services for
evaluation. They noted an "abnormal EKG" and sent him to ___ for further evaluation. He reports mild shortness of
breath, and chest pain that is worse with deep inspiration, but
review of systems was otherwise negative. No previous history of
pneumothorax.
Past Medical History:
N/A
Social History:
Does not smoke, drink alcohol or use any illicit drugs
Originally from ___, college student at ___
studying ___, wants to work ___
Physical Exam:
Physical Exam
Asymmetric chest
slight coarse/ diminished breath sounds at superior left chest;
basilar clear
no adventitious sounds on right; ant and post chest with
dermabond. slight serous strikethourgh stain on occlusive dssg
on sup lat left chest
rrr, no m/r/g
abd soft nt nd, +bs
wwp,
heent nl
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six hours
Disp #*56 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
Please take as needed, narcotics may make you constipated.
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
per day Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive while taking narcotics.
RX *oxycodone 5 mg 1 capsule(s) by mouth every four hours Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
spontaneous pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with left pneumothorax, now s/p L VATS blebectomy, CT
placement // please eval for interval change please eval for interval
change
IMPRESSION:
In comparison with the study of ___, the pigtail catheter is been
removed and replaced with a chest tube with its tip in the apex. The degree
of pneumothorax has decreased, but the lung years certainly not re-expanded.
Otherwise no change.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old male with spontaneous PTX s/p vats blebectomy with
pleurodesis, // ?interval change s/p water seal ,please do at 0900
?interval change s/p water seal ,please do at 0900
IMPRESSION:
Comparison to ___. The known left-sided pneumothorax is unchanged
in extent. The left chest tube has been slightly pulled back. There is no
evidence of tension. Stable appearance of the heart and of the right lung.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man chest tube removed at 1015 // ?lung status, CXR
should be scheduled for 1415 thanks ?lung status, CXR should be scheduled
for 1415 thanks
IMPRESSION:
Comparison to ___, 09:14. The left chest tube has been removed.
The extent of the known left pneumothorax has slightly increased. The
diameter of the pneumothorax is now approximately 2.5 cm. There is no
mediastinal shift and no diaphragmatic depression. Otherwise, the radiograph
is unchanged.
Radiology Report
INDICATION: ___ year old man with spontaneous PTX s/p chest tube removal, had
enlarging ptx post pull // ?status of PTXCXR at 1800 thanks
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ from earlier in the day
FINDINGS:
Since the prior chest radiograph, there has been no appreciable difference in
the size of the known left pneumothorax. No mediastinal shift or
diaphragmatic depression.
The lungs are otherwise clear.
IMPRESSION:
Unchanged moderate left pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with chest pain, decreased breath sounds // ?ptx
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. There is a large left-sided
pneumothorax with significant collapse of the left lung. There is minimal
tracheal deviation to the right though no convincing signs of tension
pneumothorax. No pleural effusion. Right lung is clear. Heart size is
normal.
Bony structures intact.
IMPRESSION:
Large left pneumothorax, no convincing signs of tension.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with pneumothorax s/p pigtail
COMPARISON: Prior exam from earlier today
FINDINGS:
AP portable upright view of the chest. There has been interval placement of
a left-sided pigtail chest tube with significant re-expansion of the left
lung. There is persistent trace left apical pneumothorax seen. Right lung
remains well aerated. Cardiomediastinal silhouette is unremarkable. Bony
structures are intact.
IMPRESSION:
Interval placement of the left pigtail chest tube with near complete
reexpansion of the left lung with only trace persistent left apical
pneumothorax.
Radiology Report
EXAMINATION: Chest x-ray PA and lateral
INDICATION: ___ year old man with L spont PTX // check interval changewith CT
on waterseal
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made to chest x-rays dated ___
FINDINGS:
In comparison with a prior chest x-ray dated ___ there is now a
reaccumulation of pneumothorax with left-sided pigtail chest tube overlying
interface of long and pleural space and associated subsequent mild rightward
mediastinal shift. The right lung appears well aerated and clear. The
cardiomediastinal silhouette is normal and unchanged.
IMPRESSION:
Interval reaccumulation of pneumothorax and subsequent mild rightward
mediastinal shift when compared to most recent study
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:57 ___, 10 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Pneumothorax, unspecified
temperature: 98.0
heartrate: 100.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 69.0
level of pain: 6
level of acuity: 2.0 | * You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry. Your chest tube stitch
will be removed on next week by the ___.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours for pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you. |
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, Jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of ESRD s/p DDRT ___ failed
___ now back on ___ HD via RUE, CAD, bad peripheral vascular
disease, who is presenting after HD with jaundice and confusion.
The patient was apparently at HD and was noted to have some mild
confusion so was sent to the ED.
Of note, the patient was recently admitted from ___
for asymptomatic hypotension, hypoxemia, penile pain and an
ulcer overlying his fistula. His hypotension was atributed to
fluid shifts post dialysis and resolved on its own. His
hypoxemia resolved with UF. His penile pain was from a
hydrocele. He was discharged back to rehab with plans for
outpatient f/u regarding surgical care of his fistula.
Initial vitals in the ED: 97.3 98 105/52 14 99%
Labs notable for: WBC 13.7 (baseline), H/H 10.9/34.1, PLT 246,
Cr 1.9 (below baseline), glucose 66, Alk Phos 512, T.Bili 2.4,
lipase 10, TnT 0.33. Lactate 1.9.
Patient given: Dextrose, Oxycodone 10mg, Acetaminophen 650,
Folic acid, thiamine
Imaging: CXR with moderate bilateral pulmonary edema. CT Head
unremarkable.
Exam: A&Ox3. Notable for rhoncherous breath sounds. Guaiac
positive brown stool. Multiple excoriation over the left abdomen
and chest and fistula site. Scrotum enlared. Open sores on
coccyx and left upper back draining green/yellow drainage.
On the floor, patient is examined lying in bed. Reports some
mild pain on his various skin wounds. Denies any other
complaints. No fevers, chills, nausea, vomiting, diarrhea.
Patient is anuric. Reports mild SOB and lightheadedness.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia.
Past Medical History:
CAD, s/p multiple PCI to LAD, s/p CABG
(off-pump LIMA-LAD) ___.
RBBB/LAFB+Mobitz I block, s/p DDD pacemaker ___ ___ Sigma
___, ___ 4076 A/V leads).
Pacemaker-mediated tachycardia, s/p reprogramming ___.
Atrial flutter, s/p isthmus ablation ___.
Persistent AF, on warfarin.
Hypertension
Diabetic dyslipidemia.
Diastolic heart failure (EF 88%)
Peripheral arterial disease with 4 cm SFA occlusion s/p fem-tib
bypass (___) c/b cellulitis and wound dehiscence s/p
debridement and VAC placement ___ (Extensive debridement of
left thigh and calf, with total area of 30 x 5 cm full-thickness
skin and subcutaneous tissue debridement, including muscle and
fascia; Vacuum-assisted closure dressing application)
ESRD, s/p kidney txplant ___, allograft failure, on HD since
___. Obesity.
Sleep apnea.
Diabetes
Social History:
___
Family History:
His mother died of multiple myeloma at age ___. Father died at
age ___ as a casualty of war. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ON ADMISSION:
Vitals - T: 97.9 98/46 87 20 100% on 3L
GENERAL: NAD, A&Ox3
HEENT: AT/NC, EOMI, PERRL, ptosis of left eyelid. anicteric
sclera, pink conjunctiva, mucus membranes slightly dry
NECK: nontender supple neck
CARDIAC: bruit from fistula radiates throughout precordium. RRR,
S1/S2, no murmurs, gallops, or rubs
LUNG: diminished breath sounds at bilateral bases with crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: multiple erosive abrasions scattered on the back. Stage
___ sacral ulcer.
GU: swollen scrotum without skin breakdown. Penis not
visualized. Brown discharge leaking from meatus.
EXTREMITIES: 1+ edema. Left medial thigh with healing
wound/graft, well healing scar, scabs.
PULSES: dopplerable DP and ___ pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, scab on left heel.
ON DISCHARGE:
VS: Tmax 98.3 Tc T 97.7 HR ___ BP 90/45-124/65 RR ___ SpO2
91-92% RA, Wt not recorded, I/O 24h 450/NR, 8h NR/NR
GENERAL: NAD, A&Ox3
HEENT: AT/NC, EOMI, PERRL, ptosis of left eyelid, sclera
icterus, pink conjunctiva, mucus membranes slightly dry
NECK: Nontender supple neck
CARDIAC: bruit from fistula radiates throughout precordium. RRR,
S1/S2, no murmurs, gallops, or rubs
LUNG: diminished breath sounds at bilateral bases with crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: multiple erosive abrasions scattered on the back. Stage
___ sacral ulcer.
GU: swollen scrotum without skin breakdown. Penis not
visualized.
EXTREMITIES: Edematous UE, but improving. Left medial thigh with
healing wound/graft, well healing scar, scabs.
PULSES: DP and ___ pulses palpable bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, scab on left heel.
Pertinent Results:
ADMISSION LABS:
___ 05:50PM BLOOD WBC-13.7* RBC-3.59* Hgb-10.9* Hct-34.1*
MCV-95 MCH-30.4 MCHC-32.0 RDW-20.2* Plt ___
___ 11:38AM BLOOD WBC-12.8* RBC-3.56* Hgb-10.8* Hct-33.5*
MCV-94 MCH-30.4 MCHC-32.4 RDW-19.7* Plt ___
___ 05:50PM BLOOD Neuts-88.2* Lymphs-7.5* Monos-3.9 Eos-0.2
Baso-0.1
___ 05:50PM BLOOD ___ PTT-37.5* ___
___ 05:50PM BLOOD Plt ___
___ 05:50PM BLOOD Ret Aut-2.1
___ 05:50PM BLOOD Glucose-66* UreaN-8 Creat-1.9*# Na-140
K-4.4 Cl-99 HCO3-25 AnGap-20
___ 11:38AM BLOOD Glucose-71 UreaN-11 Creat-2.5* Na-142
K-4.3 Cl-99 HCO3-24 AnGap-23*
___ 05:50PM BLOOD ALT-21 AST-30 LD(LDH)-317* AlkPhos-512*
TotBili-2.4*
___ 11:38AM BLOOD ALT-21 AST-33 LD(___)-400* AlkPhos-485*
TotBili-2.6*
___ 05:50PM BLOOD Lipase-10 GGT-149*
___ 05:50PM BLOOD cTropnT-0.33*
___ 05:50PM BLOOD Albumin-2.3*
___ 11:38AM BLOOD Mg-1.7
___ 05:50PM BLOOD Hapto-126
___ 06:30AM BLOOD Vanco-17.6
___ 05:35AM BLOOD tacroFK-5.6
___ 12:25PM BLOOD ___ pO2-60* pCO2-43 pH-7.37
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 06:08PM BLOOD Lactate-1.9
___ 12:25PM BLOOD Lactate-1.8
___ 05:50PM BLOOD CA ___ -Test-within normal limits
DISCHARGE LABS:
___ 06:14AM BLOOD WBC-15.1* RBC-3.37* Hgb-10.1* Hct-31.9*
MCV-95 MCH-29.9 MCHC-31.6 RDW-20.1* Plt ___
___ 06:14AM BLOOD Plt ___
___ 06:14AM BLOOD Glucose-83 UreaN-20 Creat-3.8* Na-142
K-4.6 Cl-97 HCO3-22 AnGap-28*
___ 06:14AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
IMAGING:
EKG ___:
IMPRESSION:
Atrial fibrillation. Left axis deviation. Right bundle-branch
block with left anterior fascicular block. There are
non-diagnostic Q waves in the anterior leads. Compared to the
previous tracing of the same day there is no significant change.
Rate PR QRS QT/QTc P QRS T
76 ___ 0 -95 51
CHEST (PA & ___:
IMPRESSION:
Moderate pulmonary edema, bilateral small pleural effusions and
cardiomegaly.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. No acute intracranial process
2. Fluid in the bilateral mastoid air cells, right greater than
left.
Recommend correlation with symptoms.
LIVER OR GALLBLADDER US ___:
IMPRESSION:
1. Limited abdominal ultrasound demonstrates a coarsened hepatic
echotexture
which may be seen in cirrhosis. New abdominal ascites when
compared to
previous exam.
2. Cholelithiasis without ultrasound evidence for cholecystitis.
MICROBIOLOGY:
___ 6:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:03 am SWAB Source: Penis.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Clopidogrel 75 mg PO DAILY
6. Gabapentin 100 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB DAILY:PRN shortness of
breath
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Pravastatin 10 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. Tacrolimus 1 mg PO Q12H
14. Nephrocaps 1 CAP PO DAILY
15. Glucose Gel 15 g PO PRN hypoglycemia protocol
16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
17. FoLIC Acid 1 mg PO DAILY
18. Cheratussin AC (codeine-guaifenesin) ___ mg/5 mL oral
DAILY:PRN cough
19. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Clopidogrel 75 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Glucose Gel 15 g PO PRN hypoglycemia protocol
10. Ipratropium-Albuterol Neb 1 NEB NEB DAILY:PRN shortness of
breath
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*24 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Pravastatin 10 mg PO QPM
16. PredniSONE 5 mg PO DAILY
17. Tacrolimus 1 mg PO Q12H
18. Cheratussin AC (codeine-guaifenesin) ___ mg/5 mL oral
DAILY:PRN cough
19. Midodrine 2.5 mg PO TID
RX *midodrine 2.5 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
20. Midodrine 10 mg PO PRE HD
RX *midodrine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Altered Mental Status
Volume Overload
Jaundice
Hypotension
Hypoxia
Hyperbilirubinemia
End State Renal Disease (ESRD) s/p renal transplant
Secondary:
Scortal edema
Dysphagia
Periphal Vascular Disease
Atrial Fibrillation
Diastolic Heart Failure
Diabetes Mellitus
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: AP and lateral chest
INDICATION: ___ with AMS and cough on plavix
COMPARISON: None
FINDINGS:
Two-view chest provided. Dual lead pacer again noted as are midline sternotomy
wires. Cardiomegaly is re- demonstrated with small bilateral pleural effusions
and moderate pulmonary edema. Difficult to exclude a superimposed pneumonia.
IMPRESSION:
Moderate pulmonary edema, bilateral small pleural effusions and cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS and cough on plavix
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 891.93 mGy-cm
CTDI: 51.69 mGy
COMPARISON: CT of the head dated ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass. Again
seen is a small left cerebellar hemisphere chronic infarct, and a small
lacunar infarct along the posterior right putamen. Prominent ventricles and
sulci are consistent with age-related involutional change. Periventricular
white matter hypodensities are consistent with chronic small vessel ischemic
disease.
No osseous abnormalities seen. A mucus retention cyst is seen in the right
sphenoid sinus. Fluid is layering in the bilateral mastoid air cells, right
greater than left. The paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process
2. Fluid in the bilateral mastoid air cells, right greater than left.
Recommend correlation with symptoms.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ male with multiple comorbidities now with painless
jaundice.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT performed on ___. Abdominal ultrasound performed
on
FINDINGS:
LIVER: Hepatic parenchyma is coarsened in echotexture. There is a small amount
of abdominal ascites, new when compared to prior exams. There are no
suspicious hepatic lesions. There is no intrahepatic biliary ductal dilation.
The portal vein is patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 7 mm.
GALLBLADDER: There are gallstones within the gallbladder. There is no
gallbladder wall thickening.
PANCREAS: The pancreas is not visualized.
SPLEEN: Normal echogenicity, measuring 12.5 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Limited abdominal ultrasound demonstrates a coarsened hepatic echotexture
which may be seen in cirrhosis. New abdominal ascites when compared to
previous exam.
2. Cholelithiasis without ultrasound evidence for cholecystitis.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Jaundice, Confusion
Diagnosed with ALTERED MENTAL STATUS , DIABETES UNCOMPL ADULT, ATRIAL FIBRILLATION, CARDIAC PACEMAKER STATUS
temperature: 97.3
heartrate: 98.0
resprate: 14.0
o2sat: 99.0
sbp: 105.0
dbp: 52.0
level of pain: 13
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know, you were
admitted with confusion and jaundice. You were found to have low
blood sugars, low blood pressures, low oxygen, and excess fluid
in your body. Since your blood pressure was low, we started you
on a new medication called Midodrine. We removed the excess
fluid from your body with dialysis and your low oxygen improved.
Your liver tests were initially abnormal. An ultrasound of your
liver and gallbladder showed no abnormalities. Your liver tests
improved without intervention. At the time of discharge, you
were less confused, you had less fluid in your body, and blood
pressure improved. You were discharged back to rehab. Please
continue to take your medications as instructed. Please followup
with your primary care doctor, ___, and other health
care providers. If you develop any worsening confusion,
abdominal pain, chest pain, shortness of breath, or
lightheadedness, please seek medical attention urgently.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
Dermatological biopsy
History of Present Illness:
Ms. ___ is a ___ year-old lady with a ___ CAD s/p MI and PCI in
___, diabetes, morbid obesity, now presenting with worsening
LLE erythema, warmth and tenderness. Patient has a history of
chronic BLE erythema. On ___, she presented to ___
___ with two days of LLE erythema and pain "from
mid tibia extending to foot," without any fevers, chills or
drainage. Patient was noted to have scattered small pustule
with surrounding erythema. At that time, she was prescribed
cephalexin 500 mg PO QID for a 10-day course, and recommended to
follow-up for evaluation of symptom resolution after three days.
Due to worsening of LLE erythema on ___, she was referred by
PCP to the ___ ED for evaluation.
.
Of note, patient's oldest son died on ___, and she
attended his funeral on ___. This has been an emotional
time for the patient, but she feels adequately supported by
other children and husband. She was seen by social work in the
ED who provided emotional support.
.
On arrival to the ___ ED, initial vital signs were: 98.2 68
131/67 18 99%. Exam was notable for LLE erythema, warmth and
tenderness. Ultrasound of the LLE showed no evidence of DVT, but
did show a ___ cyst. Labs were notable for normal WBC, with
lactate 1.4. Differential had 49.2%N and 6.5%E. Chemistry
panel was normal. Blood cultures x2 were sent. Patient was
given vancomycin 1g IV.
.
On the floor currently patient reports feeling well. Reports
some pain in the lower extremity. Denies any fevers, chills,
night sweats shortness of breath, chest pain, nausea, vomiting.
Past Medical History:
- Diabetes mellitus, last HbA1c on ___ was 6.6%
- Morbid obesity
- Peripheral vascular disease
- CAD s/p PCI ___: Cardiac catheterization by Dr. ___,
on ___, revealing: Right dominant system with proximal
40% lesion and ostial 90% right PDA lesion, which was dilated
and Cypher stented. No significant left main or LAD lesions.
Diffuse 100% mid circumflex lesion which was also Cypher stented
to 0% residual
- Hyperlipidemia
- Hypertension
- OSA on CPAP
- Osteopenia
- Ovarian cyst
- Ventral hernia
- Endometrial polyps c/b vaginal bleeding in ___
- Bell's Palsy: ___
- s/p tubal ligation
- s/p upper arm/elbow surgery
Social History:
___
Family History:
DM in parents.
Physical Exam:
Admission Physical Exam:
Vitals: 98.8 120/100 75 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without any
lesions.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Multiple small scattered pustules in the LLE with
surrounding erythema, warmth and tenderness. No area os
fluactuance or pus drainage.
Neuro: Alert and oriented x3. Right facial drop consistent with
prior diagnosis of Bell's palsy.
.
Discharge Physical Exam:
Vitals: 98.1 ___ 20 100%RA p66-110
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without any
lesions. Lips with hyperpigmented lesions, not involving mucous
membranes.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Edema in LLE
Skin: Cellulitis resolved in LLE with superficial crusting.
Rash in other extremities crusted over with macular lesions
below crusting.
Neuro: Alert and oriented x3. Right facial drop consistent with
prior diagnosis of Bell's palsy.
Pertinent Results:
Pertinent Labs:
___ 01:00PM BLOOD WBC-6.6 RBC-4.00* Hgb-12.2 Hct-36.3
MCV-91 MCH-30.4 MCHC-33.4 RDW-13.5 Plt ___
___ 01:00PM BLOOD Neuts-49.2* ___ Monos-4.9
Eos-6.5* Baso-0.4
___ 01:00PM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
___ 07:20AM BLOOD ALT-16 AST-18 AlkPhos-51 TotBili-0.8
___ 07:20AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.2
___ 01:06PM BLOOD Lactate-1.4
.
___ 1:00 pm Blood Culture, Routine (Final ___: NO
GROWTH.
.
___ 4:04 pm SKIN SCRAPINGS
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): RESULTS
PENDING.
VARICELLA-ZOSTER CULTURE (Preliminary): RESULTS PENDING.
.
___ 4:06 pm SWAB Source: Right shin pustule.
GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN. NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
.
LLE Ultrasound:
IMPRESSION:
1. No evidence of DVT in the left lower extremity.
2. Possible ___ cyst vs small amount of fluid at
posteromedial knee.
3. Subcutaneous edema.
.
Discharge Labs:
___ 06:10AM BLOOD WBC-8.4 RBC-3.62* Hgb-11.1* Hct-33.6*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.3 Plt ___
___ 06:10AM BLOOD Neuts-47.4* ___ Monos-6.3
Eos-13.8* Baso-0.5
___ 06:10AM BLOOD Glucose-102* UreaN-26* Creat-1.0 Na-136
K-4.4 Cl-103 HCO3-28 AnGap-9
___ 06:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.2
MICRO:
___ 4:04 pm SKIN SCRAPINGS
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
No Herpes simplex (HSV) virus isolated.
VARICELLA-ZOSTER CULTURE (Preliminary): RESULTS PENDING.
___ 4:04 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT ___
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
___:
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
Refer to culture results for further information.
Reported to and read back by ___ ___ 1:43PM.
___ 4:06 pm SWAB Source: Right shin pustule.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
PATHOLOGY:
DERM BIOPSY:
Skin, left arm, punch biopsy (A):
Pustular dermatosis, see note.
Note: The section shows sub- and intra-corneal neutrophilic
micropustules in a background of spongiosis. There is
superficial perivascular and dermal inflammatory infiltrate
composed of neutrophils (predominantly), lymphocytes and rare
eosinophils. No follicular involvement is noted. HSV1/2 stain
is negative. No fungi are seen in PAS - reacted sections and
the tissue gram is negative for bacteria. The findings are
consistent with pustular dermatosis, and supportive of a
pustular drug reaction in the appropriate setting. Clinical
correlation is recommended. Multiple levels have been examined.
The findings were communicated with Dr. ___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
Hold for BP<100.
2. Hydrochlorothiazide 25 mg PO DAILY
Hold for BP<100.
3. Atenolol 100 mg PO DAILY
Hold for HR <60. SBP<100.
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral BID
9. Nitroglycerin SL 0.4 mg SL PRN Chest pain
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
Hold for BP<100.
5. Lisinopril 40 mg PO DAILY
Hold for BP<100.
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN Chest pain
8. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral BID
9. Atenolol 50 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Pustular drug eruption (dermatitis), severe
2. Bacterial Cellulitis- leg
initially also treated for eczema herpeticum
dm2 controlled uncomplicated
stable native vessel cad
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 lower extremity swelling and cellulitis. Evaluate for DVT.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation was
performed on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right and left
common femoral, proximal femoral, mid femoral, distal femoral and popliteal
veins. Normal color flow is demonstrated in the posterior tibial and peroneal
veins. There is normal respiratory variation in the common femoral veins
bilaterally.
A 3.3 x 1 cm hypoechoic focus in the posterior medial knee may be a ___
cyst or small amount of fluid. Subcutaneous edema is also seen.
IMPRESSION:
1. No evidence of DVT in the left lower extremity.
2. Possible ___ cyst vs small amount of fluid at posteromedial knee.
3. Subcutaneous edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LEG
Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF LEG, POPLITEAL SYNOVIAL CYST
temperature: 98.2
heartrate: 68.0
resprate: 18.0
o2sat: 99.0
sbp: 131.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Dear ___,
___ was a pleasure taking care of you during your hospital stay
at ___. You were admitted because of cellulitis (skin
infection) in your left leg for which you have finished an
antibiotic course with significant improvement. You were also
diagnosed with a rash from a drug allergy. For this, we used a
steroid cream and discontinued certain medications. We have
added to your allergy list Cephalosporins (an antibiotic you
were given prior to coming in). Please follow up with
dermatology for further care (see below) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ female with a past medical history
of stage IIIc endometrial cancer with recent diagnosis of
metastaticu recurrence and on pembrolizumab, stage I lung
neuroendocrine carcinoma status post resection, anxiety,
depression, and history of pulmonary embolism who is admitted
from the ED with pain crisis.
Patient has had significant issues with left sided flank and
chest pain over the last several months leading to her diagnosis
of recurrent endometrial cancer. Her pain has been attributed to
her known pleural metastatic disease. She underwent palliative
XRT to her left posterior rib in ___, has been on
escalating doses of MS contin and oxycodone. She switched her
long acting opioid to fentanyl 50mcg TD patch on ___. She
called
her oncologist on ___ with progression of her typical left flank
pain, and she was referred into the ED for expedited management
of pain crisis.
In the ED, initial VS were pain 7, T 98.4, HR 100 BP 116/59, RR
20, O2 100%RA. Initial labs notable for HCT 24.5, WBC 8.4, PLT
394, ALT 6, AST 15, ALP 117, TBili <0.2, lipase 30, Na 142, K
4.3, HCO3 24, Cr 0.8. CXR was normal. She received IV morphine,
IV dilaudid, and po oxycodone. VS prior to transfer were pain 9,
T 97.3, HR 94, BP 144/90, RR 17, O2 100%RA.
On arrival to the floor, patient reports ___ left back/flank
pain that radiates around her torso under her left breast and
into her left axilla. She describes it as a grabbing and burning
pain that comes in waves. This is the same pain she has had for
months, although it is becoming more constant. Typically
oxycodone relieves it to ___, but over the last few nights she
has had less relief. She also reports some abdominal cramping
over the last day. She has a history of constipation and last BM
was 3 days ago. She is passing flatus, has a fair appetite, and
denies nausea or vomiting. Otherwise, no fevers or chills. She
has chronic rhinitis. No ST or ILI. No SOB. Her pain is somewhat
pleuritic. No dysuria. No new leg pain or swelling. No rashes.
She had a port placed last week without incident.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IIIC1 endometrial cancer, grade 2 endometrioid
with metastatic recurrence; stage IA lung neuroendocrine
carcinoma.
- ___ endomtrial biopsy (BIDH-P): Endometrial
adenocarcinoma,
endometrioid type, FIGO grade ___. The specimen is highly
fragmented with minute foci of solid growth pattern, possibly
comprising <5% of tumor volume. Definitive grading is deferred
to
hysterectomy specimen. Loss of MLH1 and PMS2. + MLH1
hypermethylation.
- ___ TH, BSO, pelvic LND: pT1b lesion, grade 2
endometrioid,
node positive ___
- ___ started pelvic RT
- ___ cisplatin C1D1
- ___ cisplatin C2D1
- ___ completed pelvic RT
- ___ completed HDR brachy
- ___ start Taxol/Carboplatin x 4 cycles
- ___ add Neulasta starting C2. Dose-reduce Taxol by 25% to
131.25mg/m2 due to neuropathy and ___ to AUC 5 based on RTOG
9708.
- ___ completed 4 cycles Taxol/Carboplatin- dose-reduced
d/t
neuropathy
- ___ underwent LUL lung segmentectomy and lymph node
resection which revealed combined large cell neuroendocrine
carcinoma (30 mitoses per 10 high power fields) with minor
component of squamous cell carcinoma
- ___ Hospitalized with left flank pain and chest
pain in the setting of new metastatic disease on PET scan.
Underwent CT guided biopsy of left pleural nodule c/w metastatic
endometrial adenocarcinoma. Received palliative radiation
therapy
to left posterior rib. Palliative care was consulted due to
difficult to control pain.
- ___: C1D1 Pembrolizumab
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Depression.
3. Toxic nodular goiter in ___ status post thyroid ablation,
now with hypothyroidism.
4. GERD.
5. Diverticulosis.
6. Allergic rhinitis.
7. Right salpingectomy for torsion in ___.
8. TVT bladder sling in ___.
9. Basal cell carcinomas of the face, left leg and left nares
status post Mohs' surgery.
10. Osteoarthritis of the knees.
11. Abnormal Pap in ___ status post cervical cone biopsy.
12. Nasal passage widening in ___.
13. Stage IA large cell neuroendocrine carcinoma with minor
component of squamous cell carcinoma s/p left lung segmentectomy
and MLND
14. h/o PE ___
Social History:
___
Family History:
Maternal grandfather: ___ cancer
Father: ___ cancers
Physical Exam:
ADMISSION EXAM:
==============
VS: T 97.8 HR 91 BP 117/74 RR 22 SAT 100% O2 on RA
GENERAL: Pleasant and well appearing woman who is in moderate
acute distress due to pain
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
moderately tender in LLQ without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk. Point tender over posterior left
T8-T11 moving anteriorally into the mid-axillary line. No
overlying rash, erythema, or induration. Full ROM of left
shoulder.
NEURO: Alert, oriented, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE EXAM:
==============
VS: T98, BP 119/75, HR 89, RR 18, 96% RA
GENERAL: Alert, NAD, sitting in bed next to her brother
EYES: ___ sclerea, PERLL, EOMI
ENT: Oropharynx clear without lesion
CARDIOVASCULAR: RRR, normal S1/S2, no M/R/G
RESPIRATORY: No respiratory distress, CTAB
GASTROINTESTINAL: Soft, moderately tender in LUQ w/o
guarding/rebound
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; normal bulk
NEURO: Alert, oriented
SKIN: 1cm macular rash on left lower back inferior to placement
of lidocaine patch, excoriations in this area
Pertinent Results:
LAB:
===
___ 07:07PM BLOOD WBC-8.4 RBC-2.55* Hgb-7.6* Hct-24.3*
MCV-95 MCH-29.8 MCHC-31.3* RDW-15.4 RDWSD-53.5* Plt ___
___ 05:20AM BLOOD WBC-5.3 RBC-2.68* Hgb-7.7* Hct-25.0*
MCV-93 MCH-28.7 MCHC-30.8* RDW-16.8* RDWSD-57.3* Plt ___
___ 07:07PM BLOOD Neuts-84.0* Lymphs-6.2* Monos-8.7
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.03* AbsLymp-0.52*
AbsMono-0.73 AbsEos-0.04 AbsBaso-0.03
___ 05:00AM BLOOD Ret Aut-1.9 Abs Ret-0.04
___ 07:07PM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142
K-4.3 Cl-102 HCO3-24 AnGap-16
___ 05:20AM BLOOD Glucose-103* UreaN-12 Creat-0.8 Na-143
K-4.4 Cl-102 HCO3-29 AnGap-12
___ 07:07PM BLOOD ALT-6 AST-15 AlkPhos-117* TotBili-<0.2
___ 05:11AM BLOOD ALT-6 AST-9 AlkPhos-102 TotBili-<0.2
___ 07:07PM BLOOD Lipase-30
___ 07:07PM BLOOD Albumin-3.5
___ 05:55AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
___ 05:00AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1 Iron-30
___ 05:20AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 05:00AM BLOOD calTIBC-181* Hapto-455* Ferritn-650*
TRF-139*
___ 05:11AM BLOOD TSH-0.71
IMAGING:
=======
CXR ___:
FINDINGS:
AP portable upright view of the chest. Port-A-Cath resides over
the right
chest wall with catheter tip in the region of the cavoatrial
junction. Suture
material is seen in the left mid lung extending from the hilum
to the left
upper lobe. Lungs are clear. No focal consolidation is seen.
There is
improved aeration at the left lung base with probable trace
residual pleural
effusion and perhaps mild residual basal atelectasis.
Cardiomediastinal
silhouette is grossly stable. Bony structures are intact.
Portable Abdomen ___:
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Osseous structures are
unremarkable. Surgical clips are seen overlying the lower, mid
pelvis. There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION:
No evidence of bowel obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Apixaban 5 mg PO BID
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Gabapentin 600 mg PO BID
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Nortriptyline 10 mg PO QHS
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO QHS
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Cyanocobalamin 500 mcg PO DAILY
13. flaxseed oil 1,000 mg oral DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU BID prn allergies
15. Lovastatin 20 mg oral DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Vitamin E 400 UNIT PO DAILY
18. LORazepam 0.5 mg PO Q6H:PRN anxiety / nausea
19. Voltaren (diclofenac sodium) 1 % topical BID:PRN
20. Aspirin 81 mg PO DAILY
21. Fentanyl Patch 50 mcg/h TD Q72H
Discharge Medications:
1. Morphine SR (MS ___ 60 mg PO Q8H
RX *morphine 60 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*21 Capsule Refills:*0
2. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*63 Tablet Refills:*0
3. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. LORazepam 0.5 mg PO Q12H:PRN anxiety / nausea
RX *lorazepam 0.5 mg 1 tablet by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
5. LORazepam 0.5 mg PO QHS
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*7
Tablet Refills:*0
6. Nortriptyline 25 mg PO QHS
RX *nortriptyline 25 mg 1 capsule by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Senna 17.2 mg PO BID
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*120 Tablet Refills:*0
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
9. Apixaban 5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. BuPROPion XL (Once Daily) 150 mg PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. flaxseed oil 1,000 mg oral DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU BID prn allergies
15. Levothyroxine Sodium 112 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Lovastatin 20 mg oral DAILY
18. Omeprazole 20 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. Vitamin E 400 UNIT PO DAILY
22. Voltaren (diclofenac sodium) 1 % topical BID:PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Pain crisis
Acute on chronic cancer associated pain
SECONDARY DIAGNOSES
===================
Metastatic endometrial cancer
Pulmonary embolism
Anemia
Hypothyroidism
Anxiety/Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with right port// check for port placement
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. Port-A-Cath resides over the right
chest wall with catheter tip in the region of the cavoatrial junction. Suture
material is seen in the left mid lung extending from the hilum to the left
upper lobe. Lungs are clear. No focal consolidation is seen. There is
improved aeration at the left lung base with probable trace residual pleural
effusion and perhaps mild residual basal atelectasis. Cardiomediastinal
silhouette is grossly stable. Bony structures are intact.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old woman with constipation.// Evaluate for bowel
obstruction.
TECHNIQUE: Portable supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Surgical clips are seen overlying the
lower, mid pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of bowel obstruction.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Body pain
Diagnosed with Chest pain, unspecified
temperature: 98.4
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 116.0
dbp: 59.0
level of pain: 7
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to ___
for management of your oncologic pain. During your admission, we
continued your MS contin therapy and ___ addition of other
pain management modalities. Patient-controlled administration of
Dilaudid was tried but found to be insufficient. What seemed to
be more efficacious was the addition of an "as needed" dose of
immediate acting morphine. We transitioned this to an oral form
with acceptable coverage of pain. Additionally, your home
medication Nortiptyline was increased from 10 to 25mg daily.
Lastly, we added a 0.5mg dose of Ativan in the evening. You had
significant constipation during your admission that was likely
due to your pain medication and you required an aggressive bowel
regimen. Inevitably, this lead to some diarrhea that should
resolve in a few days.
We recommend you follow up with your oncologist on ___
___ for your next treatment with pembrolizumab. Continue the
current pain management medication plan established during this
admission. Please do not use Fentyl patch or Oxycodone while on
the current pain medication plan. Use a daily regimen of stool
softeners and bowel activating medications provided to prevent
constipation, however, hold these medications if you still have
diarrhea.
Thank you for allowing us to be part of your care.
#Current pain regimen:
- Morphine SR (MS ___ 60mg every 8 hours
- Morphine ___ 22.5mg every 4 hours as needed for severe pain
- Gabapentin 600mg three times per day
- Nortryptiline 25mg at bedtime
- Ativan 0.5 mg at bedtime
- Ativan 0.5 mg every 12 hours as needed (reduced from every 6
hours as needed in the setting of increased pain regimen as
above to avoid excessive somnolence)
#Continue bowel regimen medications:
-Take Senna 2 tablets twice per day
-Take Miralax daily
-if no bowel movements within 48 hours, she should take Miralax
every 6 hours (in addition to senna) until she has a large bowel
movement
-If no bowel movement within 72hrs, she should call Dr. ___
___ for further instructions
Your ___ Oncology Team |
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, coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr. ___ is a ___ with history of HTN and recent rotator
cuff repair on ___ who presents with coffee ground emesis and
hypoxia. Patient reports that he underwent an uneventful
operation on ___ for an acute trauma-related rotator cuff
tear. He denies NSAID use, but does state he was started on an
aspirin around the time of the surgery to prevent blood clot.
The night prior to presentation he notes he'd vomited a black
substance. He went to bed and on morning of presentation he
suddenly felt nauseated and vomited coffee grounds (quantity
unclear). That morning he awoke, he did feel as though his
breathing was more difficult, but denied any fevers, chills or
sputum production. Prior to the surgery he'd been feeling well,
walking 5 miles most days, and hiking.
Of note, per a family member, he had some black spit up on the
pillow the morning after his TURP in ___. He currently
denies a history of abdominal pain, melena, and BRBPR. No
history of ETOH abuse.
At 5pm yesterday, he presented to an OSH where an NGT was placed
and produced coffee grounds that cleared with lavage. Per a
family member, a total was 500cc was suctioned there, and 100cc
here. Hct was 36 there, 39 on transfer here and 37.5 on repeat
here. He was also noted to be hypoxic to 60% at OSH. He was
given protonix 80mg IV and was then transferred to ___ for
further management.
In the ___ ED, initial vital signs were 98.2 78 120/58 18 97%
15L. Patient was HDS however remained hypoxic requiring NRB. A
CT showed, "1. No pulmonary embolism or evidence of acute aortic
syndrome. 2. Small left pleural effusion with bibasilar
atelectasis. Bilateral upper lobe opacities may reflect
aspiration or an infectious process." He was given
Vanc/Cefepime/Flagyl. In the ED, he reported no abdominal pain
and no further nausea. Guaiac neg from below. Afib (new onset)
noted in our ED, HR 100s now. BPs stable, no nodal blockade
given. An attempt to wean O2 supplementation to NC showed SpO2
to ___ each time. 16G and 20G for access. Mentating well.
VS prior to transfer: Today 06:23 0 97.9 111 134/60 23 94%
Non-Rebreather.
On arrival to the MICU, patient is comfortable. Denies abdominal
pain, nausea, or shortness of breath on a shovel mask satting
93%.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- HTN
- s/p rotator cuff tear repair
- BPH s/p TURP ___
- HLD
Social History:
___
Family History:
No h/o GI issues
Physical Exam:
===================
ADMISSION EXAM
===================
Vitals: T: 98.4 BP: 118/76 P: 100-110 (afib) R: 20 O2: 93%
shovel mask 40% 15L
General- Alert, oriented, no acute distress, interactive
HEENT- Sclera anicteric, dry MM, oropharynx with dried darkened
emesis on toungue
Neck- supple, JVP not elevated, no LAD
Lungs- relatively clear to auscultation bilaterally, with
scattered rhonchi
CV- irregular rate and rhythm, normal S1 + S2, ___ murmur
loudest at the apex, no rubs or gallops. PMI nondisplaced
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Right arm in large brace with cleanly bandaged right
shoulder. All extremities (including right arm) are warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro- A+Ox3, CNs2-12 grossly intact, motor function grossly
normal. Sensation intact to light touch and temperature
throughout. Gain not observed.
===================
EXAM AT DISCHARGE:
===================
Pertinent Results:
======================
ADMISSION LABS
======================
___ 08:15PM WBC-18.1* RBC-4.32* HGB-13.1* HCT-39.5*
MCV-91 MCH-30.3 MCHC-33.1 RDW-12.7
___ 08:15PM NEUTS-92.6* LYMPHS-2.6* MONOS-3.9 EOS-0.2
BASOS-0.7
___ 08:15PM GLUCOSE-123* UREA N-22* CREAT-0.8 SODIUM-129*
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-28 ANION GAP-13
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:59AM CALCIUM-8.1* PHOSPHATE-1.7* MAGNESIUM-1.4*
___ 09:30AM proBNP-742
___ 06:41PM WBC-11.6* RBC-3.87* HGB-11.4* HCT-34.6*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.0
___ 06:50PM ___ PO2-43* PCO2-39 PH-7.47* TOTAL
CO2-29 BASE XS-4
======================
PERTINENT LABS
======================
___ 01:41AM BLOOD WBC-22.0*# RBC-3.93* Hgb-11.4* Hct-36.3*
MCV-93 MCH-29.0 MCHC-31.3 RDW-13.0 Plt ___
___ 01:41AM BLOOD Neuts-89.3* Lymphs-3.2* Monos-5.1 Eos-2.2
Baso-0.2
___ 01:41AM BLOOD TSH-1.8
___ 01:41AM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.4*
Mg-2.1
___ 06:50PM BLOOD ___ pO2-43* pCO2-39 pH-7.47*
calTCO2-29 Base XS-4
======================
DISCHARGE LABS
======================
======================
MICROBIOLOGY
======================
URINE CULTURE (Final ___: ESCHERICHIA COLI.
10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria
are based on a dosage regimen of 2g every 8h.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 10,000-100,000
ORGANISMS/ML..
HELICOBACTER PYLORI ANTIBODY TEST (Final ___: POSITIVE BY
EIA.
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN
Respiratory Viral Antigen Screen (Final ___: Negative for
Respiratory Viral Antigen.
======================
IMAGING
======================
___ CTA chest
1. No pulmonary embolism or evidence of acute aortic syndrome.
2. Bilateral pulmonary opacities with bibasilar consolidations
and small
bilateral pleural effusions with are concerning for aspiration
and/or
multifocal pneumonia.
3. Several prominent paraesophageal lymph nodes. Consider upper
GI series or endoscopy for further evaluation of the esophagus.
___ CXR
REASON FOR EXAMINATION: Evaluation of the patient with hypoxia,
no evidence of pulmonary embolism on CT angiography and
potential aspiration pneumonitis.
AP radiograph of the chest was reviewed in comparison to prior
study obtained the same day earlier.
The NG tube tip passes below the diaphragm, terminating in the
stomach. The left central venous line tip is at the level of
mid SVC. Heart size and mediastinum are stable. Widespread
parenchymal opacities are overall
unchanged and might reflect pulmonary edema. Infection is a
possibility,
potentially in the lower lobes. As compared to chest CT
obtained on ___, there is overall progression of
multifocal opacities and again the concern of multifocal
pneumonia is very high.
TTE ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
___ CXR:
FINDINGS: Interval removal of nasogastric tube. Unchanged
position of left PICC. Stable cardiomediastinal contours.
Bilateral diffuse alveolar lung opacities with scattered areas
of spared lung, predominantly in the left upper lobe and right
juxtahilar region have slightly progressed in the interval and
in conjunction with CT of ___, these findings
likely represent a multifocal pneumonia, possibly secondary to
aspiration. Coexisting pulmonary edema is likely. Persistent
small pleural effusions, but no visible pneumothorax.
___ CXR:
Severe multifocal, nearly confluent bilateral pulmonary
consolidation has
continued to worsen over the past three days. Although there
could be a
component of pulmonary edema, most of the abnormality seen is
likely
pneumonia. Heart size is not enlarged, mediastinal veins are
not dilated and pleural effusion is not substantial. On the
other hand, there is a suggestion of multifocal cavitation.
___ CXR:
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is a
minimal
improvement with a decrease in extent of the pre-existing
opacities in the
bilateral perihilar areas. The other opacities are still seen
in unchanged manner. Unchanged size of the cardiac silhouette.
Unchanged left PICC line.
___ CT Chest
Final Report
HISTORY: Hypoxemia. Respiratory failure and ARDS. Rising
white blood cell count but no fever.
COMPARISON: Multiple prior radiographs most recently from ___.
TECHNIQUE: CT of the chest was performed per department
protocol without IV contrast. Coronal sagittal reformats were
reviewed.
FINDINGS:
MEDIASTINUM: There are scattered prominent mediastinal lymph
nodes that do not meet CT criteria for enlargement. There is no
hilar or axillary
lymphadenopathy by CT criteria. Calcified lymph nodes are noted
in the left hila reflective of prior granulomatous exposure. A
left-sided PICC line terminates in the upper SVC. No
mediastinal masses are present.
HEART: The heart is of normal size. There is no significant
pericardial
effusion. There minimal atherosclerotic calcifications of the
descending
aorta without aneurysmal dilatation.
PLEURA: There are bilateral pleural effusions, simple, layering
and
nonhemorrhagic on both sides. The effusion on the right is
small the
effusion; on the left it is small to moderate in size. There is
adjacent
bilateral compressive atelectasis right-sided greater than left.
LUNG PARENCHYMA: There are new widespread bilateral confluent
coalescent
ground-glass opacities with septal thicklening, predominantly in
the upper low bilaterally. The previous ___ type
opacities which occupy the lower lobes are actually improving.
There is a discrete 6-mm right middle lobe pulmonary nodule
(4:43).
UPPER ABDOMEN: A 3.5 cm hypodensity is noted in segment ___ of
the liver. An additional segment 2 hypodensity (3, 60) is also
again noted. There is a small hiatal hernia with small
paraesophageal lymph nodes.
IMPRESSION:
1. Bilateral coalescent ground-glass opacities, predominantly in
the upper
lobes reflecting either pulmonary edema, ARDS or multifocal
infection.
2. Bilateral pleural effusions left greater than right.
3. Discrete 6-mm pulmonary nodule for which follow-up chest CT
in ___ months is recommended.
CXR ___
FINDINGS: As compared to the previous radiograph, there is
unchanged evidence of massive diffuse bilateral parenchymal
opacities, likely representing a combination of pulmonary edema
and pneumonia, as described in previous reports. Borderline
size of the cardiac silhouette. Moderate tortuosity of the
thoracic aorta. No new parenchymal opacities. No larger
pleural effusions. Unchanged position of the left PICC line.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Tamsulosin 0.4 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Morphine Sulfate ___ 15 mg PO BID:PRN pain
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN shoulder
pain
7. Pravastatin 40 mg PO DAILY
8. Aspirin Dose is Unknown PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Hospital acquired pneumonia
2. Upper GI bleed
3. Gout
4. Atrial fibrillation
5. Right shoulder injury (chronic)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Coffee-ground emesis, hypoxia, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of massive diffuse bilateral parenchymal opacities, likely representing a
combination of pulmonary edema and pneumonia, as described in previous
reports. Borderline size of the cardiac silhouette. Moderate tortuosity of
the thoracic aorta. No new parenchymal opacities. No larger pleural
effusions. Unchanged position of the left PICC line.
Radiology Report
HISTORY: Hypoxemia. Respiratory failure and ARDS. Rising white blood cell
count but no fever.
COMPARISON: Multiple prior radiographs most recently from ___.
TECHNIQUE: CT of the chest was performed per department protocol without IV
contrast. Coronal sagittal reformats were reviewed.
FINDINGS:
MEDIASTINUM: There are scattered prominent mediastinal lymph nodes that do
not meet CT criteria for enlargement. There is no hilar or axillary
lymphadenopathy by CT criteria. Calcified lymph nodes are noted in the left
hila reflective of prior granulomatous exposure. A left-sided PICC line
terminates in the upper SVC. No mediastinal masses are present.
HEART: The heart is of normal size. There is no significant pericardial
effusion. There minimal atherosclerotic calcifications of the descending
aorta without aneurysmal dilatation.
PLEURA: There are bilateral pleural effusions, simple, layering and
nonhemorrhagic on both sides. The effusion on the right is small the
effusion; on the left it is small to moderate in size. There is adjacent
bilateral compressive atelectasis right-sided greater than left.
LUNG PARENCHYMA: There are new widespread bilateral confluent coalescent
ground-glass opacities with septal thicklening, predominantly in the upper low
bilaterally. The previous ___ type opacities which occupy the lower
lobes are actually improving. There is a discrete 6-mm right middle lobe
pulmonary nodule (4:43).
UPPER ABDOMEN: A 3.5 cm hypodensity is noted in segment ___ of the liver. An
additional segment 2 hypodensity (3, 60) is also again noted. There is a small
hiatal hernia with small paraesophageal lymph nodes.
IMPRESSION:
1. Bilateral coalescent ground-glass opacities, predominantly in the upper
lobes reflecting either pulmonary edema, ARDS or multifocal infection.
2. Bilateral pleural effusions left greater than right.
3. Discrete 6-mm pulmonary nodule for which follow-up chest CT in ___ months
is recommended.
Findings #3 paged to Dr. ___ on ___ @ 3:30 pm.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with hypoxia, no evidence
of pulmonary embolism on CT angiography and potential aspiration pneumonitis.
AP radiograph of the chest was reviewed in comparison to prior study obtained
the same day earlier.
The NG tube tip passes below the diaphragm, terminating in the stomach. The
left central venous line tip is at the level of mid SVC. Heart size and
mediastinum are stable. Widespread parenchymal opacities are overall
unchanged and might reflect pulmonary edema. Infection is a possibility,
potentially in the lower lobes. As compared to chest CT obtained on ___, there is overall progression of multifocal opacities and again the
concern of multifocal pneumonia is very high.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with PICC line placement.
FINDINGS: Comparison is made to prior study from ___.
There is a new left-sided PICC line with distal lead tip at the distal SVC.
The feeding tube is unchanged. The cardiac silhouette is enlarged, but
stable. There are diffuse multifocal opacities throughout both lung fields.
This is likely due to infection; however, pulmonary edema is also a
consideration. Unchanged left retrocardiac opacity. There are no
pneumothoraces identified.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Radiograph of one day earlier.
FINDINGS: Interval removal of nasogastric tube. Unchanged position of left
PICC. Stable cardiomediastinal contours. Bilateral diffuse alveolar lung
opacities with scattered areas of spared lung, predominantly in the left upper
lobe and right juxtahilar region have slightly progressed in the interval and
in conjunction with CT of ___, these findings likely represent a
multifocal pneumonia, possibly secondary to aspiration. Coexisting pulmonary
edema is likely. Persistent small pleural effusions, but no visible
pneumothorax.
Radiology Report
AP CHEST, 4:36 A.M., ___
HISTORY: A ___ man with hypoxia.
IMPRESSION: AP chest compared to ___:
Severe multifocal, nearly confluent bilateral pulmonary consolidation has
continued to worsen over the past three days. Although there could be a
component of pulmonary edema, most of the abnormality seen is likely
pneumonia. Heart size is not enlarged, mediastinal veins are not dilated and
pleural effusion is not substantial. On the other hand, there is a suggestion
of multifocal cavitation.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Recent rotator cuff repair, gastrointestinal bleeding, hypoxia,
questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is a minimal
improvement with a decrease in extent of the pre-existing opacities in the
bilateral perihilar areas. The other opacities are still seen in unchanged
manner. Unchanged size of the cardiac silhouette. Unchanged left PICC line.
Radiology Report
AP CHEST, 5:09 A.M. ON ___.
HISTORY: ___ man with pneumonia and pulmonary edema. Hypoxic.
IMPRESSION: AP chest compared to ___:
Global pulmonary consolidation, which improved radiographically between
___, has worsened. The heterogeneous quality, nondependent
distribution suggests this is not cardiogenic edema, or at least substantially
something other than cardiogenic edema, such as multifocal pneumonia. Heart
is normal size and mediastinal vasculature is not engorged. Small right
pleural effusion has been present for several days. Left pleural effusion is
minimal if any. No pneumothorax. Left PIC line ends in the mid to low SVC.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UPPER GIB
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 98.2
heartrate: 78.0
resprate: 18.0
o2sat: 97.0
sbp: 120.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Dear Mr ___,
You were admitted for a gastrointestinal bleed, that we felt was
from inflammation in the stomach, possibly caused by
Helicobacter pylori, a kind of bacteria. Following the bleed,
you developed shortness of breath that we felt was from a
pneumonia. To treat the helicobacter pylori and the pneumonia,
we started you on antibiotics, which you completed while you
were in the hospital.
We also saw that you were in a particular heart rhythm, called
atrial fibrillation, which can put you in danger of having a
stroke. Normally, we start people in atrial fibrillation on a
blood thinner, however we decided to wait because of your recent
bleeding episode. You will need to see your primary care
physician (see appointment below) to help determine if you
should start a blood thinner.
You have an appointment with the gastroenterology doctors
because of your recent bleeding episode. They may decide to
perform an endoscopy to look at your stomach. They may also
perform a test to see if you have been cured of helicobacter
pylori (the bacteria that caused the bleeding). If you would
rather see gastroenterology at ___, you can do this - please
be sure to cancel the appointment at ___ in that case.
You also have a follow up appointment with the lung doctors, who
may want to repeat a CAT scan to make sure your lungs are
getting better. You will also need a repeat CAT scan 9 months
from now to make sure a lung nodule in the right middle lobe of
your lung has healed.
You also developed gout during this hospitalization. For this
reason, we started you on colchicine. Your primary care doctor
___ determine when you should stop this medication.
Please see follow up appointments below. |
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:
laparoscopic appendectomy
History of Present Illness:
HPI: ___ who presents with 2 weeks of diffuse ___ abdominal
discomfort and nausea, exacerbated by oral intake. She had a
similar episode ___ years ago, which resolved spontaneously.
However, this time, over the past 5 days, the pain has migrated
to her right lower quadrant and is increasing in severity. She
recently had two episodes of non-bilious emesis. She also had
non-bloody diarrhea once 2 days ago, normal bowel movements
since
then. Due to the pain, she has had minimal food or fluid intake
for the past few days. She has longstanding mild reflux, for
which she takes 2 Tums nightly before sleep. Her last menstrual
period was several weeks ago. She denies fevers, chills, sick
contacts, shortness of breath, chest pain, dysuria.
Past Medical History:
Past Medical History: Asthma (last used inhalers in ___,
lumbar
disc herniation
Social History:
___
Family History:
NC
Physical Exam:
Vitals: T97.5, HR 84, BP 114/64, RR 18, 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, appropriately TTP and minimally distended
WOUNDS: bandages intact with minimal serosangineous drainage, no
surrounding erythemaExt: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:35AM BLOOD WBC-7.4 RBC-4.55 Hgb-13.1 Hct-38.3 MCV-84
MCH-28.8 MCHC-34.2 RDW-12.1 Plt ___
___ 08:35AM BLOOD Neuts-74.7* ___ Monos-4.0 Eos-2.0
Baso-0.4
___ 08:35AM BLOOD Plt ___
___ 08:35AM BLOOD Glucose-114* UreaN-11 Creat-1.0 Na-137
K-3.4 Cl-101 HCO3-26 AnGap-13
___ 08:35AM BLOOD ALT-13 AST-20 AlkPhos-73 TotBili-0.6
___: cat scan of abdomen and pelvis:
. Mildly dilated appendix up to 7-8mm with minimal hyperemic
mucosa and
non-filling of the lumen with oral contrast. These findings are
concerning
for early appendicitis in the correct clinical setting.
Consultation with
surgery is recommended. There is no pelvic free fluid or
evidence of
perforation.
2. 3mm right lower lobe nodule. In a patient of this age, this
is most likely benign
Radiology Report
INDICATION: Right lower quadrant pain. Evaluate for appendicitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet
after the administration of intravenous contrast. Coronal and sagittal
reformations were obtained.
COMPARISON: None.
FINDINGS:
CT OF THE ABDOMEN: There is a 3mm right middle lobe pulmonary nodule (2:8).
The lung bases are otherwise clear. The visualized portions of the heart and
pericardium are unremarkable. The liver enhances homogenously and there are
no focal liver lesions. The gallbladder, pancreas, spleen and adrenal glands
are unremarkable. The kidneys enhance and excrete contrast without evidence
of hydronephrosis. There is no mesenteric or retroperitoneal lymphadenopathy.
There is no free air or free fluid.
CT OF THE PELVIS: The appendix is mildly dilated measuring up to 7-8 mm in
diameter. It does not fill with oral contrast despite contrast located in the
cecum. There is mild hyperemia of the mucosa without significant surrounding
fat stranding. There is no pelvic free fluid. The colon, rectum, bladder,
and uterus are unremarkable. A 19-mm physiologic cyst in the left adnexa is
noted, and the right adnexa is unremarkable. There is no pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Mildly dilated appendix up to 7-8mm with minimal hyperemic mucosa and
non-filling of the lumen with oral contrast. These findings are concerning
for early appendicitis in the correct clinical setting. Consultation with
surgery is recommended. There is no pelvic free fluid or evidence of
perforation.
2. 3mm right lower lobe nodule. In a patient of this age, this is most likely
benign.
The case was discussed by Dr. ___ with Dr. ___ by phone at 12:26
p.m. on ___.
The case was discussed by Dr. ___ with Dr. ___ in person at 1:42
p.m. on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN/NAUSEA
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 99.0
heartrate: 109.0
resprate: 18.0
o2sat: 99.0
sbp: 126.0
dbp: 77.0
level of pain: 7
level of acuity: 3.0 | You were admitted to the hospital with lower abdominal pain.
You underwent a cat scan of the abdomen which showed early
appendicitis. You were taken to the operating room where you
had your appendix removed. You were tolerating a regular diet
and your pain was well controlled after surgery. We have
prescribed you oral pain medication. Please take as prescribed
for pain. Your vital signs are stable and you are ready for
discharge with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with super obesity, HTN, CAD, OSA and recent admission to
___ for E. coli bactermia (___) who was transferred from
___ with AMS after being "found down". Patient reports he was
discharged from ___ ___ with oral antibiotics. He went to sit
down on his bed w/ wheels and it rolled away from him. He denies
head trauma or LOC. Due to his body habitus and position, he was
stuck on the ground. He stayed awake for "hours" waiting for a
neighbor or family member to come help him. EMS finally arrived
~12 hours after being found down. He refused transport to the
hospital at that time. Family members then came to visit and
expressed concern for his ability to care for himself. They
ultimately called EMS due to c/f for patient's AMS. In the ___
ED, labs were notable for ABG ___ while on 2L O2. No chem
panel or LFTs available. Naloxone was given without any changes.
Other labs were obtained including tox screen, troponin and CK
but these are not available at time of admission to ___
was unable to do CT head ___ body habitus and patient was
transferred to ___. Upon arrival to ___, patient was alert
and oriented with no focal deficits. CT head was not done in ED.
In the ED, initial vitals were: 97.4 72 116/81 20 99% 2L Nasal
Cannula
While collecting bloodwork in the ED he was noted to have
numerous frequent episodes of bradycardia associated with apneic
episodes while sleeping. CPAP ordered in the ED while he was
sleeping. Noted to continue to have apneic episodes while on
CPAP in ED, but not bradycardic.
Labs were notable for Hgb 11.9 (MCV 106), platelets 113, chem
panel with bicarb 17, BUN 59 and Cr 1.8. UA with large leuks,
small blood, nitriate negative, and few bacteria. VBG done
several hours into ED course was 7.45/26.
CXR showed pulmonary vascular congestion, no pulmonary edema or
focal consolidation.
ECG showed bradycardia, old RBBB, prolonged QTc
He was given CTX for UTI.
On the floor, he continued to fall asleep easily. He reports
that he was discharged from ___, but was not eating well at home
due to poor appetite. At time of admission, he denies feeling
chills, fevers. He denies abdominal pain, diarrhea, emesis. He
denies chest pain, difficulty breathing. He does endorse a dry
non-productive cough for which he has had "for years".
Per ___ records, Mr. ___ was just admitted to ___ on ___ for
body aches, chills and cellulitis. He was transferred to the ICU
due to hypotension and worsening mental status which improved
significantly after IVF resuscitation. Course was complicated by
atrial fibrillation with RVR for which he received diltizem,
digoxin and metoprolol (it appears). Imaging during that
admission included clear CXR, RUQ U/S with cholelithiasis, renal
ultrasound without hydronephrosis and ___ without DVT. He was
diagnosed with E. coli bacterimia from likely urinary tract
infection and acute kidney injury. He actually left AMA w/ PO
antibiotics.
Review of systems: per HPI
Past Medical History:
- CAD s/p MI in ___ LHC was clean in ___
- Super obesity
- HFpEF (unknown EF- trying to obtain from ___
- DMII on oral medications
- Hypertension
- COPD
- HLD
- OSA on CPAP
- Fractures of left shoulder, hand
- History of bile duct obstruction
- Pancreatic pseudocyst
- Atrial fibrillation with RVR
- COPD
Social History:
___
Family History:
M w/cervical CA, passed away ___ emphysema. Reportedly 4
siblings A&W.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.8 114/67 62 18 91 RA
___: Alert, morbidly obese man, lying up against the right
side railing of the hospital bed; he sleeps without stimulation
but awakens, is coherent and gives appropriate history
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck is very thick
CV: Bradycardic rate with distant heart sounds, normal S1 + S2,
no murmurs, rubs, gallops
Lungs: Wheezes throughout, no increased work of breathing,
intermittent cough
Abdomen: Very obese abdomen with large pannus, no tenderness to
palpation
GU: Foley in place, resolving hyperpigmented fungal rash in the
right groin
Ext: Warm, well perfused, 2+ dorsalis pedis pulses; no
significant edema
Neuro: CNII-XII intact, able to roll in the bed with some
assistance
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 97,8 PO 157 / 79 52 18 94 RA
tele: freq alarming for ___ to ___, off this morning
___: Alert, morbidly obese man, lying on right side, CPAP on
bed
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck is very thick
CV: RRR with distant heart sounds, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Crackles at bases bl.
Abdomen: Very obese abdomen with large pannus w/ induration, no
tenderness to palpation
GU: Foley out, erythematous non-blanching rash in the right
groin
Ext: Warm, well perfused, 2+ dorsalis pedis pulses; no
significant edema
Neuro: CNII-XII intact, alert and oriented to person, place,
time and situation.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:16PM TYPE-ART PO2-205* PCO2-26* PH-7.45 TOTAL
CO2-19* BASE XS--3
___ 07:16PM GLUCOSE-116* LACTATE-1.1 NA+-137 K+-4.6
CL--109*
___ 07:16PM HGB-13.1* calcHCT-39 O2 SAT-94
___ 06:50PM GLUCOSE-126* UREA N-59* CREAT-1.8*#
SODIUM-136 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-17* ANION
GAP-21*
___ 06:50PM estGFR-Using this
___ 06:50PM ALT(SGPT)-28 AST(SGOT)-23 CK(CPK)-78 ALK
PHOS-56 TOT BILI-0.4
___ 06:50PM ALBUMIN-2.8*
___ 06:50PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 06:50PM WBC-6.2 RBC-3.52* HGB-11.9* HCT-37.2*
MCV-106* MCH-33.8* MCHC-32.0 RDW-14.1 RDWSD-54.9*
___ 06:50PM NEUTS-73* BANDS-0 LYMPHS-10* MONOS-9 EOS-3
BASOS-00 ATYPS-5* ___ MYELOS-0 AbsNeut-4.53 AbsLymp-0.93*
AbsMono-0.56 AbsEos-0.19 AbsBaso-0.00*
___ 06:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-2+
___ 06:50PM PLT SMR-LOW PLT COUNT-113*
___ 06:50PM ___ TO PTT-UNABLE TO ___
TO
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 04:00PM URINE RBC-4* WBC-56* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:00PM URINE WBCCLUMP-MOD MUCOUS-RARE
MICRO:
======
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL/NEGATIVE
IMAGING:
========
CXR (___): Suboptimal study. No definite focal consolidation.
Possible mild pulmonary vascular congestion.
DISCHARGE LABS:
==============
___ 06:35AM BLOOD WBC-5.9 RBC-3.35* Hgb-11.2* Hct-35.2*
MCV-105* MCH-33.4* MCHC-31.8* RDW-13.9 RDWSD-53.5* Plt ___
___ 06:35AM BLOOD Glucose-277* UreaN-45* Creat-1.5* Na-136
K-4.8 Cl-102 HCO3-25 AnGap-14
___ 06:35AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.8
___ 06:35AM BLOOD Digoxin-0.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin B Complex 1 CAP PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. GlipiZIDE 20 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
8. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation DAILY
9. Simvastatin 40 mg PO QPM
10. Pioglitazone 15 mg PO DAILY
11. cefdinir 300 mg oral daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*16 Tablet Refills:*0
2. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate [Anti-Fungal] 2 % apply once daily to
skin folds once a day Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*21 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. GlipiZIDE 20 mg PO DAILY
9. Pioglitazone 15 mg PO DAILY
10. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation DAILY
11. Simvastatin 40 mg PO QPM
12. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
==================
Mechanical Fall
Deconditioning
Bradycardia
Urinary Tract Infection
Fungal Intertrigo
Acute Kidney Injury
Toxic Metabolic Encephalopathy
SECONDARY DIAGNOSIS
===================
Hypertension
Hyperlipidemia
Type II Diabetes
Super Obesity
Diastolic Congestive Heart Failure
Macrocytosis
Folate deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough, wheezing. // please evaluate for acute
infectious process
TECHNIQUE: AP supine portable views of the chest
COMPARISON: ___
FINDINGS:
The examination is suboptimal due to some patient motion and due to patient
body habitus. Given this, no definite focal consolidation is seen. There is
no large pleural effusion or pneumothorax. There is mild prominence of the
central pulmonary vasculature which may be due to pulmonary vascular
congestion. The cardiac silhouette is enlarged. Prominence of superior
mediastinum is similar in appearance compared to chest CT scout radiograph
from ___ ; patient seen to have mediastinal lipomatosis on the prior
study.
IMPRESSION:
Suboptimal study. No definite focal consolidation. Possible mild pulmonary
vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cellulitis, Transfer, Altered mental status
Diagnosed with Urinary tract infection, site not specified
temperature: 97.4
heartrate: 72.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were in the hospital because you fell, and there was concern
that you were confused. You also had very slow heart rates which
were concerning and likely caused by your kidneys not excreting
your heart rate control drugs.
While you were in the hospital, we continued to give you
antibiotics for your blood infection discovered at ___
___. You also worked with physical therapy to begin
to gain strength.
Now that you are going home:
- continue to take antibiotics as prescribed until ___
- decrease your home dose of metoprolol XL 25mg daily (from 50mg
at home), your primary care doctor may increase the dose back to
50mg
We wish you the best!
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
naproxen
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ is a ___ w/ DM2, HBV carrier,
thrombocytopenia & anemia p/w elevated LFTs and new onset
jaundice.
Approximately 2 weeks ago patient started feeling unwell
beginning with some diarrhea & emesis ___ 24h on ___.
Since
then he has felt persistently fatigued, and his friends
commented
that his skin looked yellow0. The patient initially thought that
this was a "liver attack" that he had when he was a child and
would periodically become jaundiced. Howevever his fatigue
progressed and worsened over the past 5 days, which caused him
to
present to his PCP. PCP ordered ___ CT scan that
showed intra/extrahepatic biliary dilation and possible
ampullary
lesion c/f peripancreatic neoplasm so he was referred to BI ___
an ERCP. ROS also positive ___ some DOE/exercise intolerance,
pale stools x 2 weeks, and intentional weight loss (due to
recent
diabetes diagnosis). ROS negative ___ abdominal pain, F/C,
dysuria/hematuria, and SOB.
In the ED, he received CTX and Zosyn, as ___ as LR and insulin.
ERCP was consulted, and plan is ___ an ERCP today once he is
admitted, with likely oncology workup afterwards.
Past Medical History:
PMH:
DIABETES TYPE II
THROMBOCYTOPENIA
PERIPHERAL NEUROPATHY
CARPAL TUNNEL SYNDROME
ANEMIA
DIABETIC NEPHROPATHY
HEPATITIS B CARRIER
PAST SURGICAL HISTORY:
CARPAL TUNNEL SURGERY
RHINOPLASTY
TONSILLECTOMY
TOOTH EXTRACTIONS
Social History:
Country of Origin: ___
Marital status: Significant Other
Children: Yes: 1
Lives with: Alone
Work: ___
Tobacco use: Former smoker
Year Quit: ___
Years Since ___
Quit:
# Packs/Day: 2
# Years Smoked: 26
Pack Years: ___
Alcohol use: Present
drinks per week: 14
Alcohol use drinks about 2 glasses or wine per day
comments:
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: Activities: walks or jogs ___ minutes
daily
Diet: eats a balanced diet with all food groups
Family History:
Relative Status Age Problem Onset Comments
Mother ___ ___ DIABETES TYPE II
LUNG CANCER smoker
Father UNKNOWN
Uncle ___ ___ COLON CANCER
MGF Deceased ___ THROAT CANCER
Son Living ___ INFLUENZA hospitalized
___ 10 days,
___ recovered
___
Physical Exam:
ADMISSION EXAM:
AFVSS
Constitutional: fatigued, otherwise appears comfortable
HEENT: sclera anicteric
CV: RRR no mrg
Pulm: CTAB
Abd: NTND, no masses, no ___ sign
___: no pitting edema
Neuro: no focal deficits
Psych: pleasant affect, appropriate
Skin: slightly jaundiced skin
DISCHARGE EXAM:
Physical Examination:
___ 0814 Temp: 97.8 PO BP: 102/64 HR: 65 RR: 16 O2 sat: 97%
O2 delivery: RA
Constitutional: NAD
HEENT: sclera anicteric
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: RRR no mrg
Pulm: CTAB
Abd: NTND, no masses, no ___ sign
___: no pitting edema
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in
all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 11:15AM BLOOD WBC-4.5 RBC-2.88* Hgb-10.2* Hct-30.8*
MCV-107* MCH-35.4* MCHC-33.1 RDW-13.5 RDWSD-53.5* Plt Ct-93*
___ 11:15AM BLOOD UreaN-36* Creat-1.0 Na-138 K-4.4 Cl-103
HCO3-22 AnGap-13
___ 11:15AM BLOOD ALT-538* AST-203* AlkPhos-477*
TotBili-2.3* DirBili-1.2* IndBili-1.1
___ 11:15AM BLOOD TotProt-7.3 Albumin-4.4 Globuln-2.9
___ 10:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 Iron-142
___ 10:00AM BLOOD calTIBC-242* VitB12-1151* Folate->20
Ferritn-2272* TRF-186*
___ 11:15AM BLOOD %HbA1c-10.0* eAG-240*
IMAGING
-------
CT A/P ___
1. Moderate intrahepatic and extrahepatic biliary dilatation,
with dilatation of the common bile duct with caliber transition
at the superior margin of the pancreas. No definite cause of
obstruction is identified. Recommend further evaluation with
MRCP.
2. Possible nodular lesion at the level of the ampulla of Vater,
bears close attention on MRCP.
3. Bilateral pyelonephritis
ERCP:
1.5 cm long malignant appearing stricture at the distal CBD was
noted. A biliary sphincterotomy was performed and brushings were
obtained. A ___ 7 cm plastic biliary stent was placed
successfully.
MICROBIOLOGY
------------
___ 11:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS
--------------
___ 06:45AM BLOOD WBC-4.3 RBC-2.47* Hgb-8.7* Hct-26.0*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.8 RDWSD-48.8* Plt Ct-90*
___ 06:45AM BLOOD Glucose-202* UreaN-30* Creat-1.1 Na-142
K-4.7 Cl-109* HCO3-24 AnGap-9*
___ 06:45AM BLOOD ALT-161* AST-25 AlkPhos-233* TotBili-1.2
___ 06:45AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.2
___ 10:00AM BLOOD calTIBC-242* VitB12-1151* Folate->20
Ferritn-2272* TRF-186*
___ 11:15AM BLOOD HCV Ab-NEG
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old man with c/f pancreatic cancer// rule out panc ca vs
cholangiocarcinoma
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 177.0
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.2 cm; CTDIvol = 112.6 mGy (Body) DLP =
22.5 mGy-cm.
4) Spiral Acquisition 3.4 s, 22.3 cm; CTDIvol = 13.0 mGy (Body) DLP = 281.1
mGy-cm.
5) Spiral Acquisition 8.0 s, 52.0 cm; CTDIvol = 11.2 mGy (Body) DLP = 575.0
mGy-cm.
6) Spiral Acquisition 3.4 s, 22.3 cm; CTDIvol = 13.0 mGy (Body) DLP = 281.1
mGy-cm.
Total DLP (Body) = 1,339 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions.
Again seen is intrahepatic biliary ductal dilatation. There is pneumobilia
status post CBD stenting.There is no discrete lesion at the ampulla of Vater
status post CBD stent placement. An underlying lesion could be obscured.
Previously-seen upper CBD and intrahepatic bile duct dilation, with a
transition point at the mid CBD and stricturing throughout the pancreatic
portion, has resolved following interval stenting.
PANCREAS: There is no discrete mass at the pancreatic head. There is an
isointense mass in the pancreatic tail measuring 1.8 x 3.0 x 1.8 cm with loss
of the pancreatic duct. 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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is normal in size.
LYMPH NODES: There is a 1.2 cm periportal lymph node (series 6, image 34).
Otherwise, there is no significant retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is a replaced right hepatic artery arising from the SMA.
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. No focal ampullary mass detected. This region is obscured by a CBD stent.
2. Interval resolution of intra extrahepatic bile duct dilation upstream from
a distal CBD stricture following CBD stent placement.
3. There is slight differential enhancement and obscuration of the pancreatic
duct at the tail of the pancreas spanning 1.8 x 3.0 x 1.8 cm, which could
represent a focal lesion. Alternatively, in combination with a known distal
CBD stricture, this could represent atypical IgG4 disease. Further evaluation
with endoscopic ultrasound is suggested.
4. There is a replaced right hepatic artery.
RECOMMENDATION(S): EUS to further evaluate the tail of pancreas with possible
target for biopsy.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abnormal CT
Diagnosed with Unspecified jaundice
temperature: 97.0
heartrate: 80.0
resprate: 17.0
o2sat: 99.0
sbp: 121.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure caring ___ you during your recent
hospitalization. You came to the hospital with jaundice.
Further testing, with an ERCP, showed a narrowing of your bile
duct. A biopsy was taken and is currently pending. You are now
being discharged.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck! |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - Sternal Rewiring
History of Present Illness:
Mr. ___ is a ___ year old man with a history of coronary
artery disease status post percutaneous coronary intervention x
3, and non-ST elevation myocardial infarctions x 2. He
underwent coronary artery bypass grafting x 2 with left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the posterior descending artery with Dr.
___ on ___. He was discharged to rehab on ___ but
left shortly after arriving as he and his family were
dissatisfied with the conditions. He had been at home and on
Amiodorone and coumadin for postoperative atrial fibrillation.
His INR had been ___ all week and he received 1 mg of coumadin
daily. He has had decreased PO intake and yesterday his INR was
8. He was told by his primary care provider to hold coumadin
over the weekend and recheck the INR on ___. Overnight he
had decreased urine output and on the morning of admission, he
was short of breath and called ___. He was taken to ___
___ where he was found to have an INR of 10 and he was in
respiratory distress. He was intubated and started on empiric
Vancomycin and Zosyn. He was given 10mg of Vitamin K. He
received Atropine for bradycardia. He was sent to ___ and his
INR on arrival was 14. He was admitted to the cardiac surgical
service for further management.
Past Medical History:
- Coronary artery disease s/p 3 DES to the RCA in ___,
in-stent restenosis intervened on ___ with DES to RCA,
Rota/PCI to the RCA ___
- ___ Stage IV s/p wedge resection ___
- h/o Intraductal papillary mucinous tumor of the pancreas and
chronic pancreatitis s/p pylorus sparing Whipple procedure in
___
- DM2, insulin dependent
- GERD
- Peripheral vascular disease
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Hypogonadism
- BPH
- Depression
- COPD (Uses 3 L Home Oxygen at bedtime)
- Squamous and basal cell cancer treated in ___
- H/O. Adenomatous polyps (Colonoscopy in ___
- 0.5 cm angiomyolipoma of the right kidney
- s/p Lung wedge resection in ___
- s/p Incisional hernia repair ___
- s/p Primary umbilical herniorrhaphy ___
- s/p Biliary stent
- s/p Right and left-sided femoral bypass surgeries
- s/p Femoral endarterectomy and iliac stenting ___
- s/p Pylorus preserving pancreaticoduodenectomy (Whipple), open
cholecystectomy, Feeding jejunostomy in ___
- s/p Bilateral external iliac stent placement and right
femoro-popliteal graft Patent iliac stents without stenosis
Social History:
___
Family History:
Mother died of heart disease at age ___ years
Physical Exam:
T 94 Pulse: 54 bpm Resp:18/mt O2 sat:100% on 50% (intubated)
B/P Right:114/65 mmHG Left: 105/53 mmHG
Height: 5'8" Weight: 175 lbs
General: Intubated, sedated
Skin: Dry [X] intact [X]
HEENT: PERRLA [] 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 [X]bowel sounds
+[X]
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: Trace Left: Dopplerable
___ Right: Trace Left: Dopplerable
Radial Right: 1+ Left: 1+
Carotid Bruit -
Pertinent Results:
___ ECHO
There is akinesis of the basal inferolateral wall and at least
hypokinesis of the basal inferior wall. The mid inferolateral
wall is severely hypokinetic (mid inferior not well seen). The
basal septum is also relatively hypokinetic, which may be due to
post-op septal motion and/or ventricular interaction from RV
pressure/volume overload. The remaining segments are globally
hypokinetic (LVEF = ___ %). The right ventricular cavity
appears mildly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is an anterior space which most likely represents a
prominent fat pad. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of ___
global left ventricular systolic function is somewhat decreased
but regional dysfunction is similar. The right ventricle is
better visualized on the current study and is hypokinetic with
evidence of RV pressure/volume overload (no short axis images on
the prior). The mitral regurgitation is better visualized on the
prior study.
___ CT Head
No acute intracranial process. Atrophy and small vessel
ischemic disease.
___ CT Chest/Abd
1. Abnormally positioned sternal wires as described above with
dehiscence of the sternum. Anterior mediastinal complex
collection most likely representing a hematoma.
2. Small bilateral pleural effusions, right greater than left
with overlying atelectasis. Trace amount of abdominal ascites.
3. Lung findings overall are better evaluated on the prior
chest CT, but a spiculated lung nodule in the right upper lobe
is stable. Opacities in the left lower lobe likely reflect a
combination of atelectasis and known nodules.
___ Ultrasound/Abdomen
1. Hyperechoic wedge-shaped lesion in the left lobe. This may
represent focal fatty infiltration. This can be further
evaluated with MRI or multiphasic CT. 2. No evidence of biliary
dilation.
___ 04:38AM BLOOD WBC-8.1 RBC-3.57* Hgb-10.6* Hct-35.1*
MCV-99* MCH-29.7 MCHC-30.1* RDW-16.8* Plt ___
___ 04:38AM BLOOD ___
___ 04:38AM BLOOD Glucose-54* UreaN-14 Creat-0.7 Na-135
K-3.5 Cl-101 HCO3-29 AnGap-9
Medications on Admission:
Aspirin 81 mg PO DAILY
Furosemide 40 mg PO BID
Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Levothyroxine Sodium 50 mcg PO DAILY
Pantoprazole 40 mg PO Q24H
Tamsulosin 0.4 mg PO HS
Venlafaxine XR 75 mg PO DAILY
Acetaminophen 650 mg PO Q4H:PRN pain, fever
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
Albuterol-Ipratropium 2 PUFF IH Q6H
Amiodarone 400 mg PO BID Duration: 5 Days
then decrease to 200 mg po bid x 7 days, then 200 mg daily until
reevaluated by Cardiologist
Clopidogrel 75 MG PO DAILY
Docusate Sodium 100 mg PO BID
Metoprolol Tartrate 25 mg PO TID
Pancrelipase 5000 1 CAP PO TID W/MEALS
Potassium Chloride 20 mEq PO Q12H
Sarna Lotion 1 Appl TP BID:PRN pruritis/rash on back
TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
Warfarin 2 mg PO ONCE Duration: ___
___ MD to order daily ___ PO DAILY AFib
Vitamin D 5000 UNIT PO BID
Simvastatin 40 mg PO DAILY
Pyridoxine 50 mg PO DAILY
coenzyme Q10 400 mg ORAL DAILY
Calcium Carbonate 500 mg PO BID
Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. Amiodarone 400 mg PO BID
4. Aspirin EC 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Pancrelipase 5000 1 CAP PO TID W/MEALS
9. Potassium Chloride 20 mEq PO BID
10. Tamsulosin 0.4 mg PO HS
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4h prn Disp #*15 Tablet
Refills:*0
12. Venlafaxine 37.5 mg PO BID
13. Bisacodyl ___AILY:PRN constipation
14. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
15. Furosemide 40 mg IV BID
16. Heparin 5000 UNIT SC TID
17. Glargine 38 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Ipratropium Bromide Neb 1 NEB IH Q6H
19. Pantoprazole 40 mg IV Q24H
20. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
21. Ascorbic Acid ___ mg PO DAILY
22. Calcium Carbonate 500 mg PO BID
23. Sarna Lotion 1 Appl TP BID:PRN pruritis/rash on back
24. Simvastatin 10 mg PO DAILY
25. Acetaminophen IV 1000 mg IV Q6H:PRN pain
26. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- ___ he underwent Coronary artery bypass grafting x2, left
internal mammary artery graft to left anterior descending,
reverse saphenous vein graft to the posterior descending artery.
- Atrial fibrillation
- CAD with 3VD (70% LMCA, 80% LCx, RCA stented as below), s/p
NSTEMI ___ treated medically and multiple PCI listed below
- PERCUTANEOUS CORONARY INTERVENTIONS: 3 DES to the RCA in
___, in-stent restenosis intervened on ___ with DES to
RCA, Rota/PCI to the RCA ___
-PACING/ICD: none
OTHER PAST MEDICAL HISTORY:
--___ Stage IV s/p wedge resection ___
--h/o Intraductal papillary mucinous tumor of the pancreas and
chronic pancreatitis s/p pylorus sparing Whipple procedure in
___
--DM2, insulin dependent
--GERD
--peripheral vascular disease
--hypothyroidism
--hypogonadism
--BPH
--depression
--COPD (Uses 3 L Home Oxygen at bedtime)
--Squamous and basal cell cancer treated in ___
--H/O Adenomatous polyps (Colonoscopy in ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol/Ultram
Incisions:
Sternal - healing well, No drainage, mild erythema along
inferior pole. 3 JPs to bulb suction.
Leg Right/Left - healing well, no erythema or drainage.
No Edema
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH FROM ___
HISTORY: Rule out pneumothorax after thoracentesis.
FINDINGS: Portable AP upright chest radiograph shows improved aeration at the
right lung base, presumably status post right-sided thoracentesis. No
pneumothorax is visible. The left hemidiaphragm remains obscured and there
appears to be increased haziness of the mid and upper lung zone compared to
the study from eight hours earlier. Some of this may be exaggerated because
of increased rotation. Left-sided PICC line tubing may be slightly pulled
back and now is at the level of the mid superior vena cava.
CONCLUSION: No visible pneumothorax status post thoracentesis (presumably on
the right).
Radiology Report
REASON FOR EXAMINATION: Bilateral pleural effusions, followup.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The left PICC line tip is at the level of mid SVC. Heart size is enlarged.
Mediastinum is enlarged. Perihilar interstitial opacities are noted.
Bilateral pleural effusion is present. Right pigtail catheter tip is in
place. No pneumothorax is seen.
IMPRESSION:
Since the prior study, there is substantial interval progression of pulmonary
edema.
The apical opacity on the left is unchanged.
Radiology Report
PORTABLE CHEST RADIOGRAPH, ___
COMPARISON: Study of earlier the same date.
FINDINGS: Interval placement of feeding tube, which coils in the stomach, and
subsequently courses cephalad with distal tip directed cephalad above the
level of the clavicles within the proximal thoracic esophagus. Exam is
otherwise remarkable for improving pulmonary edema and slight decrease in
mass-like opacity at left apex which has been more fully evaluated by prior
CT. Left retrocardiac opacity and bilateral pleural effusions appear similar.
Nurse ___ was informed of the malposition of the feeding tube at
8:10 p.m. on ___ by telephone at the time of discovery.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiomegaly is accompanied by improving pulmonary vascular
congestion and decreasing pulmonary edema. Left retrocardiac opacity has
substantially improved, likely a combination of atelectasis and effusion. A
more confluent opacity at the right lung base persists, and could be due to
asymmetrically resolving edema, but pneumonia should be considered in the
appropriate clinical setting. Small right pleural effusion is likely
unchanged, with pigtail pleural catheter remaining in place and no visible
pneumothorax.
Radiology Report
AP CHEST, 3:14 P.M. ON ___
HISTORY: A ___ man after cardiac surgery. Follow up pleural
effusions.
IMPRESSION: AP chest compared to ___:
Small right, moderate left pleural effusions both increased since ___.
Heart size top normal. Edema, generally improved since ___ is
redeveloping in the left upper lung. 15 mm right upper lobe nodule and the
much larger mass at the left apex medially are presumably due to bronchogenic
carcinoma. Consolidated lung in the infrahilar portions of both lower lobes
has not improved since ___. Whether this is atelectasis alone or
concurrent pneumonia is radiographically indeterminate. No pneumothorax.
Radiology Report
HISTORY: Multilobar pneumonia and respiratory failure, evaluate ET tube
placement.
COMPARISON: None.
FINDINGS:
FRONTAL CHEST RADIOGRAPH: Endotracheal tube is 3.5 cm above the carina. The
enteric tube is within the esophagus but appears to terminate at the
gastroesophageal junction. Exact position could be determined with an
abdominal radiograph if necessary. Extensive carotid calcifications are
noted.
Multifocal opacities within the lungs, predominantly in the left upper lobe,
are consistent with pneumonia. Sutures and scarring are seen in the left
upper lung, likely from prior surgery. The heart is mildly enlarged and there
is mild pulmonary edema. There are small to moderate bilateral pleural
effusions. There is no pneumothorax.
Radiology Report
INDICATION: History of altered mental status and elevated INR. Evaluate for
bleeding.
COMPARISONS: None.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
infarction. Ventricles and sulci are prominent consistent with atrophy. The
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear. There are calcified carotid siphons bilaterally. There are no acute
fractures.
IMPRESSION: No acute intracranial process. Atrophy and small vessel
ischemic disease.
Radiology Report
INDICATION: ___ man with altered mental status, INR of 10 with
abdominal ecchymosis, evaluate for bleeding.
COMPARISONS: CT abdomen and pelvis from ___ and CT chest from
___.
TECHNIQUE: MDCT axial imaging was obtained from the thoracic inlet to the
pubic symphysis without the administration of intravenous contrast material.
Coronal and sagittal reformats were completed.
FINDINGS: The thyroid gland is unremarkable. There are no enlarged
supraclavicular, axillary, mediastinal or hilar lymph nodes. The patient is
status post CABG. The first, third, and fifth sternotomy wires from the top
appear malpositioned and there is dehiscence of the sternum. There is an
anterior mediastinal intermediate density fluid collection measuring
approximately 7.1 x 5.0 cm in the transverse and AP dimension, most likely
representing a hematoma. There is severe coronary artery disease and aortic
valvular calcifications. There is no pericardial effusion. An endotracheal
tube is in appropriate position and nasogastric tube courses below the
diaphragm into the stomach. There are small bilateral pleural effusions with
adjacent compressive atelectasis, right greater than left. The patient is
status post left upper lobe wedge resection. Opacities in the left lower lobe
likely reflect a combination of atelectasis and known nodules. A spiculated
nodule at the right upper lobe measuring 7 x 9 mm is similar in size to the
previous exam. The airways are patent to the subsegmental levels.
CT ABDOMEN WITHOUT CONTRAST: The study is limited without administration of
intravenous contrast material for evaluation of the solid organs and
vasculature. Within these limitations, the non-contrast appearance of the
liver is unremarkable. The patient is status post pylorus-sparing Whipple.
The remainder of the pancreas is unremarkable. The spleen and adrenal glands
are unremarkable. The non-contrast appearance of the kidneys is unremarkable
without hydronephrosis. Multiple renal vascular calcifications are present.
Nasogastric tube courses into the stomach. The bowel is non-obstructed and
unremarkable. There is a small amount of perihepatic ascites. The aorta is
densely calcified. There are bilateral iliac stent grafts as well as a right
SFA bypass graft.
CT PELVIS: There is a small amount of free fluid in the pelvis. The rectum
and sigmoid colon are unremarkable. The bladder is collapsed with a Foley
catheter. There are calcifications of vas deferens.
OSSEOUS STRUCTURES: Old left clavicular fracture is noted. No acute
fractures are identified. No osseous destruction is seen.
IMPRESSION:
1. Abnormally positioned sternal wires as described above with dehiscence of
the sternum. Anterior mediastinal complex collection most likely representing
a hematoma.
2. Small bilateral pleural effusions, right greater than left with overlying
atelectasis. Trace amount of abdominal ascites.
3. Lung findings overall are better evaluated on the prior chest CT, but a
spiculated lung nodule in the right upper lobe is stable. Opacities in the
left lower lobe likely reflect a combination of atelectasis and known
nodules.
Radiology Report
HISTORY: Check line placement.
___.
FINDINGS:
The ETT is 3 cm above the carina. There is a right IJ Swan-Ganz catheter with
tip in the right main pulmonary artery. The NG tube tip is in the stomach.
There are bilateral pleural effusions and bilateral lower lobe volume loss
there is a dense left upper lobe infiltrate. Heart size is moderately
enlarged. There is pulmonary vascular redistribution with ill-defined
vascularity.
Radiology Report
HISTORY: History of lung cancer and IPMN with elevated LFTs and worsening
white count. Evaluate for cholangitis.
COMPARISON: CT abdomen with contrast from ___ and ___.
FINDINGS:
Within the left lobe of the liver is a subcapsular focal somewhat rounded
wedge-shaped hyperechoic area, of unclear etiology. There is no definite
intrahepatic biliary dilatation. The common bile duct measures 4 mm. The
main portal vein is patent. The gallbladder surgically absent. A right
pleural effusion is noted.
IMPRESSION:
1. Hyperechoic wedge-shaped lesion in the left lobe. This may represent focal
fatty infiltration. This can be further evaluated with MRI or multiphasic CT.
2. No evidence of biliary dilation.
Radiology Report
AP CHEST, 5:45 P.M., ___.
HISTORY: ___ man after sternal debridement. Evaluate for
pneumothorax or effusions.
IMPRESSION: AP chest compared to ___:
Mild pulmonary edema has improved. New right pleural drain, following sternal
debridement. Small bilateral pleural effusions and severe left lower lobe
atelectasis unchanged. Heart size normal. ET tube, Swan-Ganz catheter, upper
enteric drainage tube, midline drains in standard placements. No
pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post sternal rib rewiring.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has undergone
sternal rewiring. The patient is now extubated and the nasogastric tube and
the Swan-Ganz catheter have been removed. The other monitoring and support
devices are in unchanged position. Lung volumes have slightly decreased, and
small bilateral pleural effusions as well as areas of atelectasis are still
visible. No pneumothorax is visualized. The obviously postoperative opacity
at the upper medial left aspects of the mediastinum is constant in appearance.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Sternal wires, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen
of the sternal wiring. Monitoring and support devices are constant in
appearance. Constant low lung volumes with bilateral small pleural effusions
and subsequent areas of atelectasis. Moderate cardiomegaly. No new
parenchymal opacities.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Sternal rewire, evaluation for pneumothorax.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
decreased. As a consequence, the structures at the lung bases appear denser
than on the previous image. However, there are no new parenchymal opacities
or abnormalities noted. Moderate cardiomegaly persists. The right chest tube
has been removed.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Coughing, status post unstable chest.
COMPARISON: ___, 10:30 a.m.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
The lung volumes have slightly increased, likely reflecting improved
ventilation. Otherwise, the appearance of the lung parenchyma, the
mediastinum and the cardiac silhouette, including the monitoring and support
devices as well as sternal fixations, is stable.
Radiology Report
HISTORY: New PICC.
COMPARISON: Chest radiograph ___.
FRONTAL CHEST RADIOGRAPH: A left upper extremity PICC courses into the low
SVC. A right internal jugular Cordis catheter has been withdrawn and now
terminates in the upper SVC. Sternotomy wires, CABG clips, sternal struts and
skin staples are constant.
Small to moderate bilateral pleural effusions are increased in volume. Mild
pulmonary edema and mild cardiomegaly are stable. No pneumothorax. The
opacity in the left lung apex may reflect the underlying retrosternal
collection as seen on the prior CT of ___ but is unchanged.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation for endotracheal tube.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient was intubated.
Exact location of the ETT tip is difficult to determine, given overlay by
multiple metallic devices at the level of the sternum. However, the
approximate location above the carina is 4 cm.
The other monitoring and support devices are constant. Constant appearance of
the lung parenchyma, the pleura, with a known right pleural effusion as well
as of the cardiac silhouette.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Studies dating between ___ and ___.
FINDINGS: Endotracheal tube and other support and monitoring devices are in
standard position. Status post removal of sternal wires. Mass-like opacity
at left lung apex appears similar to previous studies and has been more fully
evaluated by CT of ___. Pulmonary vascular congestion is again
demonstrated as well as mild interstitial edema. Moderate right and small
left pleural effusions are similar with adjacent basilar lung opacities.
Radiology Report
PORTABLE CHEST ___
COMPARISON STUDY: ___ radiograph.
FINDINGS: Support and monitoring devices are in standard position, and
cardiomediastinal contours are stable. Mass-like area of consolidation at
left apex appears slightly less dense and has been more fully evaluated by
recent CT. Moderate layering right pleural effusion and small left pleural
effusion are similar, with adjacent bibasilar areas of atelectasis or
consolidation.
Radiology Report
AP CHEST, 8:39 A.M., ___
HISTORY: ___ man after CABG with pleural effusion.
IMPRESSION: AP chest compared to ___ through ___:
Opacification at the base of the right lung is due substantially to moderate
right pleural effusion present for at least a week, but there is new
consolidation at the upper margin of this abnormality concerning for
pneumonia, and mild pulmonary edema has developed since ___. Severe
cardiomegaly is more pronounced and atelectasis at the left lung base
unchanged. Small left pleural effusion is presumed. Left-sided central
venous catheter ends in the mid SVC. No pneumothorax.
___ was paged at 11:45 a.m. when the findings were recognized and we
discussed the findings by telephone a minute later.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: INTUBATED
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | 1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
-Adaptic dressing followed by 4x4, wrapped with Kerlix and
waffle boots to keep bilateral heels elevated.
*Plavix should be held until pt seen by ___
surgery) in 1 week.
JPs to bulb suction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Symbicort
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
intubation/extubation while in the ICU
___ right percutaneous nephrostomy tube
___ abdominal seroma drainage
History of Present Illness:
Patient is a ___ yo male with a PMH of esophageal Ca s/p
esophagectomy ___, lung adenocarcinoma s/p cyberknife ___,
HTN, COPD, DMII, CKD, chronic diarrhea and recent lumbar
decompression and fusion surgery ___ who presents with
confusion and urinary retention from rehab
The patient had recent admission from ___ to ___ for
L3-S1 anterior and posterior decompression and fusion in a 2
stage procedure. It was c/b a dural tear which was treated with
the
head of the bed flat for 48 hours post-op. He also had urinary
retention during admission and was discharged with a foley. He
was also discharged with a lumbar corset brace for comfort and
support.
Per notes, the patient was oriented at time of discharge. He
has had gradual cognitive decline since arrival at ___. On ___
he developed a fever to 101.6. CXR revealed moderate RLL
pneumonia and a patchy right atrial opacity. UA was positive,
but urine cx showed no growth. He was started on vanc and
cefepime via R PICC line with defervescence. He pulled out his
foley at rehab on ___ and required straight catheterization on
___ for urinary retention. They attempted to straight cath him
on ___ w/o success; bladder scan showed 765ccs. Given urinary
retention and worsening MS, he was transferred to ___.
In the ED, initial vitals were: 97.2 84 146/66 20 100% RA.
- Labs were significant for: WBC 12.5, plts 640, H/H 8.___.0,
Cr 1.3, trop 0.02, lactate 1.1, bland UA.
- CT A/P revealed 3.7 x 7.0 x 15.6 cm air/fluid containing
collection in anterior abdominal wall, likely seroma, but unable
to r/o infection. RUQ U/S showed patent portal vein.
- Patient was given Vanco/Pip-Tazo and morphine (15mg total).
- Surgery and Ortho were consulted; recommend ___ drainage of
seroma. Urology also consulted for foley placement for 1L
urinary retention.
Vitals prior to transfer were: 75 143/61 95% RA
Upon arrival to the floor, the patient is somnolent but
arousable. Is AAOx1, unable to answer questions.
Past Medical History:
- Hypertension
- Lumbar spinal stenosis s/p L3-S1 anterior and posterior
decompression and fusion ___
- Sensorineural hearing loss
- Peripheral neuropathy
- Diabetes type 2
- Hypercholesterolemia
- Paroxysmal supraventricular tachycardia
- Sleep apnea
- Chronic Diarrhea (thought to be secondary to diabetic
dysmotility)
- History of pulmonary embolism, post op ___
- Pancreatic insufficiency
- Moderate COPD
- History of esophageal candidiasis
- History of alcohol abuse
- Delayed gastric emptying
- Vitreous detachment
- Chronic inflammatory demyelinating neuropathy
- Renal cysts
- Short segment dissection of the infrarenal abdominal aorta,
followed by vascular
- Esophageal cancer s/p resection of lower esophagus ___ at
___.
Course c/b empyema, felt to be d/t leakage during operation, as
well as post-op PE and subsequent esophagitis and structuring
- Lung adenocarcinoma s/p cyberknife ___, following with
serial scans
- S/P L3-5 laminectomies ___
- S/P splenectomy after MVA age ___
- S/P CCY age ___
Social History:
___
Family History:
Mother died at age ___. Father died with an aortic aneurysm.
Sister died with an abdominal cancer.
Physical Exam:
ADMISSION EXAM
====================
Vitals: 97.6 131/55 78 12 96% RA
General: Somnolent, AAOx1
HEENT: Sclera anicteric. Pupils 2mm and reactive.
Neck: Supple
CV: RRR, no m/r/g
Lungs: Diffuse rhonchi, decreased breath sounds at bases
Abdomen: Healing midline incision that looks c/d/I. Has mass to
the left of the incision that is non-tender c/w findings of
seroma on imaging.
Back: Posterior midline lumbar incision c/d/I. Sacral
ulceration.
GU: + foley
Ext: Warm, well perfused, no edema. Multiple bruises on lower
extremities.
Neuro: AAOx1
DISCHARGE EXAM
====================
VITALS: Tc 97.6, Tm 98.7, BP 140s-160s/50s, HR ___, RR 20,
94% RA
GENERAL: Alert, oriented x3, NAD
HEENT: EOMI, Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated
RESP: diminished breath sounds at bases b/l, no crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: scar from umbilicus down to pubus, clean, no erythema or
purulence, + small abdominal dressing c/d/I from seroma
drainage.
Back: linear scar down lumbar spine, no drainage; + right PCN
with clear urine
Ext: well perfused, 2+ pulses, no clubbing, cyanosis or edema
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
==================
___ 06:40PM BLOOD WBC-12.5* RBC-2.59* Hgb-8.3* Hct-26.0*
MCV-100* MCH-32.0 MCHC-31.9* RDW-13.2 RDWSD-48.4* Plt ___
___ 06:40PM BLOOD Neuts-70.2 Lymphs-18.8* Monos-7.2 Eos-2.6
Baso-0.5 Im ___ AbsNeut-8.74* AbsLymp-2.34 AbsMono-0.90*
AbsEos-0.33 AbsBaso-0.06
___ 06:40PM BLOOD ___ PTT-29.0 ___
___ 06:40PM BLOOD Glucose-111* UreaN-16 Creat-1.3* Na-134
K-4.3 Cl-98 HCO3-26 AnGap-14
___ 06:40PM BLOOD ALT-39 AST-39 AlkPhos-96 TotBili-0.5
___ 06:40PM BLOOD cTropnT-0.02*
___ 06:40PM BLOOD Lipase-23
___ 06:40PM BLOOD Albumin-3.4* Calcium-9.2 Phos-4.4# Mg-2.2
___ 07:12PM BLOOD Lactate-1.1
IMAGING
=================
___ RUQ US
1. Patent portal vein.
2. Unchanged mild intrahepatic and moderate extrahepatic biliary
duct dilation compared to ___ and likely related to
prior cholecystectomy.
___ CXR
Re- demonstration of spiculated lesion in the right apex with
associated
pleural thickening. Upper lobe predominant emphysema. Status
post
esophagectomy and gastric pull-through with associated right
basilar
atelectasis. Trace left pleural effusion.
___ CT HEAD
Limited exam secondary to motion artifact. Within these
limitations, no acute intracranial abnormality.
___ CT ABDOMEN/PELVIS
1. 3.7 x 7.0 x 15.6 cm air and fluid containing collection in
the left
anterior abdominal wall. This likely represents a postsurgical
seroma.
However, the amount of air contained within the collection is
greater than
expected given 2 week interval since surgery. Infection of this
collection cannot be excluded on the basis of this exam.
2. Status post anterior and posterior fixation of the L3 through
S1 vertebral bodies, with expected postoperative changes.
___ MRI L SPINE
1. Laminectomy with posterior spinal fusion at L3-L4 to L5-S1
with associated susceptibility and postoperative changes.
2. Fluid collection at the laminectomy site could be
postoperative in nature. Mild surrounding enhancement could be
seen in a postoperative collection but any associated infection
cannot be excluded by MRI appearances along and clinically
correlation is recommended.
3. Fluid collection associated with disc bulging results in some
spinal canal narrowing at L3-4 level.
4. Although there is no direct connection between thecal sac and
the fluid
collection, clinical correlation recommended to exclude a CSF
leak.
5. Evaluation of neural foramen from L3-L4 to L5-S1 is limited
given the
susceptibility artifact but appear to be at least moderately
narrowed at all these levels.
6. Severe spinal canal stenosis at L2-L3, above the level of
laminectomies.
___ MR HEAD
1. No acute intracranial abnormality. Volume loss in keeping
with age-related involutional changes.
___ VIDEO SWALLOW
Intermittent silent aspiration of thin liquids and penetration
of nectar thick liquids.
___ RENAL US
1. New right UVJ obstruction with new mild right
hydroureteronephrosis, few distal right ureteral calculi with
largest obstructing calculi measuring 1.1 cm at the right UVJ.
2. No left hydronephrosis.
3. Postvoid bladder volume of 104.78 cc.
___ CXR
There are no changes since ___ to explain fever.
Scar-like lesion at the site of directed radiation in the right
upper lung includes
bronchiectasis. There is no pneumonia are new intrathoracic
fluid collection. Patient has had esophagectomy and right rib
resections. Left lung is clear. Heart size normal.
MICRO
====================
___ 11:31 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
DISCHARGE LABS
====================
___ 06:10AM BLOOD WBC-8.1 RBC-2.70* Hgb-8.5* Hct-27.6*
MCV-102* MCH-31.5 MCHC-30.8* RDW-14.0 RDWSD-52.3* Plt ___
___ 06:10AM BLOOD Glucose-96 UreaN-15 Creat-1.0 Na-144
K-3.8 Cl-108 HCO3-30 AnGap-10
___ 06:00AM BLOOD ALT-40 AST-44* LD(LDH)-291* AlkPhos-99
TotBili-0.4
___ 06:10AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.9
___ 07:11AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 10 mg PO QPM
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Calcium Carbonate 500 mg PO QID:PRN reflux
5. Sucralfate 1 gm PO BID
6. Diazepam 5 mg PO Q6H:PRN muscle spasm
7. Famotidine 20 mg PO BID
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Senna 8.6 mg PO BID:PRN constipation
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. coenzyme Q10 100 mg oral DAILY
12. glimepiride 1 mg oral DAILY
13. Lactobacillus acidophilus 2 billion cell oral DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Gabapentin 600 mg PO BID:PRN pain
16. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Loratadine 10 mg PO DAILY:PRN allergies
19. Hyoscyamine 0.250 mg PO BID:PRN loose stools
20. Creon 12 2 CAP PO TID W/MEALS
21. Cyanocobalamin 500 mcg PO DAILY
22. Ferrous Sulfate 325 mg PO BID
23. Fluticasone Propionate NASAL 2 SPRY NU DAILY
24. FoLIC Acid ___ mcg PO DAILY
25. Losartan Potassium 100 mg PO DAILY
26. MethylPHENIDATE (Ritalin) 40 mg PO QAM
27. MethylPHENIDATE (Ritalin) 20 mg PO AT NOON
28. Bisacodyl 10 mg PR QHS:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Calcium Carbonate 500 mg PO QID:PRN reflux
4. Cyanocobalamin 500 mcg PO DAILY
5. Famotidine 20 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid ___ mcg PO DAILY
8. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*14 Capsule Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Pravastatin 10 mg PO QPM
11. Senna 8.6 mg PO BID:PRN constipation
12. Sucralfate 1 gm PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Fluconazole 200 mg PO Q24H
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. coenzyme Q10 100 mg oral DAILY
18. Creon 12 2 CAP PO TID W/MEALS
19. Fluticasone Propionate NASAL 2 SPRY NU DAILY
20. Hyoscyamine 0.250 mg PO BID:PRN loose stools
21. Loratadine 10 mg PO DAILY:PRN allergies
22. Vitamin D 1000 UNIT PO DAILY
23. Lactobacillus acidophilus 2 billion cell oral DAILY
24. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute metabolic encephalopathy, fever
Secondary diagnosis: s/p lumbar decompression, seroma, ___
urinary tract infection, hypertension, orthostatic hypotension,
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with spondylosis s/p back surgery on ___ now
with ongoing delirium // source of encephalopathy
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 from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are patent and prominent in keeping
with age-related volume loss.
There are scattered foci and confluent areas of T2/FLAIR hyperintensity in the
subcortical and periventricular white matter, nonspecific, likely secondary to
small vessel ischemic disease.
The orbits are unremarkable noting prior bilateral cataract surgeries.
Intracranial flow voids are maintained. Mild mucosal thickening in bilateral
ethmoid air cells. The remaining visualized paranasal sinuses are clear.
Bilateral mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial abnormality. Volume loss in keeping with age-related
involutional changes.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with spondylosis s/p back surgery on ___ now
with ongoing delirium // source of worsening back pain Source of worsening
back pain
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 9 mL of
Gadavist contrast agent.
COMPARISON: None.
FINDINGS:
For the purposes of numbering, the lowest well formed intervertebral disc
space was designated the L5-S1 level.Please note that this method is
inappropriate for surgical planning.
Please note that the evaluation is somewhat limited given the susceptibility
from the hardware.
There are postsurgical changes related to recent prior laminectomies at L3, L4
and L5 and posterior spinal fusion with bipedicular screw and rod device an
intervertebral disc graft at L3-L4, L4-L5 and L5-S1. There is associated
susceptibility somewhat limiting the evaluation. There is a large fluid
collection in the laminectomy bed and paraspinal soft tissues measuring
approximately 11.6 x 2.5 x 13 cm extending from the level of L3-S1 vertebral
bodies without any well defined connection thecal sac and fluid collection.
No definite enhancement is seen on postcontrast images.
The alignment of the lumbar spine is maintained. The vertebral body heights
are maintained at all levels. The marrow signal appears grossly unremarkable
though evaluation is limited given the susceptibility from the spinal
hardware. The conus terminates at L1. There are atrophic kidneys bilaterally
with multiple sub cm simple cysts (greater than 20). The visualized
prevertebral and retroperitoneal soft tissues otherwise appear unremarkable.
At T12-L1, bilateral neural foramen and spinal canal are patent.
At L1-L2, there is minimal disc bulge with mild bilateral facet arthropathy
causing mild bilateral neural foramen narrowing. The spinal canal is patent.
At L2-L3, there is mild broad-based disc bulge with facet arthropathy causing
mild bilateral neural foraminal narrowing. The disc bulge with facet
arthropathy and ligamentum flavum thickening is also causing severe spinal
canal stenosis at this level.
At L3-L4, there has been decompression of the spinal canal secondary to the
laminectomy. However, the combination of disc bulge and indentation by
posterior fluid collection result in spinal canal narrowing Evaluation of
neural foramen is somewhat limited given the streak artifact but appears to be
moderately narrowed.
At L4-L5, there is decompression of the spinal canal secondary to the
laminectomy. Evaluation of neural foramen is limited secondary to the
susceptibility artifact but appears at least moderately narrowed.
At L5-S1, there has been decompression of the spinal canal secondary to the
laminectomy. Evaluation of neural foramen is limited given the susceptibility
but appears at least moderately narrowed.
IMPRESSION:
1. Laminectomy with posterior spinal fusion at L3-L4 to L5-S1 with associated
susceptibility and postoperative changes.
2. Fluid collection at the laminectomy site could be postoperative in nature.
Mild surrounding enhancement could be seen in a postoperative collection but
any associated infection cannot be excluded by MRI appearances along and
clinically correlation is recommended.
3. Fluid collection associated with disc bulging results in some spinal canal
narrowing at L3-4 level.
4. Although there is no direct connection between thecal sac and the fluid
collection, clinical correlation recommended to exclude a CSF leak.
5. Evaluation of neural foramen from L3-L4 to L5-S1 is limited given the
susceptibility artifact but appear to be at least moderately narrowed at all
these levels.
6. Severe spinal canal stenosis at L2-L3, above the level of laminectomies.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with delirium s/p back surgery now electively
intubated for MRI head/back // ETT placement ETT placement
COMPARISON: Chest radiographs ___.
IMPRESSION:
New transoral drainage tube passes through the nondistended neo esophagus,
ending below the diaphragm. ET tube in standard placement. Left lung clear.
Right apical pleural parenchymal soft tissue abnormality has been questioned
on chest CT in ___
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old man with delirium, fever, s/p intubation, aspiration
on bedside evaluation evaluate for aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 04:12 min.
COMPARISON: ___ for an esophagram.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was delayed epiglottic closure and pharyngeal laryngeal
reflux resulting in intermittent silent aspiration of thin liquids and
penetration of nectar thick liquids. Large anterior osteophyte at C4-C5
displaces the esophagus anteriorly.
IMPRESSION:
Intermittent silent aspiration of thin liquids and penetration of nectar thick
liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with delirium, UTI with ___, + fever. Assess
for pyelonephritis, abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen/pelvis with contrast ___.
FINDINGS:
The right kidney measures 13.1 cm. There is mild right hydroureteronephrosis
with visualization up to the right UVJ. A 1 x 0.5 x 1.1 cm ureteral stone is
seen at the right UVJ as well as additional 0.9 and 0.8 cm calculi slightly
upstream within the distal right ureter, similar in appearance to CT abdomen/
pelvis from ___. Subcentimeter renal cysts are noted. Normal
cortical echogenicity and corticomedullary differentiation is otherwise seen.
The left kidney measures 12.3 cm. There is no hydronephrosis, stones, or
masses. Subcentimeter renal cysts are noted. Normal cortical echogenicity
and corticomedullary differentiation is otherwise seen.
The bladder is moderately well distended and otherwise normal in appearance.
No bladder calculi. Bilateral ureteral jets were not visualized. Prevoid
bladder measured 275.5 cc. Postvoid imaging demonstrated persistent right
hydronephrosis with a postvoid bladder volume of 104.78 cc.
IMPRESSION:
1. New right UVJ obstruction with new mild right hydroureteronephrosis, few
distal right ureteral calculi with largest obstructing calculi measuring 1.1
cm at the right UVJ.
2. No left hydronephrosis.
3. Postvoid bladder volume of 104.78 cc.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the ___ ___ at 2:15 ___, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ year old man with right hydronephrosis from an obstructing
stone at the UVJ. Please place right perc nephrostomy tube.
COMPARISON: Renal US ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
Dr. ___ supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
No moderate sedation was provided. Pain control was achieved by
administrating divided doses of 25 mcg of fentanyl throughout the total
intra-service time of 45 min during which the patient's hemodynamic parameters
were continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: 1 g cefazolin IV
CONTRAST: 25 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.7 min, 15 mGy
PROCEDURE: 1. Right ultrasound and fluoroscopy guided renal collecting system
access.
2. Right antegrade nephrostogram.
3. ___ F nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
prone on the exam table. A pre-procedure time-out was performed per ___
protocol. The right flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the right renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the right ureter. After a skin ___, the needle was
exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A
___ wire was advanced through the sheath into the ureter and coiled in the
urinary bladder. The sheath was then removed, the tract dilated with an ___ F
dilator, and an 8 ___ nephrostomy tube was advanced into the renal
collecting system. The wire was then removed and the pigtail was formed in the
collecting system. Contrast injection confirmed appropriate positioning.
The catheter was then flushed, 0 silk stay sutures applied and the catheter
was secured with a Stat Lock device and sterile dressings. The catheter was
attached to a bag. The patient tolerated the procedure well. There were no
immediate complications.
FINDINGS:
1. Antegrade nephrostogram showing minimal hydronephrosis with delayed
emptying of contrast into the bladder, suggestive of distal ureteral
obstruction compatible with known ureterolithiasis in the distal third of the
ureter.
2. Placement of an ___ F nephrostomy tube. Post placement contrast injection
confirmed appropriate position of the loop in the collecting system.
IMPRESSION:
Successful placement of an 8 ___ nephrostomy on the right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever and recent intubation // eval for
pneumonia eval for pneumonia
COMPARISON: CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___.
IMPRESSION:
There are no changes since ___ to explain fever. Scar-like lesion at
the site of directed radiation in the right upper lung includes
bronchiectasis. There is no pneumonia are new intrathoracic fluid collection.
Patient has had esophagectomy and right rib resections. Left lung is clear.
Heart size normal.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old man with recent lumbar decompression and fusion
surgery ___ via anterior and posterior approach now with fevers and
concern for infected abdominal seroma (CT abdomen with evidence of air c/f
infection). // drain abdominal seroma. please send for culture.
COMPARISON: CT of the abdomen and pelvis dated ___.
PROCEDURE: Ultrasound-guided drainage of a superficial left anterior
abdominal wall collection.
OPERATORS: Dr. ___, radiology trainee, Dr. ___
fellow and Dr. ___ radiologist. Dr. ___
supervised the trainee during the key components of the procedure and reviewed
and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on the
ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, an 18 ___ spinal needle was advanced
into the collection. The collection was aspirated until no remaining fluid was
present within the collection.
Approximately 90 cc of dark, serosanguineous fluid was drained with samples
sent for hematology and microbiology evaluation. Sterile dressing was
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: None.
FINDINGS:
A 5.3 x 2 x 11.2 cm anechoic collection within the left anterior abdominal
wall, lateral to the healed midline incision.
IMPRESSION:
Successful US-guided drainage of the left anterior abdominal wall collection.
Samples were sent for hematology and microbiology evaluation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Postproc hemorrhage of skin, subcu following other procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt, Altered mental status, unspecified
temperature: 97.2
heartrate: 84.0
resprate: 20.0
o2sat: 100.0
sbp: 146.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted with
fever and confusion. Your confusion was attributed to delirium
and improved with pain control. Your blood pressure was both
high and low and we monitored that closely. You also had an
episode where you were unresponsive from too much pain
medication. We changed your pain medication regimen to prevent
sedation.
We also found a kidney stone that caused something called
"hydronephrosis" (where there is back flow of urine into the
kidneys, putting pressure on the kidneys). You had a tube placed
into your right kidney to relieve that pressure. You were also
started on a medication to treat a urinary tract infection.
You also had a fluid collection drained in your abdomen.
You were discharged to rehab and will continue getting physical
therapy before you can go home.
We wish you the best,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending: ___.
Chief Complaint:
Displaced gastric tube
Major Surgical or Invasive Procedure:
Gastric tube replacement
History of Present Illness:
Ms. ___ is a ___ with history of vascular dementia (AOx1 at
baseline), anoxic brain injury (baseline R hemiplegia after MI,
s/p feeding PEG), afib on coumadin presents after his G-tube
fell out at nursing home.
Patient gets Jevityu 1.5 boulus 350mL bolus at 6a, 12p and 6p.
Flush 200ml H20 pst bolus. Last bolus at 6AM. The last two times
the GI tube was pulled out ___ and ___ it was replaced
without incident. Patient denies nausea, vomiting, abdominal
pain, diarrhea, chest pain. No fevers, chills, shortness of
breath, cough, dysuria, urinary frequency.
In the ED, initial vital signs were: T 98 P 72 BP 104/71 R 16 O2
96%sat. ED and ___ resident attempted thread foley through the
track and could. Labs were notable for Na of 148, INR of 5.2.
Status post 1L ___ NS.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
As per OMR:
- Vascular dementia
- CVA with right hemiplegia
- PE
- PAF/SVT
- MI
- Falls
- Dysphagia
- GERD
- Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on admission:
Vitals: 99.4 115/86 82 16 95%RA
General: patient appears comfortable, oriented to person.
HEENT: MMM, OP clear, EMOI, PERRL
CV: RRR, nl s1 s2, no r/m/g
Lungs: CTAB
Abdomen: NABS, NTND, LUQ stoma site c/d/i without erythema
Ext: no edema
Neuro: A&Ox1. tangential speech. aphasic, CN appear grossly
intact. did not participate in strength exam, but appears to be
moving all extremities.
Exam on discharge:
Vitals: Tm 99.1 115-146/60s-104 ___ 20 97% RA
General: Well-appearing female in NAD
HEENT: MMM, OP clear, MMM
CV: RRR, nl s1 s2, no r/m/g
Lungs: CTAB
Abdomen: NABS, NTND, LUQ stoma site with replaced G tube,
well-secured with dressing. No exudate, no surrounding erythema,
no drainage.
Ext: no edema, feet cool, DP 2+ bilaterally
Pertinent Results:
Admission labs:
___ 04:20PM BLOOD WBC-5.3 RBC-4.47 Hgb-13.4 Hct-41.2 MCV-92
MCH-30.1 MCHC-32.6 RDW-14.1 Plt ___
___ 04:20PM BLOOD ___ PTT-66.3* ___
___ 04:20PM BLOOD Glucose-117* UreaN-14 Creat-0.5 Na-148*
K-3.8 Cl-109* HCO3-30 AnGap-13
Discharge labs:
___ 08:55AM BLOOD WBC-7.2 RBC-4.41 Hgb-13.4 Hct-39.3 MCV-89
MCH-30.3 MCHC-34.0 RDW-13.8 Plt ___
___ 08:55AM BLOOD ___ PTT-49.7* ___
___ 08:55AM BLOOD Glucose-82 UreaN-7 Creat-0.5 Na-143 K-3.4
Cl-103 HCO3-31 AnGap-12
PROCEDURE: 1. Gastrostomy tube replacement.
Successful replacement of a Wills ___ gastrostomy tube
through the
existing tract. The tube is ready to use.
RECOMMENDATION: If a low profile MIC gastrostomy tube is
strongly desired, gastrostomy tube exchange may be considered
once the patient's INR is corrected.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO QID:PRN diarrhea
2. Warfarin 3 mg PO DAILY16
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. Baclofen 5 mg PO TID
6. Famotidine 40 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. potassium chloride 20 mEq/15 mL oral daily
9. Sertraline 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Baclofen 5 mg PO TID
3. Famotidine 40 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. LOPERamide 2 mg PO QID:PRN diarrhea
6. Metoprolol Tartrate 50 mg PO BID
7. Sertraline 25 mg PO DAILY
8. potassium chloride 20 mEq/15 mL oral daily
9. Warfarin 2 mg PO DAILY16
Please take as directed by your physician.
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Gastrostomy tube replacement
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with Tube fell out, tract closed // Replaced
COMPARISON: Gastrostomy tube replacement ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: The patient's hemodynamic parameters were continuously monitored
by an independent trained radiology nurse. Viscous lidocaine was applied
topically over the site. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
MEDICATIONS: Lidocaine
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2 min, 8 mGy
PROCEDURE: 1. Gastrostomy tube replacement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The upper abdomen was prepped and draped in the usual sterile
fashion.
The existing gastrostomy tube tract was crossed using a 4 ___ dilator and
Glidewire. Injection of the dilator confirmed opacification of gastric rugae.
The dilator was angled towards the fundus and ___ wire was inserted. A
16 ___ low-profile MIC gastrostomy tube with 3.5 cm stoma length was chosen
for replacement. However the tube could not be advanced through the skin
tract. The skin tract was dilated with 14 and and 16 ___ dilators. The
gastrostomy tube could still not be advanced. The Wills ___ gastrostomy
tube was easily advanced over the wire into the stomach. The retention pigtail
was formed and secured. The tube was secured with 0 silk suture and a Stat
Lock device. Contrast injection confirmed appropriate position. Sterile
dressing was applied. Patient tolerated the procedure well and there were no
immediate post-procedure complications.
FINDINGS:
1. Wills ___ gastrostomy tube in the stomach.
IMPRESSION:
Successful replacement of a Wills ___ gastrostomy tube through the
existing tract. The tube is ready to use.
RECOMMENDATION: If a low profile MIC gastrostomy tube is strongly desired,
gastrostomy tube exchange may be considered once the patient's INR is
corrected.
Gender: F
Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Arrive by AMBULANCE
Chief complaint: GTUBE EVAL
Diagnosed with UNSPEC GASTROSTOMY COMPLIC, ABN REACT-EXTERNAL STOMA
temperature: 98.0
heartrate: 72.0
resprate: 16.0
o2sat: 96.0
sbp: 104.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the ___
because your G-tube fell out. You were admitted and a new G tube
was placed. Your blood was found to be too thin and so your
warfarin (coumadin) was temporarily stopped. You are discharged
home on a lower warfarin dose. You should have your INR drawn
tomorrow (___) and follow the instructions of your physician
for dosing.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
vancomycin / Zofran (as hydrochloride)
Attending: ___
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
___ - VP shunt revision of proximal catheter.
History of Present Illness:
___ year old male with hydrocephalus s/p VP shunt placement and
epilepsy who presented to an OSH with HA, vomiting and seizures.
Mother reports at baseline he performs his own ADLs with minimal
supervision. Yesterday he c/o HA in the morning and began
vomiting in the evening. He was able to take his oral AEDs. He
vomited again this morning and then seized around 9am. He was
taken to OSH ED where he was witnessed to seize again described
as generalized tonic-clonic seizure around 2pm. Ativan was given
after resolution of the seizure. He is followed by Dr. ___ and ___ last seizure was in ___. His
mother states he becomes somnolent after a seizure and can take
___ days to return to baseline. Head CT showed hydrocephalus
compared to prior imaging from ___ and he was transferred
for neurosurgical evaluation and treatment. No recent fevers,
chills or sweats. Mother reports that he was well until the
onset of HA yesterday.
Shunt initially placed at ___ in ___ for hydrocephalus with Sz,
revised in ___, last malfunctioned in ___ and revised in
___.
During that malfunction pt had an increase in Seizures to ___
times daily for a week before the shunt was revised. His mother
does not know the details of the revision but was told that it
is
an adjustable shunt.
History obtained from Mother and sister who translates.
The patient was admitted to the Neuro ICU after surgery for
close neurologic monitoring.
Past Medical History:
PMHx:
Hydrocephalus S/P VP shunt, placed ___. revised ___, last
revision ___ in ___
? left sided prior shunt and craniotomy
Epilepsy
Social History:
___
Family History:
Family Hx: unknown.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 98.5 BP: 129/86 HR: 92 R: 16 O2Sats: 100% RA
Gen: lethargic
HEENT: right sided shunt catheter is palpable, Shunt reservoir
depresses but does not recoil/refill quickly and stays dimpled.
Incisions are well healed without erythema.
There is also a left frontal burr hole and possible craniotomy
scar well healed.
Abd: 3 abdominal incisions, 2 on the right, 1 on the left, well
healed. Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic
No eye opening
No commands
Pupils 3mm sluggish bilaterally
Motor: decreased bulk and normal tone bilaterally.
withdraws briskly x4
Purposeful x4
Sensation: Intact to touch x4
PHYSICAL EXAMINATION ON DISCHARGE:
General: laying comfortably in bed
Cognitive delay at baseline. ___. alert and
oriented
to name, hospital, not date: follows simple commands.
HEENT: right sided shunt catheter is palpable, Shunt reservoir
has recoil.
Incisions are well healed without erythema.
There is also a left frontal burr hole and possible craniotomy
scar well healed.
Motor:
RUE: ___ (flexed wrist at baseline)
LUE: ___ (weaker than R) (when post-ictal can barely get hand
off
bed)
BLE: full strength
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1000 mg PO TID
2. LamoTRIgine 200 mg PO BID
3. Topiramate (Topamax) 100 mg PO BID
4. Phenytoin Sodium Extended 200 mg PO QHS
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. LamoTRIgine 200 mg PO BID
3. LevETIRAcetam 1000 mg PO TID
4. Phenytoin Sodium Extended 200 mg PO QHS
5. Topiramate (Topamax) 100 mg PO BID
6.Rolling Walker
Rolling walker for ambulation
Dx: Seizures, deconditioning
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
Hydrocephalus
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with seizures and shunt revision.// Intubated,
please assess ETT position.
TECHNIQUE: AP portable chest radiograph
COMPARISON: None available
FINDINGS:
The tip of the endotracheal tube projects over the mid thoracic trachea.
Advancement of a gastric tube terminates in the stomach on the final image.
The tip of a right internal jugular central venous catheter projects over the
cavoatrial junction. Tubing courses along the right neck and thorax likely
reflective of a VP shunt. There is no focal consolidation, pleural effusion
or pneumothorax identified. The size of the cardiomediastinal silhouette is
within normal limits.
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea. A
gastric tube projects over the stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with hydrocephalus and VP shunt malfunction s/p
revision of proximal catheter// Please perform at 11pm. Evaluate new proximal
VP shunt catheter placement and for changes in ventricles
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Outside head CT ___ performed 10 hours earlier.
FINDINGS:
There is a right frontal approach ventricular catheter. There is air noted in
bilateral ventricles as well as along the tract of the catheter, consistent
with expected postsurgical changes.
Enlargement of the ventricles are similar to prior, where the third ventricle
measures up to 1.7 cm, previously measuring 1.6 cm, the lateral ventricles
measure up to 3.7 cm (2; 22), previously measuring up to 3.9 cm. Hyperdense
material along the left frontal convexity likely represents prior surgical
material.
There is no evidence of infarction.
Skin staples are noted in the right frontal region along with subcutaneous
gas. No evidence of fracture. Multiple burr holes are noted in the skull
consistent with prior procedures. 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. Status post revision of the right frontal approach ventricular catheter
without significant interval change in enlargement of bilateral ventricles
since prior study. Expected postsurgical changes are noted including foci of
gas along the catheter as well as in bilateral frontal horns of the lateral
ventricles.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with hydrocephalus s/p VP shunt placement and
epilepsy who presented to an OSH with HA, vomiting and seizures. s/p shunt
revision ___// assess for post op hemorrhage given seizure and left upper
extremity weakness
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 18.0 s, 18.4 cm; CTDIvol = 49.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Compared ___, again seen is a right frontal approach
ventriculostomy catheter with tip in the right lateral ventricle near the
foramen of ___. There are expected postsurgical changes, including
pneumocephalus. There is no evidence of large territorial infarction,
hemorrhage, edema, or mass. Interval decrease in size of the lateral
ventricles, measuring up to 1.6 cm, previously 3.7 cm and in the third
ventricle, measuring up to 0.8 cm, previously 1.7 cm. Again seen is
hyperdense material along the left frontal convexity, likely representing
prior surgical material.
Again seen are skin staples in the right frontal region. The paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
1. Compared to ___, again seen is a right frontal approach
ventriculostomy catheter with tip in the right lateral ventricle near the
foramen of ___.
2. Interval decrease in size of the ventricles, now consistent with mild
ventriculomegaly.
3. No acute hemorrhage, large territorial infarction, edema or mass.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ year old male with hydrocephalus s/p VP
shunt placement and epilepsy who presented to an OSH with HA, vomiting and
seizures. s/p shunt revision ___// rule out PNA rule out PNA
IMPRESSION:
Comparison to ___. The patient has been extubated. The right
jugular vein catheter is in stable position. Lung volumes continue to be
normal. Normal size of the cardiac silhouette. Normal appearance of the lung
parenchyma. No evidence of pneumonia. No pulmonary edema. No pleural
effusions.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc// s/p R 40cm DL non hep pow picc
Contact name: ___: ___ s/p R 40cm DL non hep pow picc
IMPRESSION:
Comparison to ___, 06:20. In the interval, the patient has
received a right-sided PICC line. The course of the line is unremarkable, the
tip of the line projects over the mid SVC. No complications, notably no
pneumothorax. No other change is noted.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with hydrocephalus, EVD, recent VP shunt
revision, epilepsy. Having more seizures than normal.// ?change in
hydrocephalus or new bleeding
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___ 23:16, ___ 21:48
FINDINGS:
Right VP shunt in place via right frontal burr hole, tip is near foramina
___. Dysgenesis of the corpus callosum. Very deep cortical sulcation
versus absence of the deep white matter, similar to prior. Ventricular system
is more decompressed compared to prior from ___, frontal horns are
slit-like, there is some fluid within bodies of lateral ventricles, right
greater than left, no hydrocephalus. Trace pneumocephalus, decreased since
prior. Deep white matter low-attenuation changes are less prominent than
prior. Low-attenuation change along the right ventricular drain tract, mildly
improved, there is no adjacent hemorrhage within the parenchyma. Small volume
extra-axial low-density fluid overlying right frontal and anterior parietal
lobes at the vertex, measures 0.4 cm in maximum thickness, minimally worsened,
no acute blood products.
There is no evidence of acute infarction, acute hemorrhage or mass. Very
dense linear extra-axial abnormality overlying left frontal, parietal ___,
___ be sequela of chronic calcified subdural hematoma or postsurgical change.
Left parietal, frontal burr holes are seen adjacent to this.
There is no evidence of fracture. Thickened calvarium, can be seen with
chronic anemia, chronic anti seizure medication use, no focal worrisome
abnormalities.. 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:
Interval further decompression of the ventricular system, frontal horns are
slit-like. Improved low-attenuation change along the drain tract in the
frontal lobe, no adjacent hemorrhage.
Small extra-axial low-attenuation fluid collection at the right vertex
measures 0.4 cm in thickness, minimally worsened since prior, no acute blood
products. Clinically correlate for over shunting.
Dysgenesis of the corpus callosum. Deeply invaginating sulci and
periventricular leukomalacia in the parietal lobes.
Calvarial thickening, can be seen with chronic anemia, chronic anti seizure
medication use.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p VP shunt revision// eval ventricle size
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 CTs dated ___ at ___.
FINDINGS:
The right VP shunt remains in place via the right frontal burr hole, with tip
near the foramen of ___. The ventricular system appears minimally further
decompressed compared to the ___ study, particularly in the body of
the lateral ventricles. There is no evidence of new hemorrhage, edema or
infarct. Otherwise, no significant change from the prior examination.
IMPRESSION:
1. Minimal further increase in decompression of the ventricular system,
particularly in the body of the lateral ventricles.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Lethargy, Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.5
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 86.0
level of pain: Non-verbal
level of acuity: 2.0 | You had a VP shunt revision for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
Your shunt is NOT programmable. It is MRI safe and needs no
adjustment after a MRI.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
You are NOT allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Continue to take your home anti-seizure medications as
prescribed.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old woman with hypertension, hyperlipidemia,
insulin dependent diabetes, and history of femur fracture who
presents with 3 weeks of increasing dyspnea on exertion.
She usually walks everywhere but over the last few weeks she has
noticed that she has had trouble walking due to dyspnea and has
had to stop. She thinks she has gained weight in the last year,
but isn't sure if she has gained weight in the last few weeks.
She has noticed orthopnea and concurrent ___ edema over the
last few days, and today she states she was so short of breath
her family could hear her "wheezing" from the next room. This
prompted her to present to the ED.
She does not recall any episodes of acute onset shortness of
breath or chest pain. She denies heart palpitations, dizziness,
lightheadedness.
Review of systems was notable for fever of 102 several days ago,
without return. She otherwise denies cough, dysuria, URI, or any
other infectious symptoms. ROS was otherwise notable for L
wrist
swelling, for which she was intending to see her PCP.
Past Medical History:
Hypertension
Hyperlipidemia
Insulin dependent type II diabetes
R TKR
Psoriasis
PSH: diagnostic laparoscopy ___ yrs ago, carpal tunnel release
Social History:
Lives children, son and boyfriend. She is sex active. She is
currently going through menopause. Rare tob use in high school
none since then. No tob/ ivdu.
< 65
Cigarettes: [ ] never [X ] ex-smoker [x] current Pack-yrs: 10
quit: ___ years ag_____
ETOH: [x] No [ ] Yes drinks/day: _80____
Drugs: none
Occupation: ___
Marital Status: [ ] Married [X] Single
Lives: [ ] Alone [] w/ family [ ] Other:
Received influenza vaccination in the past 12 months [ ]Y [X ]N
Received pneumococcal vaccinationin the past 12 months [Y ] [n
]N
Family History:
Mother died of lung cancer.___ She was a smoker.
Father died of chf at age ___.
No family hx of bowel dz or cancer
Physical Exam:
ADMISSION
PHYSICAL EXAMINATION:
=====================
VITALS: ___ 1546 Temp: 98.6 PO BP: 134/84 HR: 99 RR: 18 O2
sat: 97% O2 delivery: RA FSBG: 88
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP elevated
CARDIAC: distant heart sounds with RRR, no murmurs, rubs, or
gallops
LUNGS: diminished at ___ bases without crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema to the bilateral knees
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE
PHYSICAL EXAMINATION:
=====================
VITALS:Temp: Temp: 97.4 (Tm 98.2), BP: 98/64 (98-120/62-77), HR:
75 (70-88), RR: 18 (___), O2 sat: 97% (95-98), O2 delivery:
RA,
Wt: 179.7 lb/81.51 kg
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: distant heart sounds with RRR, no murmurs, rubs, or
gallops
LUNGS: CTAB, normal breath sounds at the bases today
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no edema
Pertinent Results:
ADMISSION
___ 08:22AM BLOOD WBC-3.5* RBC-4.61 Hgb-11.6 Hct-38.8
MCV-84 MCH-25.2* MCHC-29.9* RDW-14.3 RDWSD-43.8 Plt ___
___ 08:22AM BLOOD Glucose-206* UreaN-14 Creat-0.8 Na-143
K-3.7 Cl-106 HCO3-25 AnGap-12
___ 08:22AM BLOOD proBNP-1211*
___ 08:22AM BLOOD cTropnT-<0.01
___ 06:58PM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
___ 06:22AM BLOOD FreeKap-32.2* ___ Fr K/L-2.4*
TTE ___
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is mild
global left ventricular hypokinesis. The visually estimated left
ventricular ejection fraction is 40%. Left ventricular cardiac
index is low normal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18mmHg). There is Grade III diastolic dysfunction. The right
ventricular free wall is hypertrophied. Normal right ventricular
cavity size with low normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion.
IMPRESSION: Biventricular hypertrophy with mild global
biventricular systolic dysfunction. Restrictive LV filling with
elevated LVEDP and mild pulmonary hypertension. Mild mitral
regurgitation.
RECOMMEND: If clinically indicated, a cardiac MRI is warranted
for further evaluation of a restrictive cardiomyopathy. A
Tc-pyrophosphate could be considered if TTR amyloidosis is
suspected.
DISCHARGE
___ 05:59AM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-141
K-4.0 Cl-101 HCO3-25 AnGap-15
___ 05:59AM BLOOD WBC-5.7 RBC-5.81* Hgb-14.8 Hct-48.8*
MCV-84 MCH-25.5* MCHC-30.3* RDW-14.3 RDWSD-43.3 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 50 Units Breakfast
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Pravastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 (One) tablet(s) by mouth Every morning
Disp #*30 Tablet Refills:*0
2. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth Every morning Disp #*31
Tablet Refills:*0
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Every
morning Disp #*31 Tablet Refills:*0
4. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth Every morning Disp
#*31 Tablet Refills:*0
5. Glargine 50 Units Breakfast
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Aspirin 81 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
New onset heart failure
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 dyspnea and cough// r/o acute process
COMPARISON: Prior CT of the chest from ___
FINDINGS:
PA and lateral views of the chest provided. Low lung volumes. Pulmonary
vascular congestion and likely mild interstitial pulmonary edema noted. No
signs of pneumonia. No large effusion or pneumothorax. The heart is
top-normal in size. Mediastinal contour is normal. Imaged bony structures
are intact.
IMPRESSION:
Congestion with mild interstitial pulmonary edema. No signs of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Heart failure, unspecified, Chest pain, unspecified, Dyspnea, unspecified, Type 1 diabetes mellitus without complications, Long term (current) use of insulin, Essential (primary) hypertension
temperature: 97.6
heartrate: 116.0
resprate: 24.0
o2sat: 97.0
sbp: 172.0
dbp: 79.0
level of pain: 6
level of acuity: 2.0 | Dear ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you felt short of
breath. This was due to a condition where the heart is not
pumping so well, which is a condition called heart failure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-We gave you medication to remove fluid from your lungs
-We sent tests on your blood to see why you have new heart
failure
-We examined your heart with an ultrasound. We were also
planning to examine your heart with a procedure called a heart
catheterization which allows us to examine the blood flow to the
heart muscle itself. We were unable to do that procedure while
you were here but will be scheduling that procedure for early
next week.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- You should weigh yourself every day and call your doctor if
your weight goes up by more than three pounds as this can be a
sign that fluid is building up again
We wish you the best!
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pollen Extracts
Attending: ___
Chief Complaint:
hypotension, N/V
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of right breast ___ (BRCA ___ neg), initally
stage IIIA (pT3 pN2), ER/PR/HER2 positive, with right axillary
recurrence ER/PR neg, HER2 pos s/p bilateral mastectomy and LN
dissection on adjuvant pertuzumab/herceptin with
leuprolide/letrozole, PE on Lovenox, and Herceptin-induced
cardiomyopathy with LVEF ___ who presents with hypotension in
the setting of nausea/vomiting.
Patient was in a store earlier today when she began to feel
nauseous with abdominal cramping. She went into the bathroom and
had one bout of NBNB vomiting. The cramping started today,
located on her left side, lasting about ___ minutes, relieved
with vomiting and food, asociated with bloating. She then became
cold, sweaty, dizzy and lightheaded, however denies any fevers,
CP, SOB. She states that she has had diarrhea, which has been
chronic as well as a cough productive of yellow sputa. EMS was
called and brought her to the ___ ED.
In the ED, initial VS were 98 86 87/64 14 97% RA. Labs were
notable for INR 1.4, TropT 0.04, BNP 1266. CXR showed low lung
volumes, without evidence of overt pulmonary edema. She received
500 cc fluids and was sent to the OMED floor for further
management. Vitals prior to transfer 98.9 98 94/67 26 97% RA.
On arrival to the floor, patient states that her abdominal
cramping has now subsided. Denies any furtehr episodes of N/V
and has been tolerating POs.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ Pt felt a mass in right breast
- ___ biopsy confirmed malignancy
- ___ BCS/ALND; 8.0 cm grade 3 IDC with papillary features,
ER/PR+, HER2 amplified (2.6), +ALND (___). Due to margins, pt
needed re-excision in ___ and ultimately underwent right
mastectomy in ___.
- ___ adjuvant ddAC x 4. Weekly TH x ___ - ___.
Herceptin q3 week ___, stopped early in context of
cardiomyopathy.
- ___ Lupron and exemestane started
- ___ completed PMRT (___)
- ___ pt met with genetics program, blood drawn for ___
analysis but not sent due to lack of insurance coverage
- ___ left mastectomy (benign). Bilateral tissue
reconstruction done at ___.
- ___ switch from exemestane to letrozole due to tolerance
(fatigue and arthralgias), continued Lupron
- ___ BRCA negative
- ___ bilateral axillary lymphadenopathy (R>L) noted on
chest
CT in context of diagnosis of PE
- ___ CNB right axilary LN: invasive carcinoma, ER/PR neg,
HER2 2+ with FISH ratio 2.2, (low CEP17 signal number raises
possibility of monosomy 17)
- ___ FNA left axillary LN: negative for carcinoma
- ___ staging evaluation including PET-CT and bone scan with
no evidence of distant metastasis
- ___ right ALND: metastatic carcinoma involving ___ nodes
with extranodal component, largest focus of tumor 2 cm, ER/PR
neg, HER2 negative by IHC with FISH ratio 2.1 (low CEP17 signal
number raises possibility of monosomy 17)
- ___ surgical I&D of right axillary abscess
- ___ THP C1D1
- ___ THP C2D1
- ___ THP C3D1
- ___ THP C4D1
- ___ THP C5D1
- ___ THP ___ continue adjuvant HP; restart leuprolide, letrozole
PAST MEDICAL HISTORY:
- PE ___ on enoxaparin
- Herceptin-induced cardiomyopathy with LVEF down to 20%,
recovered
- GERD
- Depression
- Bilateral carpal tunnel syndrome, right > left
- Asthma
- Right arm lymphedema
- Palindromic rheumatism
Social History:
___
Family History:
Mother - OSA, ___, HTN
Sister - HTN
MGM- ___, Lung ___
Physical Exam:
ADMISSION EXAM:
=======================
VS: 98.0 108/64 90 22 95%RA
WEIGHT: 230 pounds
GENERAL: alert, oriented x 3, sitting up in bed in NAD
HEENT: NC/AT, EOMI, PERRL, MMM. JVD at clavicle
CARDIAC: distant heart sounds. RRR, normal S1 & S2, without
murmurs, S3 or S4
LUNG: mild bibasilar crackles, otherwise clear
ABD: obese, +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and dry, without rashes
LINES: L sided chest port c/d/i
DISCHARGE EXAM:
========================
VS: 98.9 (98.9) 104/72 (80-100/50-80) 93 (90-100) 20 97%RA
I/O: 1460/1000 // ___
GENERAL: alert, oriented x 3, sitting up in bed in NAD
HEENT: NC/AT, EOMI, PERRL, MMM. JVD at clavicle
CARDIAC: distant heart sounds. RRR, normal S1 & S2, without
murmurs, S3 or S4
LUNG: mild bibasilar crackles, otherwise clear
ABD: obese, +BS, soft, NT/ND, no rebound or guarding, no
appreciable HSM
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and dry, without rashes
LINES: L sided chest port c/d/i
Pertinent Results:
ADMISSION LABS:
=====================
___ 03:15PM BLOOD WBC-8.3 RBC-5.09 Hgb-11.2 Hct-37.7
MCV-74* MCH-22.0* MCHC-29.7* RDW-18.2* RDWSD-45.5 Plt ___
___ 03:15PM BLOOD Neuts-75.4* Lymphs-18.0* Monos-3.8*
Eos-2.2 Baso-0.4 NRBC-0.2* Im ___ AbsNeut-6.28*
AbsLymp-1.50 AbsMono-0.32 AbsEos-0.18 AbsBaso-0.03
___ 03:15PM BLOOD ___ PTT-32.5 ___
___ 03:15PM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-140
K-4.7 Cl-107 HCO3-18* AnGap-20
___ 03:15PM BLOOD CK-MB-3 proBNP-1266*
___ 07:15PM BLOOD Lactate-1.0
PERTINENT LABS:
=====================
___ 05:46AM BLOOD ALT-74* AST-51* CK(CPK)-139 AlkPhos-124*
TotBili-0.4
___ 05:28AM BLOOD ALT-66* AST-34 AlkPhos-114* TotBili-0.5
___ 03:15PM BLOOD cTropnT-0.04*
___ 09:23PM BLOOD cTropnT-0.07*
___ 05:46AM BLOOD CK-MB-2 cTropnT-0.05*
___ 05:46AM BLOOD CEA-2.4 ___ 10:18AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:18AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 10:18AM URINE RBC-2 WBC-28* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 10:18AM URINE CastHy-1*
___ 10:18AM URINE Mucous-OCC
DISCHARGE LABS:
=======================
___ 05:28AM BLOOD WBC-7.0 RBC-4.62 Hgb-10.1* Hct-33.9*
MCV-73* MCH-21.9* MCHC-29.8* RDW-18.1* RDWSD-45.2 Plt ___
___ 05:28AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-107 HCO3-23 AnGap-12
___ 05:28AM BLOOD ALT-66* AST-34 AlkPhos-114* TotBili-0.5
___ 05:28AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
IMAGING:
=======================
CXR (___):
Low lung volumes, without evidence of overt pulmonary edema.
CT A/P w/ Contrast (___):
1. Heterogeneous pattern of parenchymal enhancement of liver
may reflect to timing of imaging post-contrast enhancement with
differential perfusion of right versus left lobes, alternatively
differential fatty deposition between lobes. No concerning
focal liver lesion is seen. Assessment of the hepatic
vasculature limited by early phase of imaging, and this could be
assessed with ultrasound if needed.
2. Mild gallbladder wall edema, which is nonspecific and can be
seen in the setting of third spacing, underlying liver disease,
hypoalbuminemia.
3. No intra-abdominal abscess.
4. Bibasilar ground-glass opacities and interlobar septal
thickening
compatible with known NSIP. Small right pleural effusion.
MICROBIOLOGY:
========================
___ Blood Culture x 2: Pending, no growth to date
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ with sob // eval for pulm edema
TECHNIQUE: Frontal portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low, which accentuates bronchovascular markings.
Subtle bibasilar opacities are not significantly changed, and compatible with
known NSIP. There is no new focal consolidation, pleural effusion or
pneumothorax. No overt pulmonary edema. Accounting for portal technique,
cardiomediastinal silhouette is unremarkable. No acute osseous abnormalities
are identified.
The Port-A-Cath is unchanged in position with distal tip in the right atrium.
Surgical clips are seen within the right axilla.
IMPRESSION:
Low lung volumes, without evidence of overt pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with breast CA on chemotherapy p/w acute onset
of N/V, abdominal pain found to have transaminitis. Evaluate for abscess and
mets.
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis following the
intravenous administration of 150 cc of Omnipaque . Coronal and sagittal
reformatted images were also generated for review.
DOSE: 881 mGy-cm
COMPARISON: CT abdomen and pelvis from ___ and CT chest from ___ 1
FINDINGS:
LOWER CHEST: There are persistent bibasilar ground-glass opacities and
interlobar septal thickening compatible with known interstitial lung disease.
The heart is mildly enlarged. The tip of the Port-A-Cath terminates in the
proximal right atrium. There is a small right pleural effusion.
LIVER: There is heterogeneous enhancement of the liver, with relative
hypodensity of the right hepatic lobe. This may in part related to timing of
imaging post-contrast, or alternatively differential fatty a position within
the hepatic parenchyma. No definite focal liver lesion is seen on this single
phase scan. The main portal vein appears patent although was not well
assessed due to early phase of imaging post-contrast. Gallbladder
demonstrates mild wall thickening without surrounding fat stranding.
PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present.
GI TRACT: A small hiatal hernia is again noted. The stomach, duodenum, and
small bowel are within normal limits, without evidence of wall thickening or
obstruction. The colon is non-dilated without obstructive lesions. There is
sigmoid diverticulosis without evidence of acute diverticulitis. The appendix
is unremarkable.
VASCULAR: The aorta is normal in caliber without aneurysmal dilatation. The
origins of the celiac axis, SMA, bilateral renal arteries, and ___ are patent.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air, or abdominal wall hernias are noted.
Soft tissue stranding in the anterior abdominal wall likely reflects injection
sites.
PELVIC CT: The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is a small
amount of nonspecific pelvic free fluid. The uterus is unremarkable.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present.
IMPRESSION:
1. Heterogeneous pattern of parenchymal enhancement of liver may reflect to
timing of imaging post-contrast enhancement with differential perfusion of
right versus left lobes, alternatively differential fatty deposition between
lobes. No concerning focal liver lesion is seen. Assessment of the hepatic
vasculature limited by early phase of imaging, and this could be assessed with
ultrasound if needed.
2. Mild gallbladder wall edema, which is nonspecific and can be seen in the
setting of third spacing, underlying liver disease, hypoalbuminemia.
3. No intra-abdominal abscess.
4. Bibasilar ground-glass opacities and interlobar septal thickening
compatible with known NSIP. Small right pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: n/v/d, Dizziness
Diagnosed with HYPOTENSION NOS
temperature: 98.0
heartrate: 86.0
resprate: 14.0
o2sat: 97.0
sbp: 87.0
dbp: 64.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital with
abdominal pain and low blood pressure. You had a CT scan which
did not show any obvious sources of infection. Your abdominal
pain and low blood pressure improved after receiving IV fluids.
You need to talk with your oncologist, Dr. ___, to
discuss your chemotherapy regimen.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Please continue taking your medications as instructed below.
Wishing you the best,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Pain
Sickle cell pain crisis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female past medical history significant for sickle
cell disease c/b frequent hospitalizations for sickle cell
crisis and autosplenectomy on folic acid (hematologist is Dr.
___ presenting to the emergency department with back pain
and leg pain consistent with prior sickle cell crises. Patient
denies any shortness of breath cough, congestion, chest pain.
Patient denies any numbness, weakness, tingling, saddle
anesthesia, urinary symptoms.
Of note, had a recent admission in ___ for a
sickle
cell pain crisis for which she was treated with dilaudid PCA,
IVFs, and 1uPRBCs, but left AMA after she was not given
additional transfusions. Patient has been refusing hydroxyurea,
but requests transfusions, which usually limits her pain crisis.
Initial vital signs were notable for: 97.9 96 138/82 24 97% RA
Exam notable for: Patient moaning in pain, no scleral icterus,
lungs CTA b.l, abd non tender, CN grossly intact
Labs were notable for: WBC 18.1, Hgb 8.4, Retic 22, Bicarb 21,
Patient was given: Dilaudid 1mg IV x 5, IVF, lorazepam,
ketorolac
Vitals on transfer: 98.6 103 122/65 14 98% RA
Upon arrival to the floor, patient writhing in pain, moaning,
and
unable to answer questions. She was able to tell her full name,
but could not corroborate the rest of her story.
Past Medical History:
Sickle cell disease
Appendectomy
Tonsillectomy
Social History:
___
Family History:
Sister with sickle cell disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 1845 Temp: 97.8 PO BP: 119/65 HR: 121 RR: 18 O2
sat: 84%
GENERAL: Writhing/moaning in pain
HEENT: NCAT. Pupils pinpoint but equal and round
NECK: No JVD.
CARDIAC: Tachycardic, regular rhythm. Hyperdynamic S1 and S2,
___
systolic murmur, no rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. Taking shallow breaths.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses Radial 2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: Able to move all extremities, but unable to
participate in rest of neuro exam likely due to severe pain.
Able
to recite her own full name.
===============================
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 2322)
Temp: 99.1 (Tm 99.1), BP: 100/62 (100-117/62-68), HR: 77
(65-89), RR: 18, O2 sat: 93% (93-98), O2 delivery: RA
GENERAL: Not in acute distress, scleric icterus
CARDIAC: Normal rate and rhythm. no mrg.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEURO: No focal neurologic deficits.
Pertinent Results:
___ 01:10PM BLOOD WBC-18.1* RBC-2.57* Hgb-8.4* Hct-23.4*
MCV-91 MCH-32.7* MCHC-35.9 RDW-21.1* RDWSD-67.9* Plt ___
___ 01:10PM BLOOD Neuts-68.8 Lymphs-18.9* Monos-6.2
Eos-0.6* Baso-0.8 NRBC-1.4* Im ___ AbsNeut-12.42*
AbsLymp-3.41 AbsMono-1.12* AbsEos-0.11 AbsBaso-0.15*
___ 10:23AM BLOOD WBC-18.6* RBC-2.15* Hgb-6.9* Hct-19.1*
MCV-89 MCH-32.1* MCHC-36.1 RDW-21.2* RDWSD-66.3* Plt ___
___ 06:38AM BLOOD WBC-12.1* RBC-2.42* Hgb-7.8* Hct-21.7*
MCV-90 MCH-32.2* MCHC-35.9 RDW-19.8* RDWSD-62.8* Plt ___
___ 04:59PM BLOOD WBC-15.7* RBC-3.15* Hgb-9.9* Hct-29.0*
MCV-92 MCH-31.4 MCHC-34.1 RDW-20.0* RDWSD-65.4* Plt ___
___ 06:34AM BLOOD WBC-12.0* RBC-2.67* Hgb-8.6* Hct-23.1*
MCV-87 MCH-32.2* MCHC-37.2* RDW-18.6* RDWSD-57.3* Plt ___
___ 01:10PM BLOOD Ret Man-22.0* Abs Ret-0.57*
___ 06:34AM BLOOD Ret Aut-13.9* Abs Ret-0.39*
___ 06:38AM BLOOD Glucose-81 UreaN-10 Creat-0.4 Na-144
K-4.0 Cl-107 HCO3-19* AnGap-18
___ 01:10PM BLOOD ALT-19 AST-39 LD(___)-528* AlkPhos-64
TotBili-6.3*
___ 10:23AM BLOOD ALT-19 AST-50* LD(___)-744* AlkPhos-48
TotBili-6.9* DirBili-0.4* IndBili-6.5
___ 01:10PM BLOOD HCG-<5
___ 9:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 400 UNIT PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Morphine SR (MS ___ 15 mg PO Q12H
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
5. TraMADol 50-100 mg PO DAILY:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth once daily as needed Disp #*3570 Gram Gram Refills:*0
3. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg one tablet by mouth once daily as
needed Disp #*30 Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Morphine SR (MS ___ 15 mg PO Q12H
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg one tablet(s) by mouth every 4 hours
as needed for pain Disp #*5 Tablet Refills:*0
7. TraMADol 50-100 mg PO DAILY:PRN Pain - Moderate
8. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle cell crisis
Hemolytic anemia
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with likely sickle cell crisis.// ? acute chest
syndrome
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparisons to multiple prior radiograph studies dated ___, ___, ___.
FINDINGS:
Cardiomediastinal silhouette is unchanged. Mild scoliosis. No evidence of
acute focal consolidation. No pleural effusion or pulmonary edema. No
pneumothorax. Multilevel vertebral body endplate deformities are again seen
and compatible with the patient's history.
IMPRESSION:
No evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Leg pain, Lower back pain
Diagnosed with Hb-SS disease with crisis, unspecified
temperature: 97.9
heartrate: 96.0
resprate: 24.0
o2sat: 97.0
sbp: 138.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were hospitalized for sickle cell crisis.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you a blood transfusion.
- We gave you oxygen to help your blood cells from turning into
a sickle cell shape. This ensures the rest of your body receives
enough oxygen.
- We gave you IV pain medications to control your pain and
transitioned you to your home outpatient pain medications.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please make sure you stay hydrated and drink lots of fluids
regularly. Dehydration can cause you to have sickle cell crisis.
Avoid alcohol use, as this can also cause sickle cell crisis.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Extracted from neurosurgery Admission History and Physical
___ is a ___ male on aspirin 81mg daily who
presents to ___ on ___ with a mild TBI.
Family reports patient has had increased confusion, slurred
speech and falls for the last week. He was seen in the ED ___
after a fall; ___ was negative at that time. He presented
again to ___ on ___ after a fall in the bathroom,
striking his head on the sink. ___ at ___ revealed a
right convexity SDH measuring 9mm with 2mm midline shift. He was
transferred to ___ for further management."
Past Medical History:
-Non-insulin dependent type II diabetes.
-Hypertension.
-Hyperlipidemia.
-Benign prostatic hypertrophy.
-Left navicular deformity/osteoarthritis.
Social History:
___
Family History:
Review and non-contributory to subdural hematoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
O: T: 97.4 BP:135/70 HR: 72 RR: 16 O2 Sat: 96% RA
GCS at the scene: unknown
GCS upon Neurosurgery Evaluation: 15 Time of evaluation: 16:00
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]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
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Gen: WD/WN, comfortable, NAD.
HEENT: Atraumatic
Neck: Supple
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2 mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness Right
DISCHARGE PHYSICAL EXAM
=======================
VITALS: T 97.5, HR 51, BP 149/72, RR 16, O2 94% RA
GENERAL: Well appearing elderly male.
HEENT: Pupils are symmetric now. Anicteric sclerae. Oropharynx
clear.
NECK: Non-tender.
CV: Regular rate and rhythm. S1/S2. No murmur.
PULMONARY: Comfortable. Lungs are clear.
ABDOMEN: Soft. Non-tender.
EXTREMTIIES: No peripheral edema.
NEURO: Awake, alert, and attentive. He is fully oriented. His
speech is more articulate and strength is now full throughout.
Left-sided neglect resolved.
Pertinent Results:
ADMISSION LABS
==============
___ 04:11PM BLOOD WBC-7.9 RBC-4.51* Hgb-12.1* Hct-38.9*
MCV-86 MCH-26.8 MCHC-31.1* RDW-13.8 RDWSD-43.5 Plt ___
___ 04:11PM BLOOD Neuts-62.9 ___ Monos-8.7 Eos-0.9*
Baso-0.9 Im ___ AbsNeut-4.99 AbsLymp-2.07 AbsMono-0.69
AbsEos-0.07 AbsBaso-0.07
___ 04:11PM BLOOD ___ PTT-29.3 ___
___ 04:11PM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-137
K-3.8 Cl-102 HCO3-20* AnGap-15
___ 04:11PM BLOOD ALT-23 AST-19 AlkPhos-58 TotBili-0.5
___ 04:11PM BLOOD Albumin-4.1 Calcium-8.9 Phos-2.8 Mg-1.7
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
DISCHARGE LABS
==============
___ 07:18AM BLOOD WBC-6.1 RBC-4.28* Hgb-11.3* Hct-35.5*
MCV-83 MCH-26.4 MCHC-31.8* RDW-13.7 RDWSD-41.1 Plt ___
___ 07:18AM BLOOD Glucose-133* UreaN-14 Creat-0.7 Na-143
K-3.7 Cl-105 HCO3-23 AnGap-15
___ 07:18AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
___ 07:18AM BLOOD %HbA1c-6.3* eAG-134*
STUDIES
=======
CT HEAD WITHOUT CONTRAST (___)
FINDINGS:
Again seen is an acute subdural hematoma along the right
cerebral convexity measuring up to 8 mm in thickness, previously
9 mm, with extension along the right tentorial leaflet and
anterior and posterior falx. Effacement of the right
hemispheric sulci and right lateral ventricle, and 4 mm leftward
midline shift are unchanged.
No new sites of intracranial hemorrhage are identified.
Redemonstration of periventricular white-matter hypodensities,
which likely represent sequela of chronic microangiopathic
disease.
There is a small mucous retention cyst in a right ethmoid air
cell. The
visualized portion of the other paranasal sinuses, mastoid air
cells, and
middle ear cavities are clear. The visualized portion of the
orbits are
normal.
IMPRESSION:
1. No significant change in right cerebral convexity subdural
hematoma with 4 mm leftward midline shift.
2. No new sites of intracranial hemorrhage.
CT HEAD WITHOUT CONTRAST (___)
FINDINGS:
There is redemonstration of acute subdural hematoma along the
right cerebral convexity, tentorium cerebellum and anterior
falx, essentially unchanged in comparison to prior CT from ___. There is persistent, unchanged, leftward midline
shift, measuring approximately 4 mm. There is 2-3 mm of
leftward subfalcine herniation. There is no uncal herniation.
There is unchanged effacement of the right lateral ventricle,
and right hemispheric sulci.
No new area of intracranial hemorrhage or evidence of infarct is
identified. Again noted is periventricular white matter
hypodensity, likely related to chronic microangiopathic disease.
There is a mucous retention cyst in the right ethmoid air cells.
Otherwise, the visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are normal.
IMPRESSION:
1. Redemonstration of unchanged right cerebral convexity
subdural hematoma with extension along the tentorium cerebellum
and anterior falx.
2. There is resulting 4 mm of leftward midline shift, with 2-3
mm of
subfalcine herniation, which is similar in comparison to prior
CT. There is unchanged effacement of the right hemisphere sulci
and right lateral
ventricle.
3. No new areas of hemorrhage are identified.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. amLODIPine 10 mg PO DAILY
5. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID:PRN Pain
2. Chlorthalidone 12.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. LevETIRAcetam 500 mg PO BID
5. Senna 8.6 mg PO QHS
6. amLODIPine 10 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
-Right subdural hematoma/traumatic brain injury.
SECONDARY
-Left ankle osteoarthritis/deformity.
-Non-insulin dependent type II diabetes.
-Benign prostatic hypertrophy.
-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
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with subdural hemorrhage // Repeat CT after 6
hours, **1800**
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 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT head from ___ at 12:06 p.m.
FINDINGS:
Again seen is an acute subdural hematoma along the right cerebral convexity
measuring up to 8 mm in thickness, previously 9 mm, with extension along the
right tentorial leaflet and anterior and posterior falx. Effacement of the
right hemispheric sulci and right lateral ventricle, and 4 mm leftward midline
shift are unchanged.
No new sites of intracranial hemorrhage are identified. Redemonstration of
periventricular white-matter hypodensities, which likely represent sequela of
chronic microangiopathic disease.
There is a small mucous retention cyst in a right ethmoid air cell. The
visualized portion of the other paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
normal.
IMPRESSION:
1. No significant change in right cerebral convexity subdural hematoma with 4
mm leftward midline shift.
2. No new sites of intracranial hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with SDH // interval changes in SDH.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP =
901.7 mGy-cm.
Total DLP (Head) = 915 mGy-cm.
COMPARISON: Multiple prior CTs, most recent dated ___ at 18:41.
FINDINGS:
There is redemonstration of acute subdural hematoma along the right cerebral
convexity, tentorium cerebellum and anterior falx, essentially unchanged in
comparison to prior CT from ___. There is persistent, unchanged,
leftward midline shift, measuring approximately 4 mm. There is 2-3 mm of
leftward subfalcine herniation. There is no uncal herniation. There is
unchanged effacement of the right lateral ventricle, and right hemispheric
sulci.
No new area of intracranial hemorrhage or evidence of infarct is identified.
Again noted is periventricular white matter hypodensity, likely related to
chronic microangiopathic disease.
There is a mucous retention cyst in the right ethmoid air cells. Otherwise,
the visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
IMPRESSION:
1. Redemonstration of unchanged right cerebral convexity subdural hematoma
with extension along the tentorium cerebellum and anterior falx.
2. There is resulting 4 mm of leftward midline shift, with 2-3 mm of
subfalcine herniation, which is similar in comparison to prior CT. There is
unchanged effacement of the right hemisphere sulci and right lateral
ventricle.
3. No new areas of hemorrhage are identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter, History of falling
temperature: 97.4
heartrate: 72.0
resprate: 16.0
o2sat: 96.0
sbp: 135.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were hospitalized for a head bleed after
falling and striking your head. The bleed appeared stable by
serial CT scans of your head. You take aspirin for primary
prevention which was withheld due to the bleed. It might not be
safe to resume this medication after you leave the hospital. We
shared the decision to improve your strength and mobility at
rehab before returning home. Please see other instructions from
our neurosurgery colleagues below. We wish you all the best in
your recovery.
Sincerely,
Your ___ care team
*Discharge instructions for brain hemorrhage without surgery*
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
- Please do NOT take any blood thinning medication (aspirin,
ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptom after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and cough
Major Surgical or Invasive Procedure:
1) CABGx5 LIMA-LAD, SVG-rPDA, SVG-Om, SVGRamus, SVG-Diag)
2) Percutaneous endoscopic gastrostomy
3) Microsuspension laryngoscopy, vocal fold injection, left
and right voice gel. Flexible bronchoscopy with bronchoalveolar
lavage
History of Present Illness:
Mr. ___ is a ___ yo gentleman who presented to an outside
hospital with syncope and found to have a NSTEMI and cardiac
cath which showed severe 3 vesel disease. He was taken to the
operating room on ___ for a CABGx5. His post
operative course was complicated by hypoxia and copious
secretions and a CXR and chest CT which was concern for
pulmonary fibrosis. A pulmonary consult was obtained which
recomended diuresis and outpatient follow up. He was also noted
to be hoarse and evaluation by ENT showed bilateral vocal fold
hypomobility, worse on the right. He had a swallowing evaluation
which cleared him for soft solids and thin liquids. He was
discharged to rehab on POD15. At rehab on ___ he developed
chills and shortness of breath with a rectal temp of 103. He was
transported to an outside hospital where a CXR showed diffuse
pulmonary process concerning for pulmonary edema or atypical
pneumonia and was started on antibiotics and transfered here for
further care. The patient states that he feels like his cough is
worse over the last couple of days and he feels like it could be
productive but he is unable to cough anything up. In the ED he
produced a small amount of thick yellow phlegm. Patient also
reports that he has some skin breakdown on his L side of his
gluteus and is unable to lie on that side at the time of
presentation. He was admitted to cardiac surgery for further
evaluation and treatment.
Past Medical History:
Coronary artery disease, S/P.CABG
Hypertension
Dyslipidemia
Diabetes mellitus, type 1
GERD
Past Surgical History:
Skin cancer resection on forehead
Penile implant
Social History:
___
Family History:
- Mother died of brain cancer.
- Father died of lung disease.
- Uncle also has type 1 diabetes
Physical Exam:
Physical Exam on Admission:
Pulse:70 SR Resp:22 O2 sat: 98% on 4L NC
B/P Right:100/58 Left:
General:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs occasional rhonchi, no wheezes
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 1+ Left:1+
___ Right: 1+ Left:1+
Radial Right: 2+ Left:2+
sternal incision clean/dry/intact
vein harvest incision clean/dry/intact
Physical Exam on Discharge:
Pulse:81bpm Resp:18 O2 sat: 97% on RA
B/P ___ mmHG
General:Alert & oriented*3. NAD
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs occasional rhonchi, no wheezes
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x] PEG site C/D/I
Extremities: Warm [x], well-perfused [x] No Edema [X] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 1+ Left:1+
___ Right: 1+ Left:1+
Radial Right: 2+ Left:2+
sternal incision clean/dry/intact
vein harvest incision clean/dry/intact
Pertinent Results:
___ 09:30AM BLOOD WBC-10.9 RBC-3.83* Hgb-10.6* Hct-33.4*
MCV-87 MCH-27.7 MCHC-31.7 RDW-15.5 Plt ___
___ 04:15AM BLOOD WBC-12.0* RBC-3.47* Hgb-9.7* Hct-30.8*
MCV-89 MCH-27.9 MCHC-31.4 RDW-14.2 Plt ___
___ 09:30AM BLOOD ___ PTT-41.7* ___
___ 04:15AM BLOOD ___ PTT-28.5 ___
___ 09:30AM BLOOD Glucose-315* UreaN-16 Creat-1.0 Na-130*
K-4.8 Cl-93* HCO3-29 AnGap-13
___ 04:15AM BLOOD Glucose-223* UreaN-40* Creat-1.4* Na-137
K-4.1 Cl-100 HCO3-27 AnGap-14
___ ___ M ___ ___
RESPIRATORY CULTURE (Final ___:
ENTEROBACTER AEROGENES. MODERATE GROWTH.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
___ 9:11 AM
HISTORY: Failed swallow evaluation and aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of barium were administered.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is aspiration of nectar
thick liquids and penetration with honey thick liquids. There
is pharyngeal residue with all consistencies. For details,
please refer to the speech and swallow division note in OMR.
IMPRESSION:
Aspiration of nectar thick liquids, penetration of honey thick
liquids, and pharyngeal residue with all consistencies.
The study and the report were reviewed by the staff radiologist.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
4. Omeprazole 40 mg PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN pain, fever
6. Docusate Sodium 100 mg PO BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Metoprolol Tartrate 100 mg PO TID
9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
10. Furosemide 40 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Warfarin 1 mg PO DAILY AFib
14. Xopenex Neb 0.63 mg/3 mL inhalation q6h wheezing
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ipratropium Bromide Neb 1 NEB IH Q6H
___ MD to order daily dose PO DAILY16 atrial
fibrillation
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Heparin 5000 UNIT SC TID
9. Furosemide 20 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Glargine 40 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using REG Insulin
12. Guaifenesin ___ mL PO Q6H:PRN cough
13. OxycoDONE-Acetaminophen Elixir ___ mL PO Q6H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ mls by
mouth every six (6) hours Disp #*1 Bottle Refills:*0
14. Pantoprazole 40 mg IV Q12H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Scopolamine Patch 1 PTCH TD ONCE Duration: 1 Dose
17. Sodium Chloride Nasal ___ SPRY NU Q4H
18. Acetaminophen 650 mg PO Q4H:PRN pain, fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Vocal Cord Paralysis, S/P.Laryngoscopy and vocal cord injections
Percutaneous endoscopic gastrostomy.
Fever and cough
dysphagia
Pneumonia
Coronary artery disease , S/P.Coronary Artery Bypass Grafting
Hypertension
Dyslipidemia
Diabetes mellitus, type 1
Gastro Esophageal Reflux Disease
Past Surgical History:
Skin cancer resection on forehead
Penile implant
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Leg - healing well, no erythema or drainage
Edema -none
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Recent CABG and now fever. Evaluation for pneumonia.
COMPARISON: Chest radiograph ___.
FINDINGS: Portable semi-upright frontal view of the chest. There vascular
congestion and moderate pulmonary edema have increased since ___. The
mediastinal contour is widened. The heart is enlarged. Sternotomy wires and
clips over the left mediastinum are related to the prior CABG procedure.
There is contrast material in the left upper quadrant, likely from a prior
imaging study.
IMPRESSION: Moderate pulmonary edema and vascular congestion is worse since
___.
COMMENT: ___ discussed with M. ___.
Radiology Report
AP CHEST, 8:45 A.M., ___
HISTORY: ___ man after CABG, readmitted with dyspnea and fever.
IMPRESSION: AP chest compared to ___ through ___:
Over the past month, the lungs have looked best on ___. Rest of the
widespread pulmonary abnormality is due to pulmonary fibrosis. Between
___, mild pulmonary edema developed. Today, the edema has
slightly improved. It would be difficult to recognize early pneumonia,
against a background of both edema and pulmonary fibrosis. Heart is mildly
enlarged, unchanged. Pleural effusion is small, if any. No pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after CABG with failure to
swallow, assessment of the feeding tube placement.
Portable AP radiograph of the abdomen was reviewed with no prior studies
available for comparison.
The NG tube is in the stomach with the tip located in the proximal stomach.
Contrast material is noted along the rectosigmoid and left colon most likely
related to prior administration of oral contrast. There is no evidence of
bowel dilatation. Substantial changes in the lung bases are partially imaged
on the current study and potentially reflecting fibrosis as suggested on the
prior CT chest.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after CABG, assessment for
interval change.
AP chest radiograph.
As compared to ___ there is slight interval improvement in
parenchymal opacities, most likely consistent with interval resolution of the
pulmonary edema element. Pulmonary fibrosis is present, extensive.
Cardiomediastinal silhouette is unchanged. Post-sternotomy wires are stable.
The NG tube tip is in the stomach.
Radiology Report
PATIENT HISTORY: ___ years old man, status post CABG, evaluate for effusion,
pneumothorax, consolidation.
COMPARISON: Exam is compared to chest x-ray of ___.
IMPRESSION: Dobbhoff tube is unchanged ending in gastric cavity, though the
tip is not visualized. Lung volumes are still low with unchanged interstitial
reticular opacity due to pulmonary fibrosis and superimposed mild pulmonary
edema which is slightly worsened since chest x-ray of yesterday. There is no
pleural effusion or pneumothorax. Heart size mildly enlarged. Central venous
distention has worsened.
Radiology Report
HISTORY: ___ years old man postoperative day 21 status post CABG, high
diuresis day 4 with increased pulmonary secretion, possible pneumonia and
urosepsis. Please confirm Dobbhoff placement.
COMPARISON: Exam is compared to chest x-ray of the same day at 8:10 a.m.
FINDINGS: The Dobbhoff tube is looped in the lower esophagus and should be
repositioned. Lung volumes are low with interval improvement of bilateral
opacification due to reduced pulmonary edema. Persistent reticular opacity
due to pulmonary fibrosis. There is no pleural effusion or pneumothorax.
Heart size is mildly enlarged.
IMPRESSION: Looping of the Dobbhoff tube in lower esophagus. Improvement of
pulmonary edema.
Radiology Report
HISTORY: Status post cardiac surgery. Evaluation for Dobbhoff tube position.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Multiple chest radiographs the most recent on ___ at
12:29.
FINDINGS:
The lung volumes are persistently low and the previously noted bilateral
opacification of the lungs is unchanged in appearance. The Dobbhoff tube is
seen coiled in the stomach but secure in position. The heart is enlarged.
There is no evidence of pneumothorax or effusion.
IMPRESSION:
Dobbhoff tube seen coiled in the stomach, but securely positioned in the
stomach. No other significant change from the prior exam.
Radiology Report
HISTORY: Status post CABG with pneumonia. Evaluation for infiltrate.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: Multiple chest radiographs the most recent on ___.
FINDINGS:
The lungs volumes are low. No new focal opacity is identified. Again seen
are diffuse reticular opacities secondary to pulmonary fibrosis that are
similar to the prior study. Cardiomegaly is unchanged and the previously seen
pulmonary edema is resolving. The hilar contours are normal. The pleural
surfaces are clear without effusion or pneumothorax.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
HISTORY: Multiple DHT attempts, complicated by clogging, kinking, and nasal
swelling. Please place a post pyloric feeding tube.
COMPARISON: None.
FINDINGS:
The patient presented with a Dobbhoff tube, which was confirmed by fluoroscopy
to be positioned in the left bronchial tree. This tube was removed. The
right nares was then anesthetized with lidocaine jelly, and the oropharynx was
anesthetized with Hurricaine Spray. Under fluoroscopic guidance, ___
___ feeding tube was advanced post pylorically using a guidewire. 10 cc of
Optiray contrast were used to confirm post-pyloric placement. The tube was
then secured to the patient's nose. There were no immediate post-procedure
complications. Final fluoroscopic spot images demonstrated the post pyloric
feeding tube in the second portion of the duodenum.
IMPRESSION:
Successful placement of ___ feeding tube in the second portion
of the duodenum. The tube is ready to use.
Radiology Report
HISTORY: Failed swallow evaluation and aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is aspiration of nectar thick liquids and penetration with
honey thick liquids. There is pharyngeal residue with all consistencies. For
details, please refer to the speech and swallow division note in OMR.
IMPRESSION:
Aspiration of nectar thick liquids, penetration of honey thick liquids, and
pharyngeal residue with all consistencies.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation for pleural effusions and pneumothorax.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes remain
low. On today's radiograph, there is an increasing interstitial structure and
new appearance of Kerley B lines, both suggestive of increasing interstitial
pulmonary edema. The size of the cardiac silhouette remains enlarged. No
larger pleural effusions. No pneumonia.
At the time of dictation and observation, 10:13 a.m., on the ___, the referring physician, ___, was paged for notification.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after CABG.
PA and lateral upright chest radiographs were reviewed in comparison to
___.
Heart size and mediastinum are stable. Post-sternotomy wires are stable.
Subpleural interstitial changes are noted bilaterally, associated with low
lung volumes most likely consistent with interstitial lung disease. The
findings were described on chest CT from ___. Currently, no
pleural effusion or pneumothorax seen.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TRANSFER - PNA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOTENSION NOS, URIN TRACT INFECTION NOS
temperature: 98.4
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 96.0
dbp: 62.0
level of pain: 13
level of acuity: 3.0 | 1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin
Attending: ___.
Chief Complaint:
displaced feeding tube, abdominal pain
Major Surgical or Invasive Procedure:
___: Replaced Dobhoff feeding tube
History of Present Illness:
___ year old F with EtOH hepatitis, jaundice, total body pain,
who was admitted ___ to ___ for the above complaints. She
returned to the ED on ___ for abdominal pain and
nausea/vomiting. Per patient, she was napping and awoke with her
NG tube completely out, hanging by the bridle. A repeat
diagnostic paracentesis was performed and was negative for SBP.
ED labs notable for improving Bilirubin of 8.8 and WBC of 20.7
(up from 17.9 at discharge). She received morphine and had
complete resolution of her abdominal pain.
Upon examination this morning she has no complaints, feels that
her abdominal pain is greatly improved from yesterday. She
denies any chest pain, shortness of breath, worsening abdominal
pain, nausea/vomiting, or diarrhea/constipation.
Past Medical History:
EtOH Hepatitis
EtOH Abuse
Obesity
S/P Gastric Bypass
Social History:
___
Family History:
Family Hx: Father (+) EtOH abuse
Physical Exam:
===============
ADMISSION EXAM:
===============
Vitals: T98.5, 103/57, 91, 18, 99% on RA
General: Alert, oriented, no acute distress; jaundiced
HEENT: Icteric sclera, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at the right base, otherwise CTAB
Abdomen: Obese, mild tenderness to palpation in epigastrum, LUQ
and midline below umbilicus. Large volume ascites. Hepatomegaly.
GU: No Foley
Ext: Mild pitting edema midway up bilateral shins. Warm, well
perfused.
Neuro: No asterixis. CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation.
Skin: non-blanching, erythematous popular rash across abdomen
(superior to umbilicus); no intertrigo under abdominal pannus or
inguinal fold
===============
DISCHARGE EXAM:
===============
Vitals: 98.6, 108/80, 66, 18, 98% on RA
General: Alert, oriented, no acute distress; jaundiced
HEENT: Dobhoff in right nare secured with bridle, Icteric
sclera, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at the right base, otherwise CTAB
Abdomen: Obese, mild tenderness to palpation in epigastrum, LUQ
and midline below umbilicus. Large volume ascites. Hepatomegaly.
GU: No Foley
Ext: Mild pitting edema midway up bilateral shins. Warm, well
perfused.
Neuro: No asterixis. CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation.
Skin: non-blanching, erythematous popular rash across abdomen
(superior to umbilicus); no intertrigo under abdominal pannus or
inguinal fold
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 07:10PM ___ PTT-37.2* ___
___ 07:10PM PLT COUNT-432*
___ 07:10PM NEUTS-82.2* LYMPHS-9.2* MONOS-6.9 EOS-0.3*
BASOS-0.6 IM ___ AbsNeut-16.97*# AbsLymp-1.91 AbsMono-1.43*
AbsEos-0.07 AbsBaso-0.12*
___ 07:10PM WBC-20.7* RBC-2.93* HGB-10.2* HCT-31.4*
MCV-107* MCH-34.8* MCHC-32.5 RDW-15.5 RDWSD-61.3*
___ 07:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 07:10PM HCG-LESS THAN
___ 07:10PM ALBUMIN-2.3*
___ 07:10PM LIPASE-17 GGT-753*
___ 07:10PM ALT(SGPT)-33 AST(SGOT)-133* ALK PHOS-169* TOT
BILI-8.8*
___ 07:10PM GLUCOSE-78 UREA N-9 CREAT-0.4 SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 09:36PM ASCITES WBC-83* RBC-22* POLYS-6* LYMPHS-59*
MONOS-10* MESOTHELI-2* MACROPHAG-23*
___ 09:36PM ASCITES TOT PROT-1.8 GLUCOSE-98
___ 07:00AM ___ PTT-39.6* ___
___ 07:00AM PLT COUNT-389
___ 07:00AM WBC-19.9* RBC-2.62* HGB-9.1* HCT-28.2*
MCV-108* MCH-34.7* MCHC-32.3 RDW-15.2 RDWSD-60.2*
___ 07:00AM CALCIUM-7.9* PHOSPHATE-3.6 MAGNESIUM-1.8
___ 07:00AM ALT(SGPT)-30 AST(SGOT)-133* ALK PHOS-157* TOT
BILI-8.4*
___ 07:00AM GLUCOSE-52* UREA N-9 CREAT-0.3* SODIUM-137
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 09:30AM URINE MUCOUS-MOD
___ 09:30AM URINE RBC-10* WBC-7* BACTERIA-NONE YEAST-NONE
EPI-4 TRANS EPI-1
___ 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN->12 PH-7.5
LEUK-NEG
___ 09:30AM URINE COLOR-DkAmb APPEAR-Hazy SP ___
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-16.6* RBC-2.76* Hgb-9.5* Hct-29.9*
MCV-108* MCH-34.4* MCHC-31.8* RDW-14.9 RDWSD-58.8* Plt ___
___ 07:00AM BLOOD WBC-19.9* RBC-2.62* Hgb-9.1* Hct-28.2*
MCV-108* MCH-34.7* MCHC-32.3 RDW-15.2 RDWSD-60.2* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-40.4* ___
___ 07:00AM BLOOD Glucose-50* UreaN-9 Creat-0.3* Na-137
K-4.0 Cl-104 HCO3-24 AnGap-13
___ 07:00AM BLOOD ALT-30 AST-125* LD(LDH)-214 AlkPhos-167*
TotBili-7.7*
==================
PERTINENT RESULTS:
==================
Chest X-Ray (___): IMPRESSION:
Right basilar atelectasis.
CT Abdomen/Pelvis (___): IMPRESSION
1. Cirrhosis with sequela of portal hypertension, including
moderate to large ascites.
2. Patent portal and hepatic veins.
3. Status post Roux-en-Y gastric bypass, without evidence of
anastomotic leak. Small hiatal hernia. If there is concern for
ulcer, recommend direct visualization for further evaluation.
4. Diffuse anasarca.
5. Right lower lobe atelectasis.
6. A 1.8 cm hypodense nodule in the right adrenal gland is
incompletely
characterized on this study, but likely represents an adrenal
adenoma.
Chest X-Ray (___): IMPRESSION:
1. Dobboff tip within the stomach.
2. Right lower and right middle lobar segmental atelectasis, as
seen on prior CT.
Fluoro (___): IMPRESSION:
Successful placement of ___ feeding tube into the
jejunum of a patient status post Roux-en-Y gastric bypass. The
tube is ready to use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO QID
3. Miconazole 2% Cream 1 Appl TP BID
4. Thiamine 100 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting
7. Simethicone 40-80 mg PO QID:PRN abd pain/gas pain
8. Spironolactone 50 mg PO DAILY
9. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO QID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Nicotine Patch 14 mg TD DAILY
5. Omeprazole 40 mg PO BID
6. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting
7. Simethicone 40-80 mg PO QID:PRN abd pain/gas pain
8. Spironolactone 50 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
11. Acetaminophen 325-650 mg PO Q8H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth Q8H PRN Disp
#*100 Tablet Refills:*0
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Miconazole 2% Cream 1 Appl TP BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Dislodged feeding tube
Alcoholic Hepatitis (Chronic)
Abdominal Pain
Malnutrition
Secondary Diagnosis:
Alcohol withdrawal
Low back pain
Anemia
Gastric Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 6 EXAMS
INDICATION: ___ year old woman with EtOH hepatitis, s/p Dobhoff placement.
TECHNIQUE: Repeat portable chest radiograph.
COMPARISON: Chest radiograph, ___.
Chest radiograph dated ___.
CT abdomen pelvis dated ___.
FINDINGS:
On the fourth film, the feeding tube terminates in the stomach. Rightward
deviated mediastinum and right hemidiaphragm elevation reflect right lower and
right middle segmental lung atelectasis, as seen on prior chest CT.
IMPRESSION:
1. Dobboff tip within the stomach.
2. Right lower and right middle lobar segmental atelectasis, as seen on prior
CT.
Radiology Report
INDICATION: ___ year old woman with gastric bypass and EtOH Hepatitis, poor PO
intake. Here for replacement of Dobhoff NJ tube.
DOSE: Acc air kerma: 23 mGy; Accum DAP: 551.4 UGym2; Fluoro time: 2:06
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
The right nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, ___ feeding tube was advanced into the
remnant stomach and then into the jejunum using a guidewire.
10 cc of Optiray contrast were used to confirm jejunal placement. Final
fluoroscopic spot images demonstrated the feeding tube in the jejunum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful placement of ___ feeding tube into the jejunum of a
patient status post Roux-en-Y gastric bypass. The tube is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.3
heartrate: 103.0
resprate: 16.0
o2sat: 99.0
sbp: 118.0
dbp: 78.0
level of pain: 10
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted because your feeding tube
became dislodged from your nose, which required replacement. You
will continue your tube feeds at home. Your abdominal pain was
treated with tramadol and tylenol. You had no evidence of an
infection.
When sleeping at night, please use some of the tape we provided
you to tape the tube down to your cheek; you can also run the
tube behind your ear to further stabilize it. Do not remove the
tube as it provides key nutrition you need to improve.
When taking Tylenol for pain, do not exceed 325-650mg every 8
hours as needed (do not exceed 2000mg per day).
You will follow-up with Dr. ___ on ___
on ___.
It is important that you take all of your medications as
prescribed and that you attend all of your appointments as
scheduled. If you should need to reschedule an appointment,
please attempt to make a new appointment for as close to your
originally scheduled appointment as possible, in order to ensure
safe follow-up.
We wish you the best of health,
Your Care Team at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin / metformin / Penicillins
Attending: ___
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo F with long h/o asthma presenting with ___
months of poorly controlled asthma and dyspnea, admitted to w/u
of other possible causes for her dyspnea. For complete history
of her recent pulmonary course please see ED ___ c/s note. 4
months ago pt had worsening dyspnea and wheezing, with
escalation of her prednisone therapy and additon of controller
inhaler. During this time she noted worsening DOE (winded with 1
FOS), cough (productive of thick, white sputum, worse at night
and in the morning), sinusitis like symptoms. She had a CXR in
___ c/f multifocal pna, which improved with a course of
fluoroquinolone. Now tapered down to 20 pred daily. There was
previously c/f vasculitis and pt did have an ANCA which was pos
by report but subsequently normalized. Pt recently has been
started on an inhaled regimen for sinusitis, on PPI for GERD,
lasix for ? volume overload. With all of these interventions her
symptoms are ___ improved by her report but still not nml. IgE
has been low, neg aspergillus rxn. In the ED she had stable VS,
labs nml (including neg Ddimer), neg CXR, was seen by ___,
recommended admission.
ROS: Pos/neg per HPI. Pt also notes intermittent upper abd pain
___ yr
Past Medical History:
- Asthma/COPD
- Diabetes
- Hypothyroidism
- Hyperlipidemia
- Obesity
- vertebral kyphoplasty (___)
Social History:
___
Family History:
Positive for bronchitis and emphysema in her mother, even though
she was a nonsmoker. Mother also had cutaneous T-cell lymphoma.
Both parents had coronary artery disease and diabetes.
Physical Exam:
Admission:
VS: 98.2 127/75 91 18 97% rA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Scattered mild exp wheezes bilaterally, exp phase
slightly prolonged, no crackles
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,
trace pedal edema
NEURO: A+Ox3, CN II-XII grossly intact, strength/sensation
grossly nml.
Discharge:
VS: ___ 74 18 97% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: No wheezes, exp phase slightly prolonged, no crackles
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,
trace pedal edema
NEURO: A+Ox3, CN II-XII grossly intact, strength/sensation
grossly nml.
Pertinent Results:
Admission labs:
___ 11:20AM PLT COUNT-349
___ 11:20AM NEUTS-54.4 ___ MONOS-8.7 EOS-0.6
BASOS-0.7
___ 11:20AM WBC-9.5 RBC-4.26 HGB-13.6 HCT-41.2 MCV-97
MCH-31.8 MCHC-32.9 RDW-12.8
___ 11:20AM cTropnT-<0.01 proBNP-46
___ 11:20AM estGFR-Using this
___ 11:20AM GLUCOSE-133* UREA N-14 CREAT-0.7 SODIUM-144
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-29 ANION GAP-16
___ 11:30AM ___ PO2-51* PCO2-38 PH-7.46* TOTAL
CO2-28 BASE XS-2
___ 11:45AM D-DIMER-221
Discharge labs:
___ 07:55AM BLOOD WBC-5.5 RBC-3.79* Hgb-12.6 Hct-37.6
MCV-99* MCH-33.2* MCHC-33.5 RDW-13.3 Plt ___
___ 07:55AM BLOOD Glucose-127* UreaN-13 Creat-0.7 Na-144
K-4.2 Cl-107 HCO3-27 AnGap-14
___ 07:55AM BLOOD ALT-35 AST-31 AlkPhos-61 TotBili-0.5
___ 07:55AM BLOOD Calcium-9.5 Phos-5.2* Mg-2.0
___ 07:55AM BLOOD ANCA-NEGATIVE B
___ 05:21AM URINE Color-Straw Appear-Clear Sp ___
___ 05:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:21AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-3
Imaging:
CXR ___: IMPRESSION:
No acute cardiopulmonary process.
TTE ___: IMPRESSION: Normal regional and global biventricular
systolic function. No significant valvular abnormality. Normal
estimated pulmonary pressure.
CT chest ___: Pending
PFTs ___: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 20 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. aclidinium bromide 400 mcg/actuation inhalation BID
4. Pravastatin 20 mg PO DAILY
5. Furosemide 40 mg PO MWF
6. Glargine 30 Units Breakfast
7. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
8. Omeprazole 20 mg PO DAILY
9. albuterol sulfate 90 mcg/actuation inhalation q 4hrs prn
wheeze
10. Fluoxetine 20 mg PO DAILY
11. TraZODone 100 mg PO HS:PRN insomnia
12. GlipiZIDE 5 mg PO BID
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Nystatin Oral Suspension Dose is Unknown PO Frequency is
Unknown
15. Mucomyst 600 u Other BID
16. azelastine 137 mcg nasal BID
17. ipratropium bromide 0.06 % nasal TID
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Furosemide 40 mg PO MWF
3. Glargine 30 Units Breakfast
4. ipratropium bromide 0.06 % nasal TID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 20 mg PO DAILY
9. PredniSONE 15 mg PO DAILY
RX *prednisone 10 mg 1.5 tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
10. TraZODone 100 mg PO HS:PRN insomnia
11. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ ml by mouth q6hr Disp #*1
Bottle Refills:*1
12. albuterol sulfate 90 mcg/actuation inhalation q 4hrs prn
wheeze
13. azelastine 137 mcg nasal BID
14. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
15. GlipiZIDE 5 mg PO BID
16. Mucomyst 600 u Other BID
17. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*30 Capsule Refills:*1
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*1
19. Vitamin D 1000 UNIT PO DAILY
This medication can be purchased over the counter
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Asthma/COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Asthma with COPD exacerbation, worsening shortness of breath.
COMPARISON: None.
FINDINGS:
Frontal and lateral views of the chest were obtained. The lungs are clear
without focal consolidation. No pleural effusion or pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
CHEST CT ON ___
HISTORY: Occupational asthma, false positive ANCA testing, chronic
rhinosinusitis. Worsening dyspnea and persistent productive cough.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
the need for intravenous contrast agent, reconstructed as contiguous 5- and
1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs
axial images. Only prior chest imaging currently available is a conventional
chest radiograph, ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged. An
elliptical 7 x 15 mm right paramedian subcutaneous nodular opacity, 4:44,
could be a dilated vein and should be evaluated mammographically. No other
lesions in the soft tissues of the chest or upper abdominal wall suspicious
for malignancy.
Mediastinal, internal mammary, retrocrural and diaphragmatic lymph nodes are
not pathologically enlarged and hilar contours are normal. This study is not
designed for subdiaphragmatic diagnosis, but shows normal adrenal glands and
no abnormalities in the imaged portions of solid organs in the upper abdomen,
subject to the limitations of a non-contrast study.
Thyroid and esophagus are unremarkable. The aorta, pulmonary arteries and
heart are normal in size. There is no pleural or pericardial abnormality.
There is a wide variety of relatively mild pulmonary abnormality scattered
throughout both lungs, with different morphologies, including the following:
Peripheral peribronchial ground-glass opacification, right upper lobe, 4:79
and 92, (the latter containing the most prominent of the very few thickened
centrilobular bronchioles present anywhere) and lingula, 4:112, and subpleural
linear opacities with varying degrees of associated ground-glass opacification
predominantly in the lower lobes, left, 4:132, right, 4:145, left 4:161 and
167.
IMPRESSION:
When I spoke with Dr. ___ said that the patient's clinical condition had
improved recently, and that conventional radiographs showed clearing of what
were visible abnormalities in ___. Since the current chest radiograph
shows almost entirely clear lungs, there is radiographic evidence of clearing,
and the chest CT suggests the remnants of what were more serious
abnormalities. The bronchocentric distribution of some of the abnormality
suggests airway inflammation, although wall thickening of small bronchi is
minimal and there is no heterogeneity in the background density of the lungs
to suggest airtrapping (better assessed with pulmonary function tests than
routine chest CT). The near absence of centrilobular nodulation, and the
relative sparing of the lung apices argue against hypersensitivity pneumonia.
The abnormalities are much more widespread than generally seen with
cryptogenic organizing pneumonia. Perhaps the patient has allergic
bronchopulmonary aspergillosis affecting the small airways, or resolving
chronic eosinophilic pneumonia. It would be most helpful to obtain all of her
previous chest imaging, both conventional chest radiographs and CT scans and
try to correlate the radiographic findings with her clinical situation.
Small soft tissue nodule, anterior chest wall should be evaluated
mammographically.
Findings posted to online record of critical radiology findings for direct
notification of referring physician.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea on exertion
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.2
heartrate: 85.0
resprate: 22.0
o2sat: 97.0
sbp: 158.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | You were evaluated on the medicine service for the cause of your
shortness of breath. A comprehensive evaluation revealed that
you have resolving inflammation in your lungs that the steroids
are treating. It is not clear exactly what caused the
inflammation, but the pulmonologists will continue to work with
you to figure this out.
Your breathing regimen was adjusted to help your symptoms.
Please use the incentive spirometer we have provided for you at
home. The pulmonologists ___ discuss with you doing a home and
work evaluation for triggers of your breathing difficulty. This
can be discussed at followup. We also have started you on an
antibiotic to prevent infections while on the steroids.
Please make sure to take the omeprazole on an empty stomach
___
minutes prior to eating, to prevent reflux |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
CC: Type B ___ dissection
HPI: We are seeing this ___ year old female otherwise healthy in
consultation for management of an acute type B aortic
dissection.
Her past medical history is pertinent for chronic back pain
secondary to degenerative lower back disc disease (she does not
recall number and/or levels affected). She was in her usual
state
of health until this afternoon around noon when she developed
acute onset of tearing upper back pain. She describes that prior
to this onset of pain she felt numbness and dysesthesias in her
bilateral ___. She describes this pain being of different nature
regarding characteristics and intensity as her usual lower back
pain. Pain is aggravated with breathing.
She was taken to ___ for evaluation. At arrival
BP:
167/92, HR: 82, RR: 18 O2: 98% room air. Given 2 doses of
labetalol 20 mg IV with no optimal response. Work up concerning
for type B aortic dissection and transferred to ___ for
further
management.
Upon arrival to ___ ED, BP Left arm: 155/95, Right arm: 165/98
HR: 78, RR: 18, O2 sar 98% room air. NAD. AOx3. She endorses
persistent back pain and intermittent ___ numbness, although she
clearly says that this has improved since this afternoon. RRR,
no
murmurs, lungs clear. Abdomen soft, non-pulsatile mass. Pulses
are symmetric bilaterally. Grossly intact neurologically. Labs
are unrevealing. Imaging demonstrates intimal flap distant to
take off of L subclavian artery extending towards left external
iliac artery. The SMA, celiac and right renal comes off the true
lumen. She has two renal arteries. The superior one seems to
come
off the true lumen, the inferior renal artery comes from false
lumen. There is no evidence of retrograde propagation, pleural
effusion.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: Type B ___ dissection
HPI: We are seeing this ___ year old female otherwise healthy in
consultation for management of an acute type B aortic
dissection.
Her past medical history is pertinent for chronic back pain
secondary to degenerative lower back disc disease (she does not
recall number and/or levels affected). She was in her usual
state
of health until this afternoon around noon when she developed
acute onset of tearing upper back pain. She describes that prior
to this onset of pain she felt numbness and dysesthesias in her
bilateral ___. She describes this pain being of different nature
regarding characteristics and intensity as her usual lower back
pain. Pain is aggravated with breathing.
She was taken to ___ for evaluation. At arrival
BP:
167/92, HR: 82, RR: 18 O2: 98% room air. Given 2 doses of
labetalol 20 mg IV with no optimal response. Work up concerning
for type B aortic dissection and transferred to ___ for
further
management.
Upon arrival to ___ ED, BP Left arm: 155/95, Right arm: 165/98
HR: 78, RR: 18, O2 sar 98% room air. NAD. AOx3. She endorses
persistent back pain and intermittent ___ numbness, although she
clearly says that this has improved since this afternoon. RRR,
no
murmurs, lungs clear. Abdomen soft, non-pulsatile mass. Pulses
are symmetric bilaterally. Grossly intact neurologically. Labs
are unrevealing. Imaging demonstrates intimal flap distant to
take off of L subclavian artery extending towards left external
iliac artery. The SMA, celiac and right renal comes off the true
lumen. She has two renal arteries. The superior one seems to
come
off the true lumen, the inferior renal artery comes from false
lumen. There is no evidence of retrograde propagation, pleural
effusion.
Past Medical History:
Her past medical history is pertinent for chronic back pain
secondary to degenerative lower back disc disease (she does not
recall number and/or levels affected).
Social History:
___
Family History:
Unknown for cardiovascular diseae
Physical Exam:
GEN: NAD, A/O x3
C: RRR, no R/M/Gs, no chest pain
R: no resp distress, CTAB
GI: soft, NTND
Neuro: sensation and motor grossly intact in UE and ___ b/l
extremities: warm, no edema
Pulses: R: P/-/P/P L: P/-/P/P
Pertinent Results:
___ 03:35AM BLOOD WBC-7.4 RBC-3.79* Hgb-11.8 Hct-35.8
MCV-95 MCH-31.1 MCHC-33.0 RDW-12.1 RDWSD-42.1 Plt ___
___ 05:46AM BLOOD WBC-6.7 RBC-3.74* Hgb-11.8 Hct-35.9
MCV-96 MCH-31.6 MCHC-32.9 RDW-12.3 RDWSD-42.7 Plt ___
___ 03:35AM BLOOD Plt ___
___ 02:56AM BLOOD ___ PTT-29.8 ___
___ 03:35AM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-23 AnGap-15
___ 05:46AM BLOOD cTropnT-<0.01
___ 03:35AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 05:46AM BLOOD TSH-2.0
___ 02:10AM BLOOD HCG-<5
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 1200 mg PO QHS back pain
Discharge Medications:
1. Diltiazem Extended-Release 480 mg PO DAILY
RX *diltiazem HCl [DILT-XR] 240 mg 2 capsule(s) by mouth daily
Disp #*60 Capsule Refills:*0
2. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Metoprolol Succinate XL 200 mg PO BID
total 400 mg daily
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
4. Gabapentin 1200 mg PO QHS back pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute type B dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with type b dissection now with worst headache
she's ever had// ? intracranial 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 5.0 s, 39.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 524.0
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 6.2 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.4 mGy-cm.
Total DLP (Body) = 544 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Outside hospital CTA torso done ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass effect. The ventricles and sulci are within expected limits in size
and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
are patent without marked stenosis, occlusion, or aneurysm formation. The
dural venous sinuses are patent.
CTA NECK:
Known type b aortic dissection is incompletely imaged, but appears fairly
similar compared to prior CT torso. The dissection does not involve the
carotid or vertebral arteries. The carotid arteries are patent bilateral. No
proximal ICA stenosis by NASCET criteria. The vertebral arteries are patent
bilateral.
OTHER:
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.
IMPRESSION:
1. Known type B aortic dissection is incompletely imaged, but appears fairly
similar compared to prior CT torso from outside hospital done ___.
2. The dissection does not involve/extend into the carotid or vertebral
arteries.
3. No intracranial arterial aneurysm or occlusion.
4. No proximal ICA stenosis by NASCET criteria. Vertebral arteries are patent
bilateral.
5. No acute intracranial abnormality on noncontrast head CT. Specifically, no
acute large territorial infarct, hemorrhage or mass effect.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old woman with Type B dissection// evaluate interval
changes in Type B dissection
TECHNIQUE: Chest, abdomen, and pelvis CTA: Non-contrast and multiphasic
post-contrast images were acquired through chest, abdomen, and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 66.9 cm; CTDIvol = 14.5 mGy (Body) DLP = 969.0
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 9.0 s, 0.5 cm; CTDIvol = 49.7 mGy (Body) DLP =
24.8 mGy-cm.
Total DLP (Body) = 995 mGy-cm.
COMPARISON: Outside facility CTA torso dated ___.
FINDINGS:
VASCULAR:
Re-demonstrated is a type B aortic dissection, which arises just after the
takeoff of the left subclavian artery. As before, the true lumen supplies the
celiac, SMA, and likely the ___. There is a single right renal artery, which
is supplied by the true lumen. There are 2 left renal arteries, both of which
are supplied by the false lumen (2:114, 2:119, 601:28). The true lumen
supplies the right common iliac artery, while the dissection flap extends into
the left common iliac artery, and left external iliac artery, terminating just
prior to the common femoral artery.
There is a 3 vessel aortic arch. The ascending aorta remains mildly dilated,
measuring up to 4 cm. The descending thoracic aorta and abdominal aorta is
similar in caliber.
NECK BASE: Limited assessment of the neck base demonstrates no abnormalities.
MEDIASTINUM/HILA: Mediastinal and hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged. There are no coronary artery
calcifications.
PLEURA: No pleural effusion or pneumothorax.
LUNGS: There is bibasilar subsegmental dependent atelectasis, otherwise the
lungs are clear.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Several hepatic hypodensities are incompletely characterized, but most likely
represent simple cysts and are unchanged. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen 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 normal and symmetric in size. There is a marginally
delayed nephrogram on the left, which may be related to its supplied by the
false lumen of the dissection. Bilateral subcentimeter hypodensities are too
small to characterize, but most likely reflect simple cysts. No
hydronephrosis. There are no urothelial lesions in the kidneys or ureters.
There is no perinephric abnormality.
GASTROINTESTINAL: There several radiodense objects noted in the small bowel
and colon, which may reflect ingested medication. Small bowel loops
demonstrate normal caliber, wall thickness and enhancement throughout. Colon
and rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is enlarged, with multiple fibroids, as
before. The ovaries are not definitely seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The exception of a small fat containing umbilical hernia, the
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Stable appearance a type B aortic dissection originating chest distal to
the origin of the left subclavian artery. The false lumen continues to supply
the 2 left renal arteries. As before, the dissection extends into the common
iliac artery, and the external iliac artery, terminating just prior to the
common femoral artery.
2. Minimally delayed nephrogram of the left kidney is likely related to its
supplied by the false aortic lumen.
3. Stable mild dilation of the ascending aorta, measuring up to 4 cm.
4. Fibroid uterus.
5. An addendum will be issued upon the completion of 3 dimensional reformats.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: AAA, Transfer
Diagnosed with Dissection of abdominal aorta
temperature: 98.3
heartrate: 82.0
resprate: 18.0
o2sat: 98.0
sbp: 145.0
dbp: 95.0
level of pain: 4
level of acuity: 2.0 | It was a pleasure taking care of you at ___
___. During your hospitalization, you were medically
managed to control your blood pressure. You have kept your
blood pressure low and are now ready to be discharged from the
hospital.
Please continue to monitor your blood pressure. You should want
to keep your systolic blood pressure below 140.
Make sure to take your meds as prescribed.
If you experience any new onset sudden, strong pain in your
chest or back, please contact emergency services.
Follow up with your primary care provider ___ 1 week
concerning your blood pressure.
If you have any other questions, please call the office ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fatigue, fevers, LLQ tenderness
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Per Dr. ___:
___ with hx of uncomplicated diverticulitis x1, recent
choledocholithiasis s/p ERCP with stone extraction and
sphincterotomy ___ presenting with LLQ pain and fatigue x1
week, with Tmax 101 at home.
Pt describes being sent home on ___ with ciprofloxacin x1
week. Began to recover, got stronger. Ciprofloxacin completed
___. After completion of abx, pt noted that although he felt
well and strong, energetic, hungry in am. Shortly after
completing course of abx, began to develop fatigue around noon,
requiring 2 hour nap, again exhausted by evening time. In the
week prior to admission, he began to note temp in the evenings,
max of 101. Urine has remained "tea colored," which worried him
that bilirubin remained high. Although he retained an appetite,
has noted several pound weight loss between the time of the
procedure and this hospitalization. He recalls symptoms of acute
diverticulitis, and developed what he believed to be similar
symptoms. Described as LLQ, steady, worse with palpation, not
sharp, ___, most notable when driving and belt pressing in that
spot, symptoms resolved with loosening of belt. Typically
transitions to full liquid diet when these symptoms develop,
which did help with discomfort, but fatigue and fever persisted.
Denies N/V. He did take advil for evening fevers. Denies
diarrhea, endorses mild constipation with pellet-like stool.
Denies RUQ pain. He presented to ___ clinic on ___, and
was directed to ED when elevated LFTs in cholestatic pattern
were noted.
Labs at ___ on ___ (in paper chart):
WBC 12.2
ALT/AST 528/216
Tbili 2.6
Alk phos 138
In the ___ ED:
VS 96.6, 78, 115/57, 99% RA
Labs notable for WBC 5.7, Hb 11.5, ALT/AST 428/165, alk phos
120, Tbili 1.6, Dbili 0.9
UA positive
LA 2.5
CT with e/o sigmoid diverticulitis
BCx sent
Evaluated by surgery, ?micro perforation - medicine admission
with imaging of biliary system
ERCP consult requested
Received 1L NS, lorazepam, cipro/flagyl (despite documented
flagyl allergy)
ROS: All else negative
Past Medical History:
Inguinal hernia s/p repair ___
Diverticulitis approx. ___
Congenital absence of right arm below the elbow and right
ankle as well as syndactyle left hand - born with webbed hand,
s/p reconstruction - grafts taken from lower abdomen
Social History:
___
Family History:
Both parents, sibling, and aunts/uncles s/p CCY. Father died at
age ___ with MI, was a heavy smoker.
Physical Exam:
VS 97.9, 133/76, 69, 100% RA
Gen: Very pleasant male, lying in bed, NAD, nontoxic appearing
HEENT: PERRL, EOMI, clear oropharynx, MMM
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, nondistended, no rebound or guarding, +point TTP at
LLQ, negative ___ sign, +BS, no hepatomegaly
GU: No foley
Ext: R below the elbow amputation, L hand syndactyly s/p
reconstruction, RLE below the ankle amputation
Neuro: grossly intact
Discharge Exam:
98.7, 117/73, 63, 16, 99%RA
Gen: Thin, pleasant, NAD
HEENT: PERRL, EOMI, MMM
Neck: Supple, no JVD
Lungs: LCTA-bl, no w/r/r
Heart: RRR, no MRG, nl s1 and s2
Abd: Soft, NTND, no HSM
Ext: congential absence of R arm below elbow, RLE below the knee
and slightly hypotrophic L hand digits.
Neuro: CNII-XII intact; moving all extremities equally
Pertinent Results:
Admission Labs
___ 07:40AM BLOOD WBC-6.4 RBC-4.45* Hgb-13.2* Hct-39.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-12.7 RDWSD-40.0 Plt ___
___ 07:40AM BLOOD Neuts-55.3 ___ Monos-9.4 Eos-6.4
Baso-0.8 Im ___ AbsNeut-3.51 AbsLymp-1.77 AbsMono-0.60
AbsEos-0.41 AbsBaso-0.05
___ 07:40AM BLOOD ___ PTT-32.2 ___
___ 09:00AM BLOOD Glucose-117* UreaN-16 Creat-0.8 Na-140
K-3.7 Cl-107 HCO3-27 AnGap-10
___ 09:00AM BLOOD ALT-428* AST-165* AlkPhos-120 Amylase-44
TotBili-1.6* DirBili-0.9* IndBili-0.7
___ 09:00AM BLOOD Lipase-28
___ 09:00AM BLOOD Albumin-3.1*
___ 07:50AM BLOOD Lactate-2.5* Na-137 K-GREATER TH
___ 09:25AM BLOOD Lactate-1.4
___ 08:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:50AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-6.0 Leuks-NEG
___ 08:50AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
Discharge Labs:
___ 06:43AM BLOOD WBC-7.5 RBC-4.37* Hgb-13.0* Hct-38.0*
MCV-87 MCH-29.7 MCHC-34.2 RDW-11.3 RDWSD-36.5 Plt ___
___ 01:15PM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-139
K-3.6 Cl-102 HCO3-29 AnGap-12
___ 01:15PM BLOOD ALT-368* AST-147* AlkPhos-141*
TotBili-1.9*
___ 01:15PM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1
Micro:
Blood cultures NGTD
CTAP w 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 homogenous attenuation
throughout. Multiple subcentimeter hypodensities are too small
to characterize. A 1.1 cm hypodensity at the hepatic dome and a
2.0 cm hypodensity in the left hepatic lobe are likely hepatic
cysts. 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. Subcentimeter hypodensities in the kidneys
bilaterally are too small to characterize but likely cysts. No
evidence of hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the sigmoid colon is
noted, with evidence of wall thickening and fat stranding
concerning for acute diverticulitis. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Multilevel degenerative changes of the
thoracolumbar spine.
SOFT TISSUES: Patient is status post inguinal hernia repair with
postsurgical changes noted in the left inguinal region.
IMPRESSION:
Diverticulitis of the proximal sigmoid colon. No evidence of a
fluid collection or extraluminal air.
ERCP ___:
Impression:
The scout film was normal.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
The CBD was 8 mm in diameter.
No discrete filling defects consistent with stones were
identified in the CBD and CHD.
Opacification of the gallbladder was incomplete.
The left and right hepatic ducts and all intrahepatic branches
were normal.
A small segment of remaining sphincter was noted.
An extension of the previous biliary sphincterotomy was made
with a sphincterotome.
There was no post-sphincterotomy bleeding.
The biliary tree was swept repeatedly with a 9-12mm balloon
starting at the bifurcation.
Bile was removed.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically
Otherwise normal ercp to third part of the duodenum
Recommendations:
Return to ward under ongoing care.
NPO overnight with IV hydration
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY:PRN allergies
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 #*24 Tablet Refills:*0
2. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Biliary obstruction
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 a history of inguinal hernia status post repair in ___,
choledocholithiasis status post ERCP sphincterotomy on ___ for which
the patient completed 1 week of ciprofloxacin, and diverticulosis. Presents
with intermittent fevers, left lower quadrant pain for the past 4 days, and
elevated LFTs. Evaluate for diverticulitis and post op changes status post
sphincterectomy ___.
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) = 480 mGy-cm.
COMPARISON: Liver gallbladder ultrasound ___
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.
Multiple subcentimeter hypodensities are too small to characterize. A 1.1 cm
hypodensity at the hepatic dome and a 2.0 cm hypodensity in the left hepatic
lobe are likely hepatic cysts. 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.
Subcentimeter hypodensities in the kidneys bilaterally are too small to
characterize but likely cysts. No evidence of hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, with evidence of wall thickening and fat stranding
concerning for acute diverticulitis. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes of the thoracolumbar spine.
SOFT TISSUES: Patient is status post inguinal hernia repair with postsurgical
changes noted in the left inguinal region.
IMPRESSION:
Diverticulitis of the proximal sigmoid colon. No evidence of a fluid
collection or extraluminal air.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, Abd pain
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding
temperature: 96.6
heartrate: 78.0
resprate: 18.0
o2sat: 99.0
sbp: 115.0
dbp: 57.0
level of pain: 1
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
hospitalized for abdominal pain. You were found to have elevated
liver function tests concerning for a recent bile duct
obstruction. You underwent ERCP which did not show concerning
findings. You were also found to have diverticulitis and
received antibiotics for this. Your symptoms improved and you
are being discharged. Please follow up with your physicians as
below. Please avoid blood thinners or non-steroidal
anti-inflammatory medications for at least 5 days.
Best Regards,
Your ___ Medicine Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ciprofloxacin / chocolate flavor
Attending: ___.
Chief Complaint:
Cough, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ESRD on HD (___), stroke (R frontal, b/l basal ganglia
with residual L-sided deficits), CAD (s/p PCI in ___, HFrEF(EF
30% ___, IDDM (s/p L foot amputation), HTN, seizures (on
phenytoin), PAD (s/p angioplasty), dementia with ESRD on HD who
presents with cough since ___.
Patient with recent admission ___ at that time for dyspnea
and sore throat, at that time treated for acute on chronic CHF
with HD volume removal as well as E faecium UTI (at that time
with increased urinary frequency as well as smelly urine). Also
had goals of care discussion during that stay, as patient is
bed-bound at baseline and has muscular wasting. Clarified that
patient is DNR/DNI.
Since last discharge, patient's daughter reports that he was
doing well up until ___ when he had decreased food and
water
intake despite encouragement from care takes. She notes that he
really dislikes the baby food, but will eat pureed peas and
meats
(note diet downgraded at last admission).
She brought him in today mostly because of concern for cough. On
___, after returning from HD, patient developed persistent
junky cough according to his daughter. This is nonproductive. No
fevers. The cough has worsened since then, and she notes one
episode of him perhaps having difficulty with secretions or
feeling short of breath which prompted admission. She also
noticed that an ulcer on her R heel had appeared and seemed to
be
very painful to him.
He does not verbalize frequently, but seemed to endorse that he
felt like he was sick by nodding yes/no. Also had question of
chest pain reported to PCA ___.
Past Medical History:
- Vascular/Azheimer's dementia
- Multiple strokes (R frontal, b/l basal ganglia) c/b seizure
disorder
- ESRD on HD (___) via LUE fistula - oliguric; likely ___ DM,
vascular disease, HTN
- CAD ___ cath showed 3 vessel CAD with 95% mid LAD lesion,
s/p rotational atherectomy and PTCA of LAD/D2 bifurcation in
___
- HFpEF ___ LVEF = 65%
- DM type 2
- PAD
- Diverticulosis with prior history of GI bleeding (diverticular
with esophagitis and gastritis, ___
- Anemia with chart diagnosis of thalassemia trait
- R hemiarthroplasty femoral neck fx (___)
- R inguinal hernia repair with mesh (___)
- R eye cataract (___)
- L carpel tunnel (___)
- exlap and LOA for SBO/ruptured appendicitis (___)
Social History:
___
Family History:
Per OMR as patient unable to fully provide history.
- Mother died at age ___ of dementia.
- Father died in his ___ from a respiratory infection.
- Has 2 daughters who are both well and a son with UC.
- All of his male relatives with ___ and CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Initial vitals: Temp: 97.6 HR: 88 BP: 146/86 Resp: 20 O2 Sat: 98
Exam notable for:
Gen: Elderly man lying in bed in no significant distress,
following basic commands from his daughter but not speaking.
Evidence of severe malnutrition.
HEENT: Tiny vesicular lesions on upper and lower lip. Dry mucous
membranes. No overt evidence of thrush though difficult to
visualize.
Neck: No JVD.
CV: S1/S2 regular with soft systolic murmur.
Pulm: Poor respiratory effort. Rhonchi at left lung base.
Intermittent cough. No respiratory distress.
Abd: Old scarring. Multiple ventral hernias. No clear tenderness
to palpation. No clear CVAT.
GU: Inguinal hernia reducible.
Lower extremities: Warm, no edema.
Arm: Fistula with palpable thrill and no bleeding.
Feet: Large black ulcer on R heel with serous discharge and pain
to palpation, all toes amputated. L foot with ulcer on ___
digit,
black with fibrinous material. L heel also had ulcer with some
serous discharge. No obvious pain to palpation.
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0717 Temp: 98.7 PO BP: 146/72 L Lying HR: 84 RR: 18
O2 ___ 0545 Temp: 98.9 AdultAxillary BP: 164/69 R Lying HR:
76 RR: 20 O2 sat: 98% O2 delivery: Ra
GENERAL: Elderly man no acute distress, temporal wasting
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, no JVD appreciated
CV: RRR, S1/S2, ___ SEM best appreciated at LUSB
PULM: CTAB, decreased at bilateral bases
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Old scars. No CVA
tenderness.
EXTREMITIES: no cyanosis, clubbing, or edema. R heel with black
ulcer with serous discharge. All toes amputated. L foot with
lateral ___ digit ulcer, black appearing.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric. Follows commands in ___. Not talking on my exam.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:49PM BLOOD WBC-9.9 RBC-3.96* Hgb-9.0* Hct-28.0*
MCV-71* MCH-22.7* MCHC-32.1 RDW-18.7* RDWSD-45.6 Plt ___
___ 09:49PM BLOOD Neuts-78.1* Lymphs-8.8* Monos-8.9 Eos-2.5
Baso-1.2* Im ___ AbsNeut-7.74* AbsLymp-0.87* AbsMono-0.88*
AbsEos-0.25 AbsBaso-0.12*
___ 09:49PM BLOOD Glucose-226* UreaN-50* Creat-3.7* Na-131*
K-4.9 Cl-89* HCO3-24 AnGap-18
___ 09:49PM BLOOD ALT-13 AST-44* LD(LDH)-375* AlkPhos-143*
TotBili-0.3
___ 06:19AM BLOOD CK-MB-3 cTropnT-0.50*
___ 04:50PM BLOOD cTropnT-0.50*
___ 06:19AM BLOOD Calcium-8.4 Phos-1.2* Mg-2.0 Iron-27*
___ 06:19AM BLOOD calTIBC-116* Ferritn-1061* TRF-89*
___ 05:20AM BLOOD %HbA1c-5.1 eAG-100
___ 09:49PM BLOOD Lactate-2.8*
___ 10:53PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:53PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 10:53PM URINE RBC-36* WBC-62* Bacteri-MANY* Yeast-NONE
Epi-4 TransE-1
DISCHARGE LABS:
===============
___ 06:13AM BLOOD WBC-7.9 RBC-3.67* Hgb-8.3* Hct-25.6*
MCV-70* MCH-22.6* MCHC-32.4 RDW-17.6* RDWSD-43.6 Plt ___
___ 06:13AM BLOOD Glucose-147* UreaN-29* Creat-3.3* Na-143
K-4.5 Cl-100 HCO3-25 AnGap-18
___ 06:13AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.9
IMAGING STUDIES:
================
CXR (___):
1. Mild pulmonary edema with small bilateral pleural effusions,
left greater
than right.
2. Low lung volumes with moderate to severe bibasilar
atelectasis similar to
prior, however underlying pneumonia is difficult to exclude in
the appropriate
clinical setting.
CXR (___):
Comparison to ___. Stable bilateral pleural
effusions. Stable
subsequent areas of atelectasis and subsequent consolidations.
No new focal parenchymal opacities suggesting pneumonia. Mild
pulmonary edema persists.
FOOT X-RAY (___):
Status post right forefoot amputation, with no definite
radiographic evidence
of new areas of bony destruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO 4X/WEEK (___)
2. Lisinopril 10 mg PO 3X/WEEK (___)
3. Mirtazapine 7.5 mg PO QHS
4. Ramelteon 8 mg PO QHS:PRN insomnia
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Phenytoin Sodium Extended 200 mg PO QAM
8. Phenytoin Sodium Extended 130 mg PO QHS
9. Glargine 5 Units Bedtime
10. Isosorbide Mononitrate 40 mg PO BID
11. Clopidogrel 75 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. B complex with C#20-folic acid 1 mg oral DAILY
14. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. B complex with C#20-folic acid 1 mg oral DAILY
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate 40 mg PO BID
5. Lisinopril 20 mg PO 4X/WEEK (___)
6. Lisinopril 10 mg PO 3X/WEEK (___)
7. Metoprolol Tartrate 25 mg PO BID
8. Mirtazapine 7.5 mg PO QHS
9. Phenytoin Sodium Extended 200 mg PO QAM
10. Phenytoin Sodium Extended 130 mg PO QHS
11. Polyethylene Glycol 17 g PO DAILY
12. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
13. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
___:
#Severe protein calorie malnutrition
#ESRD on HD
#Dysphagia
#Hypoglycemia
#Heel ulcers
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: History: ___ with PAD, chronic foot ulcers, prior partial R foot
amputation presenting with decreased appetite, new R heel ulcer. Evaluation
for evidence of osteomyelitis of the R heel
TECHNIQUE: AP, lateral, and oblique views of the right foot and ankle.
COMPARISON: Comparison to radiograph from ___.
FINDINGS:
Patient is status post right forefoot amputation at the level of the proximal
metatarsals. No definite new area bony destruction is identified. Mild
degenerative change of the TMT joints. Extensive vascular calcifications are
again noted.
IMPRESSION:
Status post right forefoot amputation, with no definite radiographic evidence
of new areas of bony destruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cough// ? PNA ? PNA
IMPRESSION:
Comparison to ___. Stable bilateral pleural effusions. Stable
subsequent areas of atelectasis and subsequent consolidations. No new focal
parenchymal opacities suggesting pneumonia. Mild pulmonary edema persists.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Cough
Diagnosed with Pressure ulcer of right ankle, stage 2, Cough, Acidosis, Long term (current) use of insulin, Chest pain, unspecified
temperature: 97.6
heartrate: 88.0
resprate: 20.0
o2sat: 98.0
sbp: 146.0
dbp: 86.0
level of pain: UTA
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a cough.
What happened while I was in the hospital?
- You had a CXR which did not show pneumonia. It is more likely
that your cough is from aspiration or extra fluid in your lungs
from your kidney disease. We continued your regular dialysis
schedule while you were here. We also had our speech and swallow
team evaluate your swallowing function. They are recommending
continued pureed diet with thickened liquids.
- You were also found to have low blood sugars while you were in
the hospital. We have discontinued your home insulin. You're
daughter will check your blood sugars at home and you should
take these readings to your primary care provider ___ ___.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right distal femur fracture
Major Surgical or Invasive Procedure:
___ right distal femur ___ plate
History of Present Illness:
___ s/p B TKA ___ years ago at ___ who presents
s/p fall from standing at home this morning with a R distal
femur periprosthetic fracture. No other injuries, no head
strike, no loss of consciousness. Seen at OSH and transferred to
___ for further evaluation.
Past Medical History:
s/p B TKA, GERD, insomnia
Social History:
___
Family History:
noncontributory
Physical Exam:
VS afebrile, BP 135/75, HR 75, RR 12, SpO2 100% RA
GEN: Well appearing in NAD, AAOx3
PULM: respiring easily
CV: pulse palpable and regular
Focused examination of right lower extremity: SILT sural,
saphenous, superficial peroneal and deep peroneal. ___ 2+. DF/PF
intact. Incision c/d/I with ecchymosis surrounding incision site
and staples in place.
Pertinent Results:
___ 06:45AM BLOOD WBC-5.9 RBC-2.40* Hgb-8.0* Hct-24.5*
MCV-102* MCH-33.3* MCHC-32.7 RDW-15.5 RDWSD-58.4* Plt ___
___ 06:45AM BLOOD ___ PTT-25.1 ___
___ 06:45AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-139 K-3.7
Cl-102 HCO3-33* AnGap-8
___ 06:45AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Zolpidem Tartrate 5 mg PO QHS
3. Acetaminophen 650 mg PO TID
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
4. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate [Calci-Chew] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth three times daily Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
6. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe
Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ to 1 tablet(s) by mouth every 4 hours
Disp #*60 Tablet Refills:*0
8. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*20 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right periprosthetic distal femur 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: CT right lower extremity contrast
INDICATION: ___ RIGHT sided femur fracture. femur ap/lat films already
performed please eval with CT noncon r femur // ___ RIGHT sided femur
fracture. femur ap/lat films already performed please eval with CT noncon r
femur
TECHNIQUE: ___ MD CT imaging was performed through the right femur without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
DOSE: 137 0.14 mGy-cm
COMPARISON: Intraoperative images ___
FINDINGS:
There is a spiral fracture through the distal tibial diaphysis with
significant rotation of the distal femur relative to the proximal femur by at
least 90 degrees. There is a large butterfly fragment along the antro lateral
aspect of the right femur measuring 12.6 cm in craniocaudal length. A right
total knee prosthesis is in-situ, alignment of the prosthesis is within normal
limits although rotated compared to the proximal femoral shaft. No
periprosthetic loosening appreciated. The associated soft tissue stranding
and hematoma is minimal. There are mild degenerative changes at the
femoroacetabular joint. No additional fractures seen.
IMPRESSION:
Comminuted displaced spiral fracture through the distal femoral diaphysis.
The right total knee arthroplasty appears intact.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R.
INDICATION: ORIF right femur fracture
TECHNIQUE: Fluoroscopic assistance provided to the clinician in the OR
without the radiologist present. 16 spot views obtained. Fluoro time recorded
as 175.8 seconds. Side not indicated on films.
COMPARISON: Right femur radiographs from ___
FINDINGS:
Views demonstrate steps related to ORIF of a distal femur fracture, with
sideplate and screws. A 3 component knee prosthesis is also present.
IMPRESSION:
Correlation with real-time findings and, when appropriate, conventional
radiographs is recommended for further assessment.
Radiology Report
INDICATION: ___ displaced comminuted femur fracture pls obtain full length
femur films.
COMPARISON: None
FINDINGS:
Multiple views of the right femur provided. There is a spiral fracture
involving the distal shaft of the right femur with lateral and anterior
displacement of the distal fracture fragment. Right knee arthroplasty is
noted. On the lateral view of the right distal femur, the fracture line
closely approximates the distal femoral prosthesis. The right hip appears to
align normally.
IMPRESSION:
Distal femur fracture, displaced, extends to the distal femoral prosthesis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ preop
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Femur fracture, Transfer
Diagnosed with MECHANICAL LOOSENING OF PROSTHETIC JOINT, UNSPECIFIED FALL, JOINT REPLACEMENT-KNEE
temperature: 98.8
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 85.0
level of pain: 3
level of acuity: 3.0 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for fixation of your right femur
fracture by orthopedic surgery. It is normal to feel tired or
"washed out" after surgery, and this feeling should improve over
the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- right lower extremity partial (25%) weight bearing
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Partial weight bearing 25%
Treatment Frequency:
Your staples will be removed at your initial post operative
visit. You do not need a dressing over your wound as long as it
remains non draining. If a bandage is needed for seepage a dry
sterile dressing should be placed and changed daily as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Urinary tract infection/heamturia
Major Surgical or Invasive Procedure:
Antibiotic treatment of urinary tract infection.
History of Present Illness:
___ pmhx MS/neurogenic bladder requiring self-cath
s/p left lateral segmentectomy for biopsy-proven cavernous
hemangioma with hematuria, incomplete self-catheterization since
discharge secondary to clotting, continues to void spontaneously
at baseline 200-400cc/catheterization. Post-op admission
___ notable for MDR Klebsiella UTI, started on Bactrim DS
for total 14d course currently d5/14 and increasing frequency of
self-catheterization from BID to TID per Urology
recommendations.
Pt notes new difficulty with self-catheterization over preceding
___ days noting clot, minimal hematuria, without pain on
catheterization and notable for ___ urine out put per TID
catheterization. Maintains ability to spontaneously void,
reporting no subjective decrease in volume/void. Denies dysuria,
fevers, chills, suprapubic tenderness or fullness, back pain or
abdominal pain.
From a post-surgical perspective, denies abdominal pain, fevers,
chills, nausea, vomiting, change in bowel habit. Denies
warmth/erythema/drainage from surgical incision. Denies bilious
or purulent drainage from or around JP/drain insertion site.
Reports decreasing outputs <10cc/day thin serosanguinous from
JP.
Reports adequate pain control and return to baseline ADLs.
Past Medical History:
Past Medical History:
1. Large left lobe hepatic lesion of unclear etiology - As
above.
2. Multiple Sclerosis - Diagnosed around ___. Requires a
cane for ambulation. Beta interferon from approximately ___ to
one month ago.
3. Neurogenic bladder secondary to MS.
4. History GI bleeding ___ duodenum/gastric ulcer in ___ and
possibly ___.
Social History:
___
Family History:
No known family history of liver cancer, liver disease or colon
cancer.
Physical Exam:
Vital Signs:
Temperature: 99.1F, HR 91, BP 129/66, RR 16 Sa02 100% Room Air
Gen: NAD, AAOx3
Cardiac: regular rate and rhythm
Lungs: CTA B/L
ABD: Soft, non-tender, no rebound or guarding. Incision with
steri-strips. JP drain in place with minimal ~5cc of
serosanguinous fluid.
Back: No costovertebral angle tenderness.
EXT: MAE, WWP, distal pulses present.
Pertinent Results:
___ 05:20AM BLOOD WBC-8.9 RBC-3.99* Hgb-10.9* Hct-34.3*
MCV-86 MCH-27.3 MCHC-31.7 RDW-12.7 Plt ___
___ 05:15PM BLOOD WBC-10.6 RBC-4.53* Hgb-12.7* Hct-39.1*
MCV-87 MCH-28.0 MCHC-32.4 RDW-12.9 Plt ___
___ 07:45PM BLOOD WBC-8.9 RBC-4.38* Hgb-12.3* Hct-37.5*
MCV-86 MCH-28.2 MCHC-32.9 RDW-12.8 Plt ___
___ 05:20AM BLOOD ALT-49* AST-36 AlkPhos-60 TotBili-0.3
___ 05:20AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
___ 01:06PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 1:06 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
Baclofen, oxycodone prn pain, BDS'', metamucil, colace.
Discharge Medications:
1. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks: Take this first. After you finish this bottle
take 1 bactrim per day. .
Disp:*28 Tablet(s)* Refills:*0*
2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months: Please take for several months until told
otherwise by your Dr. .
___:*30 Tablet(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
-Urinary Tract Infection
-Blood in Urine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Post-operative fevers.
COMPARISON: ___.
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal and hilar
contours are normal. Pulmonary vascularity is normal and the lungs are clear.
No pleural effusion or pneumothorax is present. A drainage catheter is seen
overlying the liver.
IMPRESSION: No acute cardiopulmonary abnormality.
Radiology Report
PORTABLE AP UPRIGHT CHEST FILM, ___ AT 7:49
CLINICAL INDICATION: ___ status post hepatic segmentectomy, now with
fever of unknown origin, question cardiopulmonary pathology.
Comparison to prior study of ___ at 19:14.
Single portable AP upright chest from ___ at 7:49 is submitted.
IMPRESSION:
1. Right upper quadrant catheter remains unchanged in position. Lungs are
well inflated without evidence of focal airspace consolidation to suggest
pneumonia. No pleural effusions, pulmonary edema, or pneumothorax. Overall,
cardiac and mediastinal contours are stable.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: HEMATURIA
Diagnosed with URIN TRACT INFECTION NOS, MULTIPLE SCLEROSIS, NEUROGENIC BLADDER
temperature: 101.0
heartrate: 114.0
resprate: 16.0
o2sat: 100.0
sbp: 112.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | You were admitted for a urinary tract. Your urinary tract
infection was treated. Urology came and saw you as an inpatient
and they have the following instruction:
-Please Clean-Cath yourself 3 times a day.
-When you initially leave the hospital: please take Bactrim
Double Strength Twice a day for 14 days
-After you take Bactrim Double strength twice for 14 days, you
should start taking bactrim double strength once a day.
-You should call Dr. ___ UROLOGY to make an appointment for
an oupatient workup for your hematuria in ___ days.
___
Please resume your normal home medications. Please follow the
instructions from your previous discharge.
Your
discharge paperwork includes a prescription for Bactrim DS,
please take this for 12 more days and then continue on Bactrim
SS daily for prophylaxis. As discussed, please increase the
frequency of your self catheterization to three times a day.
Make sure to drink plenty of water. You will be tired for the
first few weeks, and should get plenty of rest and limit your
activities. Avoid heavy lifting or strenuous exercise for ___
weeks.
You have a drain in place. Please look at the site every day for
signs of infection (redness or pain, swelling, odor, yellow or
bloody discharge). Maintain the suction of the bulb, and call
the clinic if the fluid significantly changes color,
consistency, or amount. Be sure to empty the drain frequently,
and record the output. Bring this record to clinic. You may
shower; wash the area gently with warm, soapy water. Keep the
insertion site clean and dry otherwise. Avoid swimming, baths,
hot tubs; do not submerge yourself in water. Make sure to keep
the drain attached securely to your body to prevent pulling or
dislocation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zosyn / Percocet / amiodarone
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ pAF (apix), HFpEF ___ MR, 4+ TR), CAD (DES to RCA), mod
PH, SSS s/p PPM, chronic b/l pleural effusions p/w back pain and
concern for ADHF.
She presented to the ED with lower back pain x3 days and 1
episode of diarrhea ___. Back pain is in bandlike distribution
across lower back, started 3 days ago and new. Also having pain
across lower abdomen bilaterally. No fall, trauma, pain in
groin,
pain in legs, dysuria, change in urine appearance. She has been
taking bowel reg at home. 2 days ago 1 formed BM, yesterday 2
formed ___, today had diarrhea x1. No pain with urination.
Little
appetite, but yesterday had yogurt, OJ and soup.
Per report was satting in ___ on her home 3L O2. Denies
aspiration events and on presentation ED was not dyspneic, no
chest pain, no fever, no sick contacts. Yesterday was 133 lbs at
home. Lives at home with son (HCP; ___. Dry weight 126
lbs last admission. No med changes since then.
In the ED initial vitals were: T 99.1, HR 60, BP 137/68 RR 21
94% 4 lpm NC
Exam notable for: NAD, JVP at clavicle, no lower extremity
edema, L flank tender, holosystolic murmur, minimal crackles at
lung bases.
Labs notable for: Cr 1.4 (around baseline), wbc 9.9, TnT < 0.01
x2, INR 1.8, UA w/ sm leuk, but 5 epi.
Images notable for: CTAP w/o contrast w/ mild loss of L1
vertebral body (new), small to moderate b/l pleural effusion
(appear simple) w/ atelectasis, moderate cardiomegaly.
EKG: Intermittently AV paced w/ bigeminy, then AF w/ HR 97, no
STTW changes concerning for ischemia, IVCD.
Patient's oxygen requirement worsened to 6 lpm NC, CXR w/ pulm
edema and pleural effusions. Was given torsemide 100 mg followed
by lasix 60 mg IV. She was given her home dose of verapamil and
apixaban. She was having good UOP (x3 times) after diuresis.
On the floor, she is on 10 lpm NC, but this was weaned quickly
to
5 lpm NC. She stated that her abdominal pain really wasn't that
bad and she denies it currently. She states that she had one
episode of non-bloody diarrhea prior to admission. She does not
ambulate much around her house (uses a rolling walker), but has
not noticed DOE/CP/PND/orthopnea. She is currently not
complaining of any trouble breathing.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries: 80% LAD, 70% mLCX, DES to pRCA (___)
- Pump: HFpEF
- Rhythm: SSS and AF w/ PPM
3. OTHER PAST MEDICAL HISTORY
GERD
Hypothyroidism
Breast tubular carcinoma (T1AN0M0) status post excision in ___
Restrictive lung disease
Social History:
___
Family History:
Mother with MI at ___, father with h/o CHF, brother with h/o
cardiac arrest, brother with h/o afib
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 1550)
Temp: 97.9 (Tm 97.9), BP: 123/77, HR: 80, RR: 22, O2 sat:
94%, O2 delivery: 4L NC, Wt: 131.7 lb/59.74 kg
GENERAL: Well developed, well nourished female in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP up to mid neck (10 cm).
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate, but irregular rhythm. Normal S1, S2. SEM at
L
sternal border. No thrills or lifts. PPM on L NTTP.
LUNGS: Rales b/l up to mid back and decreased b/s bilateral
bases. Mild SOB when talking.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 759)
Temp: 97.4 (Tm 97.8), BP: 125/70 (104-129/63-73), HR: 63
(60-70), RR: 18 (___), O2 sat: 91% (91-96), O2 delivery: RA,
Wt: 132.05 lb/59.9 kg
Fluid Balance (last updated ___ @ 554)
Last 8 hours Total cumulative -325ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 445ml, Urine Amt 445ml
Last 24 hours Total cumulative -610ml
IN: Total 660ml, PO Amt 660ml
OUT: Total 1270ml, Urine Amt 1270ml
GENERAL: Well developed, well nourished female in NAD. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva pink.
NECK: Supple. JVP up to low neck (8 cm).
CARDIAC: Regular rate, but irregular rhythm. Normal S1, S2. ___
systolic ejection murmur at L sternal border. No thrills or
lifts. PPM on L non-tender.
LUNGS: Rales b/l at the bases R>L, decreased b/s bilateral
bases.
No respiratory distress.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS
___ 05:00PM BLOOD WBC-9.9 RBC-4.39 Hgb-12.7 Hct-40.3 MCV-92
MCH-28.9 MCHC-31.5* RDW-16.2* RDWSD-54.4* Plt ___
___ 05:00PM BLOOD Neuts-76.9* Lymphs-10.7* Monos-9.7
Eos-1.3 Baso-0.7 Im ___ AbsNeut-7.64* AbsLymp-1.06*
AbsMono-0.96* AbsEos-0.13 AbsBaso-0.07
___ 05:00PM BLOOD ___ PTT-44.4* ___
___ 05:00PM BLOOD Glucose-101* UreaN-16 Creat-1.4* Na-143
K-3.8 Cl-97 HCO3-27 AnGap-19*
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Calcium-9.6 Phos-3.7 Mg-2.1
PERTINENT/DISCHARGE LABS
___ 07:30AM BLOOD WBC-8.2 RBC-3.96 Hgb-11.7 Hct-35.9 MCV-91
MCH-29.5 MCHC-32.6 RDW-16.4* RDWSD-53.9* Plt ___
___ 12:24AM BLOOD TSH-7.2*
___ 06:03AM BLOOD T4-6.0
___ 07:30AM BLOOD WBC-8.2 RBC-3.96 Hgb-11.7 Hct-35.9 MCV-91
MCH-29.5 MCHC-32.6 RDW-16.4* RDWSD-53.9* Plt ___
___ 07:30AM BLOOD Glucose-107* UreaN-26* Creat-1.3* Na-141
K-4.1 Cl-99 HCO3-29 AnGap-13
___ 07:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
IMAGING/STUDIES
CT A/P w/o contrast ___- 1. Subtle mild loss of the superior
endplate of the L1 vertebral body is new from ___, but
otherwise age indeterminate. Mild levoscoliosis and moderate
degenerative change of the visualized lumbar spine.
2. Small to moderate bilateral pleural effusions, which appear
simple, with adjacent compressive atelectasis without definite
focal consolidation.
3. Again seen moderate cardiomegaly with coronary artery
calcifications.
CXR ___- 1. Decreased size of moderate left pleural effusion.
Trace right pleural effusion is possibly present.
2. Mild pulmonary vascular congestion.
3. Bibasilar airspace opacities, potentially atelectasis, with
infection or aspiration not excluded.
TTE ___- CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a normal
cavity size. There is suboptimal image quality to assess
regional left ventricular function. Global left ventricular
systolic function is low normal. The visually estimated left
ventricular ejection fraction is 50-55%. Left ventricular
cardiac index is depressed (less than 2.0 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Moderate to severely dilated right
ventricular cavity (moderate by unindexed ___ but given
body size likley severe) with moderate global free wall
hypokinesis. Intrinsic right ventricular systolic function is
likely lower due to the severity of tricuspid regurgitation.
There is abnormal interventricular septal motion c/w right
ventricular volume overload. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch
diameter is normal. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (valve area by
continuity does not correlate with planimetered valve are likley
due to signal contamination from TR jet). There is trace aortic
regurgitation. The mitral leaflets are mildly thickened with
leaflet straightening, but no frank systolic prolapse. There is
a central jet of moderate [2+] mitral regurgitation. There is
significant pulmonic regurgitation. The tricuspid valve leaflets
appear structurally normal with leaflets that fail to fully
coapt. There is severe [4+] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension. In the setting
of at least moderate to severe tricuspid regurgitation, the
pulmonary artery systolic pressure may be UNDERestimated. There
is no pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis and at least moderate pulmonary artery hypertension.
Severe tricuspid regurgitation with malcoaptation of tricuspid
valve leaflets. Low normal
global left ventricular systolic function. Mild aortic stenosis.
Moderate mitral regurgitation.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ with lumbar back pain and LLQ abd pain, nausea +
diarrheaNO_PO contrast// Eval for acute process, spinal fx, intraabdominal
process
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 3.6 s, 47.7 cm; CTDIvol = 10.0 mGy (Body) DLP = 475.0
mGy-cm.
Total DLP (Body) = 475 mGy-cm.
COMPARISON: Multiple prior examinations, most recent from ___
FINDINGS:
LOWER CHEST: There are small to moderate bilateral pleural effusions, which
are serous in nature, with adjacent compressive atelectasis. No definite
focal consolidation within the partially visualized lung parenchyma. 4 mm
pulmonary nodule seen in the right lower lobe, similar in appearance to prior
dating back to ___. There is moderate cardiomegaly. Moderate coronary
artery calcifications are appreciated. Cardiac conduction device leads are
seen terminating in the right atrium and right ventricle.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There are multiple
bilateral renal hypodensities, which measure simple fluid in density, largest
in the lower pole of the right kidney measuring 5.1 cm. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There are multiple colonic
diverticula without surrounding inflammation to suggest diverticulitis. There
is stranding of the mesentery, similar in extent compared to ___,
consistent with mesenteric panniculitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is an unchanged, 2.2 cm calcified fibroid in the
uterus. There is no large adnexal mass.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There are unchanged infrarenal abdominal aortic and left common
iliac artery aneurysm, measuring up to 3.0 and 1.5 cm, respectively.
Extensive atherosclerotic disease persists throughout the abdomen and pelvis.
BONES: There is diffuse osseous demineralization. Subtle loss of vertebral
body height at L1 is new from ___, but is otherwise age
indeterminate. There is no evidence of worrisome osseous lesions.There is
moderate degenerative change of the visualized lower thoracic and lumbar
spine. There is mild levoscoliosis of the visualized lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Subtle mild loss of the superior endplate of the L1 vertebral body is new
from ___, but otherwise age indeterminate. Mild levoscoliosis and
moderate degenerative change of the visualized lumbar spine.
2. Small to moderate bilateral pleural effusions, which appear simple, with
adjacent compressive atelectasis without definite focal consolidation.
3. Again seen moderate cardiomegaly with coronary artery calcifications.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:41 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath//edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, chest CT ___
FINDINGS:
Left-sided pacer device is re-demonstrated with leads in unchanged positions
in the right atrium and right ventricle. Mild cardiac enlargement is
unchanged. Mediastinal and hilar contours are similar. There is mild
pulmonary vascular congestion. A moderate size left pleural effusion has
decreased in size compared to the previous radiograph. A trace right pleural
effusion is not excluded. Bibasilar airspace opacities could reflect
atelectasis with aspiration or infection not excluded. No pneumothorax. No
acute osseous abnormality.
IMPRESSION:
1. Decreased size of moderate left pleural effusion. Trace right pleural
effusion is possibly present.
2. Mild pulmonary vascular congestion.
3. Bibasilar airspace opacities, potentially atelectasis, with infection or
aspiration not excluded.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Lower abdominal pain
Diagnosed with Low back pain
temperature: 99.1
heartrate: 60.0
resprate: 24.0
o2sat: 91.0
sbp: 137.0
dbp: 68.0
level of pain: 3
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were having back pain and you were needing to use more
oxygen that you usually do; we were concerned that you were
having a heart failure exacerbation
What was done while I was in the hospital?
- You were given one dose of IV diuretics, which you responded
well to; this caused your breathing to significantly improve
- You had a CAT scan that showed a fracture of one of the bones
in your spine; we think this is why you are having back pain
- We gave you pain medications that helped improve your back
pain
- You were seen by the hospice team and an agreement was made to
send you home with hospice care
What should I do when I get home from the hospital?
- The hospice team will see you frequently and dose your
diuretics (medications to make you urinate).
- Make sure to take all of your medications as prescribed,
especially your diuretics
- If you have fevers, chills, chest pain, problems breathing,
increased leg swelling, or generally feel unwell, please call
your doctor or go to the emergency room
Sincerely,
Your ___ Treatment Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
CC: ___ of breath
Major Surgical or Invasive Procedure:
___ CHEST TUBE INSERTION - R 8 intercostal space,
mid-scapular
___ medical thoracoscopy/pleuroscopy, pleural biopsy,
tunneled pleural catheter (pleurX) placement, pleurodesis, chest
tube placement.
___ CHEST TUBE INSERTION- R 8 intercostal space,
mid-scapular
History of Present Illness:
The patient is a ___ year old male with h/o DM, cerebral
meningioma s/p resection who presents with cough x 6 weeks who
was admitted to ___ one week ago found to have a pleural
effusion
and masses on CT scan conerning for malignancy s/p thoracentesis
with improvement in sx and resolution of cough who now presents
again with recurrence of sob and coughing 2 days after pleural
effusion removed.
At first he presented to urgent care with cough and shortness of
breath when he had a coughing fit. First treated with albuterol
but then returned on ___ because it did not improve. Given
prednisone taper and CT scan ordred. CT scan on ___ revealed
a moderate pleural effusion with complete collapse of the RLL.
He was then admitted to ___ as above.
.
+ Dry cough continues. No weight loss. No fevers, chills, night
sweats. He feels full eating less for the last two weeks. He is
only short of breath with exertion and does not have sob with
exertion. He is unable to lay flat because he will start
coughing. He does not report chest pain or discomfort with rest
or with exertion.
He does n/v/d/dysuria/rashes/neuro sx.
In ER: (Triage Vitals: 0 96.6 103 150/60 18 98% )
Meds Given: None
Fluids given: None
Radiology Studies:CXR
consults called: none
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: [- ]Medication allergies [ ] Seasonal
allergies
[X]all other systems negative except as noted above
Past Medical History:
Asthma
Diabetes type 2, uncontrolled
Hypercholesterolemia
Meningioma
Obesity
BLINDNESS - COLOR
Testicular hypofunction
Colonic adenoma
Anterior ischemic optic neuropathy of both eyes
EKG abnormality
NPDR (nonproliferative diabetic retinopathy)
Social History:
___
Family History:
His mother had breast cancer and died at age ___ from metastatic
breast cancer. His father died of AD in his ___. His children
are
in good health.
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE ___
1. VS: T = 97 .6 BP 166/60 RR 18 O2Sat on ___98% on RA
GENERAL: Well appearing male, NAD. He coughs occasionally
Nourishment: good
Grooming: good
Mentation: alert,speaks in full sentences
2. Eyes: [] WNL
PERRL Conjunctiva: injected b/l
3. ENT [] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic
[X] Edema RLE None
[X] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
Decreased breath sounds at the R base
6. Gastrointestinal [ ] WNL
Obese, soft, NT with palpation.
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[
] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [X]
CN II-XII intact [X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
9. Integument [X] WNL
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[X] Pleasant [] Depressed [] Agitated [] Psychotic
DISCHARGE PHYSICAL EXAM
===========================
GENERAL: Alert, oriented, pleasant
HEENT: NCAT
NECK: supple, ample, no LAD, trachea midline.
RESP: Diminished breath sounds, -wheezes, +crackles b/l,
-rhonchi, poor respiratory excursion.
CHEST: ___ Fr Pleur-X, dressings intact.
CV: RRR, Nl S1, S2, No MRG
ABD: Obese, distended, tympanic, NT, +BS, no rebound tenderness
or guarding
GU: no foley
EXT: WWP, 2+ pulses, no clubbing, cyanosis. <B>2+ pitting edema
to mid shin in the RLE. </B>
NEURO: motor function grossly normal.
SKIN: No excoriations or rash.
Lines/Tubes/Drains: ___ Fr Pleur-X, draining serosanguinous
and straw colored fluid, no air leaks.
Pertinent Results:
PRIOR RESULTS REVIEWED
=================
Reviewed and cr = 1.3 unchaged from ___ up from ___ when
it was 1.1
WBC = 11.8
Troponin negative
.
EKG: None in ED
.
LAST ECHO:
with an estimated LVEF of 60-65%.
The contrast study was performed by ___, RN..
CONCLUSIONS
1. Left ventricular wall thickness is mildly increased
in the septal and posterior wall regions as assessed on
the contrast study. There is no apical hypertrophy or
gradient in the apex. Wall thickness at the apex
measures up to 9 mm.
2. Overall left ventricular systolic function is
normal, with an estimated LVEF of 60-65%. Compared to
the full echo of ___, only the LV was studied on
the current study. No apparent change. On the last
study, when best seen, there is also no evident apical
HCM on the noncontrast images, though mild LVH of the
septal and posterior walls also noted then.
.:
.
CT SCAN:
___
IMPRESSION:
Moderate to large right pleural effusion, causing near complete
atelectasis of the right lower lobe, associated with multiple
scattered pleural-based soft tissue masses, and most likely
enlarged cardiophrenic lymph node, suspicious
for malignancy until proven otherwise. There is no mediastinal
shift, but diagnostic and therapeutic thoracentesis are
recommended for symptomatic relief and further assessment,
respectively.
.
Images reviewed by author
IMPRESSION: CXR
Right mid to lower lung opacity concerning for moderate pleural
effusion and adjacent consolidation. Recommend followup to
resolution.
___ pathology:
Positive for Malignancy, consistent with metastatic carcinoma.
Staining suggests metastatic renal cell carcinoma. (results in
chart)
=========
IMAGING
========
___ CXR on ADMISSION
FINDINGS: Opacification of the right mid to lower hemi thorax is
likely secondary to pleural effusion with compressive
atelectasis. Difficult to exclude underlying pneumonia or mass.
Followup to resolution advised. Left lung is clear. Heart size
difficult to assess. Mediastinal contour grossly unremarkable.
Bony structures intact.
IMPRESSION: Right mid to lower lung opacity concerning for
moderate pleural effusion and adjacent consolidation. Recommend
followup to resolution.
___ CXR on DISCHARGE
FINDINGS: The large loculated right pleural effusion has
slightly decreased following pigtail catheter drainage.
Associated opacities in the right lung are unchanged. Left
basilar subsegmental atelectasis is mild. There is no
pneumothorax. The heart and mediastinum are magnified by the
projection.
IMPRESSION: Large loculated right pleural effusion decreased
following pigtail catheter drainage. No pneumothorax.
___: CHEST CT
FINDINGS:
The examination is compared to ___. Unchanged mild
lymphadenopathy in the mediastinum. Unchanged moderate coronary
calcifications, cardiomegaly, and poor opacification of the
large mediastinal vessels. A right chest tube (3, 36) is in
situ. Unchanged appearance of the upper abdomen and of the
bones. There is unchanged evidence of a partly drained
loculated right fluidopneumothorax. The intrafissural components
of the process (4, 36) have slightly increased in extent.
Otherwise, there is the expected appearance after pleurodesis.
There is no specificfinding on CT that could explain the
appearance of an increased density on the chest radiograph.
Unchanged appearance of the left lung, with the exception of a
newly appeared minimal
lingular and left lower lobe atelectasis (4, 38).
IMPRESSION:
Minimally increasing extent of the intrafissural component of
the known
fluidopneumothorax. Otherwise unchanged appearance of the right
hemi thorax of the pleurodesis. 2 small new areas of
atelectasis in the left lung.
___ CT CHEST
IMPRESSION:
Multiloculated right-sided pleural effusion with multiple
enhancing
pleural-based masses compatible with metastatic disease.
Right-sided chest tube in place. Tiny right apical
pneumothorax.
___ CT ABDOMEN
IMPRESSION:
1. Heterogeneously enhancing right lower pole renal lesion
measuring 3.8 x 3.4 cm, with enlarged retrocrural and left
para-aortic lymph nodes, concerning for metastatic renal cell
carcinoma. Soft tissue nodularity in the supradiaphragmatic
right hemithorax is also concerning for metastatic disease.
2. Please see a separate report discussing findings within the
chest.
___ MR HEAD WITH AND WITHOUT CONTRAST
IMPRESSION:
Patient is status post bifrontal craniotomy with bifrontal lobe
encephalomalacia and postoperative change. No evidence of
recurrent meningioma
or of other masses.
___ CT CHEST WITH CONTRAST
IMPRESSION:
Minimally increasing extent of the intrafissural component of
the known
fluidopneumothorax. Otherwise unchanged appearance of the right
hemi thorax of
the pleurodesis. 2 small new areas of atelectasis in the left
lung.
===============
ULTRASOUND
===============
___ UNILAT LOWER EXT VEINS RIGHT ULTRASOUND
IMPRESSION: No evidence of deep venous thrombosis in the right
lower extremity veins.
===============
CYTOLOGY
===============
___ CYTOLOGY:
SPECIMEN(S) SUBMITTED: PLEURAL FLUID, RIGHT
DIAGNOSIS PLEURAL FLUID, RIGHT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic renal cell carcinoma; also see
patient's prior pleural fluid report
(___-___) and concurrent pleural biopsy report (___).
___ CYTOLOGY:
DIAGNOSIS:
PLEURAL FLUID, RIGHT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic high-grade renal cell carcinoma with
some, but not definitive, support for a clear cell variant.
A moderate number of tumor cells are present on cell block
preparation and on immunostains are
diffusely positive for PAX 8, renal cell carcinoma antigen,
CD10, and CA IX, and very focally positive for ___, and are
negative for AMACR, CK7, CK20, TTF-1, napsin, calretinin, and
WT-1. Dr. ___ reviewed the slide for CA IX and concurred
with the interpretation. Dr. ___ was informed of the
diagnosis via e-mail by Dr. ___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlyBURIDE 10 mg PO BID
2. Glargine 35 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Atorvastatin 40 mg PO QPM
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to chest wall Qdaily Disp
#*10 Patch Refills:*0
6. Aspirin 81 mg PO DAILY
7. GlyBURIDE 10 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN
breakthrough pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*30 Tablet
Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Renal cell carcinoma (kidney cancer)
Malignant pleural effusion
SECONDARY:
=========
#RLE Edema
#Diabetes, type II
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ man presenting with shortness of breath; evaluate for
right pleural effusion.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: No prior imaging is available.
FINDINGS:
Opacification of the right mid to lower hemi thorax is likely secondary to
pleural effusion with compressive atelectasis. Difficult to exclude underlying
pneumonia or mass. Followup to resolution advised. Left lung is clear. Heart
size difficult to assess. Mediastinal contour grossly unremarkable. Bony
structures intact.
IMPRESSION:
Right mid to lower lung opacity concerning for moderate pleural effusion and
adjacent consolidation. Recommend followup to resolution.
Radiology Report
INDICATION: ___ year old man with large volume right effusion s/p chest tube
placement with initial output of 2000mL // ? PTX //___ year old man with
large volume right effusion s/p chest tube placement with
TECHNIQUE: AP view of the chest
COMPARISON: ___
FINDINGS:
In the interval since the prior study, there has been a placement of a pigtail
catheter in the right pleural space. A right pleural effusion has decreased,
although loculations still remain. Left lung remains clear. No pneumothorax.
IMPRESSION:
Decreasing right pleural effusion status post chest tube placement.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with history of resected menigioma and remote CVA
presents with malignant pleural effusion, please asses for metastatic disease
// ?metastatic disease
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations
COMPARISON: No prior MRI available for comparison.
FINDINGS:
Patient status post bifrontal craniotomy with right greater than left
bifrontal lobe encephalomalacia and susceptibility artifact in this region
likely reflecting postoperative blood products.
There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.
The ventricles and sulci are normal in caliber and configuration. There is
dural thickening and enhancement underlying the surgical site, likely a
postoperative finding. There is no other abnormal enhancement after contrast
administration. Major vascular flow voids are preserved. The orbits are
unremarkable. There is mucosal thickening within the ethmoid air cells. The
remaining paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
Patient is status post bifrontal craniotomy with bifrontal lobe
encephalomalacia and postoperative change. No evidence of recurrent meningioma
or of other masses.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: ___ year old man with recently diagnosed malignant pleural
effusion staining positive for RCC. Assess for primary and metastatic disease.
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso without and with IV Contrast. Initially the abdomen
was scanned without IV contrast. Subsequently a single bolus of IV contrast
was injected and the abdomen and pelvis were scanned in the portal venous
phase, followed by scan of the abdomen in equilibrium (3-min delay) phase.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 2087 mGy-cm (abdomen and pelvis).
IV Contrast: 150 mL Omnipaque
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: There is a conglomeration of supradiaphragmatic soft tissue
nodules (06:45), concerning for a metastatic disease. The liver is normal in
attenuation with no focal hepatic lesions. The portal vein is patent. The
gallbladder is nondistended, with no stones.
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: At the lower pole of the right kidney there is a heterogeneous,
irregular mass with heterogeneous enhancement measuring 3.8 x 3.4 cm (09:42),
concerning for renal cell carcinoma. The superolateral aspect of the mass
abuts the renal pelvis however the mass does not appear to invade the main
renal artery or vein. Scattered areas of cortical thinning throughout the
kidneys bilaterally likely represent scarring from sequela of prior infection.
There is no hydronephrosis.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix contains air, has normal caliber without evidence of fat stranding.
RETROPERITONEUM: Right retrocrural lymph node (06:43), measures 1.4 x 1.1 cm.
Irregular, enhancing left para-aortic lymph node (6:73), measures 1.6 x 0.9
cm. Mesenteric and periportal lymph nodes are not pathologically enlarged.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is decompressed. The prostate is mildly enlarged. No
pelvic lymphadenopathy or free fluid.
BONES AND SOFT TISSUES:
No worrisome bone or soft tissue lesions are seen in the abdomen or pelvis.
IMPRESSION:
1. Heterogeneously enhancing right lower pole renal lesion measuring 3.8 x 3.4
cm, with enlarged retrocrural and left para-aortic lymph nodes, concerning for
metastatic renal cell carcinoma. Soft tissue nodularity in the
supradiaphragmatic right hemithorax is also concerning for metastatic disease.
2. Please see a separate report discussing findings within the chest.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Recently diagnosed malignant pleural effusion. Please assess for
metastatic disease.
TECHNIQUE: CT of the Chest with IV contrast.
DOSE: DLP: ___ mGy-cm
COMPARISON: None
FINDINGS:
LUNGS: There is a multiloculated right-sided pleural effusion with numerous
scattered pleural-based soft tissue masses, the dominant one a 4.5 x 2.0 cm
mass at the lateral aspect of the right upper lobe. At least two pulmonary
nodules are noted, the first in the right upper lobe measuring 7 mm (7:87) an
additional one in the right lobe Scattered areas of partial right lower lobe
collapse are associated with the effusion and lesions. A pigtail catheter
terminates in the right lateral pleural space. The left lung appears clear.
Tracheobronchial tree is patent centrally. There is a tiny right apical
pneumothorax.
MEDIASTINUM: There is no hilar or axillary lymphadenopathy by CT criteria.
There is a soft tissue mass in the anterior mediastinum abutting the pleura
(06:34) measuring 2.8 x 1.7 cm. The aorta and great vessels are unremarkable.
The heart size is normal. Physiologic pleural effusion is noted.
Calcifications of the LAD are present. Minimal calcifications of aorta are
also present without any dilatation.
BONES: No suspicious bony lesions are seen in the thoracic osseous structures.
UPPER ABDOMEN: Please see concurrent CT abdomen pelvis report from the same
day
IMPRESSION:
Multiloculated right-sided pleural effusion with multiple enhancing
pleural-based masses compatible with metastatic disease.
Right-sided chest tube in place. Tiny right apical pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with malignant pleural effusion and chest tube,
currently clamped // pleural effusion
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, there is a minimal decrease in extent
of the right pleural effusion. The right pigtail catheter is in unchanged
position. No pneumothorax. Reduction in extent of the pre-existing areas of
atelectasis. No abnormalities in the left lung. Borderline size of the cardiac
silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with metastatic RCC // post thoracoscopy, chest
tube, pleurx
IMPRESSION:
Right pigtail pleural catheter is been removed and replaced by a standard
right chest tube. Multiloculated right pleural effusion is again demonstrated
with possible small pneumothorax component and persistent adjacent atelectasis
and or consolidation in the right mid and lower lung. Mediastinal widening is
likely stable allowing for differences in technique between the exams. Small
left pleural effusion is minimally increased.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with RCC effusions s/p pleurodesis chest-tubes
// interval change. interval change.
COMPARISON: Comparison to ___ 11:19
FINDINGS:
Portable erect chest film ___ at 09:03 is submitted.
IMPRESSION:
Interval increase in pleural-based peripheral opacities in the right
hemithorax favoring increasing loculated pleural fluid and associated adjacent
atelectasis or consolidation. Possible loculated small right apical
pneumothorax. Right basilar chest tube remains in place. Linear opacity at the
left base likely reflects subsegmental atelectasis. No pulmonary edema.
Overall cardiac and mediastinal contours are likely unchanged given
differences in positioning.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with DM, HTN, cerebral meningioma s/p resection ___, with
malignant pleural effusion concerning for metastatic renal cell carcinoma, s/p
thoracoscopy and talc pleuradesis ___. // Pleuradaesis eval Pleuradaesis
eval
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
The volume of the multi loculated right pleural effusion, masking right
pleural nodules, which increased following pleurodesis has stabilized since
earlier in the day. Previous tiny right apical pneumothorax is smaller. 2
right pleural drainage tubes are unchanged in position. Most of the
atelectasis in the right lower lobe attributable to pleural abnormality is at
the base. Moderate enlargement of the cardiomediastinal silhouette is stable.
Subsegmental atelectasis at the left lung base is relatively stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with MPE (Met RCC) s/p thoracoscopy and talc
pleurodesis ___ with apparent loculated effusion on CXR this AM. ___ CT
placed // ? PTX. tube placement
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Multiple prior radiographs the most recent on ___ at
06:36 and chest CT on ___.
FINDINGS:
There has been interval placement of a right-sided pigtail catheter with
terminates over the right hemi thorax/ right upper abdomen. A chest tube is
again seen in unchanged position.
The size of a a large multiloculated right pleural effusion is stable compared
to the prior examination done earlier this morning. No pneumothorax is
identified. Opacity at the right base is consistent with atelectasis and
effusion, also similar in extent. The cardiomediastinal and hilar contours are
stable. The left lung appears clear.
IMPRESSION:
Interval placement of a right-sided pigtail catheter without significant
interval change in the size of a large multiloculated right pleural effusion.
Right basal opacity is most consistent with some compressive adjacent
atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with malignant pleural effusions s/p chest tube
placement x3 // PLEASE TAKE DAILY XRAY PRIOR TO 6am.Change from prior, chest
tube placement, r/o PTX
COMPARISON: ___.
IMPRESSION:
No relevant change as compared to the previous image. The pleural pigtail
catheter and the chest tube on the right are in unchanged position. Unchanged
extent of the loculated pleural fluid collection on the right. Subsequent
areas of atelectasis are also constant. Minimal retrocardiac atelectasis
persists. Moderate cardiomegaly without fluid overload. No pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old male with DM, HTN, cerebral meningioma s/p resection
___, clear cell Renal cell carcinoma, w/ malignant pleural effusion s/p
thoracoscopy and talc pleuradesis ___ and new chest tube placement on ___ now
with right upper lobe opacities // Please assess right upper lobe opacities
noted on CXR
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: 500 mGy-cm
COMPARISON: ___
FINDINGS:
The examination is compared to ___. Unchanged mild lymphadenopathy in
the mediastinum. Unchanged moderate coronary calcifications, cardiomegaly,
and poor opacification of the large mediastinal vessels. A right chest tube
(3, 36) is in situ. Unchanged appearance of the upper abdomen and of the
bones. There is unchanged evidence of a partly drained loculated right
fluidopneumothorax. The intrafissural components of the process (4, 36) have
slightly increased in extent. Otherwise, there is the expected appearance
after pleurodesis. There is no specific finding on CT that could explain the
appearance of an increased density on the chest radiograph. Unchanged
appearance of the left lung, with the exception of a newly appeared minimal
lingular and left lower lobe atelectasis (4, 38).
IMPRESSION:
Minimally increasing extent of the intrafissural component of the known
fluidopneumothorax. Otherwise unchanged appearance of the right hemi thorax of
the pleurodesis. 2 small new areas of atelectasis in the left lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with malignant pleural effusions s/p chest tube
placement x3 // PLEASE TAKE PRIOR TO 6AM DAILY. Please assess for interval
change.
IMPRESSION:
As compared to recent radiograph of 1 day earlier, right-sided chest tube and
pleural pigtail catheter remain in place with persistent loculated right
pleural effusion and hydropneumothorax. Overall appearance of the chest is
similar to the prior study except for worsening interstitial edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with metastatic clear cell RCC and malignant
effusion s/p pleurodesis x 2 and chest tubes x 3. // Please perform prior to
7am. Please assess for interval change.
COMPARISON: ___.
IMPRESSION:
Minimal increase of the left apical lateral pleural fluid collection.
Otherwise unchanged postoperative appearance of the right hemi thorax. The 2
chest tubes are in unchanged position. Unchanged small atelectasis at the left
lung bases, combines to mild cardiomegaly.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old male with DM, HTN, cerebral meningioma s/p resection
___, with malignant pleural effusion consistent with met high grade RCC w/
non-definitive support for a clear cell variant, with CT showing renal mass,
s/p thoracoscopy and talc pleuradesis ___ now with RLE swelling and SOB //
Please assess for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, femoral, and popliteal veins. Normal compressibility is demonstrated
in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleurodesis, chest tubes, s/p chest tube
reomoval w/ SOB // please assess for ptx, pulmonary edema, or new pna.
TECHNIQUE: AP view of the chest
COMPARISON: Multiple priors most recent on ___ at 03:30
FINDINGS:
There has been interval removal of a right-sided pigtail pleural catheter. A
large loculated right pleural effusion and adjacent pulmonary opacity is not
significantly changed from the prior study done today at 03:30. The left lung
is hypoinflated but clear. The cardiomediastinal and hilar contours are
stable. There is mild pulmonary vascular congestion and possible mild edema.
IMPRESSION:
Status post removal of right-sided pigtail catheter. Large right pleural
effusion is not significantly changed. Subtly increased pulmonary vascular
engorgement and mild pulmonary edema from the prior study done this morning.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with DM, HTN, with malignant pleural effusion ___
met RCC, s/p thoracoscopy and talc pleuradesis ___, CT x3, 2 tubes pulled
___. now with 1 pleurex. // PLEASE take CXR prior to 6AM. Change from prior,
tube placement, r/o PTX.
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: ___.
FINDINGS:
The large loculated right pleural effusion has slightly decreased following
pigtail catheter drainage. Associated opacities in the right lung are
unchanged. Left basilar subsegmental atelectasis is mild. There is no
pneumothorax. The heart and mediastinum are magnified by the projection.
IMPRESSION:
Large loculated right pleural effusion decreased following pigtail catheter
drainage. No pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with PLEURAL EFFUSION NOS, SHORTNESS OF BREATH, DIABETES UNCOMPL JUVEN
temperature: 96.6
heartrate: 103.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___:
It was a pleasure taking care of you during your admission to
___. You were admitted with fluid surrounding your lung. You
underwent a procedure to help prevent the fluid from returning.
Tests from the fluid showed you have kidney cancer, a variant of
clear cell carcinoma, and a cat scan of your body showed a small
mass in your right kidney. You were seen by the urologists and
the oncologists. You will need to follow up with urology to
discuss having your kidney removed and with oncology to discuss
treatment.
You are going home with a small Pleurx chest tube to continue to
drain fluid from the collections surrounding your lungs. Please
keep the tube insertion site water tight. It is ok to shower
with the tube in, but try to minimize how wet it gets. Please
do not submerge yourself (take a bath or go swimming) while the
tube is in place.
Please follow these instructions for your Pleurx tube (a
visiting nurse ___ help you with these):
1. Please drain Pleurx every day. Keep a log of amount & color,
and bring it with you to your appointments.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate the catheter (the part in your chest) in
any way.
5. Keep a daily log of Drainage amount and color.
6. You may shower with an occlusive dressing. Please do not
submerge yourself.
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
10. Pleurex catheter sutures to be removed when seen in clinic
___ days post PleurX placement.
Caring for a chest tube, and recovery can be challenging.
Skilled nursing and physical rehab will be beneficial. You can
arrange this with ___ Care Network Tel ___ Fax
___ Hospital Liaison ___.
It was a pleasure taking part in your care, we wish you the best
of luck. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Rofecoxib
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
A ___ male with history of liver and kidney transplant,
history of atrial fibrillation, hypertension, smoking,
prediabetes, BPH, and peripheral neuropathy referred to hospital
by PCP for complaints of chest pain with ___ T wave
changes on EKG seen in the office. Patient states for past
several months he has had a "pulling sensation" in the left
chest describes as dull pain. Pain is episodic nonexertional
lasts for a few hours and self resolves. This am patient had
this exact dull ___ chest pain while lying in bed. Later in the
day chest pain was accompanied with nausea and lightheadedness
in addition to this pain. Patient also had some "tingling in
left arm." Patient had a scheduled PCP appointment and was
referred here for concerning EKG changes.
Denies radiation of chest pain to the neck.Patient denies
wheezing, cough, fever, or chills. Patient smokes 1 pack per day
but has not had a cigarette in the past four days. Denies
diaphoresis, or changes in bowel movements. No recent changes
in PO intake. Patient was given nitroglycerin in ED with no
immediate relief of chest pain.
EKG at PCP: sinus bradycardia with rate of 45, normal axis,
normal intervals,T-wave inversions in V2-V5 with ST elevation in
V2- V3.
In the ED, initial vitals were 96.4 47 137/81 18 99% ra. In Ed
given nitroglycerin SL and morphine. Labs were significant for
Cr of 1.2, First set of troponins negative, and bicarb of 19.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Afib on flecainide, liver and kidney transplant, 2 THR,
Peripheral Neuropathy, Chronic Pain, Insomnia
Social History:
___
Family History:
Father had heart attack in his ___. Died of colon cancer in ___.
Physical Exam:
ADMISSION:
VS: T=96.4 BP=106/69 HR= 50 RR=18 O2 sat=99%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. bradycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right femoral cath site appears clean, no
hematoma or bruit.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
DISCHARGE:
VS: T=98.2 BP=120-153/60-79 HR= 53 RR=20 O2 sat=100%
Weight: 102.5
I/O: po 360/ivf 200/uop 250+. Since MN 600 po/uop 475
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. bradycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right femoral cath site appears clean, no
hematoma or bruit.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
___ 02:06PM ___ PTT-33.3 ___
___ 12:42PM GLUCOSE-106* UREA N-31* CREAT-1.2 SODIUM-136
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-19* ANION GAP-17
___ 12:42PM estGFR-Using this
___ 12:42PM cTropnT-<0.01
___ 12:42PM WBC-7.5 RBC-5.11 HGB-15.4 HCT-44.8 MCV-88
MCH-30.1 MCHC-34.4 RDW-13.3
___ 12:42PM NEUTS-52.2 ___ MONOS-5.0 EOS-1.7
BASOS-1.2
___ 12:42PM PLT COUNT-154
Cardiac Cath ___ Preliminary
1. Selective coronary angiography of this right dominant system
demonstrated no angiogrpahically-significant flow-limiting
disease. The
LMCA, LAD, LCX and RCA were patent.
2. Limited resting hemodynamics revealed mildly elevated
systemic
arterial pressure at the central aortic level 141/76.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Coronary arteries had no angiographyically-apparent
flow-limiting
disease.
CXR ___
In comparison with study of ___, the area of pneumonia at
the
right base has cleared. There are mild areas of opacification
at both bases, which most likely represent some combination of
atelectasis and scarring. Blunting of the left costophrenic
angle persists, possibly relating to pleural scarring. In the
appropriate clinical setting, supervening pneumonia would have
to be considered.
There is no evidence of pulmonary vascular congestion or
cardiomegaly.
Subclavian stent is seen on the right.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Amlodipine 5 mg PO DAILY
hold for SBP<90
3. Flecainide Acetate 150 mg PO Q12H
4. Gabapentin 400 mg PO BID
5. Lovastatin *NF* 20 mg Oral qhs
6. Metoprolol Tartrate 50 mg PO BID
7. Morphine SR (MS ___ 30 mg PO Q8H
8. Mycophenolate Mofetil 500 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 0.5 mg PO QPM
12. Tacrolimus 1 mg PO QAM
13. Tamsulosin 0.4 mg PO HS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Aspirin 325 mg PO DAILY
16. Zolpidem Tartrate 10 mg PO HS
17. Calcium Carbonate 500 mg PO DAILY
18. Vitamin D 400 UNIT PO DAILY
19. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Zolpidem Tartrate 10 mg PO HS
3. Amlodipine 5 mg PO DAILY
hold for SBP<90
4. Aspirin 325 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Flecainide Acetate 150 mg PO Q12H
7. Gabapentin 400 mg PO BID
8. Lovastatin *NF* 20 mg Oral qhs
9. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*0
10. Morphine SR (MS ___ 30 mg PO Q8H
11. Multivitamins 1 TAB PO DAILY
12. Mycophenolate Mofetil 500 mg PO BID
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Tacrolimus 0.5 mg PO QPM
16. Tacrolimus 1 mg PO QAM
17. Tamsulosin 0.4 mg PO HS
18. Tiotropium Bromide 1 CAP IH DAILY
19. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chest Pain
Secondary: Diabetes, Dyslipidemia, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Transplant, on immunosuppressive with chest discomfort.
FINDINGS: In comparison with study of ___, the area of pneumonia at the
right base has cleared. There are mild areas of opacification at both bases,
which most likely represent some combination of atelectasis and scarring.
Blunting of the left costophrenic angle persists, possibly relating to pleural
scarring. In the appropriate clinical setting, supervening pneumonia would
have to be considered.
There is no evidence of pulmonary vascular congestion or cardiomegaly.
Subclavian stent is seen on the right.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS
temperature: 96.4
heartrate: 47.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 81.0
level of pain: 4
level of acuity: 2.0 | Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
chest pain. Cardiac catheterization showed no coronary artery
disease. You had no additional episodes of chest pain.
Please take all your medications as prescribed. It will be
important for you to follow-up with your primary care doctor and
your cardiologist.
Note your metoprolol dose was lowered from 50 mg twice a day to
25 mg twice a day. If you experience atrial fibrillation at home
please take an additional dose of the metoprolol 25 mg pill. |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ who presents to ED with 5 day of worsening abdominal pain.
Pt. states that his pain initially began as a generalized
abdominal discomfort then progressed to a sharp, non radiating,
RLQ pain that was worse with movement. Today he noted a worse
appetite, associated with nausea, but denies diarrhea,
constipation, dysuria, hematuria, fevers/chills, blood in stool.
Past Medical History:
PMH: anxiety/depression, Chiari malformation, epilepsy until age
___
PSH: none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.4 74 108/58 18 99% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, tender to palpation RLQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
T: 98.1, BP: 108/70, HR: 75, RR: 18, O2: 99% RA
General: A+Ox3, NAD
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, mildly tender to palpation RLQ
Extremities: no edema
Pertinent Results:
___ 07:00PM PTT-72.2*
___ 10:50AM ___ PTT-53.1* ___
___ 06:17AM GLUCOSE-90 UREA N-9 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 06:17AM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 06:17AM WBC-6.0 RBC-4.30* HGB-12.8* HCT-37.6* MCV-87
MCH-29.8 MCHC-34.0 RDW-11.8 RDWSD-37.6
___ 06:17AM PLT COUNT-186
___ 06:17AM ___ PTT-33.0 ___
___ 02:48AM LACTATE-0.8
___ 10:15PM GLUCOSE-98 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
___ 10:15PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-91 TOT
BILI-0.4
___ 10:15PM LIPASE-26
___ 10:15PM ALBUMIN-4.7
___ 10:15PM WBC-9.2 RBC-5.16 HGB-15.2 HCT-45.8 MCV-89
MCH-29.5 MCHC-33.2 RDW-11.6 RDWSD-37.4
___ 10:15PM NEUTS-67.1 ___ MONOS-9.4 EOS-2.3
BASOS-0.1 IM ___ AbsNeut-6.15* AbsLymp-1.92 AbsMono-0.86*
AbsEos-0.21 AbsBaso-0.01
___ 10:15PM PLT COUNT-214
Imaging:
___: CT Abd/Pel:
1. Acute appendicitis, with a 13 mm appendicolith.
Rim-enhancing, circular 16 mm fluid density focus distal to the
appendicolith is nonspecific, but given free fluid in the
abdomen and pelvis, concerning for rupture with rim-enhancing
fluid collection.
2. Likely nonocclusive SMV thrombosis.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do NOT drink alcohol while taking this medication
2. Apixaban 5 mg PO/NG BID
Avoid contact sports while taking this medication
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
NO strenuous exercise while taking this medication
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please take with food. Do NOT drink alcohol while taking this
medication
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*41 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Perforated Appendicitis
Secondary:
Non-occlusive ___ thrombus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with a 5 day history of progressively worsening
right lower quadrant abdominal pain and nausea, guarding and rebound, evaluate
for 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: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.5 cm; CTDIvol = 8.6 mGy (Body) DLP = 451.4
mGy-cm.
Total DLP (Body) = 460 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: The partially imaged lung bases are clear. There is no pleural or
pericardial effusion. There is no hiatus hernia.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning
focal lesion. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. An eccentric filling defect in the mid SMV is concerning for
nonocclusive SMV thrombus (series 2, image 34 and image 39, and series 602b,
image 40). The splenic vein is patent.
The gallbladder is unremarkable without evidence of wall thickening or
inflammation.
PANCREAS: The pancreas enhances homogeneously. There is no peripancreatic
stranding or ductal dilation.
SPLEEN: There is no splenomegaly or focal splenic lesion.
ADRENALS: The adrenal glands are normal.
URINARY: The kidneys enhance normally and symmetrically. There is no
hydronephrosis.
GASTROINTESTINAL: Oral contrast fills and distends the stomach. The duodenum
is within normal limits. Multiple distended but not dilated predominantly
air-filled small bowel loops are seen throughout the abdomen. There is no
evidence of wall thickening or obstruction. The colon is filled with stool.
In the right lower quadrant there is inflamed, fluid-filled appendix
surrounded by free fluid, measuring up to 11 mm in diameter (series 601b,
image 26). Near the appendix terminus, there is a 13 mm appendecolith, with a
rim enhancing fluid collection distal to this (series 601b, image 28 and
series 2 image 60), likely small contained rupture.
VASCULAR AND LYMPH NODES: The abdominal aorta is normal in caliber without
evidence of aneurysm or dilation. Major proximal tributaries are patent.
There is no mesenteric or retroperitoneal lymphadenopathy by CT size criteria.
There is no free intraperitoneal.
CT PELVIS:
The imaged pelvic organs, including the bladder and terminal ureters, are
unremarkable. There is no pelvic sidewall, iliac chain, or inguinal
lymphadenopathy. There is a small amount of nonhemorrhagic free pelvic fluid.
MUSCULOSKELETAL: Sclerotic focus in the left femoral head likely represents a
bone island. The thoracolumbar vertebral bodies are normally aligned. No
concerning focal lytic or sclerotic osseous lesions are identified.
IMPRESSION:
1. Acute appendicitis, with a 13 mm appendicolith. Rim-enhancing, circular 16
mm fluid density focus distal to the appendicolith is nonspecific, but given
free fluid in the abdomen and pelvis, concerning for rupture with
rim-enhancing fluid collection.
2. Likely nonocclusive SMV thrombosis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:22 AM, 10 minutes after
discovery of the findings.
Modification to preliminary read was discussed with NP ___ over
phone by Dr. ___ on ___ at 08:43.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 98.1
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 135.0
dbp: 77.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
You presented to the hospital with abdominal pain and were found
to have perforated appendicitis. You were admitted to the Acute
Care Surgery service for your medical care. You received IV
antibiotics while you were in the hospital, and will receive a
prescription for an oral antibiotic regimen.
On your abdominal CT scan, you were found to have a small,
non-occlusive blood clot in one of your intestinal veins. You
were started on an IV blood thinner called Heparin. This
medication was stopped and you will be discharged on a 3 (three)
month course of Apixaban, an oral medication which prevents
blood clots. The ___ clinic will call you and arrange for
a follow-up appointment in approximately 2 (two) months.
Your pain is now better controlled and you are tolerating a
regular diet. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Instructions Regarding Apixaban:
-Please avoid contact sports
-Please do not prematurely discontinue this medication as there
may be an increased risk of blood clot complication.
-Apixaban increases the risk of bleeding and can cause serious
bleeding. Use of other medications including aspirin, Alieve,
Ibuprofen can increase bleeding risk.
-If you have a cut and have bleeding, put firm pressure over the
area for 10 minutes. If it does not improve, please go to the
Emergency Room.
-If you experience dizziness and/or heart palpitations, please
go immediately to an emergency room. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Talwin / Voltaren / Erythromycin Base / Ceclor /
diclofenac / moxifloxacin / pentazocine / propoxyphene / avalox
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o MI s/p RCA stenting (___) and on Plavix,
concussion, subdural hematoma, seizures,thrombocytopenia,
presenting status post mechanical fall. The patient states she
was using her walker at home, she was holding it with one hand,
tripped over slider and fell to the ground. She states she
landed
on her right side and now has pain in the right lateral chest
and
right flank. Since that time she has been coughing. She denies
head strike, headache, neck pain. She was seen at ___
where she was found to have right rib fractures, sixth, seventh,
eighth, ninth, tenth and right pleural effusion and so was
transferred to ___. She is
otherwise feeling well. Patient is breathing comfortably on
room
air upon interview.
Past Medical History:
Past Medical History:
Hard of hearing
h/o MI s/p RCA stent on Plavix
intracranial aneurysm
seizure
essential thrombocytopenia
HTN
BCC
Past Surgical History:
Bilateral TKR
open cholecystectomy
Open appendectomy
Social History:
___
Family History:
non contributary
Physical Exam:
Admission Physical Exam:
Vitals: 98.0 122/68 68 18 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses. Right chest/flank
area shows large area of ecchymosis and swelling. Area is
tender
to palpation. No flail chest was observed.
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.1, 124/74, 75, 16, 93 Ra
Gen: A&O x3
Pulm: LS ctab
CV: HRR
Abd: soft NT/ND
Ext: No edema
Pertinent Results:
___ 05:50AM BLOOD WBC-6.1 RBC-3.30* Hgb-11.9 Hct-36.1
MCV-109* MCH-36.1* MCHC-33.0 RDW-13.8 RDWSD-55.3* Plt ___
___ 12:00AM BLOOD WBC-7.2 RBC-3.27* Hgb-11.9 Hct-36.0
MCV-110* MCH-36.4* MCHC-33.1 RDW-13.6 RDWSD-55.5* Plt ___
___ 09:10PM BLOOD WBC-7.2 RBC-3.17* Hgb-11.3# Hct-35.1#
MCV-111*# MCH-35.6* MCHC-32.2 RDW-13.7 RDWSD-56.7* Plt ___
___ 05:50AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-141
K-4.4 Cl-103 HCO3-25 AnGap-13
___ 12:00AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-138
K-4.2 Cl-102 HCO3-24 AnGap-12
___ 09:10PM BLOOD Glucose-111* UreaN-16 Creat-0.7 Na-139
K-4.6 Cl-100 HCO3-27 AnGap-12
___ 05:50AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
___ 12:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1 Cholest-88
___ 09:10PM BLOOD Calcium-8.9 Phos-4.5 Mg-2.2
Radiology: ___ CTA head and neck Wet Read: CT head: No
intracranial hemorrhage, mass, or large territorial infarct.
Extensive periventricular and subcortical white matter
hypodensities are nonspecific and may reflect chronic small
vessel ischemic changes. MRI would be more sensitive to assess
for acute infarct.
CTA: Patent anterior/posterior circulation, circle of ___,
and
major tributaries.
CTA neck: Patent neck vessels without flow limiting stenosis.
Small right pleural effusion.
___ CXR: Fracture of at least the lateral right seventh rib,
and possibly lateral right sixth and eighth rib. Dedicated rib
series or chest CT would provide further assessment. Patchy
right
base opacity may be due to atelectasis and overlap of vascular
structures, but underlying consolidation due to pulmonary
contusion in the setting of trauma, aspiration, or pneumonia is
not excluded. Likely small right pleural effusion.
___ CXR:
Improved inspiratory volume. Patchy right base opacifications
secondary to atelectatic changes.
Medications on Admission:
MEDICATIONS:
Aspirin 81 mg daily
Atorvastatin 40 mg daily
Clindamycin 600 mg prior to dental procedure
Clopidogrel 75 mg daily
Erythromycin eye ointment 0.5% after infection as needed
Hydroxyurea 500 mg ___ (for basal cell
carcinoma)
Levetiracetam 500 mg twice daily
Metoprolol 20 mg daily
Nitrostat 0.4 mg as needed
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine HCl-menthol [Endoxcin] 4 %-1 % 1 patch to right
chest wall daily Disp #*14 Patch Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. Hydroxyurea 500 mg PO 3X/WEEK (___)
10. LevETIRAcetam 500 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
[] Fracture of the lateral right ___ rib
[] Small TIA or stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoxia, rib fractures// plz evaluate for
infectious process
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
There are relatively low lung volumes. Patchy right base opacity could relate
to atelectasis, but underlying infection, aspiration, or pulmonary contusion
in the setting of trauma is not excluded. Small right pleural effusion.. No
evidence of pneumothorax is seen. The cardiac silhouette is borderline to
mildly enlarged. The aorta is calcified and tortuous. Fractures of at least
the right lateral seventh (mildly displaced) and possibly sixth (nondisplaced)
and eighth ribs are seen. Dedicated rib series or chest CT would provide
further assessment.
Degenerative changes of the partially imaged right glenohumeral and right
acromioclavicular joints, new/progressed since the prior study..
IMPRESSION:
Fracture of at least the lateral right seventh rib, and possibly lateral right
sixth and eighth rib. Dedicated rib series or chest CT would provide further
assessment.
Patchy right base opacity may be due to atelectasis and overlap of vascular
structures, but underlying consolidation due to pulmonary contusion in the
setting of trauma, aspiration, or pneumonia is not excluded.
Likely small right pleural effusion.
Radiology Report
EXAMINATION: Q16 CT NECK
INDICATION: ___ year old woman sp fall on ASA/Plavix with new onset left lower
facial droop// bleed causing facial drop
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
746.9 mGy-cm.
2) Spiral Acquisition 5.1 s, 39.8 cm; CTDIvol = 13.3 mGy (Body) DLP = 528.0
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 38.6 mGy (Body) DLP =
19.3 mGy-cm.
Total DLP (Body) = 547 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD:
Curvilinear hyperdense material is noted within bilateral cerebral veins,
likely relating to prior injection or intravascular treatment with
embolization material. Streak artifact secondary to the material results in
suboptimal evaluation of adjacent structures. Within this confine:
There is no evidence for acute hemorrhage, vascular territorial infarction,
mass effect, or edema. The ventricles and sulci are prominent, compatible with
global parenchymal volume loss..
Periventricular and subcortical white matter hypodensities are noted, likely
the sequelae of chronic small vessel ischemic disease. The basal cisterns
remain patent. There is preservation of gray-white matter differentiation.
Calcifications are seen within the bilateral cavernous internal carotid
arteries. The paranasal sinuses, middle ear cavities, and mastoid air cells
are clear. The orbits are grossly unremarkable bilaterally.
CTA HEAD AND NECK:
There is a normal 3 vessel aortic arch, with moderate calcifications at the
origin of the brachiocephalic artery, and severe calcifications at the origin
of the right vertebral artery. Mild calcifications are also seen at the
origin of the left common carotid artery.
Partially calcified atherosclerotic disease is present within the bilateral
carotid bifurcations. Atherosclerotic calcifications are seen in the
bilateral carotid bifurcations (with a partially calcified plaque on the left)
without evidence of stenosis of the cervical internal carotid arteries by
NASCET criteria. The bilateral vertebral arteries are patent without evidence
for dissection.
Moderate calcifications are seen within the bilateral cavernous internal
carotid arteries. There is a fetal origin of the right posterior cerebral
artery. There is a dominant left posterior communicating artery with a
diminutive left P1 segment. The vessels of the circle of ___ and their
principal intracranial branches are otherwise patent without high-grade
stenosis, occlusion, or aneurysm formation. The dural venous sinuses are
patent.
OTHER:
A moderate right pleural effusion is present with adjacent atelectasis. The
thyroid gland is unremarkable in appearance. There is no cervical
lymphadenopathy by CT size criteria.
IMPRESSION:
1. No evidence for acute intracranial hemorrhage or vascular territorial
infarction.
2. Curvilinear hyperdense material within cortical draining veins are
identified, compatible with embolization material from prior intervention.
Clinical correlation is recommended.
3. Allowing for atherosclerotic disease, unremarkable intracranial and
cervical vasculature without high-grade stenosis, occlusion, or dissection.
Atherosclerotic disease of the bilateral carotid bifurcations without evidence
of stenosis by NASCET criteria of the cervical internal carotid arteries.
Radiology Report
EXAMINATION: Chest radiograph PA and lateral
INDICATION: ___ year old woman s/p fall with right ___ rib fractures,
hemothorax// please evaluate for interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Right rib fractures are again seen. Patchy right base atelectatic changes.
There is no pleural effusion or pneumothorax. The cardiac silhouette is on
the upper limits of normal. There is a coronary vascular stent. There are
degenerative changes thoracic spine.
IMPRESSION:
Improved inspiratory volume. Patchy right base opacifications secondary to
atelectatic changes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Rib pain, s/p Fall, Transfer
Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | You were admitted to ___ after a fall. You were found to have
right rib fractures. You were admitted for pain control and
monitoring of your respiratory status. While you were here you
were noted to have a slight left facial droop and slurred
speech, so Neurology was consulted. They think you likely had a
small TIA or stroke. Your symptoms are getting better and there
is no intervention at this time. You are continuing with your
Plavix and aspirin. You should follow-up as an outpatient with
Neurology. Physical Therapy and Occupational Therapy have
cleared you for discharge home with ___ services. Please note
the following:
* Your injury caused 3 right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
midline placement
History of Present Illness:
___ is a ___ man with stage IV NSCLC BRAF V600E
mutated on dafrafenib/trametinib with known mets to spine, R
shoulder, abdominal wall, who presents to ED from clinic after
found to have hyperkalemia (5.6) and ___ (Cr 2.5 from 1.6).
Reports feeling at his recent baseline today; denies urinary sx,
back pain. Has L shoulder pain and right-sided abdominal pain,
but this is not new and is related to metastases.
Patient has been on dafrafenib/trametinib since ___ after
progressing through carboplatin/nab-paclitaxel and
pembrolizumab.
Last several months he has developed progressive disease
including admission from ___ to ___ for pain control with
known progressing painful mets in his shoulder, back, and
abdominal wall. He was being evaluated for additional clinical
trials at this time. He was most recently instructed by his
oncologist to stop his dabrafenib/trametinib on ___. He was
seen
in ___ clinic today and found potassium was elevated to 5.6
and Cr was elevated to 2.5. WBC also elevated to 16.4 with 96%N
and toxic granulations. He was directed to the ED.
In the ED, initial VS were pain 5, T 97.2, HR 110, BP 150/95.
Patient was given NS, 10u IV insulin, IV dextrose, and 6mg po
dilaudid. Renal US was limited but showed no evidence of
hydronephrosis. Repeat labs notable for creatine down to 2.2 but
K of 6.5. He was given kayexelate and insulin/glucose again with
repeat K down to 5.9. He was given more fluids, and HR down to
87
prior to transfer.
On arrival to the floor, patient is having diffuse abdominal
pain
since he did not get his usual methadone in ED. He otherwise
feels well, has no complaints.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Stage IV non-small cell lung cancer, squamous cell carcinoma,
BRAF V600E mutated, diagnosed ___.
- Status post cycle 1 day 1 (C1D1) of carboplatin 6 AUC D1 and
nab-paclitaxel 100 mg/m2 D1, D8 and D15 of a 21-day cycle as
part
of clinical trial ___ ___ on ___ and last dose of
nab-paclitaxel on ___ (progression);
- Palliative radiotherapy to right shoulder and T10-T12 spine
started on ___ and completed on ___
- Status post 2 cycles of pembrolizumab 2 mg/kg on ___ and
___ (progression).
- ___: Started on dabrafenib and trametinib
- ___ - ___: admitted to ___ with fevers, thought ___
dabrafenib
- ___ - ___: admitted to ___ ICU with fevers, SEPSIS,
unclear source. mekinist discontinued, continued on dabrafanib
BID
- ___: discontinued dabrafenib given uveitis
- ___: restarted dabrafenib and mekinist at half doses given
improvement in symptoms (dabrafenib 75mg BID, trametinib 2mg
every other day)
- ___: The imaging studies from ___ showed mostly
stable
tumor burden, with some metastatic sites with minimal decrease
in
size and others with minimal growth.
- ___: Small bowel obstruction, sp surgical ileotransverse
side-to-side colostomy. Post op course notable for CDiff.
- ___: The most recent CT Scans from ___ showed new
pulmonary
nodules, his prior bone disease, increased size of soft tissue
mass abutting the right lateral body wall, increasing disease
burden in the kidneys, increased number of liver lesions,
increasing osseous metastasis; all concerning for disease
progression.
- ___: Tissue biopsy on ___ (confirmed squamous cell
carcinoma and submitted to NGS-based test using the ___
action/fusion sequencing assays - consent obtained)
- ___: Liquid biopsy using FoundationACT to evaluate for
ctDNA genomic changes on ___. The results are expected in
around ___ weeks and may help determine if there is a clinical
trial or off-label inhibitor therapy that we could consider.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus, well controlled;
2. Hypertension, well controlled;
3. Hyperlipidemia, well controlled.
4. Lung cancer, as above
5. Squamous cell cancer
6. Cdiff colitis
7. SBO sp resection ___
Social History:
___
Family History:
Brother who suffered a CVA. Father deceased from an unknown
cause. Mother alive and doing well
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 145 / 99 97 18 98 Ra
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
diffusely tender without rebound or guarding; no hepatomegaly,
no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
___ 09:53PM K+-5.9*
___ 05:38PM GLUCOSE-290* UREA N-40* CREAT-2.2* SODIUM-135
POTASSIUM-6.5* CHLORIDE-103 TOTAL CO2-19* ANION GAP-20
___ 05:30PM URINE HOURS-RANDOM UREA N-301 CREAT-26
SODIUM-65
___ 05:30PM URINE OSMOLAL-411
___ 05:30PM URINE UHOLD-HOLD
___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:55AM GLUCOSE-289*
___ 09:55AM GLUCOSE-289*
___ 09:55AM UREA N-41* CREAT-2.5* SODIUM-139
POTASSIUM-5.6* CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
___ 09:55AM ALT(SGPT)-33 AST(SGOT)-25 LD(LDH)-139 ALK
PHOS-215* TOT BILI-0.2
___ 09:55AM TSH-3.4
___ 09:55AM FREE T4-1.3
___ 09:55AM WBC-16.4*# RBC-3.46* HGB-7.7* HCT-25.3*
MCV-73* MCH-22.3* MCHC-30.4* RDW-21.2* RDWSD-54.7*
___ 09:55AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 09:55AM PLT SMR-NORMAL PLT COUNT-343
renal Doppler:
IMPRESSION:
1. Evaluation limited due to poor penetration of deeper
structures and
inability of patient to hold breath.
2. No evidence of hydronephrosis. Normal bilateral ureteral
jets seen.
3. Arterial resistive indices are elevated and are higher on the
left
(0.77-0.83) compared to the right (0.61-0.78), but demonstrate
grossly
appropriate waveforms.
CT chest:
IMPRESSION:
Small layering nonhemorrhagic pleural effusions are new. Large
left lower
lobe consolidation increased since ___ is not
explained by any
bronchial obstruction. Consider pneumonia.
Although the large left upper lobe mass invading the mediastinum
and anterior
costal pleura is stable adjacent lung nodules have increased in
size and
number, probably direct metastatic invasion, and there are new
or at larger
hematogenous metastases in the right lung.
Adenopathy, minimal if any could be due to left lower lobe
pneumonia.
2 thoracic vertebral metastases are stable. Vertebral canal is
not
compromised. More reliable assessment would be obtained with
dedicated neuro
imaging.
shoulder xray:
IMPRESSION:
In comparison with study of ___, there is little
overall change.
Mild AC and minimal glenohumeral degenerative changes without
evidence of
abnormal calcification soft tissues.
If there is a serious clinical concern for metastatic
involvement,
radionuclide bone scanning could be obtained.
CT abd/pelvis IMPRESSION:
Limited noncontrast examination demonstrates interval increase
in metastatic
disease burden in the abdomen and pelvis, with enlarging hepatic
metastases,
osseous metastases, new ascites and an enlarging soft tissue
metastasis along
the right lateral abdominal wall. Known renal metastatic
disease is poorly
evaluated without contrast.
CXR ___:
IMPRESSION:
Left lower lobe consolidation, new since ___ is
concerning for
pneumonia given the provided clinical history.
Known left upper lobe mass. Pulmonary nodular opacities are
better evaluated
by CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Dexamethasone 4 mg PO EVERY OTHER DAY
5. HYDROmorphone (Dilaudid) 6 mg PO BID:PRN Pain - Moderate
6. Losartan Potassium 50 mg PO DAILY
7. Methadone 10 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Calcium Carbonate 500 mg PO QID:PRN reflux
12. Polyethylene Glycol 17 g PO DAILY
13. Docusate Sodium 100 mg PO DAILY:PRN constipation
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM shoulder pain
RX *lidocaine [Lidoderm] 5 % 2 patches daily, shoudler, abdomen
daily Disp #*60 Patch Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM abdomen
5. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day
Refills:*0
6. Ranitidine 300 mg PO DAILY
RX *ranitidine HCl 300 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 3 tablet(s) by mouth every 6 hours Disp
#*84 Tablet Refills:*0
9. Methadone 20 mg PO TID
RX *methadone 10 mg 2 by mouth three times a day Disp #*42
Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Atorvastatin 80 mg PO QPM
12. Bisacodyl ___AILY:PRN constipation
13. Calcium Carbonate 500 mg PO QID:PRN reflux
14. Dexamethasone 4 mg PO EVERY OTHER DAY
15. Docusate Sodium 100 mg PO DAILY:PRN constipation
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
lung cancer with metastasis and cancer related pain
anemia
___ on CKD
possible pneumonia
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: History: ___ with stage IV ___ lung with known mets, who
presents with ___ and hyperkalemia.// Please do study with doopler. any
evidence of obstruction/hydronephrosis, renal artery stenosis ___ obstructive
mass
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
Evaluation limited due to poor penetration of deeper structures and inability
of patient to hold breath.
The right kidney measures 10.9 cm. The left kidney measures 9.9 cm. There is
no hydronephrosis or stones bilaterally. Heterogeneous appearance of the
renal parenchyma is consistent with diffuse infiltrative metastatic disease,
as seen on prior CT study. A 3 cm simple cyst is again seen in the lower pole
left kidney.
Renal Doppler: Intrarenal arteries show appropriate waveforms with sharp
systolic peaks and continuous antegrade diastolic flow. The resistive indices
of the right intra renal arteries range from 0.61-0.78. The resistive indices
on the left range from 0.77-0.83. Bilaterally, the main renal arteries are
patent with normal waveforms. The peak systolic velocity on the right is 43.8
centimeters/second. The peak systolic velocity on the left is 23.6
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance with
bilateral ureteral jets seen.
IMPRESSION:
1. Evaluation limited due to poor penetration of deeper structures and
inability of patient to hold breath.
2. No evidence of hydronephrosis. Normal bilateral ureteral jets seen.
3. Arterial resistive indices are elevated and are higher on the left
(0.77-0.83) compared to the right (0.61-0.78), but demonstrate grossly
appropriate waveforms.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old man with h.o metastatic lung ca, increasing pain and
FTT// reevaluate disease burden
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.3 s, 70.2 cm; CTDIvol = 7.5 mGy (Body) DLP = 525.3
mGy-cm.
Total DLP (Body) = 525 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Liver metastases were better evaluated on prior contrast
enhanced scan. Within this limitation, there is a 3.6 by 4.1 cm abdomen
hypoattenuating lesion in the right lobe of the liver, previously measuring
approximately 2.3 by 2.7 cm, using similar measurements. A hypoattenuating
lesion in the inferior right lobe of the liver measures 3.3 x 3.1 cm,
previously up to 1.6 cm. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are enlarged, with diffusely infiltrative metastatic
lesions better appreciated on prior contrast enhanced CT.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. Trace ascites noted.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Lytic right iliac lesion measures up to 3.8 cm, previously 3.5 cm.
SOFT TISSUES: The previously seen lesion along the right lateral abdominal
wall has markedly increased in size with a new large cystic component. The
soft tissue component measures approximately 4.7 x 3.7 cm, previously 3.7 x
2.9 cm. Stranding throughout the subcutaneous tissues is likely related to
anasarca.
IMPRESSION:
Limited noncontrast examination demonstrates interval increase in metastatic
disease burden in the abdomen and pelvis, with enlarging hepatic metastases,
osseous metastases, new ascites and an enlarging soft tissue metastasis along
the right lateral abdominal wall. Known renal metastatic disease is poorly
evaluated without contrast.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA RIGHT
INDICATION: ___ year old man with h.o met lung ca, prior radiation, recurrent
pain// eval for metastasis
IMPRESSION:
In comparison with study of ___, there is little overall change.
Mild AC and minimal glenohumeral degenerative changes without evidence of
abnormal calcification soft tissues.
If there is a serious clinical concern for metastatic involvement,
radionuclide bone scanning could be obtained.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Metastatic lung carcinoma. Increasing pain and failure to
thrive.
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.3 s, 70.2 cm; CTDIvol = 7.5 mGy (Body) DLP = 525.3
mGy-cm.
Total DLP (Body) = 525 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: Compared to chest CT scanning since ___, most recently
___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged and
there are no soft tissue abnormalities in the imaged chest wall suspicious for
malignancy. Increase in the general density of subcutaneous fat suggests
early anasarca.
Findings below the diaphragm will be reported separately.
There are no discrete thyroid lesions warranting further imaging evaluation.
Atherosclerotic calcification is not apparent head neck vessels or coronary
arteries. Mild enlargement main pulmonary artery, 33 mm, is unchanged. Aorta
is top-normal size, also stable. There is no pericardial effusion.
Small layering nonhemorrhagic pleural effusions, right greater than left, are
new.
Lymph nodes:
Mediastinum:
11 mm right upper paratracheal, previously 10 mm.
Prevascular 10 mm, previously 6 mm;
Right lower paraesophageal, 13 mm, previously 9 mm.
Lungs:
37 x 50 mm lobulated left upper lobe mass extending from the anterior aspect
of the left hilus to the anterior chest wall and invading the pericardium at
the level of the main pulmonary artery was 35 x 54 mm.
Subcentimeter nodules in the left upper lobe superior to this mass are more
numerous and larger. The large region of consolidation in the left lower lobe
has increased in size. There is no responsible bronchial obstruction and the
interval change is too great to attribute to malignancy. Pneumonia is more
likely. However a dozen new or growing nodules in the right lung, for example
right middle lobe, 3:141, are new or larger.
Chest cage:
Blastic and lytic lesion in the T8 vertebral body and the lytic lesion in T11
extending into the pedicle and lamina of T11 are unchanged; vertebral canal is
intact.. There are no new compression or pathologic fractures or additional
destructive bone lesions.
IMPRESSION:
Small layering nonhemorrhagic pleural effusions are new. Large left lower
lobe consolidation increased since ___ is not explained by any
bronchial obstruction. Consider pneumonia.
Although the large left upper lobe mass invading the mediastinum and anterior
costal pleura is stable adjacent lung nodules have increased in size and
number, probably direct metastatic invasion, and there are new or at larger
hematogenous metastases in the right lung.
Adenopathy, minimal if any could be due to left lower lobe pneumonia.
2 thoracic vertebral metastases are stable. Vertebral canal is not
compromised. More reliable assessment would be obtained with dedicated neuro
imaging.
Radiology Report
INDICATION: ___ year old man with stage IV lung cancer with new fever// Please
eval for pneumonia, effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and CT chest dated ___
FINDINGS:
Unchanged elevation of the left hemidiaphragm with left basilar
atelectasis/consolidation, increased since prior. Small bilateral pleural
effusions are suspected. Multiple pulmonary nodular opacities are noted
throughout the right lung, better evaluated by CT. No pneumothorax.
Abnormal contours of the left upper mediastinum corresponding to the patient's
known left upper lobe mass. Otherwise the size of the cardiac silhouette is
within normal limits.
IMPRESSION:
Left lower lobe consolidation, new since ___ is concerning for
pneumonia given the provided clinical history.
Known left upper lobe mass. Pulmonary nodular opacities are better evaluated
by CT.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Hyperkalemia
Diagnosed with Acute kidney failure, unspecified, Hypokalemia
temperature: 97.2
heartrate: 110.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 95.0
level of pain: 5
level of acuity: 2.0 | You were admitted for evaluation of cancer related pain in your
shoulder and abdominal as well as elevated potassium and
impaired kidney function. For your kidneys, you were given IV
fluids and your losartan was discontinued and replaced with
coreg for your blood pressure. You will need to follow up with a
kidney doctor in ___ couple of weeks and have your labs rechecked
in the next week.
In terms of your pain, your methadone was increased and you were
started on lidocaine patches. Please obtain your methadone
tomorrow from the pharmacy.
You were given a blood transfusion for your anemia.
You had a CT scan that showed worsening of your known cancer.
You had a low fever and CXR with possibility of pneumonia, so
you will be treated with a few days of antibiotics.
You will be following up with your oncologist and palliative
care team after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
neck swelling
Major Surgical or Invasive Procedure:
left neck exploration and drain placement
intubation and mechanical ventilation
History of Present Illness:
___ with a history of ___ disease and chronic
pancytopenia/neutropenia who is re-admitted with reaccumulation
of fluid following initial drainage of posterior/parapharyngeal
abscess on ___.
She initially presented ~3 weeks ago with neck/swallowing pain
and was found to have the above abscess on CT imaging, which was
drained and cultures ultimately grew beta streptococcus group A
and propionobacterium acnes. She was treated with meropenem for
this (changed to ertapenem upon discharge). Her initial
hospitalization (___) was complicated by intubation for
airway protection x several days, neutropenia (WBC nadir 0.6
with 67% neutrophils on ___, anemia to Hct < 21 (received 2
units pRBCs). She also developed left IJ nearly-occlusive clot,
which was not felt to be septic in origin. After multispecialist
discussion, the decision was made not to anticoagulate as risks
were felt to outweigh benefits. She was seen by hematology
during that admission and started on Neupogen, which was stopped
when WBC count came > 3500. She had planned follow up as an
outpatient for ? ___ in early ___.
After returning home, she initially stabilized and felt she was
beginning to improve; however, her husband noticed after several
days that she was developing increased swelling at the surgical
site as well as increased drainage. She also had increased pain
and developed nightsweats, though temps were in ___ (no true
fever). She came back to ED where CT scan showed re-accumulation
of fluid, and she was taken back to OR ___ by ENT for
drainage. She spent the night in SICU for observation, where she
has done well from a surgical perspective (3 drains in place, no
airway compromise).
Currently she has minimal complaints of neck pain well
controlled with dilaudid PCA. Has no difficulty swallowing,
breathing or speaking.
Past Medical History:
#Neutropenia of unknown etiology - diagnosed ___ years ago,
baseline WBC 1.8, had serial blood tests in ___ for 8 weeks
and as WBC stayed stable no treatment was initiated, had MRI at
the time but no bone marrow, has been told she has splenomegaly,
no history of prior serious infections or hospitalizations aside
from her pregnency though per husband she does take longer to
recover from minor infections
___ disease - diagnosed ___ years ago
#Fe deficiency anemia - not currently on iron supplementation
#Hx of Mononucleosis infection
#Warts on feet - on ranitidine, followed by dermatology
#Ovarian cystectomy
Social History:
___
Family History:
Father with ___ syndrome, history of mono
Mother died of lupus in ___
Aunt with severe MS
Grandfather had cancer
No history of immune disorders, clotting or bleeding disorders
Physical Exam:
PHYSICAL EXAM: on transfer
VS - 99.9/99.2 122/70 ___ 97% RA
General: lying in bed, NAD,
EENT: pressure dressing around left side of neck, erythema and
swelling in the anterior neck
CV: RRR, normal S1, S2, -mrg
Pul: CTAB on anterior exam
GI: + bowel sounds, soft, non-distended, no hepatosplenomegaly
MSK: no joint swelling or erythema, non-tender to palpation over
her knees and upper leg with full ROM
Extremities: warm and well perfused, no edema
SKIN: no lesions or skin breakdown
NEURO: alert and oriented x3, CN ___ grossly intact with
decreased sensation over the ear and lower ___ of the left face
PSYCH: non-anxious, normal affect
Physical exam on discharge:
Vitals: tm 99.1, tc 98.6. 105-117/65-80, 72-93, 20, 99% RA
GEN: pale young woman w/ neck dressing in no acute distress
HEENT: left lateral neck incision with mild tenderness
CV: RRR normal s1/s2, no m/r/g
LUNGS: CTAB
Ab: normal bowel sounds, no masses, non-tender
Ext: 2+ pulses radial and dp
Skin: no rash evident
Neuro: alert and oriented x3, CN ___ grossly intact with
decreased sensation over the ear and lower ___ of the left face
Pertinent Results:
Admission labs:
___ 04:55PM BLOOD WBC-5.0 RBC-3.59* Hgb-10.1* Hct-31.5*
MCV-88 MCH-28.2 MCHC-32.2 RDW-14.0 Plt ___
___ 04:55PM BLOOD Neuts-72.8* ___ Monos-0.4*
Eos-3.2 Baso-1.4
___ 04:55PM BLOOD Glucose-118* UreaN-15 Creat-0.4 Na-133
K-4.0 Cl-97 HCO3-28 AnGap-12
___ 01:20AM BLOOD ALT-16 AST-14 LD(LDH)-133 AlkPhos-110*
TotBili-0.5
___ 01:20AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.7 Mg-1.7
___ 05:04PM BLOOD Lactate-0.9
___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:30PM URINE UCG-NEGATIVE
.
Discharge labs:
___ 07:04AM BLOOD WBC-3.7* RBC-3.49* Hgb-9.6* Hct-30.1*
MCV-87 MCH-27.5 MCHC-31.8 RDW-14.6 Plt ___
___ 06:36AM BLOOD Neuts-54.0 ___ Monos-0.5*
Eos-5.1* Baso-1.0
___ 07:04AM BLOOD ___ PTT-37.6* ___
___ 07:04AM BLOOD Glucose-98 UreaN-9 Creat-0.4 Na-138 K-4.0
Cl-100 HCO3-30 AnGap-12
___ 06:53AM BLOOD ALT-351* AST-228* LD(LDH)-173 CK(CPK)-8*
AlkPhos-667* TotBili-0.7
___ 07:04AM BLOOD ALT-244* AST-72* CK(CPK)-9* AlkPhos-590*
TotBili-0.8
___ 07:04AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8
.
Micro:
___ blood cultures x 2 - no growth final
___ blood cultures x 2 - no growth final
___ urine culture - < 10k colonies
___ L neck wound cultures x 2 - gram stain negative, no
bacterial growth final, no fungal growth prelim
___ MRSA screen negative
___ R PICC line catheter tip - no growth final
Imaging:
___ Radiology CT NECK W/CONTRAST:
TECHNIQUE: MDCT-acquired 2.5 mm axial images of the neck were
obtained following the uneventful administration of 70 cc of
Omnipaque intravenous contrast. Coronal, sagittal reformations
were performed at 2 mm slice thickness. FINDINGS: Extensive soft
tissue swelling throughout the superficial and deep spaces of
the left neck and abnormal thickening and enhancement of the
left sternocleidomastoid and posterior cervical muscles are
again seen (2:29). There is increased rim thickening and
enhancement of an organizing fluid collection along the left
neck extending posteriorly (2:33) since ___, with a
dominant collection measuring 34 x 7 mm (2:28). Previously noted
drains have been removed with subcutaneous gas likely reflecting
packing material within a lateral incision (2:54). No bony
erosions are detected. There is improved retropharyngeal
swelling with decreased mass effect on the neighboring airway,
including slight restoration of the left piriform sinus and
decreased swelling of the left aryepiglottic fold and
epiglottis. The airway remains patent. No new fluid collections
are seen. There is no subcutaneous emphysema. Neighboring great
vessels remain patent, although there is continued marked
narrowing of the left internal jugular vein (2:34) as it passes
through the area of inflammation in the left neck. Included
views of the lung apices demonstrates minimal paraseptal
emphysema (301b:68). The thyroid is normal. IMPRESSION: 1.
Organizing rim-enhancing fluid collection concerning for an
abscess tracking along the left lateral and posterior neck,
overall slightly worsened since ___, with increased
size of a dominant posterior collection measuring up to 8 mm,
and increased thickeness of an enhancing rind. 2. Improved
retropharyngeal swelling with decreased mass effect on the
neighboring airway, including slight restoration of the left
piriform sinus and decreased swelling of the left aryepiglottic
fold and epiglottis. 3. Removal of surgical drains with
subcutaneous gas in the left neck possibly reflecting packing
material within the surgical incision. 4. Continued severe focal
narrowing the left internal jugular vein as it courses through
the area of inflammation in the left neck.
___ Liver U/S: Normal liver echotexture. No intra- or
extra-hepatic bile duct dilation. The gallbladder is collapsed.
Medications on Admission:
3. bismuth subsalicylate 262 mg/15 mL Suspension Sig: Thirty
(30) ML PO QID (4 times a day) as needed for diarrhea.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
Disp:*21 Tablet(s)* Refills:*0*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*21 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
8. ertapenem 1 gram Recon Soln Sig: One (1) Grams Intravenous
once a day.
Disp:*30 doses* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*50 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Outpatient Lab Work
Pt will need weekly CBC, Na, K, Cl, HCO3, BUN, Cr, Glucose, AST,
ALT, Total bilirubin, Alkaline phosphatase and have the results
faxed to ___ clinic at ___, attention Dr. ___.
5. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain for 2 weeks: Do not operate machinery or
drive on this medication. Do not mix with alcohol.
Disp:*50 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day as needed for constipation for 2 weeks: use
daily for constipation while taking hydromorphone (Dilaudid).
Disp:*30 packets* Refills:*2*
7. daptomycin 500 mg Recon Soln Sig: 350 mg Recon Solns
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neck abscess/infected fluid collection
Idiopathic neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left neck infection.
COMPARISON: CTs available from ___.
TECHNIQUE: MDCT-acquired 2.5 mm axial images of the neck were obtained
following the uneventful administration of 70 cc of Omnipaque intravenous
contrast. Coronal, sagittal reformations were performed at 2 mm slice
thickness.
FINDINGS:
Extensive soft tissue swelling throughout the superficial and deep spaces of
the left neck and abnormal thickening and enhancement of the left
sternocleidomastoid and posterior cervical muscles are again seen (2:29).
There is increased rim thickening and enhancement of an organizing fluid
collection along the left neck extending posteriorly (2:33) since ___, with a dominant collection measuring 34 x 7 mm (2:28). Previously noted
drains have been removed with subcutaneous gas likely reflecting packing
material within a lateral incision (2:54). No bony erosions are detected.
There is improved retropharyngeal swelling with decreased mass effect on the
neighboring airway, including slight restoration of the left piriform sinus
and decreased swelling of the left aryepiglottic fold and epiglottis. The
airway remains patent. No new fluid collections are seen. There is no
subcutaneous emphysema. Neighboring great vessels remain patent, although
there is continued marked narrowing of the left internal jugular vein (2:34)
as it passes through the area of inflammation in the left neck. Included
views of the lung apices demonstrates minimal paraseptal emphysema (301b:68).
The thyroid is normal.
IMPRESSION:
1. Organizing rim-enhancing fluid collection concerning for an abscess
tracking along the left lateral and posterior neck, overall slightly worsened
since ___, with increased size of a dominant posterior collection
measuring up to 8 mm, and increased thickeness of an enhancing rind.
2. Improved retropharyngeal swelling with decreased mass effect on the
neighboring airway, including slight restoration of the left piriform sinus
and decreased swelling of the left aryepiglottic fold and epiglottis.
3. Removal of surgical drains with subcutaneous gas in the left neck possibly
reflecting packing material within the surgical incision.
4. Continued severe focal narrowing the left internal jugular vein as it
courses through the area of inflammation in the left neck.
Radiology Report
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ performed the procedure. Dr. ___
___ (attending physician) was present and performed the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the right brachial
vein was punctured under direct ultrasound guidance using a micropuncture set.
Hard copies of ultrasound images were obtained before and immediately after
establishing intravenous access. A peel-away sheath was then placed over a
guide wire and a single-lumen PICC line measuring 36 cm in length was then
placed through the peel-away sheath with its tip positioned in the SVC under
fluoroscopic guidance. Position of the catheter was confirmed by a
fluoroscopic spot film of the chest.
The peel-away sheath and guide wire 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.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 ___
single-lumen PowerPICC line placement via the right brachial venous approach.
Final internal length is 36 cm, with the tip positioned in SVC. The line is
ready to use.
Radiology Report
INDICATION: Rising LFTs.
No comparison studies available.
TECHNIQUE: Ultrasonography of the liver and gallbladder.
FINDINGS: The liver echotexture is normal. There is no focal intrahepatic
lesion or intrahepatic bile duct dilation. The main portal vein is patent,
demonstrating proper hepatopetal flow. The CBD is not dilated, measuring 2
mm. The gallbladder is collapsed (the patient recently ate). Included views
of the pancreas and right kidney are normal. There is no free fluid. The IVC
is normal in caliber.
IMPRESSION: Normal liver echotexture. No intra- or extra-hepatic bile duct
dilation. The gallbladder is collapsed.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: NECK SWELLING
Diagnosed with NECROTIZING FASCIITIS, SWELLING IN HEAD & NECK
temperature: 98.4
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 72.0
level of pain: 4
level of acuity: 1.0 | Ms. ___,
You came to the hospital for worsening neck swelling and
drainage after your prior neck surgery. You had a scan, which
showed increased fluid in the previously drained areas of your
neck. Our ENT surgeons re-explored your neck and placed several
drains. You were seen by our infectious disease specialists, who
felt that your symptoms were due to incomplete drainage after
your first procedure. You were continued on antibiotics and your
wound and blood cultures did not grow any bacteria. Your ENT
surgeons slowly removed your neck wound drains and removed your
stitches. You will need to continue IV antibiotics for several
weeks to months. The exact duration will depend on your clinical
progress and the assessments of your ENT and infectious disease
doctors.
We have made the following changes to your medications:
START prochlorperazine maleate (Compazine) 10mg tablets, 1 tab
by mouth every 6 hours as needed for nausea
START docusate sodium 100mg capsules, 1 cap by mouth twice daily
START hydromorphone (Dilaudid) 2 mg tablets, ___ tabs by mouth
every ___ hours as needed for severe pain. Do not operate
machinery or drive on this medication. Do not mix with alcohol.
START polyethylene glycol (Miralax) 17g powder in packet, 1
packet dissolved in water by mouth daily as needed for
constipation
START daptomycin 350mg IV daily until instructed to stop by your
infectious disease specialist, Dr. ___
___ continue to take your other medications as previously
prescribed. We have made several appointments for you (see
below). We have also arranged for a nurse to come to your home
to administer your medication and to draw your blood labs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
episodes of balance deficits and difficulty speaking
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history previous 4 vessel
CABG in ___ and chronic renal failure who presents to the ED
for
further evaluation of episodes of loss of balance and slurred
speech.
Per Mr. ___, he has been in very good health since his CABG
when on ___ he was at a meeting and leaned over to
shake someone's hand. He temporarily lost his balance but did
not
fall, leaned against the chairs near him and other people around
him helped him to regain his balance. The entire episode lasted
~
20 seconds. During that time he denied any loss of
consciousness,
change in sensation, weakness, loss of coordination or other
complaints.
Two days later, ___, he was at the pharmacy and said ___ I
have
another one of those please" but it came out slurred. He tried
to
say it again and it was still slurred. With the slurred speech,
he felt his right cheek was numb, not really with feeling of
pins
and needles but just lack of feeling. After repeating what he
was
trying to say twice, the symptoms resolved and he was back to
himself. He denied any other symptoms at the time of facial
weakness, change in vision, word finding difficulty or other
concerns.
After that event, he saw his PCP and was set up for an
appointment with a neurologist for this coming ___, in the evening, he was again feeling well when
he
leaned over with his right hand to turn off a light switch and
he
again lost his balance. He leaned over his body with his right
hand over his left body and fell onto his left side and hit his
head. He again denied any weakness of his arms, legs, denies
any
sensory changes, loss of consciousness. No one witnessed the
event. After this event, he returned to the PCP and was sent to
the neurologist. After evaluation by the Neurologist, he was
sent
for an MRI which revealed subacute emobolic looking infarcts.
For
this reason, he was sent to the ED. Currently, he feels well and
is asymptomatic.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Coronary artery disease s/p stent ___
Hypetension
Gastric ulcer with GI bleed ___ years ago)
Stage III kidney disease (baseline 2.1)
BPH
Hematuria (trace at times)
Anemia
Hemorrhoids
Fibular fracture 01
Gout
Renal cyst
s/p mastoid surgery at age ___
s/p tonsillectomy
Social History:
___
Family History:
Premature coronary artery disease- father had an MI in his ___
Physical Exam:
Vitals: T:97.6 P:61 R: 16 BP:171/82 SaO2: 100RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. 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. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm 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
**Left arm weakness due to pain**
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception in upper extremities. No
extinction to DSS. In Lower extremities, there is decreased
pinprick in R foot. Loss of vibration in L leg to the midshin,
loss of viration to the ankle in the R. Proprioception decreased
to small movements in both great toes
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 1 1
R 2+ 2+ 2+ 1 1
Plantar response was flexor bilaterally.
** Pectroral reflex present b/l
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 06:01PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:01PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:01PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:30AM GLUCOSE-105* UREA N-31* CREAT-1.9* SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
___ 06:30AM ALT(SGPT)-16 AST(SGOT)-20 LD(LDH)-173 ALK
PHOS-48 TOT BILI-0.5
___ 06:30AM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-3.6
MAGNESIUM-2.2 CHOLEST-128
___ 06:30AM %HbA1c-6.0* eAG-126*
___ 06:30AM TRIGLYCER-59 HDL CHOL-65 CHOL/HDL-2.0
LDL(CALC)-51
___ 06:30AM TSH-5.3*
___ 06:30AM WBC-8.7 RBC-4.14* HGB-12.3* HCT-38.3* MCV-92
MCH-29.8 MCHC-32.3 RDW-14.4
___ 06:30AM WBC-8.7 RBC-4.14* HGB-12.3* HCT-38.3* MCV-92
MCH-29.8 MCHC-32.3 RDW-14.4
___ 06:30AM PLT COUNT-167
___ 10:45PM GLUCOSE-112* UREA N-32* CREAT-2.0* SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 10:45PM estGFR-Using this
___ 10:45PM cTropnT-<0.01
___ 10:45PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-2.2
___ 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:45PM WBC-8.2 RBC-4.36*# HGB-13.1*# HCT-40.6#
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.3
___ 10:45PM NEUTS-71.4* LYMPHS-17.0* MONOS-6.3 EOS-4.6*
BASOS-0.7
___ 10:45PM PLT COUNT-184#
___ 10:45PM ___ PTT-27.0 ___
.
ECHO
The left atrium is mildly dilated. 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%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Trace
aortic regurgitation. No definite structural cardiac source of
embolism identified.
.
Chest xray
FINDINGS: The right hemidiaphragm continues to be mildly
elevated and lung
volumes are slightly low. There is blunting of the left CP
angle likely due
to a small effusion. There are mild degenerative changes of the
spine. There
is no focal infiltrate.
.
Carotid US
Report pending - no immediate problem
Medications on Admission:
Vitamin D ___ units daily
Metoprolol XL 50mg Daily
Benicar 10mg daily
ASA 325mg daily
Simvastatin 20mg Daily
Allopurinol ___ BID
Furosimide 40mg Daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. allopurinol ___ mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
Disp:*50 Tablet(s)* Refills:*2*
7. Benicar Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral embolism with infarctions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST ON ___
HISTORY: Status post CABG, stroke.
REFERENCE EXAM: ___.
FINDINGS: The right hemidiaphragm continues to be mildly elevated and lung
volumes are slightly low. There is blunting of the left CP angle likely due
to a small effusion. There are mild degenerative changes of the spine. There
is no focal infiltrate.
Radiology Report
Standard Report Carotid US
Study: Carotid Series Complete
Reason: S/P CVA
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate heterogeneous plaque in the ICA. On the left there
is moderate heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 120/23, 78/19, 72/24 cm/sec. CCA peak systolic
velocity is 84 cm/sec. ECA peak systolic velocity is 231 cm/sec. The ICA/CCA
ratio is 1.4. These findings are consistent with 40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 139/27, 85/24, 74/27 cm/sec. CCA peak systolic
velocity is 78 cm/sec. ECA peak systolic velocity is 128 cm/sec. The ICA/CCA
ratio is 1.8. These findings are consistent with 40-59% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA 40-59% stenosis.
Left ICA 40-59% stenosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NEURO EVALUATION
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS, PTCA STATUS
temperature: 97.6
heartrate: 61.0
resprate: 16.0
o2sat: 100.0
sbp: 171.0
dbp: 82.0
level of pain: 6
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of trouble speaking and
balance problems resulting from an ACUTE ISCHEMIC STROKE, a
condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. Stroke can have many different causes,
so we
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future
strokes, we plan to modify those risk factors.
We are changing your medications as follows:
1. Please take plavix daily
2. Please stop taking aspirin
3. Please increase simvastatin to 60mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek medical
attention. In particular, since stroke can
recur, please pay attention to the sudden onset and persistence
of these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Inability to swallow
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: ___
_
________________________________________________________________
PCP:
Dr. ___ at ___.
_
________________________________________________________________
HPI:
The patient is a ___ year old male with HTN, ashtma, HLD diet
controlled with recent diagnosis of esophageal stricture s/p EGD
on ___ with bx performed negative for malignancy. EGD
demonstrated food impaction along with irritation and swelling
thus dilatation was deferred at that time. Pt was scheduled for
a repeat EGD today. In the past two weeks he has only been able
to tolerate liquids- milkshakes and water. He tried to eat baby
food but would regurgitate that immediately. He reports ___
constant sore throat- no worse with eating. He does not report
heart burn sx. He has lost 20 lbs over the past month since his
sx began.
Pt went to the GI suite today to have the procedure performed
but he could not have it done since he did not have a ride home
and he lives alone. He was told to come back in 2 weeks and was
walking out of the GI suite to catch the bus when he felt LH,
dizzy. Given that he decided to come to the ED. No LOC or
headstrike. No CP, palps/SOB/diaphoresis at time of pre-syncopal
event. He also reports a non-productive cough over the "past few
days".
He also reports dyspnea on exertion which is new for him. He
does not have SOB at rest. No leg swelling. He thinks that it
might be deconditioning because he has not been as active as he
usually is. He does walk around in his studio appartment.
In ER: (Triage Vitals:15:42 0 98.0 67 152/88 18 97% )
Meds Given:none
Fluids given:1L NS
Radiology Studies: none
consults called: GI notified by ED dashboard
.
PAIN SCALE: ___ location: throat pain
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[- ] Fever [ -] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ +] ___20__ lbs. weight loss over _1____ month
Eyes
[x] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [+] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[+ ] Shortness of breath [+ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ +] Cough- dry [- ] Wheeze [ -] Purulent
sputum [ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[- ] Palpitations [ -] Edema [ -] PND [- ] Orthopnea [ -]
Chest Pain [ +] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[- ] Nausea [-] Vomiting [] Abd pain [] Abdominal swelling
[- ] Diarrhea [+ ] Constipation - which he atributes to
decreased po intake [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
ALLERGY:
[+ ]Medication allergies - PCN per OMR [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
-Hypertension
-Esophageal stricture
-Asthma
-s/p appendectomy (in teens)
-Adeno colon polyp resection by colonoscopy
Social History:
___
Family History:
Father died of old age at age ___- pt's father told him he had
rectal cancer. His mother died of throat cancer in her ___ and
she was a heavy smoker.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
PAIN SCORE ___ - throat
1. T = 97.7 P = 62 BP = 160/98 RR = 20 O2Sat on _98% on RA
GENERAL: Well appearing male who looks much younger than his
stated age
Nourishment: good
Grooming: good
Mentation: alert, speaks in full sentences. Odd affect and
somewhat tangential historian
2. Eyes: [x] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [X] WNL
+ fillings, + HOH
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
Distant heart sounds
[] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[x] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
R DPP dopplable
L DPP with 2+ pulses
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
[] Non distended [+] obesely distended [] bowel sounds Yes/No
[] guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
Hyperpigmented lesion on posterior neck which pt tells me is ___
years old from burn while in ___.
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
Tangential, often talks about war and ___
[] Appropriate [] Flat affect [?] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
Pertinent Results:
___ 04:45PM GLUCOSE-87 UREA N-13 CREAT-1.2 SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-29 ANION GAP-12
___ 04:45PM estGFR-Using this
___ 04:45PM CALCIUM-9.1 PHOSPHATE-1.8* MAGNESIUM-2.1
___ 04:45PM WBC-7.2 RBC-4.47* HGB-14.2 HCT-42.6 MCV-95
MCH-31.7 MCHC-33.3 RDW-14.9
___ 04:45PM NEUTS-60.9 ___ MONOS-4.8 EOS-2.8
BASOS-0.6
___ 04:45PM PLT COUNT-221
EGD:
Impression: Short smooth distal esophageal stricture.
Small hiatal hernia.
Inflammed mucosa in the first part of the duodenum.
Esophageal stricture dilation with ___ over a guidewire -
___ to ___.
Otherwise normal EGD to third part of the duodenum
Recommendations: EGD with further dilation in ___ weeks.
Liquid diet today, and pureed foods untill the next EGD.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole 15 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PA AND LATERAL CHEST X-RAY
INDICATION: Patient with cough, weight loss, esophageal stricture.
COMPARISON: ___.
FINDINGS: The lungs are clear. There is no pleural effusion or pneumothorax.
Mediastinal and cardiac contours are normal. Diffuse mild degenerative spine
disease is unchanged.
CONCLUSION: There are no acute cardiopulmonary findings. There is no
pneumonia.
Given the discrepancy between preliminary report and the official report, Dr.
___ has been contacted for the results.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: TROUBLE SWALLOWING
Diagnosed with ESOPHAGEAL STRICTURE, DYSPHAGIA, UNSPECIFIED, DEHYDRATION
temperature: 98.0
heartrate: 67.0
resprate: 18.0
o2sat: 97.0
sbp: 152.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | You were admitted to the hospital with difficulty swallowing
that was felt to be due to your esophageal stricture. You
underwent an EGD with dilation and your diet was advanced to
purees. You will need to have a repeat EGD in ___ weeks. The GI
clinic will call you to schedule that procedure. Please arrange
to have someone else drive you home after the procedure.
Please take all medications as prescribed, including your
lansoprazole. Maintain a PUREED diet for the next few days. If
you do well with this, you can upgrade to soft foods. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ - Diagnostic cerebral angiogram - Negative for
cerebrovascular malformation
___ - Diagnostic cerebral angiogram - Negative for
cerebrovascular malformation
History of Present Illness:
___ is a ___ year old male who presented to the ED on
___ as a transfer from an outside facility after
developing WHOL. Imaging at the outside facility was concerning
for extensive SAH, but was negative for any cerebrovascular
malformation. The patient was transferred to ___ for
escalation of care. Neurosurgery was consulted for evaluation
and management recommendations.
Past Medical History:
None
Social History:
___
Family History:
No known family history of stroke or aneurysm.
Physical Exam:
On Admission:
-------------
Date and Time of Neurosurgical Evaluation: ___ 11:55
___ and ___ Score:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity.
[x]Grade II: Moderate to severe headache, nuchal rigidity, no
neurologic deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness, confusion, mild focal neurologic
deficit.
[ ]Grade IV: Stupor, moderate to severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident.
[x]2 SAH less than 1mm thick.
[ ]3 SAH more than 1mm thick.
[ ]4 SAH of any thickness with parenchymal extension or IVH.
___ Grading Scale:
[x]Grade I: GCS 15, no motor deficit.
[ ]Grade II: GCS ___, no motor deficit.
[ ]Grade III: GCS ___, with motor deficit.
[ ]Grade IV: GCS ___, with or without motor deficit.
[ ]Grade V: GCS ___, with or without motor deficit.
GCS:
Airway:
[ ]Intubated
[x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]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
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Total: 15
ICH Score:
GCS:
[ ]2 GCS ___
[ ]1 GCS ___
[x]0 GCS ___
ICH Volume:
[ ]1 30 mL or greater
[x]0 Less than 30 mL
IVH:
[ ]1 Present
[x]0 Absent
Infratentorial ICH:
[ ___ Yes
[x]0 No
Age:
[ ]1 ___ years old or greater
[x]0 Less than ___ years old
Total: 0
VS: T ___, HR 77-80, BP 117-141/60-84, RR 16, O2Sat 99% on room
air
General: Well-nourished adult male. Appears uncomfortable.
Laying on stretcher.
HEENT: Atraumatic.
Neck: Supple. No meningismus.
Lungs: No respiratory distress.
Extremities: Warm and well-perfused.
Neurologic:
Mental status: Awake and alert. Cooperative with exam. Normal
affect.
Orientation: Oriented to person, place, and time.
Language: Speech fluent with good comprehension. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: PERRL, 3-2mm, bilaterally.
III, IV, VI: EOMs intact bilaterally without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength ___ throughout. No drift.
Sensation: Grossly intact to light touch.
On Discharge:
-------------
General:
VS: T 98.6F, HR 55, BP 126/81, O2Sat 96% on room air
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOMs: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trap Deltoid Biceps Triceps Grip
Right 5 5 5 5 5
Left 5 5 5 5 5
IP Quad Ham AT ___ ___
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
Sensation: Grossly intact to light touch.
Right Radial Puncture Site:
- Dressing clean, dry, intact
- No drainage noted
- Soft, no hematoma
- Palpable pulses
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Do not exceed 4000mg in 24 hours.
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. Fludrocortisone Acetate 0.05 mg PO DAILY
RX *fludrocortisone 0.1 mg 0.5 (One half) tablet(s) by mouth
once daily Disp #*4 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Do not drive while taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
as needed for pain Disp #*60 Tablet Refills:*0
5. Senna 17.2 mg PO QHS:PRN Constipation - Second Line
6. Sodium Chloride 2 gm PO TID
RX *sodium chloride 1 gram 2 tablet(s) by mouth three times a
day Disp #*168 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CAROTID/CEREBRAL BILATY342HEADXA
Diagnostic cerebral angiogram with selective catheterization the following
vessels:
1. Right radial artery
2. Right and left external carotid artery
3. Right and left internal carotid artery
4. Right and left vertebral artery
Three-dimensional rotational angiogram with post processing on a separate
workstation with concurrent positioned supervision
Ultrasound of the right radial artery.
INDICATION: ___ year old man with SAH // eval for aneurysm
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 60 minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received a total of 100 mcg of
fentanyl and 3 mg of Versed and was continuously supervised by the attending
physician
___: OPERATORS: 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.
COMPARISON: None.
PROCEDURE: The patient identified and brought to the neuro radiology suite.
He was transferred to the fluoroscopic table supine moderate anesthesia was
then administered the right wrists and groin was then prepped and draped in
usual sterile fashion. Time-out procedure was performed per institutional
guidelines. The right radial artery was identified using ultrasound.
Infiltration of local anesthetic was then performed. Using a micropuncture set
the radial artery was send the access and a 5 ___ glide radio sheath was
advanced over the microwire the micro was removed and the radial artery
cocktail consisting of 2.5 mg of verapamil 200 mcg of nitroglycerin and 3000
units of heparin were then diluted and given to the radial sheath. The sheath
was then connected to continuous heparinized saline flush. Next a 5 ___
___ 2 catheter was then brought into the field flushed and connected to a
continuous heparinized saline flush and the power injector. This catheter was
then inserted through the sheath and angiogram was performed. Necks and all
038 glidewire was advanced through the catheter under fluoroscopic guidance
this was advanced to the arm and slipped into the descending aorta. The wire
was then withdrawn into the catheter and the age ___ loop was in shaped
and used to select listed vessels above. Vessel patency was confirmed via hand
injection. Standard AP and lateral views as well as 3D rotational view was
performed. Next a diagnostic catheter was removed. ___ band slot in place over
the arteriotomy site on the right radial artery was placed this was
insufflated with 15 cc of air the radius sheath was then removed and there is
no evidence for bleeding over the anteromedial site. Small air was then
removed from the sure band until there is a small amount of postop blood at
that 1 cc of air was then reinjected to the TR band. The patient was removed
from the fluoroscopy table and remain at neurologic baseline without evidence
of thromboembolic complication.
Ultrasound images of the right radial artery were stored in permanent medical
record.
FINDINGS:
Ultrasound of the right radial artery demonstrates a pulsatile single-lumen
non-compressible vessel. There is evidence of needle access into the arterial
lumen.
Right radial artery: There is good distal runoff. There is no evidence of
dissection. Vascular caliber is appropriate for catheterization. No
significant stenosis or tortuosity.
Right vertebral artery: The right vertebral artery fills the vertebrobasilar
system with filling of the right posterior inferior cerebellar artery,
bilateral superior cerebellar artery and bilateral posterior cerebral
arteries. There is a anterior inferior cerebellar artery-posterior inferior
cerebellar artery complex on the left.
Right internal carotid artery the branches are smooth and tapering. No
aneurysms, vascular malformations or early venous drainage. Normal capillary
and venous phases.
Right external carotid artery branches are smooth and tapering. No early
venous drainage or fistulas. Left internal carotid artery branches are smooth
and tapering. No aneurysm vascular malformation or early venous drainage.
Left external carotid artery branches are smooth and tapering without early
venous drainage or fistula.
Left internal carotid artery the branches are smooth and tapering. No
aneurysms, vascular malformations or early venous drainage. Normal capillary
and venous phases.
Left vertebral artery was the vertebrobasilar system. The vertebrobasilar
system has smooth tapering branches without evidence of the aneurysms or
arteriovenous malformations.
IMPRESSION:
1. Unremarkable angiogram. No aneurysms or high flow vascular lesion to
explain this subarachnoid hemorrhage.
I, Dr. ___ , was personally present and participated in the entirety of
the procedure; I have reviewed the above images and agree with the findings as
stated above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SAH now s/p diagnostic angio. // assess for
hydrocephalus, new or increased hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.7 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There has been interval redistribution of subarachnoid hemorrhage with minimal
hemorrhage seen remaining in the basal cisterns and hemorrhage now seen
primarily layering dependently in the sulci along the vertex and posteriorly
along the parietal and occipital lobes. There is no evidence of new
hemorrhage. There is mild mass effect with effacement of the sulci
bilaterally along the vertex.
There is no evidence of fracture, infarction,or mass. The ventricles are
normal in size and configuration.
A submucosal retention cyst is seen in the left maxillary sinus and there is
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 are normal.
IMPRESSION:
1. Interval redistribution of subarachnoid hemorrhage with mild sulcal
effacement. No evidence of hydrocephalus, or herniation.
2. No evidence of new hemorrhage.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC placement today now with intermittent
vtach // ?malpositioned picc Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: None available.
FINDINGS:
A right sided PICC terminates in the low SVC.
The cardiomediastinal and hilar contours are normal. No focal consolidations
are seen. There is no pulmonary edema or pleural abnormality.
IMPRESSION:
Right-sided PICC terminates in the low SVC. No evidence of acute
intrathoracic abnormality.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with R PICC, repositioned this AM; assess
adequate placement for use // ___ year old man with R PICC, repositioned this
AM; assess adequate placement for use
IMPRESSION:
In comparison with the earlier study of this date, the repositioned right
subclavian PICC line extends to the lower SVC. Otherwise, little change.
Radiology Report
EXAMINATION: Cerebral angiogram for 7 day post subarachnoid hemorrhage
follow-up
The following vessels were selectively catheterized and angiography was
performed
Right radial artery
Right vertebral artery
Right common carotid artery
Left common carotid artery
INDICATION: ___ year old man with SAH // eval for aneurysm
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 28minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received doses of fentanyl and
versed which was continuously supervised by the attending physician.
TECHNIQUE: 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.
COMPARISON: Cerebral angiogram ___
PROCEDURE: The patient was identified and brought to the neuroradiology
suite. He was transferred to the fluoroscopic table supine. Moderate sedation
was administered. Bilateral groins and right wrist were prepped and draped in
the standard sterile fashion. A time-out was performed. The right radial
artery was identified using anatomical landmarks. Infiltration of local
anesthetic was performed. Using a micropuncture set, the radial artery was
accessed and a 5 ___ slender glide radial sheath was advanced over the
microwire. The microwire was removed and radial artery cocktail, consisting
of 2.5 mg of verapamil, 200 mcg of nitroglycerin, and 3000 units of heparin,
were diluted and given through the radial sheath. The sheath was then
connected to continuous heparinized saline flush. Next a 5 ___ ___ 2
catheter was brought onto the field, flushed, and connected to continuous
heparinized saline flush the power injector. Catheter was then inserted into
the sheath and angiography was performed. Next a 038 glidewire was introduced
under fluoroscopic guidance this is advanced to the arm in selected into the
right vertebral artery. The catheter was advanced over the wire and the wire
was withdrawn. Vessel patency was confirmed via hand injection. Standard AP
and lateral views were obtained. Next the catheter was withdrawn and the wire
was reinserted and bounced off the aortic valve into the innominate artery and
the catheter followed shape in the ___ hook. The wire was withdrawn and
the catheter shaped into the right common carotid artery. Vessel patency was
confirmed via hand injection. Standard AP and lateral views were obtained as
well as high magnification transorbital and oblique views. Next the catheter
was withdrawn selected the left common carotid artery. Vessel patency was
confirmed via hand injection. Standard AP and lateral views were obtained as
well as high magnification transorbital and oblique views. Next the
diagnostic catheter was removed. A TR band selected and placed over the
arteriotomy site of the right radial artery. This was insufflated to 15 cc of
air. The radial sheath was then removed and there is no evidence of bleeding
for the arteriotomy site. A small amount of air was removed from the TR band
until there was a small amount of pulsatile blood. At that 1 cc of air was
reinjected into the TR band. Pulse oximetry was placed on the index finger
and the ulnar artery was compressed to confirm patent hemostasis. 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:
Right radial artery: Vessel caliber smooth regular. There is filling of the
radial artery retrograde filling into the brachial artery. There is filling
into the ulnar artery, anterior, and posterior interosseous arteries. No
evidence of vasospasm or occlusion.
Right vertebral artery: Vessel caliber smooth and regular. There is filling
of the right vertebral artery filling the right posterior inferior cerebral
artery. There is retrograde filling into the left vertebral artery.
Bilateral anterior-inferior cerebellar arteries fill with the left being
dominant. There is bilateral superior cerebellar artery as well as bilateral
posterior cerebral arteries and their distal territories. No aneurysms or
AVMs are identified.
Right Common carotid artery: Vessel caliber smooth and regular. There is
filling of the anterior and middle cerebral arteries and their distal
territory. There is filling across the anterior communicating artery into the
contralateral A2. The ophthalmic artery is patent. Is no evidence of
aneurysms or AVMs.
Left common carotid artery: Vessel caliber smooth and regular. There is
filling of the anterior and middle cerebral arteries and their distal
territory. There is flash filling across the anterior communicating artery
into the contralateral A2. The ophthalmic artery is patent. No evidence of
aneurysms or AVMs.
IMPRESSION:
1. Negative cerebral angiogram
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified
temperature: 98.0
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | Discharge Instructions: ___
Care Of The Puncture Site:
- You will have a small bandage over the puncture site.
- Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
- Keep the puncture site clean with water and soap and dry it
carefully.
- You may cover the puncture site with a Band-Aid if you wish.
Activity:
- You may take leisurely walks and slowly increase your activity
at your once pace once you are symptom free at rest. Don't try
to do too much all at once.
- We recommend that you avoid heavy lifting, running, climbing,
and other strenuous exercise until your follow-up.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for at least 6 months.
- No driving while taking narcotics or any other sedating
medications.
- If you experienced a seizure, you are not allowed to drive by
law.
Medications:
- Resume your normal medications and begin new medications as
directed.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Please do not take any blood thinning medications such as
aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin),
etc. until cleared by your neurosurgeon.
What You ___ Experience:
- Mild to moderate headaches that last several days to a few
weeks.
- Fatigue is very normal.
- Difficulty with short-term memory.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try an over-the-counter
stool softener if needed.
Please Call Your Neurosurgeon At ___ For:
- Fever greater than 101.4 degrees Fahrenheit.
- Severe pain, redness, swelling, or drainage from the puncture
site.
- Severe headaches not adequately relieved with prescribed pain
medications.
- Extreme sleepiness or not being able to stay awake.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
- Nausea or vomiting.
- Seizures.
- Blood in your urine or stool.
- Constipation.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden severe headaches with no known reason.
- Sudden dizziness, trouble walking, or loss of balance or
coordination.
- Sudden confusion or trouble speaking or understanding.
- Sudden weakness or numbness in the face, arms, or legs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Latex / pollen
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo F with history of non-epileptic seizure disorder
complicated by multiple falls who presented with seizure and
fall and is being admitted for urinary tract infection.
Patient reports daily seizures for years. In the last 24 hours,
patient has had five seizure-like episodes. During an episode
early this morning she fell out of bed and landed on her back.
Since then, she has had lumbar back pain that radiates to her
buttocks. She is unable to describe the pain.
In the ED, initial vital signs were 97.9, 110, 128/87, 18, 99%
RA. Labs were remarkable for WBC 22.7 with left shift, Na 147,
HCO3 21, and a positive UA. CT L-spine without fracture. Case
was discussed with outpatient neurologist. She recommended
against formal Neurology consult. She recommended discharge home
with Neurology ___ once cleared from a medical standpoint.
Patient was admitted to Medicine for "pyelonephritis."
On transfer, vitals were 98.9, 102, 123/77, 16, 100% RA.
On the floor, patient reports that she is feeling fine. When
asked about seizures, patient perseverates on ongoing issues
with her outpatient neurologist. With regards to fall, she
denies head strike and loss of consciousness. She denies lower
extremity weakness, paresthesias, fecal or urinary incontinence,
and saddle anesthesia. With regards to urinary symptoms, patient
denies dysuria but reports frequency and urgency for the last
several days. Otherwise, she is feeling well at this time. She
denies fever, chills, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, and constipation. She does
have baseline palpitations.
Past Medical History:
- Hypertension
- Asthma
- Obstructive sleep apnea
- Non-epileptic seizures
- Migraine headaches
- Shoulder pain
- Low back pain s/p "trauma with grocery cart" in ___
- Anxiety
- Developmental disorder NOS
Social History:
___
Family History:
There is no history of seizures or epilepsy. Mother with
___.
Physical Exam:
ADMISSION:
Vitals: 99.5, 93, 112/74, 18, 98% RA
GENERAL: Well-appearing female in no distress
HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear
NECK: Supple, ROM WNL
CARDIAC: Tachycardic, nl S1/S2, no MRG
LUNG: CTAB, no wheezes/rales/rhonchi
ABDOMEN: Suprapubic tenderness, non-distended, no
rebound/guarding, normoactive bowel sounds
BACK: No spinous tenderness, no flank tenderness
EXTREMITIES: Warm, well-perfused, no cyanosis/clubbing/edema
NEURO: AAOx3, CN II-XII intact, strength and sensation intact
SKIN: No concerning lesions
DISCHARGE:
Vitals- 97.9 (Tm 99.5) 129/85 85 (85-93) 18 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Labs: Reviewed, please see below
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-22.7*# RBC-4.95 Hgb-15.3 Hct-45.5
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.7 Plt ___
___ 05:00PM BLOOD Neuts-86.1* Lymphs-9.1* Monos-4.2 Eos-0.4
Baso-0.3
___ 05:29PM BLOOD Neuts-87.0* Lymphs-8.1* Monos-3.9 Eos-0.8
Baso-0.1
___ 05:00PM BLOOD Plt ___
___ 05:29PM BLOOD Plt ___
___ 05:29PM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-147*
K-3.7 Cl-110* HCO3-21* AnGap-20
___ 05:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:41PM BLOOD Lactate-1.6
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-14.3* RBC-4.49 Hgb-13.7 Hct-41.0
MCV-92 MCH-30.5 MCHC-33.4 RDW-14.9 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-142
K-3.3 Cl-104 HCO3-22 AnGap-19
___ 07:10AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.4
MICRO:
___ 07:10PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 07:10PM URINE RBC-3* WBC-11* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
___ 07:10PM URINE CastHy-5*
___ 07:10PM URINE AmorphX-RARE
___ 07:10PM URINE Mucous-FEW
IMAGING:
CXR (___): Clear per my read.
CT L-spine (___): No fracture. No orthopedic hardware in the
lumbar spine. Mild disk bulge at L4-5. Unchanged from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Zonisamide 500 mg PO QPM
3. HydrOXYzine 10 mg PO DAILY:PRN anxiety
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Multivitamins 1 TAB PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. melatonin 3 mg oral QHS:PRN insomnia
10. Calcium Carbonate 500 mg PO BID
11. Sertraline 25 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Riboflavin (Vitamin B-2) 100 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
3. Calcium Carbonate 500 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. HydrOXYzine 10 mg PO DAILY:PRN anxiety
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Riboflavin (Vitamin B-2) 100 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Sertraline 25 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Zonisamide 500 mg PO QPM
15. melatonin 3 mg oral QHS:PRN insomnia
16. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Please continue up to and on ___
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every twelve (12) hours Disp #*12 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infection, uncomplicated
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with increased seizure frequency, pain in low back
pain at what appears to be a surgical site // evaluate for acute process
COMPARISON: ___.
FINDINGS:
PA and lateral chest radiographs. Lung volumes are low. However there is no
focal consolidation or pleural effusion or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: History: ___ with increased seizure frequency, pain in low back
pain at what appears to be a surgical site.
TECHNIQUE: Routine CT of the lumbar spine with sagittal and coronal
reconstructions.
DOSE: DLP 856.92 mGycm; CTDI 31.92mGy
COMPARISON: CT - lumbar spine, ___.
FINDINGS:
The vertebral bodies are normal in height and alignment. There is no
fracture. There is no orthopedic hardware. To the extent that the contents of
the spinal canal can be evaluated, no high-grade canal stenosis is seen.
However, again noted is mild bulging at L4-5, unchanged from ___. The
included portions of the abdomen are normal. There is a probable physiologic
cyst in the right adnexa (3:88).
IMPRESSION:
No acute fracture. No orthopedic hardware in the lumbar spine. Mild disk bulge
at L4-5, unchanged from ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Seizure
Diagnosed with URIN TRACT INFECTION NOS, OTHER CONVULSIONS, SPRAIN LUMBAR REGION, UNSPECIFIED FALL
temperature: 97.9
heartrate: 110.0
resprate: 18.0
o2sat: 99.0
sbp: 128.0
dbp: 87.0
level of pain: 2
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure treating you at ___
___. You were admitted with concern for your urinary tract
infection. You were started on an antibiotic to treat and were
monitored overnight for concerning symptoms. The initial lab
value which suggested infection improved in your morning
bloodwork. Your PCP was contacted, informed of your admission,
and will see you in ___ to ensure resolution of your
symptoms. Please continue the antibiotic as prescribed.
Wishing you the best of health,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
Right knee injection
History of Present Illness:
___ year old Male recently discharged from ___ for vertebral
osteomyelitis with cauda equine syndrome for which ___ underwent
surgical debridement and long term antibiotics, which ___
finished 1 week prior to admission. ___ now presents with low
back pain radiating down his right leg, accompanied with right
leg weakness. The patient also notes fecal incontinence , but
this has been improving since the surgery in fact. ___ also notes
unchanged right knee pain. The right leg issues are chronic
since a lymph node dissection several years ago for multiple
myeloma. The patient went to his PCP who was concerned that the
patient either had recurrence of his abscess or had a
malignancy.
In the ___ ED the initial vitals were 96.7, 64, 104, 14, 99%.
The patient had a spinal MRI as below, and then was seen by
neurosurgery consult, who felt there were no acute issues, and
that they patient should get a ___ eval and could likely go to a
SNF. Unfortunately his insurance requires a prior-authorization
which cannot be completed over the weekend, and is too painful
and weak to leave. The patient was empirically treated with
vancomycin.
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
GEN: NAD, Obese
HEENT: MMM
PUL: No increased work of breathing
COR: RRR, S1/S2
ABD: NT/ND
EXT: Right leg lymphedema. Scattered hematomas left forearm
NEURO: CAOx3, no right knee effusion
Pertinent Results:
___ 02:00PM BLOOD WBC-2.1* RBC-2.63* Hgb-8.2* Hct-27.7*
MCV-105* MCH-31.2 MCHC-29.6* RDW-17.1* RDWSD-65.8* Plt Ct-61*
___ 02:00PM BLOOD Neuts-59.7 ___ Monos-13.3*
Eos-5.2 Baso-0.9 AbsNeut-1.26* AbsLymp-0.44* AbsMono-0.28
AbsEos-0.11 AbsBaso-0.02
___ 02:00PM BLOOD ___ PTT-32.7 ___
___ 02:00PM BLOOD Glucose-57* UreaN-60* Creat-1.3* Na-142
K-5.4 Cl-108 HCO3-25 AnGap-9*
___ 02:00PM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
___ 02:00PM BLOOD CRP-9.0*
___ 02:23PM BLOOD Lactate-0.9
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 7:05 pm BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending):
FEMUR (AP & LAT) RIGHT Study Date of ___ 5:49 ___
IMPRESSION:
1. No acute fracture or dislocation.
2. Severe tricompartmental degenerative changes of the right
knee.
MR ___ & W/O CONTRAST Study Date of ___ 6:24 ___
IMPRESSION:
1. Stable discitis osteomyelitis L1-L2 level.
2. Stable discitis osteomyelitis L3-L4 level, minimally improved
epidural
phlegmon, interval laminectomy. New posterior paraspinal soft
tissue
peripherally enhancing fluid may be postsurgical, infection is
difficult to exclude.
3. Moderate central canal narrowing L3-L4 level, similar.
4. Multilevel foraminal narrowing, as above.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lactulose 30 mL PO TID
2. Polyethylene Glycol 17 g PO BID
3. Vitamin A ___ UNIT PO DAILY
4. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
5. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
6. Gabapentin 600 mg PO QHS
7. Multivitamins W/minerals 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
9. Rifaximin 550 mg PO BID
10. Sarna Lotion 1 Appl TP QID:PRN itching
11. Vancomycin Oral Liquid ___ mg PO BID
12. Vitamin D 800 UNIT PO DAILY
13. LOXO-101 Study Med 100 mg PO BID
14. Nadolol 20 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Apply 1 patch Daily Disp #*15 Patch Refills:*1
2. Nortriptyline 10 mg PO QHS
RX *nortriptyline 10 mg 1 tab by mouth nightly Disp #*30 Capsule
Refills:*3
3. Gabapentin 600 mg PO TID
4. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
5. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
6. Lactulose 30 mL PO TID
7. LOXO-101 Study Med 100 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Nadolol 20 mg PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours as needed
Disp #*45 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO BID
12. Rifaximin 550 mg PO BID
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Spironolactone 25 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Vitamin A ___ UNIT PO DAILY
17. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lumbar radiculopathy
Knee osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: History: ___ with back pain, R leg weaknessIV contrast to be
given at radiologist discretion as clinically needed// Eval for acute
pathology Eval for acute pathology
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: MRI cervical, thoracic and lumbar spine with and without contrast
___
MRI lumbar spine without contrast ___.
FINDINGS:
Again seen are findings of discitis osteomyelitis at L1-L 2, L3-L4 levels.
At L1-L2, degree of edema at L1, L2 vertebral bodies, degree of vertebral body
enhancement is stable. Degree of disc space enhancement is slightly improved.
At L4-5 level, degree of extensive vertebral body edema, endplate destruction,
enhancement is similar.
Extensive anterior, and lateral paraspinal edema is similar.
Interval L3, L4 laminectomy. Posterior paraspinal peripherally enhancing
fluid collections are new since prior,, largest pocket measures 4.6 cm x 2.1
cm x 1.7 cm, is superficial and posterior to the L1, L2 spinous processes,
these findings may be postsurgical, superimposed infection is difficult to
exclude.
Circumferential epidural phlegmon is again seen at L3, L4 level, minimally
improved, without definite abscess collection. Moderate effacement of thecal
sac at L3-L4 level secondary to epidural phlegmon, probably similar to prior.
Multilevel degenerative changes, disc space narrowing, diffuse disc bulges,
posterior element hypertrophic changes.
At T12-L1, patent central canal, patent foramina.
At L1-2, mild central canal narrowing, mild bilateral foraminal narrowing.
At L2-L3, mild central canal narrowing, mild bilateral foraminal narrowing.
At L3-L4, moderate central canal narrowing, predominantly from epidural
phlegmon. Severe narrowing of bilateral foramina, combination of degenerative
changes, disc space height loss and inflammatory changes.
At L4-5, mild central canal narrowing. Moderate bilateral foraminal
narrowing.
At L5-S1, patent central canal. Mild left foraminal narrowing.
Mild-to-moderate right foraminal narrowing.
Edema bilateral ileo psoas muscles, similar.
IMPRESSION:
1. Stable discitis osteomyelitis L1-L2 level.
2. Stable discitis osteomyelitis L3-L4 level, minimally improved epidural
phlegmon, interval laminectomy. New posterior paraspinal soft tissue
peripherally enhancing fluid may be postsurgical, infection is difficult to
exclude.
3. Moderate central canal narrowing L3-L4 level, similar.
4. Multilevel foraminal narrowing, as above.
Radiology Report
INDICATION: History: ___ with right thigh/knee pain// r/o acute process or
abnormality
TECHNIQUE: Right femur, two views and right knee, three views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation. No concerning lytic or sclerotic osseous
abnormality. Mild degenerative changes of the right femoroacetabular joint
with joint space narrowing and osteophyte formation. Severe tricompartmental
degenerative changes in the right knee are demonstrated with bone-on-bone
contact, marked osteophyte formation, subchondral sclerosis, and medial
subluxation of the distal femur relative to the tibia. Small suprapatellar
joint effusion is noted. Diffuse soft tissue swelling is seen about the right
thigh. Moderate vascular calcifications and clips are noted projecting over
the right inguinal region.
IMPRESSION:
1. No acute fracture or dislocation.
2. Severe tricompartmental degenerative changes of the right knee.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Low back pain
temperature: 96.7
heartrate: 64.0
resprate: 14.0
o2sat: 99.0
sbp: 104.0
dbp: nan
level of pain: 4
level of acuity: 3.0 | Mr. ___,
You were admitted to ___ with back, leg, and knee pain. Much
of the pain appears to be driven by degenerative changes in your
lower spine as well as post-infectious inflammation. We do not
think there is an active infection there, however. Otherwise the
arthritis in your knee is likely contributing as well. You had a
steroid injection in the knee joint to try to help with this in
addition to starting some new medication to try to help with the
pain. Continuing to work with physical therapy will also be very
helpful. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Sulfa (Sulfonamide Antibiotics) / trimethoprim
Attending: ___.
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
ORIF of R distal femur ___
History of Present Illness:
Mr. ___ is a ___ year old man with metastatic pancreatic
cancer with known R femur metastases s/p XRT who presents with a
R femur fracture. He states that he was closing a window and
lost his balance. He did not fall on the leg but his legs gave
out and he landed on a nearby chair. He had sudden pain in the
right leg. He went to ___ where imaging showed a right
distal femoral fracture. He was transferred to ___.
In the ER, initial vitals: 98.7 85 177/81 20 94%. He was seen
by orthopedics who recommended full femur films and NPO for
possible surgery.
On the floor, he complains of ___ right leg pain. He
previously had pain in this leg due to the radiation and took 2
percocet every 6 hours which controlled it well. He denies any
chest pain, shortness of breath, abdominal pain, nausea,
vomiting, lightheadedness, dizziness.
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 MEDICAL HISTORY:
1. Coronary artery disease status post three-vessel CABG ___.
2. COPD.
3. Hypertension.
4. Asthma.
5. History of urinary infection.
6. Hypothyroidism.
7. Status post cataract surgery in ___.
8. Status post inguinal hernia repair in ___.
PAST ONCOLOGIC HISTORY:
___ initially presented in ___ with painless
jaundice. On ___ he underwent pancreaticoduodenectomy.
Pathology showed a pT3N0, grade 2 adenocarcinoma measuring 3.2 x
2.5 x 2.0 cm; 0 of 13 lymph nodes were involved. Margins were
negative with the closest margin 3 mm. There was no
lymphovascular invasion. Perineural invasion was seen.
Preoperative ___ measured 3039 U/mL. Postoperative ___
was 81 U/mL. Mr. ___ completed six cycles adjuvant
gemcitabine as of ___. In ___ he presented to his PCP
with right thigh pain, and imaging was consistent with bone
metastases involving the bilateral hips and thoracic spine. He
received palliative radiation to the right femur ___.
Social History:
___
Family History:
The patient's father died at ___ years with COPD and peptic ulcer
disease. His mother died at ___ years of unknown causes. A
nephew died at ___ years of testicular cancer. The patient's
sister and four children are without health concerns
Physical Exam:
ADMISSION:
VS: T98.9 BP 182/86 HR 82 RR 20 99% RA
GENERAL: alert and oriented, NAD, appears thin and chronically
ill
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: Swelling of the right thigh. 2+ dorsalis pedis/
posterior tibial pulses.
NEURO: Sensation intact in the right leg and foot.
DISCHARGE:
VS: Tc 98.4 76 110/64 18 92/RA
GENERAL: NAD, alert, interactive
HEENT: neck supple
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB, distant breath sounds, no crackles or wheezes
Abd: BS+, soft, NT, ND
Extremities: R thigh with surgical dressing c/d/i, right thigh
with several bright red hematomas, R ankle with edema improved,
R knee in ace bandage, compression stockings b/l
Pertinent Results:
LABS ON ADMISSION ___ 02:35AM BLOOD WBC-11.4*# RBC-3.78* Hgb-11.6* Hct-36.7*
MCV-97 MCH-30.6 MCHC-31.5 RDW-15.2 Plt ___
___ 02:35AM BLOOD Neuts-81.6* Lymphs-9.6* Monos-7.4 Eos-0.9
Baso-0.5
___ 02:35AM BLOOD ___ PTT-33.3 ___
___ 02:35AM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-142
K-4.2 Cl-109* HCO3-27 AnGap-10
INTERIM:
___ 05:01AM BLOOD TSH-5.1*
___ 11:30AM BLOOD ALT-11 AST-20 AlkPhos-100 TotBili-0.4
DISCHARGE:
___ 06:00AM BLOOD WBC-10.6 RBC-2.95* Hgb-8.9* Hct-28.7*
MCV-97 MCH-30.3 MCHC-31.2 RDW-15.1 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-100 UreaN-45* Creat-1.3* Na-135
K-4.0 Cl-106 HCO3-25 AnGap-8
___ 06:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.1
MICRO
URINE CULTURES NEGATIVE
SPUTUM
___ 5:30 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
THIS IS A CORRECTED REPORT (___).
Reported to and read back by ___ ___ ___) ___ AT
12:40PM.
SPARSE GROWTH Commensal Respiratory Flora.
NO STAPHYLOCOCCUS AUREUS ISOLATED.
.
PREVIOUSLY REPORTED AS POSITIVE FOR STAPH AUREUS (SPARSE
GROWTH)
___.
.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
***BLOOD CULTURES - FINAL RESULTS PENDING AT DISCHARGE***
Imaging:
PELVIS AP
IMPRESSION:
Status post ORIF of a distal right femoral fracture. The
visualized proximal aspect of the hardware is without evidence
of complication. Fracture alignmentis not evaluated as the
distal femur was not included on these radiographs.
CT PELVIS
IMPRESSION:
1. 17 x 7 mm sclerotic lesion in the left iliac crest, not
significantly
changed in size compared to the CT from ___. Unchanged
2 mm
sclerotic lesion in the posterior acetabulum, correlating to an
area of focal tracer uptake on the recent bone scan. Both of
these lesions are highly concerning for metastases, possibly
related to known pancreatic
adenocarcinoma, although given the sclerotic nature of these
lesions,
metastatic prostate carcinoma cannot be excluded. Correlation
with PSA is
recommended.
2. Status post ORIF of a distal right femoral fracture, with
partial
visualization of the hardware. Postoperative changes along the
anterior aspectof the right thigh.
CXR
IMPRESSION:
There has been substantial progression of the minimal right
basal opacity
currently demonstrated is a large consolidation in conjunction
with smallerleft basal opacity, findings concerning for
multifocal bibasal pneumoniaversus massive aspiration. Mild
vascular enlargement is present. Post sternotomy wires are
unremarkable. Upper lungs are essentially clear. Smallamount of
pleural effusion is most likely present. There is no
pneumothorax
___ CXR
FINDINGS: Cardiomediastinal contours are stable. Interval
improvement in bibasilar opacities, most likely due to resolving
atelectasis with adjacent small pleural effusions. No new foci
of consolidation are identified to suggest a new source of
infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Lisinopril 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Omeprazole 40 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Levothyroxine Sodium 37.5 mcg PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation q6H PRN SOB
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Simvastatin 40 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Tiotropium Bromide 1 CAP IH DAILY
11. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral tid w/meals
12. Acetaminophen 650 mg PO Q8H
13. CefePIME 2 g IV Q12H Duration: 8 Days
14 day course, last day ___. Enoxaparin Sodium 40 mg SC DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q4 hrs prn Disp #*50
Capsule Refills:*0
16. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth q12 hrs
Disp #*16 Tablet Refills:*0
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
18. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
19. albuterol sulfate 90 mcg/actuation inhalation q6H PRN SOB
20. Docusate Sodium 100 mg PO BID
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Senna 8.6 mg PO BID:PRN constipation
23. Bisacodyl ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Distal femur fracture
Healthcare-associated pneumonia
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R.
INDICATION: Surgical monitoring
COMPARISON: No comparison
IMPRESSION:
8 spot film images document right femur or shaft stabilization. No
radiologist was present at the procedure.
Radiology Report
INDICATION: ___ year old man with pancreatic ca // pelvic lesion?
TECHNIQUE: Pelvis, 2 images total.
COMPARISON: Pelvic/hip radiographs from ___.
FINDINGS:
The patient is status post interval placement of a right femoral
intramedullary rod with a proximal interlocking screw. There are overlying
skin staples. The known distal femoral fracture is not included on the
provided radiographs. The femoroacetabular joints are congruent. There is
mild superior joint space narrowing along both hips. Degenerative changes are
noted along the lower lumbar spine. A 7 mm radiodense structure projects over
the lower right aspect of the pelvis, correlating to a coarse calcification
just medial to the right inguinal canal on the CT from ___.
IMPRESSION:
Status post ORIF of a distal right femoral fracture. The visualized proximal
aspect of the hardware is without evidence of complication. Fracture alignment
is not evaluated as the distal femur was not included on these radiographs.
Radiology Report
INDICATION: ___ year old man with pancreatic ca // pelvic lesions
TECHNIQUE: MDCT axial images were acquired through the pelvis without
administration of intravenous contrast material. Multiplanar formats were
performed.
DOSE: DLP: 291 mGy-cm (abdomen and pelvis.
COMPARISON: Abdominal/pelvic CT studies from ___ and ___.
FINDINGS:
The patient is status post recent ORIF of the right femur, with postoperative
subcutaneous and intramuscular edema as well as foci of air seen along the
anterior proximal aspect of the right thigh. The right femoral intramedullary
rod and proximal interlocking screw are intact.
Within the left iliac crest, there is a predominantly sclerotic lesion
measuring 17 x 7 mm, similar in size compared to the prior CT from ___, allowing for differences in imaging technique. There is increased
adjacent thinning along the posterior cortex of the iliac wing (03:20). This
lesion corresponds to an area of focal tracer uptake on the bone scan from ___. Along the left posterior acetabulum, there is a 2 mm sclerotic
lesion, not significantly changed, which may correlate to a second area of
subtle area of tracer uptake on the prior bone scan (3:89, 7:91). No
additional suspicious lytic or blastic lesions are identified. There are mild
degenerative changes at both hip joints. There also moderate degenerative
changes along the lower lumbar spine, particularly involving the facet joints.
Aortic and bilateral iliac artery calcifications are noted. There is colonic
diverticulosis, without evidence of diverticulitis. There are moderate sized
bilateral inguinal hernias, not significantly changed. A left renal cyst is
partially imaged.
IMPRESSION:
1. 17 x 7 mm sclerotic lesion in the left iliac crest, not significantly
changed in size compared to the CT from ___. Unchanged 2 mm
sclerotic lesion in the posterior acetabulum, correlating to an area of focal
tracer uptake on the recent bone scan. Both of these lesions are highly
concerning for metastases, possibly related to known pancreatic
adenocarcinoma, although given the sclerotic nature of these lesions,
metastatic prostate carcinoma cannot be excluded. Correlation with PSA is
recommended.
2. Status post ORIF of a distal right femoral fracture, with partial
visualization of the hardware. Postoperative changes along the anterior aspect
of the right thigh.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancereatic ca, now febrile, leukocytosis,
cough // PNA, effusion, or other acute process
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
There has been substantial progression of the minimal right basal opacity
currently demonstrated is a large consolidation in conjunction with smaller
left basal opacity, findings concerning for multifocal bibasal pneumonia
versus massive aspiration. Mild vascular enlargement is present. Post
sternotomy wires are unremarkable. Upper lungs are essentially clear. Small
amount of pleural effusion is most likely present. There is no pneumothorax
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: Right PICC line placement
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
There has been interval placement of a right PICC line which terminates in the
mid to distal SVC. There is no pneumothorax. The patient is status post median
sternotomy with intact sternotomy wires. There is slightly worsening airspace
disease at the right lung base. Small bilateral pleural effusions are
unchanged. The heart and mediastinum are within normal limits despite the
projection. No bony or soft tissue abnormality is identified.
IMPRESSION:
Right PICC line in satisfactory position in the mid to distal SVC.
Slightly worsening airspace disease at the right lung base.
Stable small bilateral pleural effusions.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ on
the telephone on ___ at 1:10 ___, 2 minutes after discovery of the
findings.
Radiology Report
COMPARISON: ___ radiograph.
FINDINGS: Cardiomediastinal contours are stable. Interval improvement in
bibasilar opacities, most likely due to resolving atelectasis with adjacent
small pleural effusions. No new foci of consolidation are identified to
suggest a new source of infection.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg pain
Diagnosed with PATHOLOGIC FX FEMUR NECK, SECONDARY MALIG NEO BONE, MALIG NEO PANCREAS NOS
temperature: 98.7
heartrate: 85.0
resprate: 20.0
o2sat: 94.0
sbp: 177.0
dbp: 81.0
level of pain: 8
level of acuity: 2.0 | Dear Mr. ___,
It was pleasure taking care of you during your hospitalization
at ___. You were admitted to the hospital with leg pain and
were found to have a fracture of your right femur, related to
your bone metastases. You had surgery to fix the fracture. You
had fevers and were started on antibiotics for pneumonia.
We wish you the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year-old male s/p laproscopic cholecystectomy
on ___
for gallstone pancreatitis who presents with fevers and
worsening abdominal pain. The patient notes that since
discharge following his laparoscopic
cholecystectomy, he has had intermittent nausea and dull
epigastric pain. He has been constipated and bloated, taking
laxatives and suppositories with subsequent watery diarrhea. He
continued to feel bloated and constipated. On the evening prior
to admission, he began to experience worsening RUQ pain. He was
having poor oral intake. Had a fever of 100.9 one day prior to
admission.
Past Medical History:
Past Medical History: Hypertension, Hyperlipidemia
Past Surgical History: lap chole ___, R Hip replacement in
___
Social History:
___
Family History:
N/C
Physical Exam:
On admission:
Vitals: 98.2 F, HR 90, BP 159/99, RR 16 97%
GEN: A&O, NAD
HEENT: No scleral icterus
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft and protuberent, mildly tender to palpation in RUQ, no
rebound or guarding,hypoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS 98.9, 67, 124/77, 14, 99% RA
Gen: NAD, AAO x 3
Abdomen: Soft, non-tender, active BS.
Pertinent Results:
___ 05:00AM BLOOD WBC-9.3
___ 04:57AM BLOOD WBC-11.4* RBC-4.52* Hgb-14.4 Hct-41.1
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.4 Plt ___
___ 11:05AM BLOOD WBC-12.7*
___ 05:50AM BLOOD WBC-12.0* RBC-4.74 Hgb-14.7 Hct-42.9
MCV-91 MCH-31.1 MCHC-34.3 RDW-12.2 Plt ___
___ 12:00AM BLOOD WBC-11.3* RBC-5.31 Hgb-16.6 Hct-47.6
MCV-90 MCH-31.2 MCHC-34.9 RDW-12.5 Plt ___
___ 12:00AM BLOOD Neuts-75.8* Lymphs-15.9* Monos-5.3
Eos-2.7 Baso-0.4
___ 04:57AM BLOOD Plt ___
___ 05:50AM BLOOD Plt ___
___ 12:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-86 UreaN-6 Creat-1.0 Na-137 K-4.7
Cl-101 HCO3-26 AnGap-15
___ 04:57AM BLOOD Glucose-123* UreaN-7 Creat-1.0 Na-134
K-4.3 Cl-101 HCO3-30 AnGap-7*
___ 05:50AM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-135
K-3.8 Cl-98 HCO3-31 AnGap-10
___ 12:00AM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-136
K-3.6 Cl-95* HCO3-30 AnGap-15
___ 05:00AM BLOOD ALT-65* AST-26 AlkPhos-100 TotBili-0.4
___ 04:57AM BLOOD ALT-68* AST-24 AlkPhos-95 TotBili-0.3
___ 05:50AM BLOOD ALT-91* AST-31 AlkPhos-104 Amylase-49
TotBili-0.4
___ 12:00AM BLOOD ALT-106* AST-47* AlkPhos-123 TotBili-0.6
___ 05:00AM BLOOD Lipase-69*
___ 04:57AM BLOOD Lipase-73*
___ 05:50AM BLOOD Lipase-55
___ 12:00AM BLOOD Lipase-60
___ 05:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.3
___ 04:57AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3
___ 05:50AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.4
IMAGING:
___ CT abdomen and pelvis with contrast
1. No complications of cholecystectomy.
2. Persistent peripancreatic stranding compatible with
pancreatitis.
Although the overall volume of peripancreatic ascites is
similar, there is mild enhancement of fluid in the paracolic
gutter compatible with progressive organization of the fluid.
There is no drainable fluid collection at this time.
Medications on Admission:
Imiq___ 5% cream for genital warts, losartan 100mg ___ daily
nystatin-triamcinolone cream for perianal itching, simvastatin
20mg ___ 81 mg ___ daily, Vit D
Discharge Medications:
1. Aspirin 81 mg ___ DAILY
2. Losartan Potassium 100 mg ___ DAILY
3. Simvastatin 20 mg ___ DAILY
4. Acetaminophen 325-650 mg ___ Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with abdominal pain and recent laparoscopic
cholecystectomy.
COMPARISON: ___.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after the
administration of intravenous contrast. Oral water soluble contrast. Images
were displayed in multiple planes.
FINDINGS: The visualized lung bases are clear. The liver enhances
homogeneously. There is no focal liver lesion. Portal and hepatic veins are
patent. Clips are seen in the gallbladder fossa from recent cholecystectomy.
There is no collection in the operative bed. Diffuse peripancreatic stranding
is again seen. Overall, the amount of perihepatic ascites is similar compared
with ___. However, there is progressive organization of the fluid with
a tiny enhancing foci of fluid in the left paracolic gutter (2:31). The
pancreatic parenchyma enhances homogeneously. The spleen and adrenal glands
are unremarkable. The kidneys enhance symmetrically and excrete contrast
promptly. A hypodensity in the mid left kidney is unchanged. There is no
mesenteric or retroperitoneal adenopathy.
PELVIS: The remainder of the bowel is normal in caliber and appearance. A
normal caliber appendix is seen in the right lower quadrant. There is no free
pelvic fluid. The bladder and prostate are normal. The pelvis is obscured by
streak artifact from a right total hip prosthesis. A left-sided inguinal
hernia contains fat.
BONE WINDOWS: There are no concerning lytic or sclerotic bone lesions.
IMPRESSION:
1. No complications of cholecystectomy.
2. Persistent peripancreatic stranding compatible with pancreatitis.
Although the overall volume of peripancreatic ascites is similar, there is
mild enhancement of fluid in the paracolic gutter compatible with progressive
organization of the fluid. There is no drainable fluid collection at this
time.
Findings were discussed in person with Dr. ___ after image
interpretation at 1:30 a.m.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with CHRONIC PANCREATITIS, HYPERTENSION NOS
temperature: 98.2
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 159.0
dbp: 99.0
level of pain: 3
level of acuity: 3.0 | You were admitted to ___ on
___ with complaints of fevers and abdominal pain. A CT scan
of your abdomen and pelvis showed some fluid surrounding your
pancreas, but not complications of your prior cholecystectomy.
As a result, you were admitted to the inpatient floor for
further management and observation.
You were initially were given bowel rest while your liver
function tests were checked on a daily basis. As the levels
decreased, your diet was advanced slowly to a regular, solid
food diet.
At this time, you have recovered well and are being discharged
with the following instructions.
o Please resume taking your prior home medications. If you have
pain, you may take Tylenol or ibuprofen as needed.
o A follow-up appointment with the Surgery team has been
arranged for you (see below). Please contact the office if you
have any questions or concerns.
o If you experience any of the below warning signs, please seek
immediate medical attention and/or go to your local Emergency
Department. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues /
Morphine / Flagyl / Codeine / Remicade / Iodine-Iodine
Containing / Purinethol / Biaxin / Cipro / Augmentin
Attending: ___.
Chief Complaint:
Nausea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman ___ Crohns s/p ileal
resection x2 (___), c/b recurrent SBO managed
conservatively. She states that her symptoms started 2 days ago,
with cessation of bowel movements and flatus. She then developed
severe nausea, moderate RLQ pain, and abdominal distention.
These
symptoms are all consistent with her previous obstructive
episodes. She denies vomiting. These symptoms started following
dinner with matzos and green beans during a trip to ___.
She returned to ___ when her symptoms worsened, and
presented to ___. A CT there showed a transition point in the
RLQ, and she was transferred to ___. ACS was consulted for
further management.
Upon initial assessment, Ms. ___ denies fever, chills,
vomiting, chest pain, shortness of breath, or dysuria. She
endorses nausea and abdominal pain.
Past Medical History:
Past Medical History:
- Crohn's disease
- Kidney stones: ___ episodes of flank pain over past ___.
Lithotripsy in ___
- Fibromyalgia: Dx in ___
- Neuro-cardiogenic syncopy dx in ___
- HTN
-Ovarian cysts
Past Surgical History:
-Ileal resection ___
-TAH, appendectomy ___
-Cataracts
Social History:
Marital status: Married
Children: Yes: 3, sons and one daughter
Lives with: ___
Work: ___
Tobacco use: Former smoker
Tobacco Use quit ___ years ago
Comments:
Alcohol use: Present
drinks per week: 2
Alcohol use week
comments:
Depression done
Screening:
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: Activities: trainer 2/wk, treadmill and wts
other days
Seat belt/vehicle Always
restraint use:
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:
99.6F, 60, 138/66, 16, 96%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, moderately distended, tender RLQ, no rebound, well
healed midline laparotomy scar.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.3 PO BP: 138/73 HR: 51 RR: 16 O2: 99% Ra
GEN: A+Ox3, NAD
HEENT: MMM
CV: sinus bradycardia, regular rhythm
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l. left antecubital with ecchymosis and
mild induration resembling resolving phlebitis
Pertinent Results:
IMAGING:
OSH CT A/P ___
1. Findings compatible with a high-grade small bowel
obstruction.
There are dilated fluid-filled loops of proximal and mid small
bowel and the distal small bowel is decompressed. There is a
focal abrupt transition point identified in the right
midabdomen.
Circumferential wall thickening is identified in the small bowel
at the level of transition. Imaging findings are consistent with
provided hx of crohn's disease with secondary small bowel
obstruction. there is no pneumatosis. There is no pneumatosis.
there is no free air.
2. Small amount of perihepatic fluid
3. Mild dilation of intrarenal collecting system on the R as
well
as the R renal pelvix with abrupt transition. These findings
suggest changes of probable chronic UPJ obstruction on the R.
low
density lesions in the R kidney cannot be characterized due to
lack of contrast but are similar when compared to prior studies
and likely reflect cysts.
___: Abdominal x-ray (supine & erect):
Small bowel obstruction, this may be partial versus early
complete
___: Abdominal x-ray (portable):
There has been slow, antegrade movement of oral contrast into
the distal small bowel, however, there is persistent small-bowel
obstruction.
LABS:
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. balsalazide 2250 mg oral TID
2. FoLIC Acid 1 mg PO DAILY
3. HydrALAZINE 50 mg PO TID
4. Losartan Potassium 50 mg PO DAILY
5. Methotrexate 25 mg PO QMON
6. Spironolactone 25 mg PO 3X/WEEK (___)
7. Verapamil SR 120 mg PO QPM
Discharge Medications:
1. balsalazide 2250 mg oral TID
2. FoLIC Acid 1 mg PO DAILY
3. HydrALAZINE 50 mg PO TID
4. Losartan Potassium 50 mg PO DAILY
5. Methotrexate 25 mg PO QMON
6. Spironolactone 25 mg PO 3X/WEEK (___)
7. Verapamil SR 120 mg PO QPM
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: 71W PMH Crohns s/p ileal resections, recurrent SBOs, now w/
SBO.// ?progression of PO contrast. compare to prior.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
There are again dilated loops of small bowel measuring up to 4.3 cm, similar
to prior. No air is seen in the colon. There has been slow, antegrade
movement of oral contrast, which is now seen in the distal small bowel loops
in the right lower quadrant and pelvis.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Multiple, small rounded opacities in the
lower pelvis likely represent phleboliths, as before.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
There has been slow, antegrade movement of oral contrast into the distal small
bowel, however, there is persistent small-bowel obstruction.
Radiology Report
INDICATION: 71W PMH Crohns s/p ileal resections, recurrent SBOs, now w/ SBO//
Q SBO
TECHNIQUE: Addomen supine and left lateral decubitus
COMPARISON: CT ___
FINDINGS:
There are dilated loops of small bowel measuring up ti 4.3cm. Multple air
fluid levels are seen on the left lateral decubitus view. Air is seen in the
colon
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Small bowel obstruction, this may be partial versus early complete
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Bowel obstruction, Transfer
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 99.6
heartrate: 60.0
resprate: 16.0
o2sat: 96.0
sbp: 138.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to ___ with a
small bowel obstruction. You were treated with bowel rest and
received intravenous fluid for hydration. This bowel
obstruction self-resolved and you had return of bowel function.
Your diet was advanced and you are now tolerating a regular
diet. You are now ready to be discharged home.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toradol / Ambien / capsaicin / Tetracycline
Attending: ___.
Chief Complaint:
lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with transfusion dependent anemia secondary to uterine
fibroids s/p hysterectomy in ___, recently admitted to ___
for MRSA line infection, discharged on ___ on linezolid now
presenting with headache and lumbar spine MRI concerning for
lumbar osteomyelitis and discitis.
The patient was admitted to ___ from ___ to
___ and treated for polymicrobial bacteremia w/ MRSA and
several strep spp, infectious source presumably indwelling PICC
line. She had a complete work up at ___ with TEE and
abdominal ultrasound which were both negative. She was
discharged on Vancomycin, and represented to ___ on ___ with
report of fever at home to 100.5. During her stay at ___, she
was afebrile, her PICC line was pulled, blood cultures remained
negative, TTE showed no vegetations, and she was discharged on
linezolid to complete a 2 week course of antibiotics (course
complete on ___. At that time, she complained of acute on
chronic back pain, but lower spine imaging was not performed.
She also complained of headache, and was treated as migraine.
On ___, she returned to the ED with headache. Given her recent
hospital course, she had imaging of the head and spine, which
was pending at ED discharge, and then received morphine and
naproxen. After being discharged, her MRI L spine was found to
have discitis, osteomyelitis at L4-L5 and possibly at L5-S1. She
was called to come back in.
In the ED, initial vs were: 99.1 115 150/84 20 94% RA. Labs were
remarkable for Hct 34 (recent baseline 35-38). Blood cultures,
ESR, and CRP were drawn. She was seen by spine service, who
recommended IV antibiotics and ___ guided drainage. Patient was
given 2 doses IV morhpine and zofran. Vitals on Transfer: 98.2
104 140/40 16 96% RA.
On the floor, vs were 97.9, 149/101, 103, 16, 97% on RA. She
endorsed ___ lower back pain and headache.
Back pain - just lateral to lumbar spine on L side, feels
different than prior herniated disc pain, radiates to thighs
causing achiness in thighs, shooting pain in feet, and numbness
in b/l pinky toes.
HA - constant, fluctuating in severity, feels "wet hot" on the L
side of her head and behind the L eye. Also has blurry vision in
L eye which is unchanged since her eye exam during last
hospitalization. Worsened by loud noise. Accompanied by neck
pain and tenderness lateral to C spine on L.
Also c/o daily chills and soaking night sweats. No recorded
fevers at home. Also has nausea, vomited once yesterday,
nonbloody, no abdominal pain. Has been having loose stools BID,
no watery diarrhea or blood. No vaginal bleeding, dysuria,
vaginal discharge, cough, SOB, CP.
Review of sytems:
(+) Per HPI
(-) Denies fever, recent weight loss or gain. Denies sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
constipation or abdominal pain. No dysuria. Ten point review of
systems is otherwise negative.
Past Medical History:
-hepatitis C, treated with IFN per patient
-bipolar disorder
-obesity
-hyperlipidemia
-uterine fibroids s/p uterine embolization and eventual
hysterectomy.
-P-ICC placed in ___ for frequent blood transfusions for anemia
from fibroids with resultant line infection ___
-anemia from uterine fibroids
-asthma (never intubated)
-OA
-L5-S1 herniated disc
Social History:
___
Family History:
Mother- CVA in ___
Father- died of MI at age ___ also had DM, HTN
Brother: DM HTN
Physical Exam:
ADMISSION EXAM:
Vitals- 97.9, 149/101, 103, 16, 97% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI.
Neck- supple, JVP not elevated, no LAD. L paraspinal muscles
tender and inflammed in the cervical region.
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Old surgical
scars c/d/i.
GU- no foley
MSK - spinal point tenderness in the C6/C7 region and L5/S1
region. Paraspinal tenderness near L5.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact. ___ strength in UEs. ___ strength in RLE.
___ strength in LLE quads, hamstrings, and gastroc but limited
by pain. 2+ reflexes throughout and downgoing babinski's b/l.
DISCHARGE EXAM:
Vitals- 98.1, 113/69, 88, 16, 99% RA
General- Alert, oriented x3, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI.
Neck- supple, JVP not elevated, no LAD. L paraspinal muscles
tender and inflammed in the cervical region but without spasm.
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Old surgical
scars c/d/i.
GU- no foley
MSK - spinal point tenderness in the C6/C7 region and L5/S1
region. Paraspinal tenderness near L5.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact. ___ strength in UEs. ___ strength in RLE.
___ strength in LLE quads, hamstrings, and gastroc but limited
by pain. 2+ reflexes.
Pertinent Results:
ADMISSION LABS:
___ 02:36PM BLOOD WBC-8.9 RBC-4.88 Hgb-12.9 Hct-38.4
MCV-79* MCH-26.5* MCHC-33.7 RDW-18.8* Plt ___
___ 02:36PM BLOOD Neuts-65.8 ___ Monos-5.5 Eos-3.9
Baso-0.9
___ 02:36PM BLOOD Glucose-80 UreaN-14 Creat-0.9 Na-137
K-4.3 Cl-102 HCO3-27 AnGap-12
___ 02:10PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 02:10PM URINE RBC-11* WBC-28* Bacteri-FEW Yeast-FEW
Epi-6 TransE-<1
PERTINENT LABS:
___ 08:45PM BLOOD WBC-7.1 RBC-4.39 Hgb-11.9* Hct-34.0*
MCV-77* MCH-27.0 MCHC-34.9 RDW-18.8* Plt ___
___ 08:45PM BLOOD ESR-11
___ 08:45PM BLOOD CRP-0.5
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-7.8 RBC-4.36 Hgb-11.6* Hct-35.0*
MCV-80* MCH-26.6* MCHC-33.1 RDW-18.5* Plt ___
___ 06:30AM BLOOD ___ PTT-28.5 ___
MICRO:
___ BLOOD CULTURE x2 NO GROWTH.
IMAGING:
___ CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
___ MR ___ & W/O CONTRAST
IMPRESSION: Findings concerning for discitis, osteomyelitis at
L4-L5 and
possibly at L5-S1, although severe degenerative changes can have
a similar appearance. No evidence for epidural abscess.
___ LUMBO-SACRAL SPINE (AP & LAT)
IMPRESSION: Degenerative disease at L4-5 as seen on MRI from
one day prior, better characterized on prior day MRI. Please
note, abscess cannot be detected on radiograph.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Ferrous Sulfate 325 mg PO BID
3. Gabapentin 300 mg PO TID
4. Naproxen Dose is Unknown PO Frequency is Unknown
5. Nortriptyline 75 mg PO BID
6. OxycoDONE (Immediate Release) ___ mg PO BID:PRN pain
7. Paroxetine 40 mg PO DAILY
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D 50,000 UNIT PO Frequency is Unknown
Discharge Medications:
1. Fluconazole 150 mg PO ONCE Duration: 1 Dose
RX *fluconazole 150 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Ferrous Sulfate 325 mg PO BID
4. Gabapentin 300 mg PO TID
5. Nortriptyline 75 mg PO BID
6. OxycoDONE (Immediate Release) ___ mg PO BID:PRN pain
7. Paroxetine 40 mg PO DAILY
RX *paroxetine HCl 40 mg 1 tablet(s) by mouth once a day Disp
#*3 Tablet Refills:*0
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Capsaicin 0.025% 1 Appl TP TID
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
11. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Degenerative joint disease of the L4-L5 spine
SECONDARY DIAGNOSES:
Iron Deficiency Anemia secondary to uterine fibroids(transfusion
dependent)
HCV in SVR
recent MRSA bacteremia in setting of PICC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
LUMBAR SPINE RADIOGRAPH PERFORMED ON ___
___ MRI.
CLINICAL HISTORY: ___ female with MRI of the lumbar spine suggestive
of L4-5 osteomyelitis/discitis, question abscess.
FINDINGS: AP and lateral views of the lumbar spine provided. Please note,
radiograph is not a sensitive study for the detection of abscess. There is
extensive sclerosis at the L4-5 level with loss of disc space and articular
surface irregularity as seen on MRI of the lumbar spine from one day prior.
There is no compression deformity. SI joints and hip joints appear normal.
IMPRESSION: Degenerative disease at L4-5 as seen on MRI from one day prior,
better characterized on prior day MRI. Please note, abscess cannot be
detected on radiograph.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL MRI
Diagnosed with LUMB/LUMBOSAC DISC DEGEN
temperature: 99.1
heartrate: 115.0
resprate: 20.0
o2sat: 94.0
sbp: 150.0
dbp: 84.0
level of pain: 7
level of acuity: 2.0 | Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because you had back
pain and we thought there was an infection in your lower back.
You were seen by an infectious disease doctor who determined
that your back pain was due to osteoarthritis. You did not need
to continue your abx.
Please take all your medications as prescribed.
You have an appointment with your primary care doctor Dr. ___
on ___. That appointment information is included below
Thank you for allowing us to participate in your care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Avandia / Ibuprofen
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
Past Medical History:
CKD Stage IV
DM2
HTN
Hypothyroidism
CHF
Anemia of chronic renal insufficiency
GERD
Systolic CHF in ___, well compensated
PSHx:
Laporoscopic PD catheter placement ___
LURT ___
Social History:
___
Family History:
Father - ___ Heart Disease
Physical Exam:
Vitals: 97.4 188/62 52 18 100 RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, distended, well
healed abdominal scar w/ palpable transplant kidney
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
___ 09:49AM GLUCOSE-157* UREA N-20 CREAT-1.7* SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-21* ANION GAP-18
___ 09:49AM ALT(SGPT)-17 AST(SGOT)-20 LD(LDH)-143 ALK
PHOS-116 AMYLASE-124* TOT BILI-0.7
___ 09:49AM LIPASE-31
___ 09:49AM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-1.9
___ 09:49AM WBC-6.8 RBC-4.02* HGB-10.0* HCT-32.7* MCV-81*
MCH-24.9* MCHC-30.6* RDW-15.2 RDWSD-44.8
___ 09:49AM PLT COUNT-186
___ 12:52AM URINE HOURS-RANDOM
___ 12:52AM URINE UHOLD-HOLD
___ 12:52AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:52AM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:53PM COMMENTS-GREEN TOP
___ 09:53PM LACTATE-1.5 NA+-136 K+-4.8 CL--107 TCO2-17*
___ 09:47PM GLUCOSE-205* UREA N-24* CREAT-1.7*
SODIUM-132* POTASSIUM-7.1* CHLORIDE-101 TOTAL CO2-18* ANION
GAP-20
___ 09:47PM estGFR-Using this
___ 09:47PM ALT(SGPT)-24 AST(SGOT)-59* ALK PHOS-107 TOT
BILI-0.5
___ 09:47PM LIPASE-42
___ 09:47PM ALBUMIN-4.3
___ 09:47PM WBC-8.8 RBC-4.33* HGB-10.7* HCT-36.3* MCV-84
MCH-24.7* MCHC-29.5* RDW-15.4 RDWSD-46.6*
___ 09:47PM NEUTS-70.9 LYMPHS-18.3* MONOS-7.8 EOS-2.2
BASOS-0.3 IM ___ AbsNeut-6.26* AbsLymp-1.61 AbsMono-0.69
AbsEos-0.19 AbsBaso-0.03
___ 09:47PM PLT COUNT-205
IMAGING
___ CT Abdomen/Pevlis w contrast
1. Mild hydronephrosis and mild perinephric stranding centered
about the
transplanted kidney. Allowing for technical differences, the
hydronephrosis is likely unchanged from the prior study.
Correlation with urinary analysis is recommended to exclude
infection. For assessment of the transplant vasculature please
see the ultrasound from the same date.
___ Renal Ultrasound
1. Unchanged mild hydronephrosis in the transplanted kidney.
2. Resistive indices are mildly elevated (0.80-0.83), increased
from prior.
Radiology Report
EXAMINATION: CT abdomen pelvis.
INDICATION: +PO contrast; History: ___ with R sided abdominal pain. Abd
distention. Hx of kidney transplant. Last Cr 1.9+PO contrast // ?infection or
obstruction
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without contrast.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 16.6 mGy (Body) DLP = 912.3
mGy-cm.
Total DLP (Body) = 912 mGy-cm.
COMPARISON: MRI abdomen ___.
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: Bilateral upper pole renal hypodensities with trace calcifications,
are consistent with simple renal cysts, better characterized on MR ___. Numerous nonobstructive stones are noted within the renal collecting
systems, bilaterally measuring up to 4 mm. The kidneys are somewhat atrophic,
bilaterally. There is a small amount of perinephric stranding and fascial
thickening adjacent to the patient's transplanted kidney. Mild hydronephrosis
allowing for technical differences is likely unchanged. There is no focal
perinephric fluid collection.
GASTROINTESTINAL: There is significant distention of the stomach which
contains a large amount of contrast and ingested material without evidence of
obstruction. The visualized small bowel is unremarkable. There is
diverticulosis throughout the colon without evidence of diverticulitis. 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 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. 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. Mild hydronephrosis and mild perinephric stranding centered about the
transplanted kidney. Allowing for technical differences, the hydronephrosis
is likely unchanged from the prior study. Correlation with urinary analysis
is recommended to exclude infection. For assessment of the transplant
vasculature please see the ultrasound from the same date.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Right sided abdominal pain
Diagnosed with Unspecified abdominal pain
temperature: 98.2
heartrate: 56.0
resprate: 18.0
o2sat: 100.0
sbp: 202.0
dbp: 61.0
level of pain: 5
level of acuity: 3.0 | You came in with abdominal pain. Based on an extensive
evaluation including physical exam, bloodwork, and imaging
(kidney ultrasound and CT) we found no evidence of problems with
your transplant or other causes of abdominal pain. Your pain
seemed to resolve with Tylenol and gas-x (simethicone).
While in the hospital, your blood pressure was high so we
started you on a new blood pressure medication: amlodipine 5mg
daily. It occasionally causes mild swelling of your feet--which
is not harmful--but please follow up with your primary care
doctor about your blood pressure.
We also increased your sirolimus dosing and decreased your
mycophenolate mofetil dosing per the renal transplant team.
It was a pleasure to take care of you. Wishing you good health.
Best,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
Fevers, abdominal pain
Major Surgical or Invasive Procedure:
___: Successful CT-guided placement of an ___ pigtail
catheter into a left upper quadrant collection.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of metastatic
melanoma s/p recent subtotal pancreatectomy and splenectomy on
___. He was transferred from ___ earlier
this evening after presenting with complaints of fevers,
abdominal discomfort, and copious biliage drainage from around
his G-J tube.
He reports that ___ days after discharge, he began to develop
temperatures up to 100.9 at home. Although he would
intermittently deffervesce, his temperatures would run up and
down. Concurrently, he developed a low-grade abdominal
"discomfort", which he describes as located beneath his incision
and he noticed an increasing amount of bilious leakage from
around his GJ tube which has been hard to control despite
multiple dressing changes per day. He also gradually developed
increased fatigue, SOB, and diaphoresis. He apparently called
Dr.
___ and was prescribed keflex 2 days ago.
At ___, he was found to have a WBC of 27.8 and he
received a dose of vanc/levoflox/zosyn. CT torso revealed an
intraabdominal fluid collection and he was subsequently
transferred to ___ for further evaluation.
Past Medical History:
- Melanoma
- ___: completed 4 weeks of interferon therapy
- HTN
- HLD
- impaired glucose tolerance
- proteinuria
- h/o colon polyps, most recent colonoscopy ___ (Dr ___
- multiple lipomas
- remote history of migraines
- morbid obesity
- elevated PSA
- dysphagia
- urinary urgency
- hemorrhoids
- LBBB
PSH:
- ___: wide local excision of a 2-mm thick melanoma from
his
right posterior shoulder. Sentinel lymph node biopsy with 3
lymph nodes removed with no evidence of melanoma by H and E and
immunohistochemistry, but one node was positive by RT-PCR.
- right axillary lymph node dissection
- ___: excisional Bx right posterior thorax soft tissue
mass, pathology c/w ruptured epidermal cyst
- ___: VATS LUL wedge resection
- bilateral inguinal herniorrhapies in ___ and ___
- right knee surgery in ___
- sinus surgery ___ trauma
- L rotator cuff surgery in ___
- tonsillectomy
Allergies: ACEi
Social History:
___
Family History:
Mother: died of cardiac problems. h/o DM, HTN
Father: renal cell carcinoma
Cancers in the family: Sister with gallbladder ___ and
polycythemia ___. There is no family history of melanoma,
colorectal cancer, breast or ovarian cancer.
He has three children who are alive and well.
Physical Exam:
On Admission:
VS - 99.1 108 134/69 16 93% 2L Nasal Cannula
GEN - NAD, ___ at bedside, appears diaphoretic
HEENT - NCAT, EOMI, no scleral icterus
___ - tachycardic, regular
PULM - CTAB, slightly increased work of breathing
ABD - obese, mildly distended, incision C/D/I but with some
staple erythema; there is drainage of bilious fluid around GJ
tube site
EXTREM - warm, well-perfused, no peripheral edema; no calf
tenderness
Prior Discharge:
VS: 98.2, 68, 127/65, 18, 93% RA
GEN: NAD, pleasant
CV: RRR, no m/r/g
PULM: CTAB
ABD: Right subcostal incision open to air with steri strips and
healinf well. Midline G/J-tube capped with dsd and site c/d/i.
Left flank with ___ drain to gravity drainage with minimal
yellowish output, site c/d/i.
EXTR: Warm no c/c/e
Pertinent Results:
___ 05:54AM BLOOD WBC-12.7* RBC-3.34* Hgb-9.3* Hct-30.4*
MCV-91 MCH-28.0 MCHC-30.8* RDW-14.9 Plt ___
___ 10:32AM BLOOD ___
___ 05:00AM BLOOD Glucose-166* UreaN-16 Creat-0.7 Na-144
K-3.9 Cl-105 HCO3-32 AnGap-11
___ 03:20PM ASCITES Amylase-1055
___ 3:20 pm PERITONEAL FLUID
PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ ___:
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter
into a left upper quadrant collection. Samples was sent for
microbiology and laboratory evaluation.
___ CTA CHEST:
IMPRESSION:
1. Pulmonary emboli involving the distal-most right main
pulmonary artery, and bilateral segmental and subsegmental
branches as described above, involving all lobes, with increased
thrombus burden as compared to the reference CT from ___. No CT evidence for right-sided heart strain.
2. Small left pleural effusion with moderate left lower lobe
atelectasis.
3. Interval slight decrease in size of a subdiaphragmatic left
upper quadrant collection at the splenectomy bed, which contains
a pigtail catheter.
4. Post subtotal pancreatectomy.
___ ___:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ ECHO:
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF = 60%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
is not well seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
___ CRX:
FINDINGS:
Compared to the prior study there is slight improved aeration in
the left
lower lobe but there continues to be elevated left hemidiaphragm
and left
lower lobe volume loss. Otherwise, there is is no significant
interval change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. CeleBREX (celecoxib) 200 mg oral daily
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO DAILY
6. Tolterodine 4 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Octreotide Acetate 100 mcg SC Q8H
RX *octreotide acetate 100 mcg/mL (1 mL) 1 injection SC every
eight (8) hours Disp #*42 Syringe Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain , fever
4. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Please continue Lovenox until your INR is therapeutic.
RX *enoxaparin 80 mg/0.8 mL 1 syringe SC every twelve (12) hours
Disp #*14 Syringe Refills:*0
5. Glargine 6 Units Bedtime
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
7. Piperacillin-Tazobactam 4.5 g IV Q8H
___ last day for this medication
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*30 Vial Refills:*0
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO DAILY
11. Tolterodine 4 mg PO DAILY
12. Amlodipine 2.5 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Warfarin 5 mg PO DAILY16
Goal INR ___. Your PCP ___ follow up on INR level and will
contact you to adjust dosage.
RX *warfarin [Coumadin] 1 mg 5 tablet(s) by mouth once a day
Disp #*150 Tablet Refills:*0
15. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 5 cans
J-tube QD
Please infuse with rate 75 cc/hr for 16 hrs per day. Needs
tubefeed for 90 days
RX *nut.tx.gluc.intol,lac-free,soy [Glucerna 1.5 Cal] 5 cans by
J-tube once a day Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Metastatic melanoma
2. Pulmonary emboli
3. Intraabdominal fluid collection
4. Pancreatic fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man subtotal pancreatectomy and splenectomy ___ now
with SOB, increased work of breathing // eval for acute interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___ obtained at 11:21
IMPRESSION:
Heart size and mediastinum are stable. Elevated left hemidiaphragm. Is
unchanged. No new consolidations demonstrated. Left lower lobe area of
atelectasis is most likely secondary to elevated left hemidiaphragm and
unlikely to represent infectious process. Minimal amount of pleural effusion
cannot be excluded.
Radiology Report
INDICATION: ___ year old man with metastatic melanoma, s/p subtotal
pancreatectomy and splenectomy ___. Readmitted with fever, increased
abdominal pain and fluid collection on CT // Please drain peripancreatic fluid
collection and leave the drain in. Please send fluid for gram stain, cultures
and amylase
COMPARISON: CT performed on ___.
PROCEDURE: CT-guided drainage of a left upper quadrant collection.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist, who was present and supervising throughout the total procedure
time.
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 left anterior oblique position on the CT scan
table. Limited preprocedure CTscan was performed to localize the collection.
Based on the CT findings an appropriate skin entry site for the drain
placement was chosen. The site was marked. Local anesthesia was administered
with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
pigtail catheter into the collection. The plastic stiffener and the wire were
removed. The pigtail was deployed. The position of the pigtail was confirmed
within the collection via CT fluoroscopy.
Approximately 240 cc of dark brown fluid was aspirated with a sample sent for
microbiology and laboratory evaluation. The catheter was secured by a
StatLock. The catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 281 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
15 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into a left
upper quadrant collection. Samples was sent for microbiology and laboratory
evaluation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new picc // 46cm left picc. ___ ___
Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has received a left-sided
PICC line. The tip of the line projects over the confluence of
brachiocephalic vein and superior vena cava. If positioning in the mid SVC is
intended, the device should be advanced by approximately 4 cm. No
pneumothorax. Unchanged appearance of the lung parenchyma, with known
elevation of the left hemidiaphragm.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: New left PICC line.
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___ at 10:49 hours.
FINDINGS:
A newly placed left-sided PICC line terminates low in the SVC near the
superior cavoatrial junction. There is no pneumothorax. Elevation of the left
hemidiaphragm with subjacent left lower lobe subsegmental atelectasis is
unchanged. The right lung is clear. Multiple right axillary clips are again
noted. There is a partially imaged drainage catheter in the left upper
quadrant.
IMPRESSION:
Left PICC line in satisfactory position with no pneumothorax.
Stable elevation of the left hemidiaphragm with left lung base subsegmental
atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stage III melanoma s/p LUE VATS wedge
resection ___, subtotal pancreatectomy w/ splenectomy ___ now with SOB
and sat 77%RA. // SOB, increasing O2 requirement
COMPARISON: ___
IMPRESSION:
No relevant change as compared to the previous examination. Elevation of the
left hemidiaphragm and unchanged position of the left PICC line. No
pneumothorax. No larger pleural effusions. Unchanged size of the cardiac
silhouette.
Radiology Report
EXAMINATION: Chest CTA.
INDICATION: ___ year old man with stage III melanoma s/p LUE VATS wedge
resection ___, subtotal pancreatectomy w/ splenectomy ___, desat to
77% RA with SOB, now 91%4L // Pulmonary embolism. Please perform PE protocol.
TECHNIQUE: Axial multidetector CT scan from the upper chest to the diaphragm
was performed following the administration of intravenous contrast.
Multiplanar reformatted images in coronal and sagittal axis were generated.
Oblique maximum intensity projection images were obtained.
Examination DLP: 757 mGy-cm.
Intravenous contrast: 100 cc of Omnipaque.
COMPARISON: Reference CT examination from ___. CT examination
from ___.
FINDINGS:
CT OF THE CHEST WITHOUT IV CONTRAST:
Large filling defects are seen within the distal-most right main pulmonary
artery (series 3, image 83), extending to multiple right segmental branches
(series 3, image 84, 76, 64, 108, 118, 130), involving the right upper,
middle, and lower lobes. Pulmonary emboli are also present within the left
upper lobe segmental branches (series 3, image 68, 51) and subsegmental
lingular (series 3, image 93) and left lower lobe branches (series 3, image
93). The overall thrombus burden appears increased since the reference chest
CT from ___.
There is no pneumothorax or focal consolidation. A small left pleural effusion
is accompanied by moderate left lower lobe atelectasis (series 3, image 104).
The thoracic aorta is patent and normal in caliber, without dissection. A left
PICC terminates within the mid SVC. The heart size is normal, and there is no
pericardial effusion. There is no CT evidence for right heart strain.
Right axillary clips denote prior lymph node dissection (series 3, image 53,
46). There is no axillary, mediastinal, or hilar lymphadenopathy. The thyroid
appears normal. No enlarged supraclavicular lymph nodes are present.
The left hemidiaphragm is slightly elevated. A subdiaphragmatic left upper
quadrant collection, at the splenectomy bed, measures 11.6 x 7.3 cm axially
(series 3, image 150), and contains a pigtail catheter within the lower
portion (series 3, image 168), overall decreased in size since the ___ CT. The patient is post subtotal pancreatectomy. Linear branching
densities along the resection site (series 3, image 213) denotes suture
material, confirmed on the non contrast portion of the CT examination from ___. The adjacent celiac trunk is patent and normal in caliber.
Included views of the liver, gallbladder, adrenal glands, and bowel are within
normal limits. Arising from the upper pole of the left kidney is a
well-circumscribed 12 mm hypodensity, too small to completely characterize on
this early phase examination, likely representing a benign cyst. A
percutaneous gastrostomy tube is appropriately positioned (series 3, image
197).
There are no osseous lesions concerning for malignancy or infection.
IMPRESSION:
1. Pulmonary emboli involving the distal-most right main pulmonary artery,
and bilateral segmental and subsegmental branches as described above,
involving all lobes, with increased thrombus burden as compared to the
reference CT from ___. No CT evidence for right-sided heart strain.
2. Small left pleural effusion with moderate left lower lobe atelectasis.
3. Interval slight decrease in size of a subdiaphragmatic left upper quadrant
collection at the splenectomy bed, which contains a pigtail catheter.
4. Post subtotal pancreatectomy.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with HTN, HLD, and stage III melanoma with
pancreatic metastasis s/p subtotal pancreatectomy and splenectomy ___ p/w
pancreatic leak s/p ___ drainage now with PE // Rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old man with PE, transient desat // Eval for interval
change
TECHNIQUE: Portable chest radiograph
COMPARISON: Multiple chest x-rays from ___ through ___
FINDINGS:
There is opacification of the inferior left hemithorax, which is due to left
lower lobe collapse and a small effusion; these findings are better
demonstrated on CT chest dated ___. There is also chronic left
hemidiaphragm elevation. No new areas of consolidation. No pneumothorax.
Stable cardiomediastinal silhouette. The left PICC line is unchanged in
position and terminates in the distal SVC.
IMPRESSION:
No significant interval change. Left lung base opacity is due to LLL collapse
and small pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with metastatic melanoma s/p subtotal panc ___
now with PEs // please evaluate for interval change
TECHNIQUE: Portable chest
___
FINDINGS:
Compared to the prior study there is slight improved aeration in the left
lower lobe but there continues to be elevated left hemidiaphragm and left
lower lobe volume loss. Otherwise, there is is no significant interval change.
IMPRESSION:
No substantial change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD ABSCESS, Abd pain
Diagnosed with PERITONEAL ABSCESS
temperature: 99.1
heartrate: 108.0
resprate: 16.0
o2sat: 93.0
sbp: 134.0
dbp: 69.0
level of pain: 3
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital for an intraabdominal fluid
collection concerning for a pancreatic leak. This was drained by
Interventional Radiology. Ove the course of your hospital stay
you developed chest pulmonary embolsim and were admitted to the
ICU. You were started on anticoagulation therapy and your
condition has subsequently resolved. You have tolerated tube
feed at goal, passing gas and your pain is controlled with pain
medications by mouth. You may return home to finish your
recovery.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
___ Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. ___
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
.
G/J-tube care: Please flush with 30 cc of tap water Q8H. Monitor
for signs and symptoms of infection or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider ___:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
___ your doctor if you are unable to eat for several days, for
whatever reason. Also ___ if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your ___ dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised ___ taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, ___ sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, ___, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: ___, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your ___ dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and ___ when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much ___ you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When ___ is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way ___ works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Pollen Extracts
Attending: ___
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old male with history of HCV/EtOH
cirrhosis s/p standard criteria deceased donor liver transplant
in ___ on tacrolimus, stage IV CKD being worked on for renal
transplant, DM, HTN who presents with diarrhea x 4 days and mild
diffuse abdominal pain before bowel movements.
Patient had a fish sandwich at ___ 4 days PTA.
Initially BM loose then became profuse, watery and green. He has
been staying hydrated with Pedilyte. Associated with subjective
fevers and chills for the same duration. Only has mild abd pain
immediately before a BM, none now. Mild nausea, no emesis.
Denies increased abdominal girth, BRBPR, melena. Cough baseline
and non-productive. No dysuria, urinary frequency. No chest
pain, shortness of breath, palpitations. His symptoms are
actually improving with decreasing number of BMs today. His
appetite is also improving and he wants to have some food now.
In the ED initial vitals were: 99.2 ___ 16 98% ra
- Labs were significant for 6.8>13.0/37.6<207, BUN/Cr 81/3.9.
Normal LFTs, Lipase 67. ABG 7.47/36/113. Lactate 2.2
- Patient was given 1L NS
- KUB negative.
Vitals prior to transfer were: 98.3 90 142/96 18 100% RA
On the floor, patient says he does not have any abdominal pain.
Feels overall well and wants to eat.
Review of Systems:
(+) per HPI
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, shortness of breath, chest pain,
vomiting, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Per OMR and recent PCP ___:
- HCV/etoh cirrhosis s/p transplant in ___
- Insulin Dependent DM c/b has peripheral neuropathy
- Chronic neck, low back, and foot pain - on oxycodone
- Asthma/dyspnea
- HTN: amlodipine, lisinopril, lasix, metoprolol
- Stage III CKD - Chronic kidney disease with glomerular
disease, biopsy ___ showing membranoproliferative
glomerulonephritis, nodular
diabetic glomerulosclerosis, and tubular atrophy with
interstitial fibrosis.
- Chronic cough
- Obesity
- Chronic pain on narcotics contract.
- Diabetes- w/ nephropathy, on insulin, f/b ___. A1C 7.8% in
___.
- OSA: on CPAP by sleep clinic.
- ?osteopenia
- Asthma- Symbicort + albuterol. PFTs in ___ showing mild
restrictive defect w/ mild gas exchange defect, neither of which
is classic for asthma, but in any case sx are stable so continue
current regimen.
- Restless legs syndrome- already on oxycodone for his pain.
Sleep clinic rx'd pramipexole to help.
- Dry eyes, rx artificial tears OTC
- Bone mineral disease
Social History:
___
Family History:
no renal or liver disease, positive for DM, prostate cancer,
brain cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.8, 149/93, 92, 20, 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly tender to palpation in all
quadrants, no rebound/guarding, no hepatosplenomegaly. well
healed surgical scars.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, no asterixis, CN II-XII grossly intact, moving all
ext.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical exam:
Vitals - 97.9 86 138/87 18 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese belly, nondistended, +BS, nontender to palpation
in all quadrants, no rebound/guarding, no hepatosplenomegaly.
well healed surgical scars.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: A&Ox3, no asterixis, CN II-XII grossly intact, moving all
ext.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Pertinent Results
___ 07:00PM BLOOD WBC-6.8 RBC-4.67 Hgb-13.0* Hct-37.6*
MCV-80* MCH-27.9 MCHC-34.7 RDW-14.3 Plt ___
___ 05:00AM BLOOD WBC-6.6 RBC-4.18* Hgb-11.7* Hct-33.8*
MCV-81* MCH-27.9 MCHC-34.5 RDW-14.5 Plt ___
___ 07:00PM BLOOD Neuts-67.0 ___ Monos-11.7*
Eos-1.3 Baso-0.5
___ 05:00AM BLOOD ___ PTT-26.7 ___
___ 07:00PM BLOOD Glucose-246* UreaN-81* Creat-3.9* Na-137
K-3.8 Cl-95* HCO3-26 AnGap-20
___ 05:00AM BLOOD Glucose-236* UreaN-82* Creat-3.9* Na-137
K-3.5 Cl-96 HCO3-28 AnGap-17
___ 05:00AM BLOOD ALT-16 AST-22 AlkPhos-79 TotBili-0.2
___ 05:00AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.8
___ 05:00AM BLOOD tacroFK-8.7
___ 07:16PM BLOOD pO2-113* pCO2-36 pH-7.47* calTCO2-27 Base
XS-2 Comment-GREEN
___ 07:16PM BLOOD Lactate-2.2*
IMAGING
ABDOMINAL FILM ___
FINDINGS:
Upright AP radiographs through the abdomen demonstrates
nonobstructive bowel
gas pattern. On upright images, no free air is identified under
bilateral
hemidiaphragms. Single AP image of the pelvis is within normal
limits.
IMPRESSION:
No acute intra-abdominal abnormality.
The study and the report were reviewed by the staff radiologist.
CXR
IMPRESSION:
Heart size is normal. Mediastinum is stable. Lungs are
well-aerated. There is
minimal opacity in the left lower lung, potentially representing
infectious
process, with father PA and lateral views being beneficial for
pre size
characterization of the finding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal ___ pumps QAM
2. Clindagel (clindamycin phosphate) 1 % topical BID
3. Mupirocin Cream 2% 1 Appl TP BID
4. Guaifenesin-Dextromethorphan 10 mL PO TID:PRN cough
5. Sofosbuvir 400 mg PO DAILY16
6. simeprevir 150 mg oral daily
7. Tacrolimus 1 mg PO Q12H
8. NPH 35 Units Breakfast
NPH 35 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Torsemide 200 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 puffs daily
13. Omeprazole 40 mg PO DAILY
14. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
15. Cetirizine 5 mg PO DAILY:PRN Allergy symptoms
16. albuterol sulfate 90 mcg/actuation inhalation Q8H PRN SOB
17. Metolazone 5 mg PO DAILY
18. Calcitriol 0.25 mcg PO EVERY OTHER DAY
Discharge Medications:
1. Guaifenesin-Dextromethorphan 10 mL PO TID:PRN cough
2. NPH 35 Units Breakfast
NPH 35 Units Dinner
Insulin SC Sliding Scale using REG Insulin
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
6. simeprevir 150 mg oral daily
7. Sofosbuvir 400 mg PO DAILY16
8. albuterol sulfate 90 mcg/actuation inhalation Q8H PRN SOB
9. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal ___ pumps QAM
10. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
11. Calcitriol 0.25 mcg PO EVERY OTHER DAY
12. Cetirizine 5 mg PO DAILY:PRN Allergy symptoms
13. Clindagel (clindamycin phosphate) 1 % topical BID
14. Mupirocin Cream 2% 1 Appl TP BID
15. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 puffs daily
16. Tacrolimus 0.5 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gastroenteritis
Secondary Diagnosis
Diabeties
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: ___ male with abdominal pain.
COMPARISON: Ultrasound dated ___.
FINDINGS:
Upright AP radiographs through the abdomen demonstrates nonobstructive bowel
gas pattern. On upright images, no free air is identified under bilateral
hemidiaphragms. Single AP image of the pelvis is within normal limits.
IMPRESSION:
No acute intra-abdominal abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p liver transplant with diarrhea and
fevers/chills. // r/o PNA
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size is normal. Mediastinum is stable. Lungs are well-aerated. There is
minimal opacity in the left lower lung, potentially representing infectious
process, with father PA and lateral views being beneficial for pre size
characterization of the finding.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Chest pain, Abd pain
Diagnosed with DIARRHEA, LIVER TRANSPLANT STATUS
temperature: 99.2
heartrate: 106.0
resprate: 16.0
o2sat: 98.0
sbp: 151.0
dbp: 102.0
level of pain: 10
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for diarrhea. It
is suspected that the diarrhea occured from some food you had
eaten several days prior. In the hospital you did well and the
diarrhea resolved. Please continue to drink fluids in order to
stay hydrated. During your hospital stay it was noted that your
tacrolimus level was high. Your medication dose has been changed
to 0.5mg in the morning and 0.5mg at night. Please follow up
with a tacrolimis level check at your next Liver doctor
appointment this ___. if your weight increases by
more than 3 pounds please call your doctor.
We wish you a quick recovery!
Sincerely,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck and arm swelling
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
Left side chest tube placement ___
Bronchoscopy ___
Left side central line placement ___
History of Present Illness:
___ man with ESRD on HD (TThS), DMII, and right
brachiocephalic vein occlusion status post recanalization on
___ who presents with neck and upper extremity swelling
concerning for SVC syndrome in the setting of proximal venous
thromboses.
He does not endorse any respiratory symptoms such as shortness
of
breath, although he does report neck discomfort. He had the
symptoms for approximately 4 months, but they have progressed
over the past several days. The swelling is no worse first
thing
in the morning. He was in an outside hospital and was advised to
transfer here for interventional radiology revision of his
brachiocephalic stents. He denies any fevers or chills. He
denies active chest pain he denies abdominal pain.
In ___, he developed severe right arm edema causing him
severe
pain. He had a successful venous recanalization by ___ on
___.
- In the ED, initial vitals were:
T 98.3F HR 76 BP 132/65 RR 18 O2 94% RA
- Exam was notable for:
"Bilateral upper extremities are both swollen. There is
significant soft tissue edema in the upper extremity noted
during
ultrasound-guided IV insertion."
- Labs were notable for:
WBC 5.8 Hgb 10 Plt 197
Cr 5 BUN 46
Trop 1.05 MB 6
INR 1.1
- Studies were notable for:
CTA Chest
1. Nonocclusive thrombus within the distal portion of the
otherwise patent right brachiocephalic vein stent.
2. Narrowing of the midportion of the left subclavian stent,
which is otherwise patent.
3. Partially imaged left axillary vein stent demonstrates
moderate intraluminal thrombus within its midportion, with
distal
patency as it continues into the left subclavian vein.
4. Enlarged left axillary, supraclavicular, and mediastinal
lymph
nodes, likely reactive.
5. Left lower lobe consolidative opacities are concerning for
pneumonia.
6. Stable 9 mm left lower lobe pulmonary nodule compared to at
least ___.
7. Diffuse chest wall anasarca.
- The patient was given:
IV CefTRIAXone 1 gm
IV Azithromycin 500 mg
- ___ were consulted:
Recommended obtaining CTV, NPO for possible procedure. No urgent
intervention unless airway compromise.
On arrival to the floor, the patient endorses the above history.
He currently has some left arm and right shoulder pain.
Past Medical History:
ESRD on HD TThS
DMII
Right brachiocephalic vein occlusion status post recanalization
Cataract surgery in both eyes. Blind in left eye.
CKD - dialysis ___
DMII
Recently started on Elaquis for clot in brachial artery stent on
___.
Cataract surgery in both eyes. Blind in left eye.
Social History:
___
Family History:
___ daughter has a pacemaker. Father died in his ___ from a
stroke. His mother, sister, and grandmother all had dementia,
mother and grandmother at older ages.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ ___ Temp: 98.0 PO BP: 164/97 Sitting HR: 107 RR: 18 O2
sat: 94% O2 delivery: Ra
GENERAL: Alert and interactive elderly man, tangential. In no
acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
Swollen face and neck.
CARDIAC: Irregular. 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.
EXTREMITIES: Significant edema over left upper extremity.
Otherwise, no clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Lying in bed in no acute distress, awake and alert.
HEENT: Sclerae anicteric. Pale conjunctivae. MMM.
CARDIAC: Normal rate and rhythm. Grade ___ systolic murmur at L
upper sternal border.
LUNGS: Lungs clear to auscultation anteriorly. No wheezes or
rhonchi appreciated.
ABDOMEN: Soft, non distended, non-tender to palpation.
EXTREMITIES: Both L and R upper extremity appear slightly
edematous, unchanged from prior. No edema in legs bilaterally.
NEUROLOGIC: Awake and interactive this morning. Face symmetric.
Pupils equal and reactive. Moving all limbs with
purpose.
Pertinent Results:
ADMISSION LABS:
======================
___ 11:30PM BLOOD WBC-5.8 RBC-3.47* Hgb-10.0* Hct-31.5*
MCV-91 MCH-28.8 MCHC-31.7* RDW-18.3* RDWSD-60.5* Plt ___
___ 09:44PM BLOOD ___ PTT-22.6* ___
___ 08:00PM BLOOD Glucose-134* UreaN-46* Creat-5.0* Na-137
K-4.7 Cl-89* HCO3-27 AnGap-21*
___ 02:30AM BLOOD ALT-131* AST-212* CK(CPK)-1059*
AlkPhos-101 TotBili-0.6
___ 06:29AM BLOOD CK-MB-11* cTropnT-1.19*
OTHER RELEVANT LABS:
=======================
___ 05:44PM BLOOD Lupus-PRESENT* dRVVT-S-1.80*
dRVVT-C-1.26* dRVVTNR-1.42*
___ 9:00 am BRONCHIAL WASHINGS
RESPIRATORY CULTURE (Final ___:
~7000 CFU/mL Commensal Respiratory Flora.
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Piperacillin/Tazobactam test result performed by ___.
SENSITIVITIES: MIC expressed in MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING:
=============
CT-V Chest ___
FINDINGS:
1. Nonocclusive thrombus within the distal portion of the
otherwise patent
right brachiocephalic vein stent.
2. Narrowing of the midportion of the left subclavian stent,
which is
otherwise patent.
3. Partially imaged left axillary vein stent is thrombosed
within its
midportion, with distal patency as it continues into the left
subclavian vein.
4. Enlarged left axillary, supraclavicular, and mediastinal
lymph nodes,
likely reactive.
5. Left lower lobe consolidative opacities are concerning for
pneumonia.
6. Stable 9 mm left lower lobe pulmonary nodule compared to at
least ___.
7. Diffuse chest wall anasarca.
TTE ___
CONCLUSION:
IMPRESSION: Poor image quality. 1) Severe aortic stenosis
(area/gradient mismatch due to likely low flow, low gradient
conditions in setting of normal LV systolic function). The
patient has severe systolic/diastolic systemic arterial
hypertension. Consider repeat echocardiography when blood
pressure is better controlled to improve stroke volume and with
it assessment of aortic stenosis severity. 2) Echocardiographic
evidence for diastolic dysfunction with elevated PCWP.
3)Moderate pulmonary systolic arterial hypertension likely type
II in etiology.
Cardiac cath ___
No angiographically apparent coronary artery disease.
___ 6:05 ___
CT HEAD W/O CONTRAST
IMPRESSION:
Previously described subacute left cerebellar infarction is
better assessed on
recent MRI brain performed ___. Otherwise, no evidence
of large
vascular territory infarction or intracranial hemorrhage.
DISCHARGE LABS
======================
___ 05:15AM BLOOD WBC-4.2 RBC-2.61* Hgb-8.0* Hct-25.6*
MCV-98 MCH-30.7 MCHC-31.3* RDW-18.7* RDWSD-67.0* Plt ___
___ 05:15AM BLOOD ___ PTT-92.8* ___
___ 05:15AM BLOOD Glucose-150* UreaN-29* Creat-3.9* Na-134*
K-4.5 Cl-95* HCO3-30 AnGap-9*
___ 07:15AM BLOOD ALT-<5 AST-34 AlkPhos-121 TotBili-0.6
___ 12:00AM BLOOD CK-MB-7 cTropnT-1.09*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Acetate 1334 mg PO TID W/MEALS
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Nortriptyline 10 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Terazosin 4 mg PO QHS
7. Vitamin D ___ UNIT PO DAILY
8. amLODIPine 5 mg PO DAILY
9. TraMADol 50 mg PO BID:PRN Pain - Moderate
10. Apixaban 2.5 mg PO BID
11. Atorvastatin 40 mg PO QPM
12. Escitalopram Oxalate 10 mg PO DAILY
13. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Amiodarone 200 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY constipation
5. FoLIC Acid 1 mg PO DAILY
6. Heparin IV per Weight-Based Dosing Protocol
Indication: Treatment of Acute DVT and/or PE
Continue existing infusion at 800 units/hr
Therapeutic/Target PTT Range: 60 - 99.9 seconds
Start: Today - ___, First Dose: 1500 hrs
Stop Instructions: Keep on untill warfarin therpatic at ___ for
48 hours
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
8. Meropenem 500 mg IV Q24H Duration: 12 Days
9. Metoprolol Tartrate 12.5 mg PO Q6H
10. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
11. Nephrocaps 1 CAP PO DAILY
12. Polyethylene Glycol 17 g PO DAILY constipation
13. Senna 8.6 mg PO BID constipation
14. Thiamine 100 mg PO DAILY
15. Atorvastatin 80 mg PO QPM
16. Levothyroxine Sodium 50 mcg PO DAILY
17. Terazosin 4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
SVC syndrome
E.coli pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with chest and arm pain// eval for acute pathology
COMPARISON: Prior chest radiograph dated ___ and CT of the chest
dated ___.
FINDINGS:
AP upright and lateral views of the chest provided. Vascular stents project
over the left axilla and the left apex as well as the right superior
mediastinum. There is a similar pattern of volume loss and atelectasis at the
left lung base in the setting of a left hemidiaphragmatic eventration. The
right lung is clear. No signs of pneumonia. No edema. Overall
cardiomediastinal silhouette appears stable. Bony structures are intact.
IMPRESSION:
Persistent left basal atelectasis in the setting of left hemidiaphragmatic
eventration. No signs of pneumonia. Vascular stents again noted in the left
axilla and projecting over the upper lungs.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with neck swelling// Please perform CT Venogram of
the chest to evaluate for SVC syndrome, OR planning for potential venous
recanalization
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 3.8 s, 30.1 cm; CTDIvol = 7.0 mGy (Body) DLP = 210.0
mGy-cm.
2) Spiral Acquisition 3.7 s, 28.8 cm; CTDIvol = 14.6 mGy (Body) DLP = 422.0
mGy-cm.
Total DLP (Body) = 632 mGy-cm.
COMPARISON: CT chest performed ___.
FINDINGS:
HEART AND VASCULATURE: Right brachiocephalic vein stent is seen with
nonocclusive intraluminal thrombus seen at its most distal portion ___
601:49). A left subclavian stent is also in place with narrowing at its
midportion (for example 601:51), however the stent is otherwise patent without
evidence of stenosis or intraluminal thrombus. A left axillary vein stent is
partially evaluated and appears to have occlusive thrombus within its
midportion (for example 601:53), with proximal patency as it joins the
subclavian vein.
Pulmonary vasculature is well opacified. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma. No pericardial
effusion. Coronary artery calcifications are moderate.
AXILLA, HILA, AND MEDIASTINUM: Prominent left-sided axillary lymph nodes
measure up to 1.0 cm in short axis (for example 05:18). No right-sided
axillary lymphadenopathy. Scattered mediastinal lymph nodes measure up to 1.1
cm in the periaortic station (05:33). No hilar lymphadenopathy. There is
diffused chest wall anasarca.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Left lower lobe consolidative opacities demonstrate
heterogeneous enhancement, concerning for superimposed pneumonia on a
background of atelectasis. A 9 mm left lower lobe pulmonary nodule is noted
(05:33), and is unchanged compared to ___. The airways are patent
to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show prominent
left-sided supraclavicular lymph nodes measure up to 1.2 cm (5:1). There is
diffuse soft tissue stranding edema throughout the base of the neck, no focal
fluid collection is identified.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Nonocclusive thrombus within the distal portion of the otherwise patent
right brachiocephalic vein stent.
2. Narrowing of the midportion of the left subclavian stent, which is
otherwise patent.
3. Partially imaged left axillary vein stent is thrombosed within its
midportion, with distal patency as it continues into the left subclavian vein.
4. Enlarged left axillary, supraclavicular, and mediastinal lymph nodes,
likely reactive.
5. Left lower lobe consolidative opacities are concerning for pneumonia.
6. Stable 9 mm left lower lobe pulmonary nodule compared to at least ___.
7. Diffuse chest wall anasarca.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory arrest leading to cardiac
arrest// intrathoracic process
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Consolidative opacity in the left lower lobe could represent atelectasis or
pneumonia. The ETT is in acceptable position. Cardiomediastinal silhouette
is stable. There are no pleural effusions. No pneumothorax. Vascular stents
are in place.
Radiology Report
INDICATION: ___ year old man with recent arrest, now intubation and OG//
please confirm OG placement
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None.
FINDINGS:
Enteric tube terminates within the expected location of the stomach. Foley
catheter is in place. There is hyperdense material seen within the bladder
presumably represents IV contrast. Additional linear radiopaque material
projects over the lower pelvis may represent sequela to hernia repair. There
are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No acute abdominal process identified.
Enteric tube terminates in expected location of the stomach.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with sudden cardiac arrest, on heparin gtt, now
unresponsiveplease do portable// eval for ICH, please do portable
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: CT head ___ and MR head ___
FINDINGS:
There is no evidence of acute large territory infarction or hemorrhage. There
is questionable loss of gray-white matter differentiation of the temporal
lobes and occipital lobes, although this is likely artifactual. Focal
hyperdensity in the right posterior periventricular white matter is unchanged
and likely represents calcification as better described on the MR of ___. There is prominence of the ventricles and sulci suggestive of
involutional changes. Opacification of the intracranial vessels and
prominence of the falx is likely related to recent contrast administration.
There is severe diffuse swelling of the soft tissues. There is no evidence of
fracture. The ethmoid air cells are near completely opacified. There is
moderate polypoid mucosal thickening throughout the bilateral maxillary
sinuses. Small air-fluid levels are seen within the bilateral sphenoid
sinuses. The bilateral mastoid air cells are near completely opacified, and
the bilateral middle ear cavities are partially opacified. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or large territorial infarction.
2. Questionable loss of gray-white matter differentiation of the temporal and
occipital lobes could be artifactual, however early hypoxic ischemic injury is
a consideration.
3. Severe soft tissue swelling of the scalp can be seen with SVC syndrome as
reportedly suspected.
4. Severe paranasal sinus disease. Air-fluid levels in the sphenoid sinuses
could be related to supine positioning or acute sinusitis.
Radiology Report
EXAMINATION: Chest radiograph, portable AP view.
INDICATION: Query increase in congestion.
COMPARISON: ___.
FINDINGS:
Endotracheal tube terminates about 3.5 cm above the carina. Orogastric tube
heads into the stomach. Venous stents are again visible. Cardiac,
mediastinal and hilar contours appear stable. There is persistent volume loss
at the left lung base with elevation of the left hemidiaphragm and probable
retrocardiac opacification. On this study, there is new left midlung opacity
obscuring the left cardiac border suggesting volume loss in the lingula. New
mild interstitial process suggests pulmonary edema. Cardiac, mediastinal and
hilar contours appear stable. No pleural effusion on the right. It is
difficult to exclude a trace pleural effusion on the left. No pneumothorax.
IMPRESSION:
Evidence for very mild new pulmonary edema. New lingular opacification with
volume loss. This could be seen with atelectasis. Developing infectious
process is possible, however.
RECOMMENDATION(S): Short-term follow-up repeat radiographs may be helpful.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with resp failure// ? pneumonia
TECHNIQUE: Portable chest radiograph
COMPARISON: ___
FINDINGS:
Support lines and devices are unchanged. Cardiomediastinal silhouette is
stable. Persistent volume loss of the left lung base with elevation of the
left hemidiaphragm. There is opacification at lingula, slightly improved
compared to prior. Mild improvement in pulmonary vascular congestion.
IMPRESSION:
Slight interval improvement of lingular opacification.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man s/p PEA arrest// s/p PEA arrest evaluate for
hypoxic brain injury
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON
1. CT head ___.
2. MR head ___.
FINDINGS:
Small focus of left cerebellar DWI hyperintense signal (1002:4) is without
clear ADC correlate, with a faintly FLAIR hyperintense correlate (13:5),
possibly a small subacute infarct.
Elsewhere, there is no evidence of additional acute infarction, extra-axial
collection, mass, mass effect, parenchymal edema.
The ventricles and sulci are prominent, compatible with global parenchymal
volume loss.
Bilateral periventricular and deep white matter foci of T2/FLAIR signal
hyperintensity are nonspecific but compatible with mild changes of chronic
white matter microangiopathy.
There are bilateral subgaleal fluid collection (12:15), symmetric, in the
dependent posterolateral head. There is diffuse subcutaneous and deep soft
tissue edema consistent with a generalized edematous state.
Visualized portions of the major intracranial vascular flow voids appear
preserved.
There is pansinus moderate to severe mucosal thickening, worst in the ethmoid
which is nearly completely opacified. There are air-fluid levels in the
sphenoid sinus. There are bilateral mastoid effusions.
Aside from bilateral lens extraction, the globes and orbits are within normal
limits.
IMPRESSION:
1. Possible very small subacute left cerebellar infarct.
2. Otherwise, no other acute intracranial abnormality identified.
3. Mild global parenchymal volume loss and mild changes of chronic white
matter microangiopathy.
4. Findings consistent with a generalized edematous state, including bilateral
subgaleal fluid collections and diffuse soft tissue edema.
5. Pansinus mucosal thickening and bilateral mastoid effusions.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with ESRD on HD (TThS), DMII,and right
brachiocephalic vein occlusion s/p recanalization who presents with SVC
syndrome found to have non-occlusive clots in right brachiocephalic vein.
Hospital course completed by new discovery of severe aortic stenosis, toxic
metabolic encephalopathy, and PEA arrest.// Bleed? Infection? Colitis?
Diverticulitis? PNA?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 71.7 cm; CTDIvol = 19.3 mGy (Body) DLP =
1,382.6 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 1,401 mGy-cm.
COMPARISON: CTA chest dated ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings. Briefly, bilateral pleural
effusions are partially visualized with compresses of atelectasis at the right
lung base.
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. Periportal edema is noted. The hepatic and
portal veins are patent. The gallbladder is minimally distended, possibly
related to NPO status. In addition, there is trace pericholecystic fluid
which in the setting of periportal edema and diffuse anasarca may related to
third spacing.
PANCREAS: There is fatty atrophy of the pancreas. The visualized parenchyma
demonstrates normal attenuation throughout, without evidence of focal lesions
or pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are mildly atrophic in keeping with the patient's history
of ESRD. There are bilateral simple renal cysts and hypodensities too small
to characterize. A 10 mm hypodensity in the upper pole of the right kidney is
indeterminate, measuring approximately 30 Hounsfield units on these
postcontrast images but stable dating back to ___ (02:58). No
hydronephrosis. No perinephric abnormality. A 4 mm hyperdensity in the upper
pole of the left kidney may reflect retained contrast excretion or a small
nonobstructing stone (02:58).
GASTROINTESTINAL: The stomach is unremarkable within the limitation of CT.
Enteric tube tip is in the first portion of the duodenum. No evidence of
bowel obstruction. The colon is redundant. Extensive sigmoid diverticulosis
without evidence of diverticulitis. The appendix is normal.
PELVIS: Bladder is largely decompressed and contains high-density material
which may reflect residual contrast media. Trace free fluid is noted in the
presacral space
REPRODUCTIVE ORGANS: The prostate and seminal vesicles appear normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Note is made of a vascular catheter entering from the left common
femoral vein with the tip terminating just below the common iliac vein
bifurcation.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Diffuse body wall anasarca is noted. There is evidence of prior
anterior abdominal wall and inguinal hernia repairs. There are bilateral fat
containing inguinal hernias.
IMPRESSION:
1. No acute process within the abdomen or pelvis.
2. Mild gallbladder distension; correlate for NPO status. Trace
pericholecystic fluid is favored to represent third spacing in the setting of
periportal edema and diffuse body wall anasarca.
3. Bladder wall thickening is likely related to underdistention, however
correlation for cystitis is recommended.
4. Indeterminate 10 mm hypodensity in the upper pole of left kidney as
described above, stable dating back to ___.
5. Colonic diverticulosis without evidence of diverticulitis.
6. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with ESRD on HD (TThS), DMII,and right
brachiocephalic vein occlusion s/p recanalization whopresents with SVC
syndrome found to have non-occlusive clots inright brachiocephalic vein.
Hospital course completed by newdiscovery of severe aortic stenosis, toxic
metabolicencephalopathy, and PEA arrest.// Bleed? Infection? Colitis?
Diverticulitis? PNA?
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: mGy-cm
COMPARISON: ___.
FINDINGS:
Large fluid collection around the right shoulder is incompletely imaged.
There are extensive anasarca, with substantial fluids amounts ventral to the
sternum. Rather extensive left axillary lymphadenopathy (2, 13). Relatively
extensive mediastinal lymphadenopathy. Moderate coronary and aortic valve
calcifications. No pericardial effusion. The upper abdomen is reported in
detail in the dedicated abdominal CT report. Small right and moderate left
pleural effusion with adjacent areas of atelectasis. The patient is intubated
and carries a feeding tube. The assessment of the lung parenchyma is limited
by extensive respiratory motion. There is minimal non characteristic
ground-glass at the dorsal aspect of the right lower lobe but no evidence of
pneumonia is seen. The presence of a known left lower lobe pulmonary nodule
is confirmed.
IMPRESSION:
Extensive intra and extra thoracic lymphadenopathy. New small right and
moderate left pleural effusion, with areas of adjacent atelectasis and a known
left lower lobe nodule, but without evidence of pneumonia. Fluid collection
around the right shoulder.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old man with ESRD on HD (TThS), DMII, and right
brachiocephalic vein occlusion s/p recanalization who presents with SVC
syndrome found to have non-occlusive clots in right brachiocephalic vein.
Hospital course completed by new discovery of severe aortic stenosis, toxic
metabolic encephalopathy, and PEA arrest.// Fluid seen on CT last night in
right upper extremity/shoulder. ? of edema from fluid overload vs
hematoma/bleeding from dialysis catheter
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right shoulder.
COMPARISON: Correlation with CT chest from ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right shoulder. No fluid collection is identified. Note is made of a small
acromioclavicular joint effusion with what appears to be synovial thickening
and osteophytes. There is no significant hyperemia associated with this.
IMPRESSION:
No evidence of right shoulder fluid collection. Arthritic changes and small
joint effusion at the AC joint noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with shock, hypoxic resp failure// ? pulm edema
TECHNIQUE: Chest AP
COMPARISON: Multiple prior chest radiographs, most recently ___.
Chest CT dated ___.
FINDINGS:
An endotracheal tube terminates 2 cm above the carina. Enteric tube
terminates underneath the right hemidiaphragm, likely in the distal stomach.
Multiple vascular stents are present.
Lung volumes are low. Hazy opacification of the left hemidiaphragm is likely
accounted for by a layering pleural effusion. Additionally, volume loss of
the left lung base is present, consistent with atelectasis. Mild pulmonary
vascular congestion and pulmonary edema is present. The left heart border is
obscured by left lung opacification.
IMPRESSION:
1. Mild pulmonary edema.
2. Layering left pleural effusion with increasing left lung opacity, likely
reflecting atelectasis.
Radiology Report
INDICATION: ___ year old man with ESRD and SVC syndrome// ___ year old man with
ESRD and SVC syndrome
COMPARISON: CT of the chest from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
ANESTHESIA: General anesthesia was adminsitered by the anesthesiology
department.
MEDICATIONS: Per anesthesia nots
CONTRAST: 75 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 71 minutes, 1546 mGy
PROCEDURE:
1. Right common femoral vein access
2. SVC gram from right common femoral vein access
3. Right brachial vein fistula access
4. Right brachial vein fistulagram
5. Right brachocephalic venogram
6. Left subclavian vein access
7. Left subclavian venogram
8. Right brachiocephalic vein angioplasty and stenting with a 10 mm x 68 mm
Wallstent
9. Left brachiocephalic vein angioplasty and stenting with a 10 mm x 68 mm
Wallstent
10. Post stenting venograms from the right and left brachiocephalic veins.
11. Right brachial vein fistulagram
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right arm
fistula, left upper chest and right groin were prepped and draped in the usual
sterile fashion.
Under direct ultrasound guidance, access was obtained in the patent right
common femoral vein using a micropuncture needle. Images before and after the
access were saved. The access was upsized to a 6 ___ sheath using a
micropuncture access set. Through the right common femoral vein sheath, a
Kumpe catheter was advanced into the ___ and a SVC venogram was performed
which showed complete exclusion of both brachiocephalic veins due to the right
brachiocephalic vein stent.
Next, under direct ultrasound guidance, access was obtained in the patent
right brachial vein fistula using a micropuncture needle. Images before and
after the access were saved. The access was upsized to a 6 ___ sheath using
a micropuncture access set. Through the sheath, a Kumpe catheter was advanced
into the right brachiocephalic vein and a venogram was performed which showed
flow into the left brachiocephalic vein. Through this access, attempts were
made to enter the ___ using a Kumpe, Sos, RDC catheter. After failure, a 6
___ Morph sheath was advanced into the edge of the stent and multiple
attempts were made to regain access into the ___, which failed.
Due to failure of the right brachial access, under direct ultrasound guidance,
access was obtained in the patent left subclavian vein fistula using a
micropuncture needle. Images before and after the access were saved. The
access was upsized to a 6 ___ sheath using a micropuncture access set.
Through the sheath, a Kumpe catheter was advanced into the left
brachiocephalic vein and a venogram was performed which showed flow into the
left brachiocephalic vein. Through this access, attempts were made to enter
the ___ using a Kumpe, Sos, RDC catheter. After failure, a 6 ___ Morph
sheath was advanced into the edge of the stent. Using a morph sheath and RDC
catheter, the back end of a Fathom wire was advanced into the SVC via the
bottom most strut of the existing stent. A Rubicon was advanced over the wire
and a road runner was successfully advanced into the SVC after recanalization.
Next, a snare was advanced from the femoral access, and used to snare the wire
coming from the left brachial access. The snare catheter was then maneuvered
cranial to the stent into the right brachiocephalic vein. The stent access
was then angioplastied using a 10 mm balloon. After balloon angioplasty a
wire was advanced through the left and right brachiocephalic vein access into
the IVC. The femoral approach catheter was then removed. Over these wires,
after upsizing the right fistula and left subclavian access to 7 ___
sheatsa 10 mm x 68 mm Wallstent was advanced into position and deployed. The
stents were angioplastied using 10 mm balloons. Post-angioplasty venography
was performed from the right and left brachiocephalic veins. At this point,
the fistula had a thrill. The right fistula catheter was pulled into the
proximal fistula and a fistulagram was performed.
Next, a temporary dialysis catheter was advanced into the left subclavian
access, which will be dictated separately. The right brachial vein fistula
access was closed with purse string sutures. The right common femoral vein
access was removed and pressure was held until hemostasis was achieved.
Sterile dressings were applied to all access sites. The patient tolerated the
procedure well.
FINDINGS:
Occluded SVC due to right brachiocephalic vein stent extending into the left
brachiocephalic vein confirmed by right brachiocephalic and left
brachiocephalic venograms. Successfuly recanalization of SVC using sharp
access from the left. Successful bilateral brachiocehpalic vein stenting to
the SVC with brisk flow after stenting. Patent right arm fistula.
IMPRESSION:
Successful recanalization of SVC with bilateral kissing stents placed from
both brachiocephalic veins into SVC.
Radiology Report
INDICATION: ___ year old man with shock and hypoxic resp failure s/p pea
arrest, needs access// picc placement
COMPARISON: No relevant comparisons available.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
ANESTHESIA: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: Per anesthesia notes.
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.1 min, 1 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 neck was prepped and draped in the usual
sterile fashion.
Under continuous ultrasound guidance, the patent left subclavian 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.
After sequential dilation of the soft tissue tract using 12 ___ and 14
___ dilators, a triple lumen 14 ___ dialysis catheter was advanced over
the wire into the superior vena cava with the tip in the distal SVC. All
three 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 left subclavian vein. Final fluoroscopic image showing triple lumen
temporary subclavian catheter with catheter tip terminating in the distal
superior vena cava.
IMPRESSION:
Successful placement of a left subclavian triple lumen temporary dialysis
catheter. The line is read to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with rising white count, hypoxic resp failure//
?new infiltrate
IMPRESSION:
In comparison with the study ___, there is increasing opacification in
the left hemithorax with obscuration of the hemidiaphragm. This suggests
worsening layering pleural effusion, since the underlying pulmonary markings
are still seen. Cardiomediastinal silhouette is stable and there again is
mild pulmonary vascular congestion.
No definite acute focal consolidation is appreciated. However, given the
extensive changes described above, it would be difficult to unequivocally
exclude superimposed aspiration/pneumonia.
Radiology Report
INDICATION: ___ year old man with SVC syndrome// pulmonary edema status
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___. Chest CT from ___.
FINDINGS:
ET tube is 1.4 cm from the carina. Enteric tube seen within the stomach.
Vascular stents project over the mediastinum and left axillary region.
Increased opacity in the left hemithorax likely due to layering effusion with
adjacent atelectasis. Small right pleural effusion likely persists. No
pulmonary edema. Cardiac silhouette is not adequately assessed.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 4 EXAMS ___
INDICATION: In brief, this is a ___ year old man with ESRD on HD (TThS), DMII,
and right brachiocephalic vein occlusion s/p recanalization who presents with
SVC syndrome found to have non-occlusive clots in right brachiocephalic vein.
Hospital course completed by new discovery of severe aortic stenosis, toxic
metabolic encephalopathy, and PEA arrest.// Dobhoff placement Dobhoff
placement
IMPRESSION:
Compared to chest radiographs ___ through ___ at 17:00.
4 sequential frontal chest radiographs show repositioning of the
transesophageal feeding tube, initially in the right lower lobe bronchus, then
in the right main bronchus, then looped in the hypopharynx and nasopharynx.
If the nasogastric tube was subsequently repositioned, no radiographic image
of that has been submitted.
The final radiograph in the series shows no pneumothorax, moderate left
pleural effusion comparable to ___. Severe left lower lobe atelectasis.
Heart size top-normal.
It also shows the tip of the endotracheal tube at the carina, 4 cm below
desired position should be repositioned. Left subclavian dual channel
catheter traverses a caval stent. Second right brachiocephalic caval stent is
in place.
RECOMMENDATION(S): Remove malpositioned transesophageal feeding tube.
Withdraw endotracheal tube 4 cm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with ESRD on HD (TThS), DMII, and right
brachiocephalic vein occlusion now w/ increased WOB// eval for worsening
edema, PNA eval for worsening edema, PNA
IMPRESSION:
Compared to chest radiographs ___ through ___ one.
Left lower lobe collapse, moderate left and small right pleural effusions are
unchanged. There is probably no pulmonary edema. Cardiac silhouette not
appreciably enlarged. No pneumothorax. Bilateral central vein stents in
place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with dophoff placement// dophoff placement
dophoff placement
IMPRESSION:
Compared to chest radiographs ___ through ___ at 11:24.
Single frontal chest radiographs shows transesophageal feeding tube in the
left lower lobe bronchus. No other interval change, including persistent left
lower lobe collapse and stable moderate left and small right pleural
effusions.
NOTIFICATION: The findings were discussed with ___, MD, by ___
___, M.D. on the telephone at 12:30, IMMEDIATELY following discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with fever. Encephalopathic so no localizing
symptoms. Has difficulty with secretions and previously failed swallow study
so high concern for aspiration.// Does this patient have a pneumonia? Does
this patient have a pneumonia?
IMPRESSION:
Compared to chest radiographs ___ through ___.
No nasogastric drainage or feeding tube in place.
Large left pleural effusion is larger. No pneumothorax. Left lower lobe
still collapsed. Right lung is better inflated. Basal atelectasis unchanged.
Left border of the mediastinum is substantially obscured by combination of
atelectasis and pleural effusion. Upper mediastinal widening suggests
increase in caliber of mediastinal veins.
Vascular stents left subclavian and bilateral brachiocephalic veins in place.
Left subclavian dual channel catheter traverses the left stents and ends in
the upper SVC.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 4 EXAMS
INDICATION: ___ year old man with dysphagia// eval dobhoff placement
TECHNIQUE: Chest AP
COMPARISON: Chest radiograph dated ___
FINDINGS:
Serial chest radiographs demonstrate a Dobhoff tube initially extending into
the right mainstem bronchus, coiling on itself and terminating within the left
mainstem bronchus (image 3 and 4). Subsequent images demonstrate the Dobhoff
tube within the right mainstem bronchus (image 5 and 6) and left mainstem
bronchus (image 7 and 8).
Cardiomediastinal silhouette is unchanged. No acute focal consolidation.
There is redemonstration of a large left pleural effusion, unchanged. No
pneumothorax. Vascular stents are again seen in the left subclavian and
bilateral brachiocephalic veins. A left subclavian dual channel catheter
traverses the stents and ends in the upper SVC, unchanged.
IMPRESSION:
1. Dobhoff tube with tip terminating in the left mainstem bronchus.
2. Large left pleural effusion with associated atelectasis of the left lower
lobe, unchanged.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:36 pm, 1
minutes after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph, 3 portable AP upright views.
INDICATION: Dysphagia. Nasogastric tube placement. Third of three views
depicts nasogastric tube terminating in the stomach. Bilateral kissing
brachiocephalic/caval venous stents appear unchanged. Left subclavian venous
catheter again terminates in the upper superior vena cava within 1 of the
stents. Cardiac contours are obscured. Mediastinal and hilar contours are
probably stable. Small pleural effusion probably persists on the right. Left
pleural effusion is medium in size and probably unchanged with partial
atelectasis of the left lower lobe and process probably the lingula.
COMPARISON: ___, earlier on the same day.
FINDINGS:
Third of three views depicts a nasogastric tube terminating in the stomach.
Bilateral kissing brachiocephalic/superior vena caval venous stents appear
unchanged. Left subclavian venous catheter again terminates in the upper
superior vena cava within one of the stents. Cardiac contours are partly
obscured. Mediastinal and hilar contours are probably stable. Small pleural
effusion probably persists on the right. Left pleural effusion is medium in
size and probably unchanged with partial atelectasis of the left lower lobe
and probably the lingula.
IMPRESSION:
New nasogastric tube terminating in the stomach. Otherwise, no definite
short-term change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress// Is there evidence of
pneumonia or pleural effusion?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
There is complete atelectasis of the left lung with cysts shift of mediastinum
to the left. The previously visualized NG tube has been repositioned and the
tip projects now over the stomach. Right lung is clear. There is a small
right pleural effusion with right basilar atelectasis. Vascular stents are
unchanged.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with hx ESRD on HD, brachiocephalic vein thrombosis s/p
stenting, T2DM, initially presented with ___ syndrome/stent thrombosis s/p
bilateral recanalization on ___. Now with worsening LUE swelling.// Please
complete CTA and CTV of chest to eval for stent rethrombosis
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 1.9 s, 29.7 cm; CTDIvol = 4.7 mGy (Body) DLP = 138.2
mGy-cm.
2) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 22.0 mGy (Body) DLP = 653.5
mGy-cm.
3) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 22.0 mGy (Body) DLP = 653.8
mGy-cm.
Total DLP (Body) = 1,445 mGy-cm.
COMPARISON: CT of the chest from ___.
FINDINGS:
HEART AND VASCULATURE: Two stents are seen extending into the SVC with the
first originating in the right brachiocephalic vein and the second in the left
subclavian. Contents of the stents are difficult to assess directly due to
reconstruction artifact, but based on the pattern of flow, these seem likely
to remain patent. An additional stent is seen in the left subclavian which is
difficult to assess given the passage of the chest Port catheter. The left
axillary vein stent is completely occluded. Pulmonary vasculature is well
opacified to the segmental 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. A
left-sided chest Port is seen extending through the left subclavian and
terminates at the ___.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is a large left-sided pleural effusion with resultant
collapse of the entire left lung. There is a small right-sided pleural
effusion. No pneumothorax.
LUNGS/AIRWAYS: Right-sided basilar atelectasis.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Nasogastric tube is seen terminating the stomach. Included portion
of the upper abdomen is unremarkable.
BONES: There are no suspicious bone lesions. Minimally displaced on non
healed fractures involving the left lateral fourth and fifth ribs show no
change.
IMPRESSION:
1. Complete occlusion of the left axillary vein stent. Difficult to assess
left subclavian stent given passage of chest Port catheter through it. Stents
terminating in the superior vena cava are difficult to assess directly due to
reconstruction artifact but these seem to remain patent.
2. Large progressively increased left-sided pleural effusion with resulting
collapse of the entire left lung. Small right-sided pleural effusion, but
somewhat increased, with overlying atelectasis.
3. No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with hx ESRD on HD, brachiocephalic vein
thrombosis s/p stenting, initially presented with SVC syndrome/stent
thrombosis and now s/p bilateral recanalization of SVC (___). Left arm
becoming more swollen// Please evaluate left arm for thrombosis
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the right subclavian veins.
Evaluation of the left subclavian vein and axillary vein is limited due to
patient positioning.
The patient is status post brachiocephalic fistula creation. There is
occlusive thrombus in the cephalic vein outflow extending proximally up the
left upper extremity, including an area which appears to be stented.
Additionally, there is thrombus within the left internal jugular vein. Mild
edema is noted in the subcutaneous tissues.
IMPRESSION:
1. Venous thrombosis involving the left internal jugular vein.
2. Thrombosis of the cephalic outflow of the brachiocephalic fistula,
including an area which appears to be stented.
3. Limited evaluation of the subclavian and axillary veins do to patient
positioning.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:40 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with ?large left pleural effusion// ?left pleural effusion
?left pleural effusion
IMPRESSION:
Comparison to ___. There is unchanged complete opacifications of the
left hemithorax, caused by a large left pleural effusion. Subsequent mild
rightward mediastinal shift. Stable appearance of the right lung. The
monitoring and support devices are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Assess NG tube placement.// Assess NG tube placement.
TECHNIQUE: Single frontal view of the chest
COMPARISON: Multiple prior radiographs, most recently on ___
FINDINGS:
An enteric tube terminates in the gastric antrum or just past the pylorus in
the first portion of the duodenum. Multiple vascular stents are again noted.
There is unchanged complete opacification of the left hemithorax. The right
lung is clear, with the right costophrenic angle not included in the field of
view.
IMPRESSION:
An enteric tube terminates in the gastric antrum or first portion of the
duodenum.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L pleural effusion, atelectasis// post L
chest tube insertion post L chest tube insertion
IMPRESSION:
Comparison to ___, 10:43. A left-sided pigtail catheter was inserted.
A large part of the left-sided pleural fluid collection is now drained. There
is an 8 mm left apical pneumothorax without evidence of tension. Stable
course of the feeding tube, stable appearance of the right lung parenchyma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L sided chest tube placed yesterday with
high output.// Positioning of chest tube Positioning of chest tube
IMPRESSION:
Type of tube tip is in the stomach. Multiple vascular stents are
re-demonstrated. Left pigtail catheter is in place. There is interval most
likely decrease in pleural effusion on the left, moderate and loculated.
Right pleural effusion is moderate. There is vascular congestion but no overt
pulmonary edema. No pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with L pleural effusion, chest tube, interval
improvement?// Interval improvement in L pleural effusion?
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and reconstructed as contiguous 5-millimeter and
1.25 millimeter thick axial, 2.5 millimeter thick coronal and parasagittal and
8 x 8 millimeter maximum intensity projection axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.9 s, 30.2 cm; CTDIvol = 16.2 mGy (Body) DLP = 487.3
mGy-cm.
2) Spiral Acquisition 1.9 s, 30.2 cm; CTDIvol = 16.2 mGy (Body) DLP = 487.0
mGy-cm.
Total DLP (Body) = 974 mGy-cm.
COMPARISON: Multiple chest radiographs dating back to ___ and ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid is slightly
heterogenous with multiple subcentimeter hypoattenuating lesions which most
likely represents thyroid nodules. There are vascular stents extending to the
superior vena cava, unchanged in appearance and position. The left stent
extends from the left subclavian and the right extends from the right
brachiocephalic vein. Of note, flow within the stent cannot be evaluated on
the current non-contrast CT. There is mild calcification of the right
subclavian artery and aortic arch. There is diffuse subcutaneous fat
stranding concerning for anasarca.
UPPER ABDOMEN: The study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen demonstrates mildly
thickened adrenal glands bilaterally without discrete mass. The pancreas is
fatty replaced and atrophic.
MEDIASTINUM: There are a few enlarged mediastinal lymph nodes which measure up
to 11 mm in short axis, (series 2, image 16). There is a small locule of air
at the left paramediastinal region suggesting trace pneumomediastinum.
HILA: The hilar evaluation is limited by lack of intravenous contrast
HEART and PERICARDIUM: Cardiac size is mildly enlarged, unchanged. There is
there is no pericardial effusion. Severe calcified atherosclerosis involving
the coronary arteries. There is calcification of the aortic valve.
PLEURA: Moderate for right pleural effusion, unchanged. Small loculated left
pleural effusion, decreased in size with a pigtail catheter in place. There
is a small left anterior pneumothorax. No evidence of tension.
LUNG:
1. PARENCHYMA: Subadjacent to the bilateral pleural effusions is moderate
bibasilar relaxation atelectasis. At the left upper lobe is a lobulated
hypodense pulmonary nodule which measures 8 mm, (series 302, image 266),
unchanged when compared to CT chest dated ___. No new pulmonary
masses or nodules.
2. AIRWAYS: There is mild retained aerosolized secretions in the lower
trachea, (series 302, image 236). The airways are otherwise patent to the
subsegmental level without evidence of central mucous plugging.
CHEST CAGE: A mildly displaced oblique fracture of the lower sternum
demonstrated, (series 303, image 102), unchanged. Multiple mildly fractures
of the left rib fractures of indeterminate age. Multiple nondisplaced right
rib fractures are likely healing. No concerning lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Minimal interval decrease in size of a small loculated left pleural
effusion with a pigtail catheter in place.
2. Interval development of a left small anterior pneumothorax which is likely
secondary to placement of the pigtail catheter. No evidence of tension.
3. Trace pneumomediastinum.
4. Moderately-sized right pleural effusion, unchanged.
5. A 8 mm pulmonary nodule at the left lower lobe is unchanged.
6. Multiple mildly rib fractures of indeterminate age and a displaced oblique
fracture of the lower sternum unchanged when compared to CT chest dated ___
RECOMMENDATION(S): The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 7:30 pm, 60 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with please place single lumen tunneled femoral
access line for patient with renal issues. ___ aware. on tube feeds. will
stop now ___// please place single lumen tunneled femoral access line for
patient with renal issues. ___ aware. on tube feeds. will stop now ___
COMPARISON:
Chest x-ray ___
TECHNIQUE:
OPERATORS: Dr. ___ radiology fellow) and Dr. ___
(___) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure. Dr. ___,
___ radiologist, personally supervised the trainee during the key
components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA:1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site
FLUOROSCOPY TIME AND DOSE: 2.03 min, 10 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient with the help of a translator. The patient was then
brought to the angiography suite and placed supine on the exam table. A
pre-procedure time-out was performed per ___ protocol. The left upper chest
was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left subclavian 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 to make appropriate measurements for catheter
length.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine, a small skin incision was made at the tunnel entry site. A 30
cm catheter was selected. The single lumen power line was tunneled from the
entry site towards the venotomy site from where it was brought out using a
tunneling device. The venotomy tract was dilated using the introducer of the
peel-away sheath supplied. Following this, the peel-away sheath was placed
over the wire through which the catheter was threaded into the SVC with the
tip in the distal SVC. The sheath was then peeled away. The catheter was
sutured in place with ___ Prolene. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking. The tip is in the
distal SVC. The catheter was flushed and single lumen was capped. Sterile
dressings were applied. The patient tolerated the procedure well.
FINDINGS:
Patent left subclavian vein. Final fluoroscopic image showing 5 ___
single-lumen power linecatheter with tip terminating in the distal SVC.
IMPRESSION:
Successful placement of a 5 ___ single-lumen tunneled power line in the
left subclavian Vein. The tip of the catheter terminates in the distal SVC.
The catheter is ready for use.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 6 EXAMS
INDICATION: ___ year old man with dobhoff that was pulled// evaluation of
placement urgently for replacement of ___ let MD know when on floor
so can evaluate scan and replace dobhoff. ___ Thank you evaluation of
placement urgently for replacement of ___ let MD know when on floor
so can evaluate scan and replace dobhoff. ___ Thank you
IMPRESSION:
Comparison to ___. No relevant change is seen. Stable left pigtail
catheter in the pleural space. Stable small left pleural effusion. Moderate
cardiomegaly persists. Mild pulmonary edema is present. The fifth of 5
images shows the feeding tube with the tip projecting over the proximal parts
of the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff placement// dobhoff pulled. please
___ MD ___ when 5 min from floor. thank you
TECHNIQUE: AP chest x-ray
COMPARISON: AP chest x-ray dated ___ 07:56
FINDINGS:
In comparison to the prior study dated ___ at 07:56, there has been
interval placement of a Dobbhoff tube with the tip seen well below the
diaphragm. The trachea appears midline and patent. There are bilateral low
lung volumes, unchanged from prior. Again demonstrated is a left-sided chest
tube without appears to be in stable position. No pneumothorax. Multiple
endovascular stents are seen within the region of the right and left
brachiocephalic vein, subclavian vein, axillary vein. All appear to be in
stable position from prior.
IMPRESSION:
1. Interval placement of a Dobbhoff tube with the tip seen well below the
diaphragm.
2. Stable bilateral low lung volumes.
3. Stable positioning of the left-sided chest tube.
4. No migration of the multiple endovascular stents.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with desat to 40/50// ___ year old man with desat
to 40/50
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 16:33.
IMPRESSION:
The support lines and tubes are in stable position. A small left apical
pneumothorax is new compared to prior study. Small bilateral pleural
effusions with compressive atelectasis in the lungs bases and cardiomegaly
with central pulmonary vascular congestion is unchanged from prior study.
There is no pulmonary edema. Multiple vascular stents are noted. There are
no acute osseous abnormalities.
Radiology Report
INDICATION: ___ with ESRD on HD, brachiocephalic vein thrombosis s/p
stenting, T2DM, initially presented on ___ with SVC syndrome/stent thrombosis
and NSTEMI, with course c/b PEA arrest, encephalopathy, new found AS, ectopy,
who was most recently transferred to the ICU on ___ for hypoxemic respiratory
failure secondary to a pleural effusion and mucous plugging, now stable.//
eval dobhoff placement
TECHNIQUE: Portable supine abdominal radiograph was obtained with limited
views of the chest and abdomen.
COMPARISON: Radiograph dated ___
FINDINGS:
2 radiographs with limited views of the chest and abdomen.
CHEST:
Left lower lobe airspace opacification with small effusion and chest tube.
Cardiomediastinal silhouette appears normal. Venous stents in situ. Central
line terminates in the cavoatrial junction.
ABDOMEN:
There are no abnormally dilated loops of large or small bowel. Dobhoff tube
terminates in left upper quadrant overlying the mid stomach on second view.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Dobhoff tube seen terminating in the mid stomach on second view.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with history of SVC syndrome, multiple episodes
of venous stent thrombosis, now with increased L arm swelling concerning for
re-occlusion of L axillary or other stent.// CT-V to evaluate for occlusion of
vasculature/L axillary or brachiocephalic stent
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE:
Total DLP (Body) = 568 mGy-cm.
COMPARISON: Chest CT ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
Re-demonstrated are 2 stents extending into the SVC. The first stent
originates in the right brachiocephalic vein and is patent. The second stent
originates in the left brachiocephalic vein and is non-opacified. 2
additional stents are seen in the left subclavian vein and left axillary vein
both of which are also non-opacified. A left subclavian catheter is seen
extending into the SVC.
AXILLA, HILA, AND MEDIASTINUM: Multiple bilateral supraclavicular lymph nodes
measure up to 1.0 cm on the left (301:12). Multiple bilateral axillary lymph
nodes measure up to 1.1 cm on the left (301:94). Multiple subcentimeter left
subpectoral lymph nodes are also noted. Multiple mediastinal lymph nodes
measure up to 1.0 cm in the prevascular region (301:75).
PLEURAL SPACES: Moderate right pleural effusion, unchanged. Moderate left
pleural effusion, increased since the prior study. There is no pneumothorax.
LUNGS/AIRWAYS: A 1.0 cm hypodense nodule in the left lower lobe (301:84) is
unchanged since ___. Left lower lobe collapse is unchanged.
Mild-to-moderate right lower lobe atelectasis is unchanged. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates a diffusely
atrophic pancreas. Enteric tube terminates in the proximal stomach.
BONES: Bilateral rib fractures and sternal fracture again are again noted. No
suspicious osseous abnormality is seen.?
IMPRESSION:
1. The left brachiocephalic, subclavian, and axillary veins stents are
non-opacified. Further evaluation with angiography is recommended and
probably a better modality for evaluation of the vessel/stent patency than CT.
2. The right brachiocephalic vein stent is patent.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Left lower lobe collapse and mild-to-moderate right lower lobe atelectasis,
unchanged.
5. Moderate bilateral pleural effusions, unchanged.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:01 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with new onset left side weakness, concern for
hemorrhage.// ___ year old man with new onset left side weakness, concern for
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 =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: MRI brain performed ___. CT head performed ___.
FINDINGS:
The previously described subacute left cerebellar infarct is better assessed
on recent MRI brain performed ___. There is no evidence of large
vascular territory infarction,hemorrhage,edema, or mass. There is prominence
of the ventricles and sulci suggestive of involutional changes. Mild
periventricular and subcortical white matter hypodensities are nonspecific but
likely reflect the sequelae of chronic microvascular ischemic disease.
There is no evidence of fracture. There is mild opacification of the
bilateral mastoid air cells, right greater than left. The middle ear cavities
are clear. There is trace fluid layering in the left sphenoid sinus.
Otherwise, the remainder of the paranasal sinuses are essentially clear. A
nasoenteric tube is partially evaluated. Status post bilateral lens
replacements.
IMPRESSION:
Previously described subacute left cerebellar infarction is better assessed on
recent MRI brain performed ___. Otherwise, no evidence of large
vascular territory infarction or intracranial hemorrhage.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: B Arm pain, Neck pain, Transfer
Diagnosed with Compression of vein
temperature: 98.3
heartrate: 76.0
resprate: 18.0
o2sat: 94.0
sbp: 132.0
dbp: 65.0
level of pain: 8
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for swelling in your neck
and arm
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were found to have blood clots in some of the veins that
supply your neck and arm. We removed some of the blood clots
- You are being treated for an infection in your lungs with
antibiotics
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx dementia, prior CVA, DM, HTN, recent admission for
encephalopathy, p/w weakness and hypotension.
Had recent admission ___ for toxic metabolic
encephalopathy and ___. During last admission, CT head was
without acute process. Infectious work up was negative. The
patient's level of consciousness waxed and waned throughout the
admission, which his family reported was his new baseline since
his recent admission to ___ for TIA. On day of discharge, he was
alert and oriented x1-2 (baseline).
On day of admission, family reported to ED that pt had gradual
onset of generalized weakness. They recently purchased an
automatic BP machine, and note that his SBP in the ___ measured.
Patient did not report any chest pain, SOB, n/v, hemoptysis or
hematemesis. He has been constipated since discharge.
Family called EMS. EMS initial vitals was notable for Pulse: 120
Pulse Reg: REGULAR BP: 76/P RR: 20 SpO2%: 94 ROOM AIR.
In the ED, initial vitals were: 97.8 119 109/61 20 98% RA
- Labs were significant for no leukocytosis, Hgb 11.7 (higher
than most recent discharge hgb), normal chemistry except BS of
341, no acidosis/gap, mildly elevated ALT/AST 67/78, lactate
2.3, UA notable for few bacs, small leuks, neg nitrite.
- Imaging revealed:
# CT abd/pelvis
Large stool burden throughout the colon without evidence of
obstruction.
# CXR
No acute cardiopulmonary process.
- The patient was given
___ 17:45 IVF 1000 mL NS 1000 mL ___
___ 19:42 IVF 1000 mL NS 1000 mL ___
___ 19:42 IV CefePIME 2 g ___
___ 21:10 IV Vancomycin 1000 mg ___
Also was given 1mg IV Ativan prior to transfer. Haldol was
written for, but not administered.
- Vitals prior to transfer were: 97.8 81 150/88 20 100% RA
Upon arrival to the floor, patient is found comfortable in bed,
mildly lethargic. He does not speak ___, but is accompanied
by a family friend who intermittently helps care for him at
home. She translates, but the patient is not oriented, and may
be hard-of-hearing. Though she has not seen the patient in 2
months, she was told that he had no fevers, chills, nausea,
vomiting, chest pain or pressure, abdominal pain at home. His
appetite is typically very good. He does have constipation on a
regular basis. He had urinary problems last week (unspecified)
but they resolved. He does seem confused to her. REVIEW OF
SYSTEMS: Per HPI, limited by encephalopathy.
Past Medical History:
Type 2 Diabetes
Hyperlipidemia
Diabetic Retinopathy
Glaucoma
Benign Hypertension
Prior Stroke
Peripheral Neuropathy
Social History:
___
Family History:
No family history of stroke
Physical Exam:
======================
ADMISSION EXAM:
======================
Vitals: 97.6 79 150/81 18 98%RA
General: ___, responds to loud voice, no acute
distress
HEENT: Pinpoint but symmetric, reactive pupils, sclera
anicteric, clear OP, MMM
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Limited exam, but clear to auscultation bilaterally, no
wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining yellow urine
Ext: WWP, no edema
Neuro: Face symmetric, moves all four limbs in bed
======================
DISCHARGE EXAM:
======================
Vitals: T 97.6 BP 139/94 HR 125 RR 18 98% RA
General: AOx1 (baseline), ___, in NAD
HEENT: Pinpoint but symmetric, reactive pupils, sclera
anicteric, clear OP, MMM
Neck: Supple, JVP not elevated
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: CTAB, no w/r/r
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No Foley
Ext: WWP, no edema
Neuro: AOx1, moving all four limbs.
Pertinent Results:
=====================
ADMISSION LABS:
=====================
___ 05:25PM BLOOD WBC-7.3 RBC-3.76* Hgb-11.7* Hct-36.0*
MCV-96 MCH-31.1 MCHC-32.5 RDW-12.5 RDWSD-43.5 Plt ___
___ 05:25PM BLOOD Neuts-70.5 Lymphs-15.7* Monos-9.6 Eos-3.4
Baso-0.4 Im ___ AbsNeut-5.16 AbsLymp-1.15* AbsMono-0.70
AbsEos-0.25 AbsBaso-0.03
___ 05:25PM BLOOD ___ PTT-32.1 ___
___:25PM BLOOD Glucose-341* UreaN-19 Creat-1.1 Na-140
K-4.2 Cl-100 HCO3-29 AnGap-15
___ 05:25PM BLOOD ALT-78* AST-67* AlkPhos-128 TotBili-0.3
___ 05:25PM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.3 Mg-1.6
___ 05:50PM BLOOD Lactate-2.3*
=========================
PERTINENT RESULTS:
=========================
MICROBIOLOGY:
=========================
___ 05:55PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 05:55PM URINE RBC-15* WBC-12* Bacteri-FEW Yeast-NONE
Epi-<1
=========================
IMAGING:
=========================
CXR (___): No acute cardiopulmonary process.
===
CT Abdomen/Pelvis With Contrast (___): Large stool burden
throughout the colon without evidence of obstruction.
Prostatomegaly.
===
Bilateral Lower Extremity Ultrasounds ___ for
DVT.
=====================
DISCHARGE LABS:
=====================
None.
Radiology Report
INDICATION: ___ male with hypotension.
TECHNIQUE: AP and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
AP upright and lateral chest radiographs demonstrate low lung volumes.
Cardiomediastinal and hilar contours are stable relative to prior examination
dated ___. No evidence of pulmonary edema, pleural effusion, or
pneumothorax. Imaged osseous structures demonstrates bilateral
acromioclavicular joint degenerative changes, left greater than right. Imaged
upper abdomen is without an acute abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ male with dementia. Unclear source for hypotension.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained after the uneventful administration of intravenous contrast. No oral
contrast was administered. Coronal and sagittal reformations were generated
and reviewed.
DOSE: DLP: 906 mGy cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
Chest: There is elevation of the right hemidiaphragm. Bibasilar atelectasis
is symmetric and mild. There is no pleural or pericardial effusion.
Extensive atherosclerotic calcifications involve the coronary arteries most
pronounced in the left anterior descending and circumflex coronary arteries.
The liver is homogeneous in attenuation without a focal lesion. There is no
intrahepatic biliary duct dilation. The portal vein is patent. There is no
radiopaque cholelithiasis. The pancreas is atrophic. The spleen and
bilateral adrenal glands are normal.
The kidneys present symmetric nephrograms and excretion of contrast. There is
no hydronephrosis or perinephric fluid stranding. A large cortical
hypodensity projects from the interpolar region of the right kidney
posteriorly and measures 3.4 x 5.1 cm, most consistent with a simple cyst.
There is a small hiatal hernia. The stomach is otherwise unremarkable. Loops
of small bowel are nondilated. Extensive fecal loading involves the entire
colon. There is no abdominal free fluid or air.
The abdominal aorta is normal in caliber without aneurysmal dilatation.
Extensive atherosclerotic calcifications are present. There is no
retroperitoneal or mesenteric adenopathy.
Pelvis: A Foley catheter is identified within a decompressed bladder. Foci
of air within the bladder lumen are presumably iatrogenic. The prostate gland
is massively enlarged measuring approximately 6.4 x 7.6 cm in axial dimension
(2:81), unchanged. There is no pelvic free fluid. There is no inguinal or
pelvic sidewall adenopathy. A small fat containing umbilical hernia is noted.
Multilevel degenerative changes are moderate to severe. No lesion worrisome
for malignancy or infection is identified.
IMPRESSION:
Large stool burden throughout the colon without evidence of obstruction.
Prostatomegaly.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with persistent tachycardia // 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 demonstrated
in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Retention of urine, unspecified, Urinary tract infection, site not specified, Type 2 diabetes mellitus with hyperglycemia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Dear Mr. ___,
You came to the hospital because you were having low blood
pressures at home. We gave you fluids, and your blood pressure
improved. This could have been due to a blood pressure
medication that was recently started. We also found that your
heart rates were high. We think this was caused by an
obstruction in your bladder. We replaced your urinary catheter,
and your heart rates improved. You will keep this catheter in
until your appointment with Urology.
Please stop taking amlodipine and follow-up with your primary
care physician for ___ blood pressure check.
We wish you the best of health.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neosporin AF / adhesive tape
Attending: ___.
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH metastatic breast CA currently on immunotherapy, bell's
palsy with left-sided facial droop, vasovagal episodes with
significant bradycardia and cyanosis, p/w nausea, vomiting,
diarrhea and thrush. Patient developed several episodes of
emesis
last night and was having difficulty tolerating PO. Also
endorsing sore throat and thrush, for which she has been
prescribed magic mouthwash with minimal resolution. Denies
fevers/chills, CP, dyspnea, abdominal pain, BRBPR, melena,
dysuria, and rashes.
ED spoke w her oncologist in ___ (Dr. ___
___), said to hold her new immunotherapy drug Ibrance
as thought to be causing the above symptoms. She started the
drug
about 2.5 weeks ago.
In the ED, initial vitals:98.4 80 122/46 18 98% RA
- Exam notable for:
General: pale-appearing elderly female in NAD
HEENT: NC, AT. PERRLA. EOMI. Nares patent. EOMI.
Neck: cervical lymphadenopathy
Chest: coarse lung sound to LLL
CV: RRR, nrml s1/s2, no m/g/r.
Abdomen: soft, non-tender, no HSM
Ext: trace pitting edema to BLLE
Neuro: AOx3, left facial droop, otherwise cn2-12 intact.
- Labs notable for:
- CBC 2.2/7.___ w 510 ANC
- CHEM BUN 24 Cr 1.8
- Coags INR 1.2
- LFTs AP 114
- UA perfectly normal
- Imaging notable for: normal CXR
- Pt given:
___ 22:39 PO/NG Atorvastatin 10 mg ___
___ 22:39 PO/NG Carvedilol 6.25 mg ___
___ 22:39 TD Fentanyl Patch 12 mcg/h
___ 22:39 PO/NG Mirtazapine 15 mg ___
___ 22:51 PO/NG LORazepam .5 mg ___
- Vitals prior to transfer: 98.4 81 126/57 18 97% RA
Upon arrival to the floor, the patient reports the above story.
Past Medical History:
Metastatic breast cancer ___ s/p lumpectomy and ___
(involvement of bone, liver)
___
Decreased EF and MR after ___ that has since largely resolved
neuropathy secondary to ___
htn
anxiety
glaucoma
CKD
Social History:
___
Family History:
No history of heart disease or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: T 98.5 PO BP: 112/56 HR: 86 RR: 18 O2 sat: 94% RA
GENERAL: appears younger than age, NAD
HEENT: sclera anicteric, MMM, OP w thrush
CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, known L facial droop (bell's), moving all
extremities w purpose and against gravity
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1129)
Temp: 97.3 (Tm 99.4), BP: 111/61 (103-124/61-70), HR: 74
(74-88), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: Ra
GENERAL: appears younger than age, NAD.
HEENT: sclera anicteric, MMM, thrush appears to be resolving on
OP exam, does have what appears to be some angular chelitis.
CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, known L facial droop (bell's), moving all
extremities w purpose and against gravity
Pertinent Results:
ADMISSION LABS:
==============
___ 05:35PM BLOOD WBC-2.2* RBC-2.77* Hgb-7.7* Hct-24.5*
MCV-88 MCH-27.8 MCHC-31.4* RDW-19.8* RDWSD-56.0* Plt Ct-36*
___ 05:35PM BLOOD Neuts-23* Bands-0 Lymphs-71* Monos-5
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-0.51* AbsLymp-1.56
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02
___ 10:00PM BLOOD ___ PTT-28.2 ___
___ 05:35PM BLOOD Glucose-124* UreaN-24* Creat-1.8* Na-140
K-5.0 Cl-95* HCO3-28 AnGap-17
___ 10:00PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.4
___ 05:35PM BLOOD ALT-16 AST-38 AlkPhos-114* TotBili-0.3
___ 05:35PM BLOOD Lipase-47
___ 09:48PM BLOOD Lactate-1.4
PERTINENT LABS/MICRO/IMAGING:
============================
___ 01:21PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:21PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 01:21PM URINE RBC-1 WBC-7* Bacteri-FEW* Yeast-NONE
Epi-0
___ 9:27 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 9:34 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 9:54 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 9:30 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Time Taken Not Noted Log-In Date/Time: ___ 1:58 pm
BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 1:21 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Imaging:
----------
CXR ___:
No acute intrathoracic process.
DISCHARGE LABS:
===============
___ 08:38AM BLOOD WBC-3.0* RBC-3.19* Hgb-9.0* Hct-29.5*
MCV-93 MCH-28.2 MCHC-30.5* RDW-18.9* RDWSD-55.8* Plt Ct-21*
___ 08:38AM BLOOD Neuts-20* Bands-0 Lymphs-75* Monos-3*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0 NRBC-1* AbsNeut-0.60*
AbsLymp-2.31 AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 08:38AM BLOOD Glucose-105* UreaN-26* Creat-1.6* Na-139
K-4.5 Cl-100 HCO3-25 AnGap-14
___ 08:38AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. Fentanyl Patch 12 mcg/h TD Q72H
3. Sertraline 25 mg PO DAILY
4. Letrozole 2.5 mg PO DAILY
5. Movantik (naloxegol) 25 mg oral DAILY
6. Mirtazapine 15 mg PO QHS
7. Atorvastatin 10 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. LORazepam 0.5 mg PO BID
10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
Discharge Medications:
1. Maalox/Lidocaine 15 mL ORAL Q4H:PRN pain with swallowing
RX *alum-mag hydroxide-simeth [Almacone] 200 mg-200 mg-20 mg/5
mL 15 ml by mouth every four hours as needed Disp #*355
Milliliter Milliliter Refills:*1
2. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
RX *nystatin 100,000 unit/mL 5 ml by mouth every eight hours as
needed Disp #*480 Milliliter Milliliter Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Carvedilol 6.25 mg PO BID
6. Fentanyl Patch 12 mcg/h TD Q72H
7. Letrozole 2.5 mg PO DAILY
8. LORazepam 0.5 mg PO BID
9. Mirtazapine 15 mg PO QHS
10. Movantik (naloxegol) 25 mg oral DAILY
11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
12. Sertraline 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Pancytopenia
-Vomiting/Diarrhea
-Odynophagia
SECONDARY:
-Metastatic breast cancer
-___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with metastatic cancer, leukopenia and slightly coarse lung
sounds to LLL.// PNA?
COMPARISON: Prior chest radiograph from ___
FINDINGS:
PA and lateral views of the chest provided. Surgical clips project over the
left chest wall. Lungs appear clear bilaterally. There is no focal
consolidation, effusion, or pneumothorax. There are no signs of congestion or
edema. The cardiomediastinal silhouette is normal. Imaged osseous structures
are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Other pancytopenia
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because your blood counts were
low and you were vomiting and having diarrhea.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received IV fluids because you were dehydrated from the
vomiting and diarrhea.
-You received a blood transfusion because your hemoglobin was
low and you were feeling more tired than usual, and you
responded appropriately to the transfusion.
-Your blood counts continue to improve since stopping the
Ibrance.
-Your vomiting and diarrhea resolved since stopping the Ibrance
and getting IV fluids, and your sore throat improved with the
Magic Mouthwash and Nystatin rinses. As a result, you were able
to eat and drink more.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all medications as prescribed.
-Please attend all ___ clinic appointments.
-Please follow-up with your oncologist at ___ in
___ to discuss further treatment options.
We wish you all the best,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shrimp
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/migraines, presents with headache, neck stiffness. Pt
first presented to urgent care ___ with vesicular skin lesions
diagnosed with shingles, started on Valtrex. Then seen ___
with urinary incontinence and headache, UA ___, pt given
migraine cocktail and sent home. Headache did not improved and
then developed neck pain/stiffness and nausea/vomiting.
Instructed by PCP to present due to concern for VZV meningitis.
In ED ID contacted, recommended empiric Rx, no LP given
overlying rash. Pt given ceftriaxone, acyclovir and vanc,
morphine and zofran.
On arrival to floor pt reports severe continued headache and
neck pain, no relief with morphine in ED. No other complaints.
Rash no longer painful.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Varicella zoster
Migraine Headaches
Asthma
Depression
Social History:
___
Family History:
father CAD/PVD/CVA - Early; Hyperlipidemia; Hypertension;
Depression
mother ___ and HTN
Physical Exam:
Admission Exam
Vitals: T:98.6 BP:108/68 P:71 R:16 O2:98%ra
PAIN: 9
General: mild distress due to pain
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: healing vesicular rash on right in L1 dermatome, does not
cross midline
Neuro: alert, follows commands +neck stiffness
DISCHARGE DAY EXAM
Vitals:
Pertinent Results:
___ 09:00PM GLUCOSE-88 UREA N-5* CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
___ 09:00PM ALT(SGPT)-19 AST(SGOT)-27 LD(LDH)-200 ALK
PHOS-31* TOT BILI-0.4
___ 09:24PM LACTATE-1.5
___ 09:00PM ALBUMIN-3.9
___ 09:00PM WBC-8.7 RBC-3.77* HGB-12.5 HCT-38.0 MCV-101*
MCH-33.1* MCHC-32.8 RDW-12.8
___ 09:00PM NEUTS-47.7* ___ MONOS-4.0 EOS-11.9*
BASOS-0.7
___ 09:00PM PLT COUNT-188
___ 09:00PM ___ PTT-29.4 ___
___ 09:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
Lumbar puncture
Tube #4, 1 WBC (85% lymphs, 15% monos), 4 RBCs
Glucose 66, protein 29
Micro
BCx and UCx NGTD
CSF Gram stain negative, bacterial cx NGTD
HSV and VZV CSF PCRs pending
CXR -- REASON FOR EXAMINATION: Chest tightness, history of
asthma and wheezing. PA and lateral upright chest radiographs
were reviewed with no prior studies available for comparison.
Heart size is normal. Mediastinum is normal. Assessment of the
lungs demonstrate diffuse opacities involving both upper and
lower lobes, right slightly more than left, lower lobe
substantially more upper lobe and given the patient's symptoms,
these findings might reflect interval development of infectious
process, for example viral or atypical. No pleural effusion is
seen. No pneumothorax is seen. There is no evidence of
pulmonary edema.
KUB -- IMPRESSION: Moderate amount of stool throughout the
colon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
2. etodolac 200 mg oral q6 prn pain
3. ValACYclovir 1000 mg PO Q8H
4. ALPRAZolam 1 mg PO TID:PRN anxiety
5. ALPRAZolam 2 mg PO QHS
6. Paroxetine 40 mg PO DAILY
7. Mirtazapine 15 mg PO HS
8. Sumatriptan Succinate 50 mg PO BID:PRN migraine
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. ALPRAZolam 1 mg PO TID:PRN anxiety
3. ALPRAZolam 2 mg PO QHS
4. Mirtazapine 15 mg PO HS
5. Paroxetine 40 mg PO DAILY
6. ValACYclovir 1000 mg PO Q8H
7. Acetaminophen 1000 mg PO Q8H
8. Docusate Sodium 100 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO BID
12. Sumatriptan Succinate 50 mg PO BID:PRN migraine
Discharge Disposition:
Home
Discharge Diagnosis:
Varicella-zoster meningitis and mild pneumonitis -- not
confirmed, but strongly suspected
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with abdominal pain and distention in the setting
of opiate use.
TECHNIQUE: Frontal radiographs of the abdomen and pelvis were obtained with
the patient in upright and supine positions.
COMPARISON: None available.
FINDINGS:
There is a normal bowel gas pattern without evidence for obstruction or ileus.
A moderate amount of stool is seen throughout the colon. No free
intraperitoneal air is detected.
IMPRESSION:
Moderate amount of stool throughout the colon.
Radiology Report
REASON FOR EXAMINATION: Chest tightness, history of asthma and wheezing.
PA and lateral upright chest radiographs were reviewed with no prior studies
available for comparison.
Heart size is normal. Mediastinum is normal. Assessment of the lungs
demonstrate diffuse opacities involving both upper and lower lobes, right
slightly more than left, lower lobe substantially more upper lobe and given
the patient's symptoms, these findings might reflect interval development of
infectious process, for example viral or atypical. No pleural effusion is
seen. No pneumothorax is seen. There is no evidence of pulmonary edema.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: HEADACHE
Diagnosed with MENINGITIS NOS
temperature: 96.7
heartrate: 84.0
resprate: 18.0
o2sat: 98.0
sbp: 113.0
dbp: 66.0
level of pain: 7
level of acuity: 3.0 | You were admitted with suspected varicella-zoster virus (aka VZV
or shingles) meningitis. We also found that it might have
affected your lungs a bit (based on a chest x-ray). We treated
you with an anti-viral medication, as well as pain medications.
It's important that you follow-up with your doctor to review
test results that were pending at the time of discharge (see
below) and thereby determine the course of treatment for the
anti-viral medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending: ___.
Major Surgical or Invasive Procedure:
EGD
attach
Pertinent Results:
___ 06:05AM BLOOD WBC-6.0 RBC-2.69* Hgb-7.9* Hct-25.2*
MCV-94 MCH-29.4 MCHC-31.3* RDW-14.8 RDWSD-49.8* Plt ___
___ 06:05AM BLOOD Glucose-90 UreaN-13 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 06:05AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0 Iron-19*
___ 06:05AM BLOOD calTIBC-355 Ferritn-28 TRF-273
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 7 mg PO DAILY
2. FLUoxetine 40 mg PO DAILY
3. TraZODone 50 mg PO QHS
4. Warfarin 10 mg PO 2X/WEEK (MO,FR)
5. Warfarin 15 mg PO 5X/WEEK (___)
6. Enoxaparin (Treatment) 70 mg SC Q12H
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*45 Tablet Refills:*0
2. Warfarin 10 mg PO DAILY16
3. FLUoxetine 40 mg PO DAILY
4. PredniSONE 7 mg PO DAILY
5. TraZODone 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
gastric petechiae, duodenitis
supratherapeutic INR
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 ITP, seronegative APLS comes with 1 day of dyspnea,
fatigue // r/o acute process
COMPARISON: Chest CT from ___
FINDINGS:
PA and lateral views of the chest provided. Calcified granuloma projects over
the left mid lung. The lungs are otherwise clear. Cardiomediastinal
silhouette is normal. No large effusion or pneumothorax. Bony structures are
intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with history of seronegative APLS, multiple PEs
on warfarin with L posterior calf tenderness // r/o clot
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the right posterior tibial and peroneal
veins. Normal color flow is demonstrated in the left posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Melena
Diagnosed with Anemia, unspecified
temperature: 96.4
heartrate: 65.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 47.0
level of pain: 7
level of acuity: 2.0 | Dear Ms. ___,
You were admitted for concern of a GI bleed. You had an EGD done
during this admission to evaluate for cause of bleed. You did
not have any further episodes of bleeding and your blood counts
remained stable.
You will need:
Repeat EGD in ___ for biopsies
Also will need a right upper quadrant US for further evaluation
You INR was also elevated. You will need to follow up with your
PCP as soon as possible for an INR check to make sure your
warfarin dose does not need to be re-adjusted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / codeine / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
cough and weakness
Major Surgical or Invasive Procedure:
___ flex bronch + rigid bronch + EBUS / TBNA 4R,7,4L, 11L +
bronchial wash
History of Present Illness:
___ y.o F with CAD s/p stent, GERD, COPD who presents as a
transfer with confusion and weakness with CT evidence of LLL
with atelectasis and or pneumonitis. Patient originally
presenting to ___ with cough and weakness and was found to
have a postobstructive pneumonitis on CTA. Per the ED Dash, the
patient received CTX and doxycycline at ___. Given need for
possible interventional pulmonology, they recommended transfer
to ___. Upon arrival ___ our ED, the patient was noted to be
confused, but endorsed poor memory at baseline. She other wise
denied fevers, chills, chest pain, dyspnea, nausea, vomiting,
changes ___ bowel or bladder function, rashes, or lesions.
___ the ED, initial VS were 98.3, HR 90, 125/73 18 98% on RA. CTA
chest with a 4 cm LLL mass and tumor with associated mediastinal
and left hilar lymphadenopathy. It is associated with left lower
lobe basilar atelectasis and/or pneumonitis.
The patient reports she is ___ the hospital because they found
"something on my lung." She reports that her husband and
daughter ___ like the way I looked." She endorses ongoing
nausea, without vomiting, and one episode of loose stools. She
denies chest pain, shortness of breath, weakness, dysuria. She
reports that she feels off of balance of the past two months,
and he had a fall with a head strike, that required stitches.
ROS: Pertinent positives and negatives as noted ___ the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- TIA vs complex migraine
- HTN
- HLD
- GERD
- Asthma
- TIA x 3
- UTIs
- AAA s/p repair
- Diverticulosis
- Macular degeneration
- Cardiac stent
- COPD
Social History:
___
Family History:
sister had stroke
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death
Physical Exam:
Admission Physical EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and ___ no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, + systolic murmur
RESP: Decreased breath sounds of left posterior lung, +
occasional inspiratory wheezes bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, ___ grip strength, ___
hip flexion, ___ dorsiflexion bilaterally
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented,, answers questions appropriately however
with some difficulty with recall, face symmetric, gaze conjugate
with EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Discharge Exam:
Seen and examined by me on day of discharge
VITALS: 98.4 PO 138 / 70 R Lying 73 16 95 RA
GENERAL: Alert and ___ no apparent distress
EYES: Sclerae Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, Mucous
membranes moist
CV: Heart regular, + systolic murmur
RESP: Intermittent rattling cough, lungs CTA no wheezing, rales
appreciated, breathing nonlabored
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, moving all extremity
spontaneously
SKIN: No rashes or ulcerations noted
NEURO: alert, oriented to self, hospital (not ___, for date
says ___, Face symmetric, gaze conjugate with EOMI, speech
fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission ___:
===========
___ 06:03AM BLOOD WBC-13.5* RBC-4.33 Hgb-12.0 Hct-37.6
MCV-87 MCH-27.7 MCHC-31.9* RDW-14.4 RDWSD-46.4* Plt ___
___ 04:56AM BLOOD ___ PTT-31.3 ___
___ 06:03AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-146
K-3.8 Cl-111* HCO3-23 AnGap-12
___ 05:15PM BLOOD cTropnT-<0.01
___ 06:03AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
___:
CBC: 16.6, H/H 13.8, 42.3, Plt 318
BMP: BUN/Cr ___
LFTS: ALT 14, AST 20, alk phos 105
UA with moderate leuk esterase, + epithelial cells
Microbiology:
========
Sputum culture:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
___ 9:05 am BRONCHIAL WASHINGS LEFT BRONCHIAL WASH.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Discharge ___:
===========
___ 08:20AM BLOOD WBC-10.3* RBC-4.38 Hgb-12.3 Hct-38.1
MCV-87 MCH-28.1 MCHC-32.3 RDW-14.5 RDWSD-46.2 Plt ___
___ 08:20AM BLOOD Glucose-97 UreaN-7 Creat-1.0 Na-146 K-4.0
Cl-108 HCO3-24 AnGap-14
___ 08:20AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.9
Imaging:
=======
CTA PE protocol ___ ___
1. No PE.
2. 4 cm left lower lobe (superior segment) mass/tumor.
Associated mediastinal/left hilar lymphadenopathy.
3. Left lower lobe basilar atelectasis or pneumonitis. Clinical
correlation.
CXR ___
Chest hyperinflation, tortuous descending aorta.
Retrohilar mass, about the same compared with CT from one week
earlier.
MRI HEAD W & W/O CONTRAST
1. 5 x 4 x 3 mm homogeneously enhancing extra-axial lesion along
the inferior margin of the anterior falx cerebri, best seen on
high-resolution MP RAGE images, unclear whether present on the
prior noncontrast MRI which was performed without
high-resolution images. Diagnostic considerations include a
tiny meningioma versus a small metastasis.
2. Small chronic infarcts within bilateral basal ganglia. A
small chronic infarct ___ the right caudate nucleus was not seen
on the prior MRI, but this could have been secondary to
differences ___ slice selection.
3. Extensive supratentorial white matter signal abnormalities,
nonspecific but likely sequela of chronic small vessel ischemic
disease ___ this age group.
4. Unchanged enlargement of the ventricles and sylvian fissures
without enlargement of sulci at the vertex, most likely
secondary to central and perisylvian predominance of global
parenchymal volume loss. However, the callosal angle is
slightly reduced, and superimposed communicating hydrocephalus,
which would be a clinically based diagnosis, could be
considered ___ an appropriate clinical setting.
RECOMMENDATION(S): Follow-up brain MRI with and without
contrast for reassessment of the small subfalcine extra-axial
lesion.
CXR ___
The left lower lobe mass is again seen. Lucency seen ___ the
retrocardiac left lower lobe could represent a tiny pneumothorax
or postoperative changes. Lungs are low volume. Heart size is
top-normal. There is no pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
4. ClonazePAM 0.5 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First Line
9. Aspirin 81 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
4. ClonazePAM 0.5 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First Line
9. Aspirin 81 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
RX *albuterol sulfate 90 mcg ___ puff INH every six (6) hours
Disp #*1 Inhaler Refills:*1
3. LevoFLOXacin 750 mg PO Q48H Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
4. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH once a day Disp #*30 Capsule Refills:*0
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
11. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First
Line
12. Ranitidine 150 mg PO BID
13. HELD- ClonazePAM 0.5 mg PO BID This medication was held. Do
not restart ClonazePAM until you talk to your primary care
doctor
14. HELD- TraMADol 100 mg PO Q6H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until you talk to
your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
lung mass with post-obstructive pneumonia
5 x 4 x 3 mm homogeneously enhancing extra-axial lesion along
the inferior margin of the anterior falx cerebri
SVT: AVNRT
Acute hypoxic respiratory failure
chronic small vessel ischemic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with CAD s/p stent, AAA s/p repair, COPD who
presents with likely obstructing pulmonary left lower lobe tumor with
worsening memory and gait instability. Evaluate for underlying brain
metastasis.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6 cc Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI head without contrast dated ___.
FINDINGS:
There is a 5 x 4 x 3 mm (craniocaudad, transverse, AP, images 901:45,
900:75-76) homogeneously enhancing extra-axial lesion along the inferior
margin of the anterior falx cerebri, with low T2 signal (08:13), best seen on
high-resolution MP RAGE images. It was not seen on the prior noncontrast MRI,
which did not include high-resolution MP RAGE images. Diagnostic
considerations include a tiny meningioma, but follow-up is needed to exclude a
metastasis. No additional enhancing lesions are identified. No evidence for
pathologic leptomeningeal or pachymeningeal contrast enhancement.
No evidence for acute infarction or intracranial blood products. Again seen
is confluent T2/FLAIR hyperintensity along the lateral ventricles, as well as
discrete foci of T2/FLAIR hyperintensity in the supratentorial white matter,
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group. Multiple small chronic infarcts are again seen in the
bilateral lentiform nuclei and left caudate nucleus, the latter on image 7:14.
Small chronic infarct in the right caudate nucleus, also on image 7:14, was
not clearly seen on the prior MRI, though this could have been secondary to
differences in slice selection.
There is enlargement of the ventricles and sylvian fissures without
enlargement of sulci at the vertex, most likely secondary to central and
perisylvian predominance of global parenchymal volume loss, unchanged.
However, callosal angle is slightly reduced.
Major vascular flow voids are grossly preserved. Dural venous sinuses appear
patent on postcontrast MP RAGE images.
There is a small mucous retention cyst in the right maxillary sinus and mild
mucosal thickening in the ethmoid air cells. There is evidence of bilateral
cataract surgery.
IMPRESSION:
1. 5 x 4 x 3 mm homogeneously enhancing extra-axial lesion along the inferior
margin of the anterior falx cerebri, best seen on high-resolution MP RAGE
images, unclear whether present on the prior noncontrast MRI which was
performed without high-resolution images. Diagnostic considerations include a
tiny meningioma versus a small metastasis.
2. Small chronic infarcts within bilateral basal ganglia. A small chronic
infarct in the right caudate nucleus was not seen on the prior MRI, but this
could have been secondary to differences in slice selection.
3. Extensive supratentorial white matter signal abnormalities, nonspecific but
likely sequela of chronic small vessel ischemic disease in this age group.
4. Unchanged enlargement of the ventricles and sylvian fissures without
enlargement of sulci at the vertex, most likely secondary to central and
perisylvian predominance of global parenchymal volume loss. However, the
callosal angle is slightly reduced, and superimposed communicating
hydrocephalus, which would be a clinically based diagnosis, could be
considered in an appropriate clinical setting.
RECOMMENDATION(S): Follow-up brain MRI with and without contrast for
reassessment of the small subfalcine extra-axial lesion.
NOTIFICATION: The findings and recommendations were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 6:51 pm, 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: S/P LLL tumor debulking// S/P LLL tumor debulking
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The left lower lobe mass is again seen. Lucency seen in the retrocardiac left
lower lobe could represent a tiny pneumothorax or postoperative changes.
Lungs are low volume. Heart size is top-normal. There is no pleural effusion
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with Weakness, Other nonspecific abnormal finding of lung field, Pneumonia, unspecified organism
temperature: 98.3
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted with decreased appetite and feeling unwell.
You were found to have lung mass causing obstruction and
pneumonia from this. You underwent a procedure called
bronchoscopy to find out what the lung mass is. The results are
not ready yet but they should be ___ the next week or two. Your
heart rate went fast but this was controlled well with your
metoprolol.
You had a picture of your head taken (MRI) that showed a tiny
spot that might be a tumor or mass. You will need to have this
repeated as an outpatient.
You should complete your antibiotics for pneumonia at home as
directed. You have some new inhalers recommended by the
pulmonology doctors.
You will have a physical therapist evaluate you at home to help
with your balance.
Please followup regarding your lung mass as below.
It was a pleasure caring for you and we wish you the best,
Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Painless Jaundice
Major Surgical or Invasive Procedure:
PTBD placement ___, revision on ___ and ___.
Metal stent placed ___. Repeat cholangiogram and drain capped
on ___. External drain removal ___.
History of Present Illness:
___ w/ hx of stage III gastroadenocarcinoma s/p partial
gastrectomy and Roux-En-Y in ___ (declined adjuvant therapy in
favor of nutritional supplements) now presents with painless
jaundice, which began last month and has been progressive. +
unintentional 5 lb weight loss. He reports recent dark urine and
light stools. No n/v, fever/chills, abd pain,
diarrhea/constipation. + mild fatigue.
ROS otherwise negative in full.
Had CT scan by PCP which reportedly showed intrahepatic and CBD
dilation of 1.3cm with no discrete masses or calculi.
Past Medical History:
PMH: migraine, H. pylori, stage III gastroadenocarcinoma s/p
partial gastrectomy and Roux-En-Y in ___
PSH: Undescended testicle (___)
Social History:
___
Family History:
FamHx: father with MI
Physical Exam:
Admission:
General: Thin, very jaundiced, NAD
VSS
HEENT: Normocephalic, atraumatic, icteric sclerae. EOMI.
Oropharynx with moist mucous membranes.
Neck: Supple
Cardiac: Regular rate, S1, S2. No murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally.
Abdomen: Well healed surgical scar. Liver edge palpable,
coarse. Mild RUQ tenderness to deep palpation. No palpable
hepatosplenomegaly. Normoactive bowel sounds.
Extremities: Without any clubbing, cyanosis, or edema.
Back: Without any point spinal tenderness.
Skin: Without any notable rashes but + marked jaundice
Neurologic: Grossly intact, fluent speech
Psych: appropriate affect
Exam on day of discharge:
T 98.2 BP: 135/92 HR: 60 R:18 O2 100%RA
General: Cachectic man. + Jaundice.
HEENT: + scleral icterus
Lungs: Clear B/L on auscultation
___: RRR S1, S2 present
ABd: Soft, nontender. Nondistended. Small dressing on right side
of abdomen, clean/dry/intact.
EXT: no edema. + muscle wasting.
Pertinent Results:
Biliary brushings: ___
Suspicious for adenocarcinoma (see note).
NOTE: The ThinPrep slide shows a few clusters of atypical
epithelial cells with nuclear crowding, architectural
disarray, and moderate nuclear anisonucleosis. The cells
are morphologically compatible with some areas of the
patient's prior gastric adenocarcinoma ___,
reviewed). Background ductal cells show reactive changes.
See also concurrent surgical pathology specimen
(___).
.
___ ___ ___ Male ___
Report to: ___. ___
___ by: ___. ___
SPECIMEN SUBMITTED: CBD BIOPSY (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ Subtotal gastrectomy.
___ Slides referred for consultation.
DIAGNOSIS:
Common bile duct, biopsies:
Highly distorted fragments of biliary-type mucosa with fibrous
stroma, strips of benign, superficial epithelium, and a few
crushed, atypical periductal glands that cannot be further
characterized; six levels were examined; see note.
.
___ ___ procedure
CONCLUSION:
1. Uncomplicated brush and forceps biopsy of the distal common
bile duct
stricture as described.
2. Uncomplicated replacement of internal-external 8 ___
biliary drain.
.
___ ___ procedure CONCLUSION:
1. Uncomplicated tube cholangiogram with drain exchange and
upsize. The
original drain did not demonstrate flow into the bowel, this was
improved with
the new 12 ___ drain. This is an internal-external biliary
drain.
2. Uncomplicated radial jaw biopsy multiple positions along the
distal common
bile duct stricture, specimens to pathology in formalin.
.
___ ___ Procedure IMPRESSION:
1. Cholangiography demonstrating a relatively long segment CBD
stricture.
2. Placement of a 10 mm x 60 mm WallFlex biliary stent with
balloon
dilatation.
3. Probable filling defects on post-stent cholangiogram
suggestive of
hemorrhage.
4. Placement of a 12 ___ internal-external biliary drain
(not pigtailed)
to allow drainage across the stent. We will leave the catheter
on free
drainage for one to two days. If the bleeding settles, we will
return the
patient for a cholangiography and either removal of the drain or
placement of
an additional stent depending on the findings at that time.
.
___ ___ Procedure IMPRESSION:
1. Free flow of contrast from the intrahepatic biliary tree, via
the CBD
stent into the duodenum.
2. Removal of the internal-external biliary drain.
3. Placement of a 10 ___ anchor drain which has been capped.
A
purse-string suture has been placed around the catheter.
___ ___ procedure:
IMPRESSION:
1. Non obstructed cholangiographic appearance post-CBD
stenting.
2. Removal of an anchor drain from the intrahepatic biliary
tree.
___ 09:20AM BLOOD WBC-10.3 RBC-3.60* Hgb-11.8* Hct-34.8*
MCV-97 MCH-32.7* MCHC-33.8 RDW-17.3* Plt ___
___ 07:45AM BLOOD Neuts-67.4 ___ Monos-6.1 Eos-5.4*
Baso-0.9
___ 07:45AM BLOOD ___ PTT-30.0 ___
___ 06:55AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-136
K-4.8 Cl-98 HCO3-32 AnGap-11
___ 06:55AM BLOOD ALT-122* AST-97* LD(LDH)-198 AlkPhos-238*
TotBili-4.9*
___ 06:55AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0
___ 07:45AM BLOOD VitB12-1077* Folate-14.1
___ 06:35AM BLOOD Triglyc-130 HDL-25 CHOL/HD-22.2
LDLcalc-503*
___ 10:35AM BLOOD IgG-1021
___ 10:35AM BLOOD ___
___ 10:35AM BLOOD CEA-2.0
Medications on Admission:
No prescription medications
.
Multiple herbal medications, pt's wife to bring in list.
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Painless jaundice / bile duct obstruction
Secondary diagnosis:
history of stage III gastric adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with common bile duct obstruction, history of
gastric adenocarcinoma, suspected recurrence, ERCP unable to reach due to
Roux-en-Y anatomy from prior gastric carcinoma resection.
PHYSICIAN: ___, M.D., attending, was present and supervising, ___
___, M.D., fellow, was assisting.
MEDICATIONS: General anesthesia was administered by the anesthesiologist.
FLUOROSCOPY TIME: 13.4 minutes.
RADIATION DOSE: 56 mGy.
PROCEDURE DETAILS: Informed consent was obtained from the patient. The
patient was positioned supine in the angiography suite. A timeout was
performed. Anesthesia was induced by anesthesiology. Our procedural timeout
was then performed. The area was prepped and draped in sterile fashion.
Fluoroscopy was used intermittently.
After administration of local anesthesia, from the right mid axillary line,
22-gauge needle with ultrasound and fluoroscopic guidance was advanced into
the liver parenchyma. Multiple passes were made with intermittent injection
of contrast until bile duct was reached. The biliary system was then
opacified, filling much of the right lobe system with little filling of the
left. The ducts were massively dilated. The common bile duct was not
initially seen. Attempts were made to pass the wire at our first access point
unsuccessfully. Attention was then turned to a different posterior right lobe
biliary radicle. A needle was placed into this radicle and a wire was
advanced into the biliary tree. The AccuStick set was used to dilate the
tract. Through the AccuStick sheath, the nitinol wire was then passed and
over this wire, a 5 ___ sheath could be placed. Through this sheath, a
glide wire and a Kumpe catheter were used to navigate the biliary tree in
attempt across the common bile duct stricture. At this point, contrast
injection demonstrated massively dilated common bile duct with an abrupt
cutoff. With manipulation of the Kumpe catheter and Glidewire, the
obstruction was crossed and the small bowel was reached. Through the Kumpe
catheter, the Glidewire was exchanged for an Amplatz and over this Amplatz, an
8 ___ internal-external biliary drain was positioned with the distal
pigtail in the bowel and the side holes within the liver. The pigtail was
formed and the catheter was affixed to the skin with suture and adhesive
device. The patient was extubated in the procedure room and transferred to
the post-anesthesia care unit in stable condition.
FINDINGS: Massively dilated biliary tree to the level of the lower common
bile duct where there was an abrupt cutoff. Left lobe ducts were not well
filled during this examination, the desire was not to over distend the biliary
system on the first pass. On cross-sectional imaging, all the intrahepatic
bile ducts appear to communicate with the only point of obstruction being in
the common bile duct.
CONCLUSION:
Uncomplicated percutaneous transhepatic biliary drain with placement of
internal-external 8 ___ drainage catheter. Plan to perform procedure in
several days to take biopsies of the stricture in the common bile duct.
Radiology Report
INDICATION: ___ male with prior history of adenocarcinoma of the
stomach status post resection, now with common bile duct obstruction, ?
malignant etiology.
PHYSICIAN: ___, M.D. (the attending, present and supervising), ___
___ M.D. (attending, supervising), ___, M.D., .
MEDICATION: Moderate sedation was provided by administering divided doses of
fentanyl totaling 175 mcg and Versed totaling 2 mg throughout the total
intraservice time of 45 minutes, during which the patient's hemodynamic
parameters were continuously monitored.
In addition, the patient received 10 mL of 1% lidocaine to the drain insertion
site.
FLUOROSCOPY TIME: Six minutes 42 seconds.
PROCEDURES:
1. Over the wire cholangiogram
2. Brush and radial jaw biopsy of distal common bile duct stricture.
3. Exchange for new ___ internal-external biliary drain .
PROCEDURE DETAILS: Informed consent was obtained from the patient. The
patient was positioned supine in the angiography suite. The area was prepped
and draped in sterile fashion. Appropriate timeout was performed.
Fluoroscopy was used intermittently.
A scout image was obtained. Contrast was injected into the indwelling
internal-external biliary drain. This showed flow into nondilated
intrahepatic ducts with minimal flow into the bowel. A ___ wire was
passed along the length of the catheter into the bowel where it was coiled.
The drain was then removed and a 7 ___ sheath was passed through the
stricture into the bowel along the ___ wire. An Amplatz wire was then
passed through the sheath in addition and then the sheath was removed and
reinserted over only the ___ wire leaving the Amplatz as a safety wire.
The sheath was pulled back to the proximal-to-mid portion of the stricture.
Two passes were made with a brush sample sent to cytology. Four passes were
then made with the radial jaw device targeting the area of stricture. The
sheath was then removed. Satisfactory tissue samples were obtained. Over the
safety wire, a new 8 ___ internal-external biliary drain was advanced to
have its distal pigtail in the bowel and the side holes in the liver.
Positioning was confirmed with contrast injection. The catheter was affixed
to the skin with suture and StatLock device and covered with an appropriate
dressing. The patient left the department in stable condition without any
immediate complication.
SPECIMENS: Two passes with a brush sent to cytology, four passes with a
radial jaw sent to pathology.
CONCLUSION:
1. Uncomplicated brush and forceps biopsy of the distal common bile duct
stricture as described.
2. Uncomplicated replacement of internal-external 8 ___ biliary drain.
Radiology Report
PROCEDURES: Biliary catheter check and exchange.
INDICATION: ___ year-old man with gastric adenocarcinoma status post surgery,
presenting with distal common bile duct stricture. He is status post
internal-external biliary drainage as well as biopsies, and is now having some
leaking around his drain and lab abnormality with the drain capped, concern
for drain placement blockage or malposition.
PHYSICIAN: ___, MD, fellow performed the procedure; ___,
MD, attending was present and supervising the entire procedure.
FLUOROSCOPY TIME: 4 minutes, 36 seconds.
MEDICATIONS: Moderate intravenous sedation was provided by administering
divided doses of fentanyl totaling 150 mcg throughout the total intraservice
time of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored.
PROCEDURE IN DETAIL:
Informed consent was obtained from the patient. He was positioned supine in
the angiography suite. Appropriate timeout was performed. The area was
prepped and draped in sterile fashion. Fluoroscopy was used intermittently.
Initial contrast injection demonstrated good flow into intrahepatic bile ducts
without significant flow into the bowel or distal portion of the tube. This
was concerning for a clogged tube. We elected to exchange and upsize the
tube. A 0.035 inch ___ wire was passed through the tube after the pigtail
suture was released. The tube was removed, and a new 10 ___
internal-external biliary drain was positioned with the pigtail just beyond
the stricture to rest in the bowel and the sideholes of the liver. This was
attached to the skin with suture and adhesive device and appropriate bandages
placed. The patient left the department in good condition without any
immediate complications.
IMPRESSION:
Exchange of occluded 8 ___ biliary drain for a new 10 ___
internal-external biliary drain. The tube was left capped. Plan to follow
the patient clinically over the next ___ hours and consider discharge home.
Radiology Report
INDICATION: ___ male with gastric adenocarcinoma status post surgery,
now with common bile duct obstruction. Initial biopsy was suspicious for
malignancy, unclear if it is a primary or recurrence. Patient has been having
leaking around tube.
PHYSICIAN: ___, M.D., attending, was present and supervising the
entire procedure, ___, M.D., fellow, was assisting.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
fentanyl, totalling 175 mcg and Versed totaling 2.5 mg throughout the total
intraservice time of 47 minutes during which the patient's hemodynamic
parameters were continuously monitored.
FLUOROSCOPY TIME: 11 minutes 40 seconds.
PROCEDURES: Tube cholangiogram. Biliary drain exchange. Forceps biopsy of
common bile duct stricture.
PROCEDURE DETAILS: Informed consent was obtained from the patient. The
patient was positioned supine. The area was prepped and draped in sterile
fashion. Appropriate timeout was performed. Fluoroscopy was used
intermittently.
Following acquisition of scout images, the indwelling 10 ___
internal-external biliary drain was injected with contrast. Additional images
were acquired. The catheter was cut and ___ wire was advanced down the
length of the catheter to come out of the end hole. The catheter was removed
and an 8 ___ sheath was placed. A Kumpe catheter was advanced along the
wire and used to exchange the wire for an Amplatz which was then advanced
distally into the bowel. A second Amplatz wire was passed through the sheath
to follow the same course and pass distally into the bowel. The sheath was
then removed and advanced over one of the wires leaving the second wire as a
safety wire. The sheath was advanced all the way through the stricture into
the duodenum without difficulty. The sheath was then slowly pulled back with
contrast injections to perform a pullback cholangiogram. The wire was then
removed and a guiding catheter was placed into the sheath and used to direct
the radial jaw biopsy device. This was used to take samples at multiple
angles from within the common bile duct stricture. A total of seven samples
were obtained. There appeared to be a good amount of tissue. This was sent
to pathology in formalin. The sheath was then removed and a new 12 ___
internal-external biliary drain was advanced over the safety wire to leave the
distal pigtail in the bowel just below the ampulla and the proximal end seated
well within the liver. This was attached to the skin with a suture and
adhesive device. This was left to gravity drainage overnight.
SPECIMENS: Seven passes with the radial jaw were sent to pathology in
formalin.
FINDINGS: Redemonstrated tight stricture of the distal common bile duct. At
the start of the case contrast injected into the indwelling tube flowed into
intrahepatic ducts without any flow into the bowel. After placement of the
new tube there was flow into both the intrahepatic ducts and the bowel as the
tube was injected. No additional strictures are noted in the visualized bile
ducts.
CONCLUSION:
1. Uncomplicated tube cholangiogram with drain exchange and upsize. The
original drain did not demonstrate flow into the bowel, this was improved with
the new 12 ___ drain. This is an internal-external biliary drain.
2. Uncomplicated radial jaw biopsy multiple positions along the distal common
bile duct stricture, specimens to pathology in formalin.
Radiology Report
INDICATION: ___ man with stage III gastric cancer presenting with
biliary obstruction, external biliary drain in place. Please internalize
external biliary drain.
PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
CONTRAST: 20 mL Optiray 320.
RADIATION: Fluoroscopy time 10 minutes 12 seconds.
MEDICATION: The patient received moderate conscious sedation with divided
doses of 150 mcg of fentanyl and 4 mg of Versed throughout the total
intraservice time of 1 hour. In addition, the patient received 4 mg of
Zofran. During this period, the patient's hemodynamic parameters were
continuously monitored.
PROCEDURES:
1. Cholangiography via the existing PTBD.
2. Placement of a 10 mm x 60 mm WallFlex biliary stent.
3. Balloon dilatation of the WallFlex biliary stent.
4. Repeat cholangiography via a 9 ___ sheath.
5. Placement of a 12 ___ internal-external biliary drain.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. The patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin of the right anterior and
lateral abdominal wall was prepped and draped in usual sterile fashion
including the existing PTBD. An initial controlled image demonstrated a
single 12 ___ pigtail catheter in the right upper quadrant. A small
injection of Optiray 320 demonstrated mildly prominent intrahepatic ducts,
persistent stricturing of the common bile duct and flow of contrast into the
duodenum. The catheter was cut and ___ wire was advanced via the
catheter into the duodenum, the catheter was then removed and a Kumpe catheter
was advanced over the ___ wire into the duodenum. The ___ wire was
then removed and an Amplatz Super Stiff wire was advanced via the Kumpe
catheter into the duodenum. The Kumpe was then exchanged for a 9 ___, 45
___ Tip sheath was advanced into the central intrahepatic ducts, common
bile duct and down to the duodenum. A pullback cholangiogram was performed
which demonstrated a relatively long segment of stricturing of most of the
length of the common bile duct. Based on this, a 10 mm x 60 mm WallFlex
biliary stent was selected and was deployed through the 9 ___ sheath under
fluoroscopic guidance. Balloon dilatation of the stent was performed using a
10 mm x 40 cm x 80 ___ balloon. This was inflated at the proximal end
of the stent initially, then in the main portion of the stent where there was
clearly a tight stricture. Following completion of the balloon dilatation,
there was initially rapid flow of contrast via the stent into the duodenum,
however, subsequent cholangiography via the sheath demonstrated holdup at the
proximal end of the stent. There were apparent filling defects seen within
the more superior portion of the common bile duct thought likely to be related
to blood. This was supported by the fact that aspiration via the sheath
produced a small amount of clotted blood. Alternatively, there may be a short
segment of stricture not covered by the stent. Therefore, we proceeded to
place a de-stringed 12 ___ biliary drainage catheter through the stent into
the duodenum following removal of the sheath. This will allow both internal
and external drainage. The catheter has been left on free drainage to allow
any residual blood to drain. Recommend leaving the catheter on free drainage
for one to two days. If bleeding settles we will bring the patient back for
repeat cholangiography to assess internal drainage.
IMPRESSION:
1. Cholangiography demonstrating a relatively long segment CBD stricture.
2. Placement of a 10 mm x 60 mm WallFlex biliary stent with balloon
dilatation.
3. Probable filling defects on post-stent cholangiogram suggestive of
hemorrhage.
4. Placement of a 12 ___ internal-external biliary drain (not pigtailed)
to allow drainage across the stent. We will leave the catheter on free
drainage for one to two days. If the bleeding settles, we will return the
patient for a cholangiography and either removal of the drain or placement of
an additional stent depending on the findings at that time.
Radiology Report
INDICATION: ___ man with gastric cancer, biliary obstruction, ___
stent and drain in situ, please perform cholangiogram plus minus additional
stenting, if needed.
PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
CONTRAST: 15 of Optiray 320.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. The patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin of the right anterior
abdominal wall and the existing drain were prepped and draped in the usual
sterile fashion. The pre-existing catheter was cut and ___ wire was
advanced via the catheter, which was then removed. A ___ sheath was
advanced over the wire and placed proximal to the stent. A small injection of
Optiray demonstrated mildly dilated intrahepatic bile ducts, filling of the
stent in the common bile duct and opacification of the duodenum. There was
free flow of contrast into the duodenum and empyting of the opacified bile
duct. Given this appearance, we did not feel further stenting was necessary.
Specifically, the previously concerning area proximal to the stent appears to
have cleared, likely reflecting debris post-balloon dilatation. Therefore, we
removed the sheath and placed a 10 ___ anchor drain with the tip proximal
to this stent. This has been capped and can be uncapped if patient develops
symptoms attributable to biliary obstruction. There were no immediate
post-procedure complications. A purse-string suture was placed around the
drain site to limit any leaking around the drain as we downsized from the 12
___ drain into a 10 ___.
IMPRESSION:
1. Free flow of contrast from the intrahepatic biliary tree, via the CBD
stent into the duodenum.
2. Removal of the internal-external biliary drain.
3. Placement of a 10 ___ anchor drain which has been capped. A
purse-string suture has been placed around the catheter.
Radiology Report
INDICATION: ___ man with common bile duct stricture status post
internal stent placement, please evaluate for drain removal.
PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___
___ (radiology attending) who was present and supervised the procedure.
MEDICATION: 5 mL of 1% lidocaine infiltrated around the drain site.
CONTRAST: 15 cc Optiray 320.
PROCEDURE DETAILS:
Following discussion of the risks, benefits, and alternatives to the
procedure, informed written patient consent was obtained. The patient was
brought to the angiographic suite and placed supine on the table. A
pre-procedure timeout was performed using three patient identifiers. An
initial control image demonstrated an anchor drain situated superior to a
common bile duct stent, which is fully expanded and unchanged in position
compared to the most recent prior study. Injection of a small volume of
Optiray opacified mildly prominent intrahepatic ducts, the common hepatic
duct, and rapidly drained into the common bile duct stent and down to the
duodenum. Ducts are decompresed compared to prior studies and the contrast
cleared rapidly. There was no evidence of holdup within the common bile duct
and contrast preferentially flows down the stent and not into the non
distended gallbladder. The findings were discussed with the patient who was
eager to have the anchor drain removed. The suture holding the catheter in
place was cut as well as a pursestring suture placed around the opening. The
catheter was cut and removed without difficulty. A sterile dressing was
applied. There were no immediate post-procedure complications.
IMPRESSION:
1. Non obstructed cholangiographic appearance post-CBD stenting.
2. Removal of an anchor drain from the intrahepatic biliary tree.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: JAUNDICE
Diagnosed with OBSTRUCTION OF BILE DUCT, JAUNDICE NOS, MALIG NEOPL STOMACH NOS
temperature: 97.7
heartrate: 60.0
resprate: 16.0
o2sat: 96.0
sbp: 111.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | You were admitted to ___ with painless jaundice.
Interventional radiology placed a drain. You had biopsies and
brushing done during one of your ___ procedures. The biopsies
were indeterminant and the brushings showed cells which were
suspicious for recurrent of gastric adenocarcimona.
Ultimately, you underwent a stent placement to the biliary duct,
with removal/internalization of your external drain (which had
been complicated by pain and cellulitis (infection)). Now your
bile ducts appear to be draining well. The external drain was
removed.
Your nutritional state requires supplementation. Your daily
calorie intake was measured at 1000 cal / day. In order to
maintain your current wt, you need approx 1800 cal/day, but
should likely have ___ cal/day to gain some weight to improve
your constitution for ongoing cancer treatment as we discussed.
You are encouraged to continue to increase your caloric intake,
and to drink at least three Ensure Plus's per day.
Your liver enzymes are still elevated. You need to have these
checked in one week by your primary care physician. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Cefazolin / Sertraline Hcl / Zoloft / Ancef
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is well known to the thoracic surgery service. He was
recently discharged following admission for a left
pneumonectomy. He had pain control issues during his admission,
but was doing well at the time of discharge. He has two
complaints now at the time of examination. He states that he has
been experiencing shortness of breath since mid day ___. He
states that he typically has SOB, but that this seemed to be
worsened. He states that he woke up this am (___) with
increasing shortness of breath. When his home ___ went to visit
his O2 stat was reportedly in the 80's. He states that he called
the hospital and was instructed to return to the ED. His other
issues is that he has had nausea and had emesis yesterday. He
has not had a bowel movement since he was discharged. However,
he states that it's not unusual for him to go a week at a time
without a BM. He continues to have ___ pain at the left
thoracotomy incision site, and feels that this is likely
contributing to his SOB.
Past Medical History:
1. Numerous pneumothoraces (starting at age ___, L>R) s/p
multiple
chest tubes.
- Left apical posterior segmentectomy in ___.
- Has had pleurodesis.
- LUL wedge resection with LLL bleb resection and
nodaldissection (___) for infected lobe refractory to home
abx
2. Left lung Aspergillus fumigatus empyema
- s/p left modified ___ window and debridement of empyema
cavity, closure of bronchopleural fistula, serratus anterior
muscle flap, latissimus muscle flap, and bronchoscopy with
bronchoalveolar lavage (___)
- s/p irrigation and debridement of left chest through ___
window, remodeling of serratus muscle flap and fistula closure
___
- s/p L main stem bronchus stenting to completely bypass left
upper lobe (___)
- maintained on voriconazole therapy
3. Chronic left chest pain ___ allodynia, sharp) and chronic
left thigh pain ___ dull, throbbing) following his multiple
pulmonary procedures. Followed by pain service.
4. Multiple pneumonias
5. Colonic abscess x1 (per OMR, pt does not recall)
6. Depression
7. Anxiety
8. Raynaud's phenomenon
9. Left vocal cord paresis ___ procedure on ___
10. s/p open appendectomy
11. L inguinal hernia repair
Social History:
___
Family History:
Mother had a mild stroke at ___ but is otherwise "healthy".
Father died at ___ of ruptured cerebral aneurysm. Has 5 brothers
and 3 sisters. 1 sister has RSD, younger brother has recent
diagnosis of MS, and another sister has a "chronic pain
syndrome" Pt also described a brother with TB.
Physical Exam:
Temp: 98.6 HR: 107 BP: 132/101 RR: 14 O2 Sat: 100%RA
GENERAL
A&Ox3, mild distress and appears to be in pain
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings: Clear to Auscultation on right side, no
breath sounds on left side ___ pneumonectomy.
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[] Cervical nl [] Supraclavicular nl [] Axillary nl
[] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 10:15PM WBC-7.9 RBC-3.32* HGB-7.8* HCT-26.0* MCV-78*
MCH-23.5* MCHC-30.0* RDW-16.4*
___ 10:15PM NEUTS-70.7* ___ MONOS-6.4 EOS-2.4
BASOS-0.3
___ 10:15PM PLT COUNT-590*#
___ 10:15PM ___ PTT-29.1 ___
___ 10:15PM GLUCOSE-101* UREA N-9 CREAT-0.6 SODIUM-136
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-31 ANION GAP-13
___ CXR :
The patient is status post left pneumonectomy. There is a large
residual
associated air-fluid level in the left hemithorax, but probably
unchanged, and overall there is volume loss with leftward shift
of mediastinal structures.
Moderately extensive subpleural scarring at the right lung apex
appears
stable. There is no new focal opacity. There is no pleural
effusion on the right. Contrast is visualized along the splenic
flexure of the colon. There is no free air.
___ KUB :
Long contrast column along the colon, which appears highly
redundant with
somewhat unclear anatomy on the radiographs. Mild dilatation of
the colon and persistent contrast retention from four days
earlier suggesting slow motility.
If distal obstruction is a concern CT could be considered
although the
presence of highly dense contrast is likely to limit the study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Gabapentin 800 mg PO TID
3. Mirtazapine 30 mg PO HS
4. Voriconazole 200 mg PO Q12H
5. Acetaminophen 650 mg PO Q6H
6. Docusate Sodium 200 mg PO BID
7. Sucralfate 1 gm PO QID
8. Atorvastatin 40 mg PO DAILY
9. MethylPHENIDATE (Ritalin) 35 mg PO QAM
10. Polyethylene Glycol 17 g PO BID constipation
11. Diltiazem 30 mg PO TID
12. Fentanyl Patch 50 mcg/h TD Q48H
13. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
14. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Diltiazem 30 mg PO TID
3. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice a day
Disp #*120 Capsule Refills:*2
4. Gabapentin 800 mg PO TID
5. MethylPHENIDATE (Ritalin) 35 mg PO QAM
6. Mirtazapine 30 mg PO HS
7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
8. Pantoprazole 40 mg PO Q12H
9. Voriconazole 200 mg PO Q12H
10. Bisacodyl 10 mg PO EVERY OTHER DAY
RX *bisacodyl 5 mg 2 tablet(s) by mouth every other day Disp
#*60 Tablet Refills:*2
11. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*2
12. Acetaminophen 650 mg PO Q6H
13. Atorvastatin 40 mg PO DAILY
14. Fentanyl Patch 50 mcg/h TD Q48H
15. Polyethylene Glycol 17 g PO BID constipation
RX *polyethylene glycol 3350 17 gram 17Gm powder(s) by mouth
twice a day Disp #*60 Packet Refills:*2
16. Sucralfate 1 gm PO QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Dyspnea after left pneumonectomy.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The patient is status post left pneumonectomy. There is a large residual
associated air-fluid level in the left hemithorax, but probably unchanged, and
overall there is volume loss with leftward shift of mediastinal structures.
Moderately extensive subpleural scarring at the right lung apex appears
stable. There is no new focal opacity. There is no pleural effusion on the
right. Contrast is visualized along the splenic flexure of the colon. There
is no free air.
IMPRESSION:
Stable post-operative findings.
Radiology Report
EXAMINATION: ABDOMINAL RADIOGRAPHS
INDICATION: Nausea and obstipation.
TECHNIQUE: Abdomen, two views.
COMPARISON: Barium esophagram was performed 4 days ago; no prior dedicated
abdominal films are available.
FINDINGS:
There is contrast, stool and mild dilatation throughout a long segment of the
colon, although some parts of the colon do not contain contrast; the anatomy
is somewhat unclear. The small bowel is largely gasless. The stomach does
not appear distended. There is no free air.
IMPRESSION:
Long contrast column along the colon, which appears highly redundant with
somewhat unclear anatomy on the radiographs. Mild dilatation of the colon and
persistent contrast retention from four days earlier suggesting slow motility.
If distal obstruction is a concern CT could be considered although the
presence of highly dense contrast is likely to limit the study.
Radiology Report
INDICATION: ___ year old man with constipation post L pneumonectomy, evaluate
for passage of contrast.
TECHNIQUE: Two supine radiographs of the abdomen and pelvis were obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
There has been no significant interval change in the appearance of the bowel
with contrast throughout mildly dilated loops of colon measuring up to 7.5 cm.
There has been no passage of contrast into the rectum, suggestive of slow
motility. The small bowel is largely gasless. There is no evidence of
intraperitoneal free air on this limited supine view. Post-pneumonectomy
changes are partially visualized at the left lung base.
IMPRESSION:
Mildly dilated loops of colon without passage of contrast compatible colonic
ileus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Nausea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.5
heartrate: 107.0
resprate: 16.0
o2sat: 96.0
sbp: 157.0
dbp: 77.0
level of pain: 8
level of acuity: 2.0 | * You were admitted to the hospital with constipation and some
shortness of breath. Your chest xray is stable and your
constipation was relieved with enemas. You will need to use
more bowel medications at home to prevent this from happening
again.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
and you should follow up in the pain clinic for help with
weaning off. Make sure that you have regular bowel movements
while on narcotic pain medications as they are constipating
which can cause more problems. Use a stool softener or gentle
laxative to stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic. If
your doctor allows you may also take Ibuprofen to help relieve
the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
Right Frontal Craniotomy and Evacuation of Subdural Hematoma on
___.
History of Present Illness:
___ ___ hypothyroidism presents as transfer from ___ for ___ evaluation.
Patient notes that today at 1145 AM she developed spontaneous R
facial droop and slurred speech, which lasted 5 min and resolved
spontaneously. About 1 week ago had a similar episode with
slurred speech alone. She has head a headache for one month now,
worst in the morning when she awakes. HA has persisted since
that
time. HA lasted at ___ in intensity for about 2 weeks. Right
now it is ___ and dull. No precipitating factor or thunderclap
onset. Of note, sister has history of cerebral aneurysms --
patient was told to be checked, but has not done this.
Denies any trauma. No LOC. No numbness/tingling extremities. No
weakness. Patient is not currently anticoagulated, though takes
ASA.
Past Medical History:
PMHx: hypothyroid
No PSHx
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
GCS 15
R pupil 3-4 mm, L pupil 3-4 mm, both round and equally reactive
to light
A&Ox3, CN II-XII intact, strength ___ in all four extremities,
sensation to light touch grossly intact, no dysmetria with FTN
OSH CT head: Moderate to large R frontal fluid collecting with
density suggesting subacute subdural hemorrhage. Mass effect on
R
hemisphere with 4 mm midline shift and mild subfalcine
herniation.
PHYSICAL EXAMINATION ON DISCHARGE:
A&Ox3
PERRL
Face symmetrical
tongue midline
Motor: ___ throughout
Incision c/d/i
No pronator drift
Pertinent Results:
CTA Head & Neck: ___
Final results pending.
ECHO: ___
Contrast study was performed with 3 iv injections of 8 ccs of
agitated normal saline, at rest, with cough and post-Valsalva
maneuver.
Chest X-Ray: ___
There is no acute cardiopulmonary process.
MRI Brain: ___
1. No evidence of acute infarction or intracranial hemorrhage.
2. Status post evacuation of a right subdural hematoma, with
residual
pneumocephalus and postsurgical changes
CT HEAD W/O CONTRAST ___
S/p removal of right subdural drainage catheter. Stable right
convexity
subdural collection with layering of air and fluid, as well as
stable small amount of residual blood products.
Medications on Admission:
Synthroid 50 mcg, ASA
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headaches
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*50 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
3. Duloxetine 60 mg PO DAILY
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
5. Levothyroxine Sodium 50 mcg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Subdural Hematoma
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: CTA head and neck
INDICATION: ___ woman with a family history of cerebral aneurysm, now
with subdural hematoma.
TECHNIQUE: Multidetector axial CT images were obtained through the head
without the use of intravenous contrast. Following this, CT angiogram images
of the head and neck were obtained during the administration of intravenous
contrast. Coronal and sagittal images were reconstructed from the source
data. At a separate workstation, 3D angiographic images and post-processing
of those images was obtained.
COMPARISON: CT head without contrast ___ from an outside
institution.
FINDINGS:
This study was obtained at 17:17 hours on ___ and 3D images were
not provided for review until ___.
NECT: Again identified is a mixed density subdural collection with thin
membranes overlying the right cerebrum measuring up to 16 mm in maximal width.
There is mass effect on the underlying cerebral sulci, and shifting of the
midline structures to the left of approximately 5 mm. Partial effacement of
the right lateral ventricle is present as well. The findings are unchanged
compared to the prior examination. No new intracranial hemorrhage is
identified.
CTA HEAD: The posterior circulation is noted to be small in caliber, and
there is fetal origin of both posterior cerebral arteries. The right vertebral
artery effectively terminates as its ___ branch. The major intracranial
vessels are patent without evidence of high-grade stenosis or occlusion. No
aneurysm or arteriovenous malformation is identified. Some distortion of the
distal arterial branches and cortical veins within the right cerebral
hemisphere is present secondary to mass effect from the subdural collection.
There is no evidence for cerebral venous sinus thrombosis. No CTA spot sign is
present.
CTA NECK: The aortic arch demonstrates a normal branching pattern. The
vertebral arteries are small in caliber, but patent. The bilateral common
carotid, internal carotid and external carotid arteries are patent. There is
no evidence of significant stenosis by NASCET criteria, occlusion or
dissection.
Cervical spine degenerative changes are noted. Mild scarring and atelectasis
is seen at the lung apices.
IMPRESSION:
1. Mixed-density subdural hematoma, layering over the right cerebral
convexity, with associated mass effect and subfalcine herniation, unchanged.
2. No evidence for aneurysm or arteriovenous malformation.
Radiology Report
REASON FOR EXAM: ___ years old woman with subdural hemorrhage (SDH), preop for
craniotomy; assess for acute cardiopulmonary process.
COMPARISON: There are no prior chest x-rays for comparison at the time of
dictation.
FINDINGS: AP portable single-view chest x-ray shows normal lung volumes
without consolidations or nodules. Cardiomediastinal silhouette is normal.
There is no pleural effusion or pneumothorax.
IMPRESSION: There is no acute cardiopulmonary process.
Radiology Report
HISTORY: Transient right facial droop.
TECHNIQUE: Routine ___ enhanced MR examination including axial SE,
sagittal-MPRAGE, and post-contrast images, the latter with axial and coronal
reformations.
COMPARISON: Comparison is made to CT head dated ___.
FINDINGS:
There is no acute infarct or acute intracerebral hemorrhage. Principal
intracranial vascular flow voids are preserved. The patient is status post
evacuation of a right subdural hematoma, with a small residual fluid
collection, a right parietal burr hole, and moderate pneumocephalus.
Additionally noted is stable, 5 mm midline shift towards the left. The
ventricles and sulci are normal in size and configuration. No diffusion
abnormality is detected. No intracranial mass identified.
The brainstem, posterior fossa, and cervicomedullary junction are preserved.
The orbits, periorbital, and paracavernous spaces are normal. No abnormality
of the skull base and calvaria is identified.
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Status post evacuation of a right subdural hematoma, with residual
pneumocephalus and postsurgical changes.
Radiology Report
HISTORY: ___ female status post evacuation of right subdural
hemorrhage.
COMPARISON: ___ and approximately 17:30.
TECHNIQUE: Head CT was performed without intravenous contrast. Multiplanar
reformatted images were reviewed. DLP 891.93 mGy-cm.
FINDINGS:
There has been interval right craniotomy and subdural drain placement. There
is air, fluid and a small amount of residual hyperdense blood layering in the
right subdural space. There is stable mild leftward shift of normally midline
structures. There is partial effacement of the right lateral ventricle and
persistent effacement of the right frontal sulci. The basal cisterns appear
patent. The imaged portions of the paranasal sinuses and mastoid air cells
are clear; left mastoid is underpneumatized.
IMPRESSION:
Interval evacuation of right subdural hemorrhage. Residual large right
subdural collection contains air, fluid and small amount of residual blood.
Persistent mass effect.
Findings discussed with Dr. ___ by Dr. ___ by telephone at 18: 53 on ___ at the time of initial review of the study.
Radiology Report
HISTORY: Status post right subdural hematoma evacuation.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
DLP: 780.44
COMPARISON: Comparison is made CT head dated ___.
FINDINGS:
The patient is status post right craniotomy. There has been interval removal
of the right subdural drainage catheter. Redemonstrated is a stable right
convexity subdural collection with layering of air and fluid, as well as
stable small amount of blood products. Mild leftward shift of midline
structures and mild effacement of the right lateral and third ventricles is
unchanged; there is no associated dilatation of the fourth ventricle. There
is no evidence of acute large vascular territorial infarction. The basal
cisterns appear patent. The left mastoid is underpneumatized, but otherwise
clear. The visualized paranasal sinuses and right mastoid air cells are clear.
IMPRESSION:
S/p removal of right subdural drainage catheter. Stable right convexity
subdural collection with layering of air and fluid, as well as stable small
amount of residual blood products.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with SUBDURAL HEMORRHAGE, HYPOTHYROIDISM NOS
temperature: 97.9
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 118.0
dbp: 65.0
level of pain: 1
level of acuity: 2.0 | Craniotomy for Subdural/Epidural Hematoma
Dr. ___
-___ a friend/family member check your incision daily for signs
of infection.
-Take your pain medicine as prescribed.
-Exercise should be limited to walking; no lifting, straining,
or excessive bending.
-Dressing may be removed on Day 2 after surgery.
-**Your wound was closed with staples, you must wait until after
they are removed to wash your hair. You may shower before this
time using a shower cap to cover your head.
-Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
-Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
-If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this after seen in follow up.
-**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
-Clearance to drive and return to work will be addressed at your
post-operative office visit.
-Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
-New onset of tremors or seizures.
-Any confusion or change in mental status.
-Any numbness, tingling, weakness in your extremities.
-Pain or headache that is continually increasing, or not
relieved by pain medication.
-Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
-Fever greater than or equal to 101° F. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenergan Plain / Ketorolac / Neurontin / Ibuprofen / Celebrex /
Spiriva with HandiHaler / Lidocaine / Methadone / Zolpidem /
tramadol
Attending: ___.
Chief Complaint:
chest and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with history of chronic pain
___ narcotic bowel syndrome, Sjogrens, adrenal insufficiency,
PE, c. diff colitis who was recently admitted with chest pain
?PNA vs ILD who returns with continued chest pain and abdominal
pain.
On ___ patient was admitted after 1 week of pleuritic chest
pain and shortness of breath. CTA Chest at that time ruled out
PE at and above the segmental level. Patient was started on a 7
day course of Azithromycin with plans for pulmonary follow up
and potential high-res CT.
She she was discharged, initially felt the chest pain was
getting better. 2 days prior to admission, had sudden worsening
of her pleurtic chest pain in the AM. right lower chest without
change to dyspnea. the pain radiates from the right chest to
right upper quadrant. No diaphoresis. The pain was none
exertional. Has some nausea, and had ___ bouts of diarrhea 1 day
PTA, but denies emesis, constipation. No BRBR, no melena. She
endorses subjective fever (Tm 99.7 at home but states that
normal temp for her is 96.9).
She has been taking her PO Dilaudid in addition to her other
pain meds withou significant change to her symptoms. She has
also been taking higher than the recommended 3gm daily of
tylenol. She has been taking maybe ___ a day for the last few
days, she's not very sure.
Due to her symptoms she told her daughter (per pt's report) that
"it would be better if I just did not breathe any more" but she
did not endorse any direct SI. Given her increased tylenol use,
uncontrolled pain, and possible SI, patient was send to the ED.
In the ED initial vitals were: 98.0 72 130/68 18 98%
- Labs were significant for normal CBC, Chem 7, LFTs.
- Imaging significant for normal renal U/S and clear CXRs
- Patient was given Cefpodoxime, Doxycycline and Dilaudid 1mg x
2.
Vitals prior to transfer were: 98.0 60 130/67 17 98% RA
On the floor, patient continues to have right chest and RUQ
pain.
Past Medical History:
- Chronic pain syndrome followed by ___
- Chronic abdominal pain, ?narcotic bowel, extensive negative
workup
- Hypertension
- Insulin resistance
- Adrenal insufficiency, diagnosed in ___, on steroids
- Hypothyroidism
- Sjogren's syndrome
- Moderate persistent asthma
- GERD, "very severe"
- Appendicitis in ___. Did not undergo appendectomy.
- PTSD
- Degenerative disc disease
- Arthritis
- Chronic foot and ankle pain
- Oral thrush
- Abdominal hernia
- s/p cholecystectomy
- s/p L1-L5 laminectomy and discectomy
- Pulmonary embolism in ___
- C. diff in ___
- Psychogenic non-epileptic seizures (PNES): ___ in ___.
Social History:
___
Family History:
Grandfather with colon cancer. Father with lung cancer,
esophageal cancer, and melanoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.4 113/64 64 18 96% RA
GENERAL: NAD, lying in bed mostly comfortable. there are times
when she expressed pain in the right chest through the interview
process.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: pain not reproducibel with palpation
ABDOMEN: nondistended, +BS, mild pain to palpation in the RUQ,
no rebound or guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3. CN II-XII intact
DISCHARGE PHYSICAL EXAM:
VS: Tm 99.1 Tc 98.4 BP 111-146/54-89 HR 75 RR 18 ox 99% RA
GENERAL: lying in bed, occasionally grimacing
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2 distant, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: pain not reproducible with palpation
ABDOMEN: nondistended, +BS, no rebound or guarding, tender to
palpation of RUQ without guarding or rebound
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3. grossly normal
SKIN: scattered seborrheic keratoses on back
Pertinent Results:
LABS ON ADMISSION:
___ 08:16PM BLOOD WBC-8.1 RBC-4.24 Hgb-12.9 Hct-38.8 MCV-91
MCH-30.3 MCHC-33.2 RDW-13.3 Plt ___
___ 08:16PM BLOOD Neuts-73.9* ___ Monos-4.8 Eos-1.8
Baso-0.5
___ 08:16PM BLOOD Plt ___
___ 08:55AM BLOOD ___ PTT-31.5 ___
___ 08:16PM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
___ 08:16PM BLOOD ALT-18 AST-21 AlkPhos-72 TotBili-0.3
___ 08:16PM BLOOD Lipase-36
___ 08:16PM BLOOD cTropnT-<0.01
___ 08:55AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0
___ 08:16PM BLOOD Albumin-4.3
___ 08:23PM BLOOD Lactate-1.1
___ 08:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
OTHER LABS:
___ 08:55AM BLOOD WBC-6.4 RBC-4.04* Hgb-12.4 Hct-36.6
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.3 Plt ___
___ 09:40AM BLOOD WBC-5.9 RBC-3.88* Hgb-11.9* Hct-35.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.3 Plt ___
___ 09:40AM BLOOD Plt ___
___ 08:55AM BLOOD Plt ___
___ 08:55AM BLOOD ___ PTT-31.5 ___
___ 09:40AM BLOOD Glucose-123* UreaN-8 Creat-0.8 Na-138
K-4.0 Cl-99 HCO3-27 AnGap-16
___ 08:55AM BLOOD Glucose-78 UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-101 HCO3-28 AnGap-14
___ 09:40AM BLOOD ALT-17 AST-18 AlkPhos-80 TotBili-0.2
___ 08:55AM BLOOD ALT-18 AST-22 AlkPhos-68 TotBili-0.3
___ 09:40AM BLOOD Lipase-25
___ 09:40AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.8
___ 08:55AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0
MICRO:
no new micro
IMAGING:
___OPPLER: No evidence of deep venous thrombosis in
the bilateral lower extremity veins.
___ Chest pa/lat: The lungs are clear. There is no evidence of
pneumonia, pneumothorax, or pleural effusion. Cardiac silhouette
is normal in size. No acute cardiopulmonary process
___ Renal ultrasound: No hydronephrosis. No stones visualized.
Moderate postvoid residual.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with RUQ abdominal pain, recent pneumonia //
evaluate for acute proces
TECHNIQUE: Chest PA and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear. There is no evidence of pneumonia, pneumothorax, or
pleural effusion. Cardiac silhouette is normal in size.
IMPRESSION:
No acute cardiopulmonary process
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ female with pleuritic chest pain and history of DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Examination dated ___
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPERTENSION NOS
temperature: 98.0
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 130.0
dbp: 68.0
level of pain: 9
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You presented
with abdominal pain and were evaluated by medicine and
gastroenterology doctors who ___ cause of
your pain. The pain specialists suggested a nerve block, which
you declined. You can consider this as an outpatient, and follow
up with your primary care doctor, ___, and the
___.
Best wishes,
Your ___ Medicine Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Positive stress test and severe three vessel
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x3 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and the third obtuse marginal artery.
History of Present Illness:
Mr. ___ is ___ male with known 3V
CAD previously evaluated for coronary revascularization by
___ in ___ and recommended to undergo cardiac surgery. Pt
deferred at that time. He opted for medical management and chose
to do outpt cardiac rehab. He presented ___ from cardiac rehab
with chest pain and bradycardia. He is now amenable to cardiac
surgery.
Past Medical History:
CAD
Asthma
Hx of anxiety
Diverticulosis
Knee pain
bipolar disorder
Past Surgical History:
s/p Tonsillectomy
s/p Broken clavicle surgery
s/p Appendectomy
Social History:
___
Family History:
His father was found dead at the age of ___ from presumed MI
Physical Exam:
BP:105/64 Heart Rate: 76 O2 Saturation 96% R/A
Height: 71" Weight: 218lbs
General: NAD, pleasant
Skin: Dry [X] intact [X] Warm [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] JVD []
Chest: Lungs clear bilaterally [X]
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Carotid Bruit:none appreciated
Pertinent Results:
Echo ___
Conclusions
Pre-bypass
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. There is mild regional left ventricular systolic
dysfunction with basal inferior and basal inferolateral
hypokinesis. EF is 45-55% (48% by 3D quantification). Right
ventricular free wall thickness is normal. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate (___)
mitral regurgitation is seen.
Post-bypass
The patient is sinus rhythm and receiving a phenylephrine
infusion.
LV EF > 55% . There are no new regional wall motion
abnormalities.
RV systolic function is unchanged.
The aorta is intact following decannulation (aorta visualized,
but no capture of image).
Dr. ___ was notified in person of the results while the exam
was performed in the operating room.
I certify that I was present for this procedure in compliance
with ___ regulations.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 17:44
.
___ 06:05AM BLOOD WBC-4.7 RBC-2.85* Hgb-8.9* Hct-27.1*
MCV-95 MCH-31.2 MCHC-32.8 RDW-12.8 RDWSD-44.4 Plt ___
___ 01:00AM BLOOD WBC-5.5 RBC-2.48* Hgb-7.8* Hct-23.9*
MCV-96 MCH-31.5 MCHC-32.6 RDW-12.8 RDWSD-45.1 Plt ___
___ 07:05AM BLOOD ___
___ 06:05AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-133
K-4.0 Cl-97 HCO3-26 AnGap-14
___ 08:47AM BLOOD Glucose-123* Na-133 K-4.0 Cl-99 HCO3-26
AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Cetirizine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
CAD
Asthma
Hx of anxiety
Diverticulosis
Knee pain
bipolar disorder
Past Surgical History:
s/p Tonsillectomy
s/p Broken clavicle surgery
s/p Appendectomy
Discharge Condition:
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- trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with 3v CAD, with chest pain concerning
progressing angina, neg trops,no changes on EKG, in evaluation for CABG //
pre-op for CABG
TECHNIQUE: Chest two views
COMPARISON: ___ 14:43
FINDINGS:
Chronic fracture left clavicle, adjacent wiring. Lungs are clear. Benign
enchondroma proximal left humerus. Normal heart size, pulmonary vascularity
IMPRESSION:
No acute changes
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with CAD (3v disease), HLD, here with chest pain,
trops neg/no EKG changes, preop for CABG. // pre-op CABG
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None.
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 82 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 60, 7, and 75 cm/sec, respectively. The peak end diastolic
velocity in the right internal carotid artery is 22 cm/sec.
The ICA/CCA ratio is 0.91.
The external carotid artery has peak systolic velocity of 95 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild heterogeneous plaque at the level of the
proximal left ICA.
The peak systolic velocity in the left common carotid artery is 78 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 62, 65, and 72 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 25 cm/sec.
The ICA/CCA ratio is 0.92.
The external carotid artery has peak systolic velocity of 99 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Mild heterogeneous plaque at the level of the proximal left ICA. No
hemodynamically significant stenosis.
Radiology Report
EXAMINATION: CXR chest
INDICATION: ___ year old man s/p CABG // FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Surg: ___ (s/p CABG) Contact name: ___: ___
TECHNIQUE: Portable AP radiograph of the chest was performed.
COMPARISON: Chest radiograph from ___.
FINDINGS:
An endotracheal tube terminates appropriately above the carina. A right
internal jugular central venous catheter terminates in the SVC. An enteric
tube courses below the inferior margin of the study. There is a left basilar
chest tube. There are median sternotomy wires and mediastinal clips from
recent CABG.
Retrocardiac and left basilar opacities likely represent atelectasis. The
heart is normal in size. There is no pleural effusion or pneumothorax.
IMPRESSION:
1. Status post CABG. Support lines and tubes in standard position as
detailed above.
2. Retrocardiac and left basilar opacities, likely representing atelectasis.
This preliminary report was reviewed with Dr. ___
radiologist.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cabg // r/o ptx, on h20 seal. r/o ptx,
on h20 seal.
IMPRESSION:
In comparison with study of ___, with the left chest tube on water seal,
there is no evidence of pneumothorax. The patient has taken a better
inspiration. Endotracheal and nasogastric tubes have been removed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABG // eval for pneumothorax with chest
tube clamped
COMPARISON: Chest x-ray from ___
FINDINGS:
Right IJ central line tip overlies proximal SVC. Mediastinal drain and left
chest tube noted.
No obvious pneumothorax. Possibility of a tiny left apical pneumothorax is
difficult to X completely exclude.
Cardiomediastinal silhouette is unchanged, with sternotomy wires noted.
There is upper zone redistribution, without overt CHF.
Patchy retrocardiac opacity is similar to prior. Blunting of the left
costophrenic angle is again noted.
Subsegmental atelectasis the right cardiophrenic region is improved.
A cerclage wire overlies the overlap point of the left clavicle and left
scapular spine. At the edge of these films, there is increased density in the
left proximal humerus likely representing chondroid calcification.
IMPRESSION:
No obvious pneumothorax, though a tiny left apical pneumothorax would be
difficult to exclude.
Cardiomediastinal silhouette unchanged. Upper zone redistribution, without
overt CHF again noted.
Left base opacity essentially unchanged. Slight interval improvement in
cardiophrenic angle atelectasis.
Chondroid calcifications noted in the visualized portion of the left proximal
humerus, though the lesion extends beyond the edge of these films. Though not
fully evaluated, the appearance is suggestive of a chondroid lesion such as an
enchondroma. Recommend further assessment with dedicated left humerus
radiographs, though this can be pursued when the patient is stable.
RECOMMENDATION(S): Recommend further assessment with dedicated left humerus
radiographs, though this can be pursued when the patient is stable.
Radiology Report
INDICATION: ___ year old man s/p CABG // eval for pneumothorax
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier today
FINDINGS:
The tip of the right internal jugular central venous catheter has been
retracted and now projects over the upper SVC. There has been interval
removal of the left chest tube and mediastinal drains. No pneumothorax
identified. There is left lower lung zone atelectasis and a possible small
left pleural effusion. The size of the cardiac silhouette is unchanged.
IMPRESSION:
Interval removal of the left chest tube and mediastinal drains. No
pneumothorax identified.
Interval retraction of the right internal jugular central venous catheter, the
tip which now projects over the upper SVC.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with CABG // predischarge eval predischarge
eval
IMPRESSION:
In comparison with the study of ___, the right IJ catheter has been
removed. Cardiac silhouette remains at the upper limits of normal or mildly
enlarged. No definite vascular congestion, though there are bilateral small
pleural effusions with basilar atelectatic changes.
There is sclerosis in the proximal humeral shaft on the left. This probably
represents an old healed bone infarct. A shoulder series could be obtained to
better characterize this process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Bradycardia
Diagnosed with Bradycardia, unspecified
temperature: 97.7
heartrate: 46.0
resprate: 18.0
o2sat: 95.0
sbp: 114.0
dbp: 64.0
level of pain: 3
level of acuity: 2.0 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Dicloxacillin / Morphine / Compazine /
Reglan / Amicar / Verapamil / Ambien / Valtrex / Percocet
Attending: ___.
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
ultrasound guided PIV placement
History of Present Illness:
___ year-old female with history of ESRD on HD s/p failed
transplant presenting with muscle weakness and noted to have
hyperkalemia.
Patient reported gradual onset of muscle weakness that started
this afternoon similar to prior episodes of hyperkalemia. She
stated that she felt as if her legs would give out from under
her and shaky all over. Of note, patients last K was 6.0 on
___ prior to HD which is higher than her baseline. In
addition, patient also reported some constant abdominal
discomfort in the left upper abdomen and nausea with no
vomiting. This AM she said that she had some minimal bright red
blood on the toilet paper when wiping but no significant blood
loss. No constipation or strainging when having BMs. She denies
any other episodes of bright red blood or black stools. She also
has recently been evaluated by her PCP for sinus congestion,
headache, and fever. She was started on doxycycline however,
given GI distress, this was changed to levofloxacin.
Patient has not missed any HD sessions. She has been taking her
kayexylate as scheduled. Denies any recent excessive exercise or
muscle pains. Denies any yellowing of eyes or skin to suggest
hemolysis. Denies any dietary changes.
In the ED, initial vital signs were 98.6 54 137/68 18 100% ra.
Exam significant for some slight epigastric tenderness on exam.
Labs significant for K of 7.6, Na of 132, H/H of 9.8/29.3 (down
from 11.8/36.3 in ___, INR of 1.4. She was given 10 units of
insulin IV, dextrose, and calcium gluconate. ECG done without
signs of hyperkalemia. Finger stick dipped into the ___ and
patient symptomatic. She was treated with D50 and juice.
She was evaluated by renal who recommended admit to MICU for
urgent dialysis.
On transfer, vitals were: 98.5 77 118/48 20
On arrival to the MICU, patient feels much improved from her
symptomatic hypoglycemic episodes. Her abdominal pain has
resolved completely.
Past Medical History:
# ESRD DUE TO: Thrombotic microangiopathy, s/p renal transplant
___, graft failed and started on RRT in ___ previously on PD,
switched to HD in ___, (tunneled catheter placed ___,
s/p right transplant nephrectomy ___
# ACCESS: Left AVF created ___ Right brachiocephalic AV
fistula placed ___.
- Thrombotic microangiopathy s/p renal transplant in ___
- Antiphospholipid antibody syndrome
- SLE
- ___ deficiency
- DVT (___) involving the left internal jugular, left
axillary and one of the left proximal brachial veins, on
warfarin
- OSA on CPAP (auto CPAP ___ with 50 mL EERS and two liters
oxygen per Dr. ___ recent note)
- Depression
- Anxiety
- Seizure disorder, unclear etiology
- bipolar disorder
- H/o malignant HTN c/b hypertensive encephalopathy and PRES
- Hyperlipidemia
- Raynaud's phenomenon in ___
- GERD
- Gastritis in ___
- Migraine headaches
- s/p TAH-BSO at ___ for heavy menses and bleeding ovarian cysts
- H/o aspiration pneumonia, pulmonary hemorrhage and ___
- H/o gout, on chronic prednisone
- dry eye
- glaucoma
- Diplopia thought to be due to lamotrigine, followed by
neurology
- s/p cholecystectomy
- H/o T7 compression fracture
- H/o tardive dyskinesia
Social History:
___
Family History:
Father with anti-phospholipid syndrome, HTN, DM.
Sister with MS.
___ siblings with asthma, HTN.
Physical Exam:
ADMISSION EXAM:
Vitals- T:97.4 BP:138/62 P:62 R: 18 O2: 100% RA
General- comfortable in NAD
HEENT- sclera anicteric, MMM
Neck- supple
CV- RRR, ___ systolic murmur heard throughout
Lungs- clear to auscultation bilaterally
Abdomen- soft, mildly tender to palpation throughout, +BS. no
rebound or guarding. surgical scars noted
GU - no foley
Ext- no edema, warm and well perfused
Neuro- A&Ox3. CN II-XII grossly intact. strength 4+/5 in upper
and lower extremities
DISCHARGE EXAM:
Vitals: T:97.7 BP:151/65 P:89 R:20 O2:100%RA
General: Well appearing, NAD
HEENT: PERRL, anicteric, MMM, oropharynx nonerythematous,
dilated veins on left face
Neck: Supple, 2+ carotids, no bruits, no LAD, swelling of L
neck, unchanged from prior
Lungs: CTAB, no w/r/r
CV: RRR, II/VI systolic murmur loudest at base, no radiation to
carotids, no rubs or gallops
Abdomen: +BS, soft, NTTP, No HSM. Surgical scars in b/l lower
quadrants and superior to umbilicus, well healed.
Ext: Swollen L upper extremity (greater than yesterday) with
cool fingers b/l. 2+ radial pulses b/l. Diminished sensation to
light touch in L fingers. L fingers are cyanotic. Bruits
auscultated in both fistulas. 2+ DP pulses b/l. No ___ edema.
Skin: No rashes
Neuro: No facial droop or slurred speech. Moving all extremities
equally.
Pertinent Results:
ADMISSION LABS:
___ 07:57PM BLOOD WBC-6.1 RBC-2.91* Hgb-9.8* Hct-29.3*
MCV-101* MCH-33.6* MCHC-33.4 RDW-19.3* Plt ___
___ 07:57PM BLOOD Neuts-64.7 ___ Monos-7.7 Eos-0.1
Baso-0.4
___ 07:57PM BLOOD Plt ___
___ 08:49PM BLOOD ___ PTT-48.6* ___
___ 07:57PM BLOOD Glucose-92 UreaN-91* Creat-7.8*# Na-132*
K-7.6* Cl-90* HCO3-23 AnGap-27*
___ 07:57PM BLOOD Calcium-8.9 Phos-8.4*# Mg-2.8*
___ 12:17AM BLOOD calTIBC-142* VitB12-703 Hapto-80
___ TRF-109*
___ 08:03PM BLOOD K-7.7*
DISCHARGE LABS
___ 08:09AM BLOOD WBC-4.5 RBC-2.70* Hgb-9.7* Hct-27.0*
MCV-100* MCH-36.1* MCHC-36.1*# RDW-20.2* Plt ___
___ 12:03PM BLOOD ___ PTT-48.0* ___
___ 08:09AM BLOOD Glucose-104* UreaN-63* Creat-6.4*#
Na-125* K-5.2* Cl-88* HCO3-19* AnGap-23*
___ 08:09AM BLOOD Calcium-9.0 Phos-5.5* Mg-2.3
IMAGING
___: CTA abd/pelvis:
1. No evidence of bowel ischemia or GI bleed. No acute
findings to explain patient's symptoms.
2. Status post cholecystectomy and hysterectomy.
3. Multiple tiny pancreatic hypodensities which likely
represent pancreatic cysts or IPMNs.
4. Caclified right pelvic mass, consistent with failed prior
renal
transplant.
___: Ultrasound of left upper ext: No evidence of deep venous
thrombosis in the left upper extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 7.5 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Restasis (cycloSPORINE) 0.05 % ___ BID
6. econazole 1 % Topical daily
7. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
8. Labetalol 200 mg PO BID
9. LaMOTrigine 200 mg PO BID
10. Levofloxacin 500 mg PO Q48H
11. Omeprazole 40 mg PO BID
12. Ondansetron 4 mg PO BID:PRN nausea
13. Sodium Polystyrene Sulfonate 7.5 gm PO 3X/WEEK (___)
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Triamcinolone Acetonide 0.025% Cream 1 Appl TP QD
16. Warfarin 4 mg PO 3X/WEEK (___)
17. Warfarin 3 mg PO 3X/WEEK (___)
18. QUEtiapine Fumarate 100-200 mg PO QHS
19. sevelamer CARBONATE 1600 mg PO TID W/MEALS
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES DAILY
21. Sarna Lotion 1 Appl TP QID:PRN itch
22. Docusate Sodium 200 mg PO BID
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Docusate Sodium 200 mg PO BID
4. LaMOTrigine 200 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES DAILY
6. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
Take on ___ and ___. Nephrocaps 1 CAP PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO BID:PRN nausea
10. QUEtiapine Fumarate 100-200 mg PO QHS
11. Restasis (cycloSPORINE) 0.05 % ___ BID
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Sodium Polystyrene Sulfonate 7.5 gm PO 3X/WEEK (___)
15. Warfarin 5 mg PO DAILY16
Or as directed by Dr. ___
___ *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
16. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
17. econazole 1 % Topical daily
18. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
20. Triamcinolone Acetonide 0.025% Cream 1 Appl TP QD
21. Outpatient Lab Work
Please check Chem-10 and INR on dialysis days starting ___.
Please fax results to Dr. ___ at ___. Phone # is
___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
-Hyperkalemia, unknown etiology
-Subtherapeutic INR
-Edema of left arm due to brachiocephalic and subclavian vein
stenosis and increased venous collaterals
SECONDARY
-Systemic Lupus Erythematosus
-Antiphospholipid Antibody Syndrome
-Thrombotic Microangiopathy
-End-stage renal disease, dialysis-dependent
-Left Upper Extremity venous thrombosis ___
- ___ deficiency
- Depression
- Anxiety
- Possible history of Thrombotic Thrombocytopenic Purpura
- Malignant hypertension with history of hypertensive
encephalopathy and PRES
- Hyperlipidemia
- Raynaud's phenomenon
- Gastroesophageal reflux
- History of aspiration pneumonia, pulmonary hemorrhage and
acute lung injury
- Chronic constipation
- Gallstone pancreatitis status post cholecystectomy
- Complex sleep-disordered breathing, on CPAP
- T7 compression fracture
- Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: End stage renal disease on hemodialysis status post failed renal
transplant, antiphospholipid ___ deficiency, now with abdominal
pain, hyperkalemia, acute anemia, and weakness, concerning for bowel ischemia
or GI bleed.
TECHNIQUE: Multiphasic MDCT imaging of the abdomen and pelvis with
intravenous contrast was performed. Multiplanar reformats were prepared and
reviewed.
COMPARISON: Comparison is made CT abdomen pelvis from ___.
FINDINGS:
ABDOMEN: Right lung base opacities have improved from prior exam. The
remaining opacity likely reflects atelectasis or scarring. The visualized
lung bases are otherwise clear. The liver is homogeneous in texture with no
focal lesions. There is no biliary ductal dilatation. The patient is status
post cholecystectomy. The pancreas demonstrates multiple tiny hypodensities
which likely represent pancreatic cysts or IPMNs, but is otherwise
unremarkable. The spleen and adrenal glands are normal. The kidneys are
atrophic and demonstrate several small cysts, consistent with history of
end-stage renal disease on hemodialysis. The stomach, duodenum, and
intra-abdominal loops of bowel are normal in caliber and unremarkable. There
is no evidence of bowel ischemia. There is no focus of extravasation to
suggest acute gastrointestinal hemorrhage. Numerous prominent retroperitoneal
and bilateral iliac chain lymph nodes are seen, measuring up to 10 mm but not
pathologically enlarged by CT criteria. These nodes are unchanged from prior
exam and likely reflect reactive nodes. The intra-abdominal aorta is normal
in appearance. The major intra-abdominal arteries and veins are patent.
PELVIS: A calcified right retroperitoneal mass is again seen, consistent with
failed prior renal transplant. The sigmoid colon and rectum are normal in
appearance. The bladder is decompressed, consistent with end stage renal
disease. The patient is status post hysterectomy. There is no pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis. A small
fat-containing inguinal hernia is again seen.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. A stable T12 compression fracture is again
seen with mild retropulsion, unchanged from prior exam.
IMPRESSION:
1. No evidence of bowel ischemia or GI bleed. No acute findings to explain
patient's symptoms.
2. Status post cholecystectomy and hysterectomy.
3. Multiple tiny pancreatic hypodensities which likely represent pancreatic
cysts or IPMNs.
4. Caclified right pelvic mass, consistent with failed prior renal
transplant.
Radiology Report
HISTORY: History antiphospholipid antibody and various clots, now with
increasing swelling in the left upper extremity.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed on
the left upper extremity veins.
COMPARISON: Left upper extremity ultrasound from ___.
FINDINGS:
The jugular and axillary veins are patent and compressible with transducer
pressure. There is normal flow with respiratory variation in the bilateral
subclavian veins. The brachial, basilic and cephalic veins are patent,
compressible with transducer pressure and show normal color flow and
augmentation. Note is made of collaterals within the left upper extremity.
The fistula appears patent.
IMPRESSION:
No evidence of deep venous thrombosis in the left upper extremity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperkalemia, Abd pain
Diagnosed with HYPERKALEMIA, HYPOGLYCEMIA NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, SYST LUPUS ERYTHEMATOSUS
temperature: 98.6
heartrate: 54.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 68.0
level of pain: 8
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure to care for you during your hospitalization at
___.
You were admitted because of high potassium. It was difficult to
determine the reason why your potassium was elevated, but
perhaps it was related to a low INR. You were treated with
urgent hemodialysis. You should continue to follow your low
potassium diet. You will be discharged on 5mg warfarin daily.
You'll need an INR checked during dialysis ___.
In addition, your left arm was noted to be swollen. An
ultrasound did not show clots. It is likely related to the many
collaterol veins that have formed around your fistula and a
narrow exit for the blood to leave that arm. You should keep
your arm elevated above the level of your heart as frequently as
possible.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o a. fib who presents after having a syncopal event
this morning. The patient went to the post office this morning
and he began to feel lightheaded on entering the building but
was able to walk to his P.O. box. The next thing he remembers he
was being passed out his hands and knees on the floor with a
small amount of blood dripping from his head. The patient
otherwise denies having any chest pain, palpitations or
shortness of breath prior. He did hit his head, however the
patient did not have any symptoms after the fall. The patient
otherwise afterwards went to see a movie. After the movie, the
patient received a call from PCP about blood work that was done
yesterday and afterwards the patient told PCP the story and PCP
referred patient to the ED. Otherwise the patient does not have
any neck pain.
.
In the ED, initial vitals were 98.1 62 160/70 20 100%. EKG
showed sinus rhythm with occasional irregular sinus beats, no ST
changes, no TWI. CXR normal. Vital signs on transfer to the
floor were T 98.2, P 62, 153/74, RR: 16, 98% ra.
.
.
Currently, patient was complaining of ___ posterior headache
over past 3 hours, which is now improving.
Past Medical History:
-CHF associated with post-op a. fib required lasix briefly
-paroxysmal a. fib after surgery
-HLD
-BPH
-Anemia
-R Total hip replacement
-s/p small bowel resection due to ischemic bowel
-appendectomy
Social History:
___
Family History:
father- CAD/PVD, mother rheumatic heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.8 F, BP 166/82, HR 68, R 18, O2-sat 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC, superficial abrasion on forehead, PERRLA, EOMI,
sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM;
largely unchanged, notable for negative orthostatics
Pertinent Results:
Admission labs:
WBC-8.1 RBC-4.62 HGB-13.7* HCT-40.4 PLT COUNT-247
NEUTS-74.3* ___ MONOS-5.3 EOS-1.2 BASOS-0.5
GLUCOSE-106* UREA N-16 CREAT-0.8 SODIUM-143 POTASSIUM-4.3
CHLORIDE-105 TOTAL CO2-29 ANION GAP-13
TSH-1.4
CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.0
CK-MB-2 cTropnT-<0.01 x2
.
Urinalysis- negative for blood, nitrites, leuks, ketones
.
EKG: sinus rhythm with occasional irregular sinus beats, no ST
changes, no TWI
.
STUDIES:
CXR ___- The heart is normal in size. The mediastinal and
hilar contours are unremarkable aside from patchy
atherosclerotic calcification along the aortic arch. There is no
pleural effusion or pneumothorax. The lungs appear clear.
Moderate anterior osteophytes are noted along the mid thoracic
spine, with smaller ones along the thoracolumbar junction.
.
CT head ___- No CT evidence for acute intracranial process.
Medications on Admission:
-Cholestyramine 4 gm packet
-Omeprazole 20 mg po daily
-Tamsulosin 0.4 mg po daily
-Multivitamin
-Loratinine 10 mg po daily prn
-Finasteride 5 mg po daily
-Metoprolol 50 mg po BID
-Simvastatin 10 mg po qHS
-Aspirin 81 mg po daily
Discharge Medications:
1. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Syncope
SECONDARY DIAGNOSIS:
1. Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Syncope. Question cardiomegaly.
COMPARISONS: None.
TECHNIQUE: Chest, three views.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
are unremarkable aside from patchy atherosclerotic calcification along the
aortic arch. There is no pleural effusion or pneumothorax. The lungs appear
clear. Moderate anterior osteophytes are noted along the mid thoracic spine,
with smaller ones along the thoracolumbar junction.
IMPRESSION: No evidence of acute disease. Normal cardiac size.
Radiology Report
INDICATION: ___ male with syncope and head strike, now with posterior
headache.
COMPARISON: None available.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
reviewed.
FINDINGS: There is no evidence for acute intracranial hemorrhage, large mass,
mass effect, edema, or hydrocephalus. There is preservation of gray-white
differentiation. The basal cisterns appear patent. White matter hypodensity
is likely secondary to sequela of chronic small vessel ischemic disease.
Prominent ventricles and sulci suggest age-related involutional changes.
Visualized bones and soft tissues are unremarkable. Visualized portions of
the paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No CT evidence for acute intracranial process.
These findings were discussed with Dr. ___ by Dr. ___ by
telephone at 1:18 a.m. on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, HYPERTENSION NOS
temperature: 98.1
heartrate: 62.0
resprate: 20.0
o2sat: 100.0
sbp: 160.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care you during your admission at
___.
You were admitted because of an episode in which you were
lightheaded and lost consciousness. You hit your head when you
fell, but a CT scan showed no bleed in your brain.
You were monitored overnight and had no abnormal heart rhythms.
Your blood pressure was not too low, and you felt back to your
normal self at the time of discharge.
We were concerned that your medication to control your heart
rate (metoprolol) may have been causing your heart rate and
blood pressure to be too low, causing you to feel lightheaded
and lose consciousness. We have decreased this medication.
You have follow-up scheduled with your cardiologist on ___
___. Please discuss this admission and the medication
changes with your cardiologist. We recommend that you have an
echocardiogram of your heart as an outpatient.
The following changes were made to your medication regimen:
- DECREASE metoprolol to 25mg twice a day
Please continue the remainder of your medications as prescribed
prior to admission |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Cough and malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of
hypertension and prior paroxysmal atrial fibrillation who
presented with nonproductive cough to ___ and was found
to have afib with RVR. Mrs. ___ endorses the onset of
nonproductive cough, rhinorrhea and malaise on ___. She
also noted an intermittent dull aching LUQ pain, lasting
seconds, that is non-positional and non-pleuritic. Has URI sick
contacts in her family. Her symptoms worsened throughout the day
and overnight. As a result she did not take her morning atenolol
on ___. She called EMS and was transported to ___.
On arrival to ___ 160/90, HR 72, afebrile. CXR
showed mild pulmonary edema. ECG originally demonstrated SR with
LBBB, however, at 10:15 AM, she developed an irregular WCT at a
rate of 160/min with an unchanged LBBB. This was felt to be VT
at the time and the patient felt malaise, so she was given 25
mcg fentanyl, 1 mg versed and underwent DCCV with 200J x2
without any change in her rhythm. She was started on amiodarone
150 mg IV x 1 and 1 mg/hr gtt and transferred to ___.
ED COURSE:
- Initial vitals: T 98.9, HR 94, BP 181/81, RR 17, 92% RA.
- EP was consulted for evaluation. CTA ruled out PE, but showed
some broncholar thickening with mucous c/f pneumonia. Started on
doxy/CTX
- Patient was given metoprolol 25mg, CTX/doxy, started on
heparin gtt and 10mg IV lasix
Decision was made to admit to ___ for further management.
Transfer VS were: BP 181/81 HR 94 BPM, RR 14 O2sat 92% RA
On arrival to the floor, patient reports the above history.
Endorses nonproductive cough and malaise, but no fevers. No
orthopnea or PND- sleeps flat with 1 pillow. She does not weigh
herself regularly. No chest pain or palpitations. Denies
shortness of breath unless walking up several flights of stairs.
No changes in urinary or bowel habits. Denies any history of
heart failure or atrial fibrillation. Reports resolution of
cough and malaise while lying down following ED course.
Past Medical History:
Hypertension
Paroxysmal atrial fibrillation
Recent cataract surgery
Bilateral TKR
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS: 97.8 118/73 70 18 94%2L Weight: 79.1 kg
GENERAL - NAD, comfortable. Mood, affect appropriate.
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, pink
conjunctivae, MMM, OP clear, no pallor or cyanosis of the oral
mucosa.
NECK: No LAD, JVP 9cm, no carotid bruits
LUNGS: Crackles over bilateral bases to ___ up thorax, rhonchi
at RLB, breathing comfortable on 2L
HEART: RRR, normal S1, S2. No m/r/g.
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES - Warm and well-perfused. No clubbing, cyanosis, or
edema. 2+ peripheral pulses (radials, DPs).
NEURO - DOWB intact, CN II-XII grossly intact, muscle strength,
grossly intact throughout, able to sit up in bed without
assistance
DISCHARGE PHYSICAL EXAM
VITAL SIGNS: Wt 76.2kg
Tm 98.7 BP ___ P ___ sinus RR ___ Sp02 93% ___
GENERAL: Appears younger than stated age
NECK: No LAD, JVP 7-8cm, visible venous pulsations at 60 degrees
upright.
LUNGS: Crackles at base that are faint. Breathing comfortably
off of oxygen.
HEART: RRR, normal s1/2, no m/r/g
EXTREMITIES: Warm, no edema
NEURO: Alert, oriented, affect appropriate, able to sit up
without help, no tremors, moves all 4 extremities, CN II-XII
grossly intact
Pertinent Results:
LABORATORY DATA
___ 12:35PM BLOOD WBC-17.2* RBC-4.77 Hgb-15.2 Hct-45.9*
MCV-96 MCH-31.9 MCHC-33.1 RDW-13.9 RDWSD-49.1* Plt ___
___ 08:50AM BLOOD WBC-12.0* RBC-3.94 Hgb-12.5 Hct-37.2
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.1 RDWSD-48.6* Plt ___
___ 03:15PM BLOOD WBC-11.7* RBC-4.16 Hgb-13.1 Hct-40.0
MCV-96 MCH-31.5 MCHC-32.8 RDW-14.1 RDWSD-49.9* Plt ___
___ 07:25AM BLOOD WBC-9.2 RBC-4.30 Hgb-13.6 Hct-40.9 MCV-95
MCH-31.6 MCHC-33.3 RDW-14.3 RDWSD-49.9* Plt ___
___ 12:35PM BLOOD Neuts-90.1* Lymphs-3.5* Monos-5.3
Eos-0.0* Baso-0.5 Im ___ AbsNeut-15.46* AbsLymp-0.60*
AbsMono-0.91* AbsEos-0.00* AbsBaso-0.08
___ 12:58PM BLOOD ___ PTT-136.0* ___
___ 05:13PM BLOOD ___ PTT-150* ___
___ 08:50AM BLOOD ___ PTT-67.3* ___
___ 07:25AM BLOOD ___ PTT-29.0 ___
___ 12:35PM BLOOD Glucose-146* UreaN-18 Creat-0.7 Na-138
K-3.8 Cl-102 HCO3-20* AnGap-20
___ 08:50AM BLOOD Glucose-120* UreaN-19 Creat-0.7 Na-137
K-3.7 Cl-103 HCO3-27 AnGap-11
___ 03:15PM BLOOD Glucose-111* UreaN-25* Creat-0.8 Na-136
K-4.4 Cl-101 HCO3-25 AnGap-14
___ 07:25AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-23 AnGap-16
___ 12:35PM BLOOD cTropnT-<0.01 proBNP-831*
___ 08:50AM BLOOD cTropnT-<0.01
___ 12:35PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.7
___ 07:25AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
___ 08:50AM BLOOD TSH-2.9
___ 12:50PM BLOOD Lactate-2.3*
___ 09:20AM BLOOD Lactate-1.3
IMAGING/STUDIES
___ EKG
Baseline artifact. Atrial fibrillation or flutter with variable
block.
Intraventricular conduction delay of left bundle-branch block
type. No
previous tracing available for comparison. Clinical correlation
is suggested.
___ CT PE
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Predominantly dependent multifocal airspace opacities and
interstitial thickening suggesting pulmonary edema. An
underlying pneumonia cannot be excluded especially in the left
upper lobe where consolidations appear more focal and nodular.
3. Moderate cardiomegaly. Reflux of contrast into the IVC
suggests component of right heart failure.
4. Moderate left and small right nonhemorrhagic pleural
effusions.
5. Narrowing and mucus plugging of the left lower lobe bronchus
resulting in left lower lobe atelectasis.
___ TTE
Conclusions: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. 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 leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO QAM
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 3 Days
last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
take in AM
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO QHS
take every night
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth every night
Disp #*30 Tablet Refills:*0
4. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation with rapid ventricular response
Hypertension
Left bundle branch block
Community acquired pneumonia
Pulmonary edema
Moderate tricuspid regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with refractory tachycardia
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 460 mGy-cm.
COMPARISON: Chest radiograph ___ at 11:06
FINDINGS:
CT CHEST WITH IV CONTRAST: The partially imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. Scattered
mediastinal lymph nodes are not pathologically enlarged by CT size criteria.
Left hilar lymph nodes measure up to 1.5 x 1.2 cm, likely reactive. Small
right hilar lymph nodes are not pathologically enlarged.
The heart is moderately enlarged. There is no pericardial effusion. The
thoracic aorta and proximal great vessels are normal in caliber and well
opacified with scattered atherosclerosis. No dissection is present. The main
pulmonary artery is normal in caliber. The pulmonary arteries are well
opacified to the subsegmental level without evidence of filling defect to
suggest pulmonary embolism. Reflux of contrast into the hepatic veins
suggests a component of right heart failure.
There are moderate left and small right nonhemorrhagic pleural effusions.
There are numerous diffuse predominantly dependent consolidative opacities
bilaterally with more focal and nodular opacification in the left upper lobe.
Diffuse septal thickening suggests a component of pulmonary edema. There is
narrowing and mucus plugging of the left lower lobe bronchus resulting in left
lower lobe atelectasis.
OSSEOUS STRUCTURES: There is no worrisome blastic or lytic lesion. Exuberant
low anterior osteophytes likely reflect DISH.
UPPER ABDOMEN: This study is not optimized for evaluation of subdiaphragmatic
structures however the partially visualized solid organs and stomach are
grossly normal.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Predominantly dependent multifocal airspace opacities and interstitial
thickening suggesting pulmonary edema. An underlying pneumonia cannot be
excluded especially in the left upper lobe where consolidations appear more
focal and nodular.
3. Moderate cardiomegaly. Reflux of contrast into the IVC suggests component
of right heart failure.
4. Moderate left and small right nonhemorrhagic pleural effusions.
5. Narrowing and mucus plugging of the left lower lobe bronchus resulting in
left lower lobe atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Unspecified atrial fibrillation, Pneumonia, unspecified organism
temperature: nan
heartrate: 145.0
resprate: 18.0
o2sat: 95.0
sbp: 154.0
dbp: 98.0
level of pain: nan
level of acuity: 1.0 | Ms. ___,
You were admitted to ___ for evaluation of a heart rhythm
called "atrial fibrillation". You were given medicine to slow
your heart rate down and a medicine to thin your blood to
prevent strokes. An ultrasound of your heart did not show a
significant structural problem to cause your atrial
fibrillation. It is very important to follow-up with the
___ clinic at ___ on ___. Please be
extra careful to avoid falls and maintain a regular diet.
We also believe that you initially presented with pneumonia. You
were treated with antibiotics which you will continue on
discharge.
It was a pleasure taking care of you during your stay- we wish
you all the best!
- Your ___ Medicine Team |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___ - Official Report Pending
History of Present Illness:
___ year old male with CAD s/p first CABG ___ s/p redo CABG
___, with cath in ___ showing three patent vein grafts and a
known occluded LIMA-LAD. Presents after house flooded overnight
from vandalism, had to go up and down three flights of stairs
twice, which he normally never does (ambulates flat surfaces
only, uses elevator). Developed substernal chest pain and
tightness that did not ratiate. Associated with the CP was a
neck coldness. He denied nausea, vomiting. Firemen on site for
the vandalism and flooding called EMS, pt was transported here.
Chest discomfort improved with SL nitro x3, states that he no
longer has pain but that he does feel a residual tightness.
In the ED, initial vitals were 6 98.2 85 103/66 20 92% RA
ECG essentially unchanged from baseline
CXR with Mild vascular congestion
Labs significant for INR 3.5, H/H 12.9/38.7, Trop <.01 x1, Cr
1.1, plts 115
Patient was given ASA 324, sublingual nitro, placed on nitro
gtt, 500mL NS.
Patient was seen by cardiology fellow who recommended "Agree
with starting on nitro gtt, admit to ___. Would hold off on
heparin until INR is resulted. Was previously scheduled for cath
this coming ___, will add to schedule for ___
On arrival to the floor patient reports residual chest
tightness, no chest pain. No SOB.
Past Medical History:
Urothelial cancer s/p local resection
s/p laparoscopic cholecystectomy
Hypertension
Hyperlipidemia
NIDDM c/b neuropathy of his toes
COPD
s/p hernia repair x 2
Atrial fibrillation on coumadin
BPH
Arthritis
Chronic back pain
Throat polypectomy
Coronary artery disease, s/p CABG (___)
Social History:
___
Family History:
Per report, one brother died of heart disease at age ___, another
brother died of lung cancer in his ___, another brother died at
age ___ of pancreatic cancer. Parents lived into their ___. Two
sisters are healthy. A younger brother had rheumatic fever.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 130/64 73 18 96%RA
wt: none recorded
I&O: none recorded
General: Pleasant, NAD
HEENT: NC AT, EOMI, MMM
Neck: JVD to 6cm at 45 degrees
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 rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 ___ 92-97%RA
wt: 77.6 (78.6)
I&O: 370/HNV
TELE: afib to rate of ___ with HR ___
General: Pleasant, NAD
HEENT: PERRL, EOMI, MMM
Neck: JVD below the level of the clavicle
CV: Distant heart sounds, RRR, normal S1 + S2, no murmurs,
gallops, rubs auscultated
Lungs: Clear to auscultation bilaterally, no wheezes, rhonci
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Skin: no rashes
Pertinent Results:
CXR ___
FINDINGS:
Lung volumes are low. Low consolidation, pneumothorax, or large
pleural effusion is identified. Cardiac silhouette is
sternotomy wires are intact. Vascular congestion is mild.
IMPRESSION: Mild vascular congestion.
CATH ___
**RESULTS PENDING**
LABS:
___
WBC-6.5 RBC-4.10* Hgb-12.9* Hct-38.7* MCV-94 MCH-31.5 MCHC-33.3
RDW-13.6 RDWSD-46.5* Plt ___ PTT-47.7* ___
Glucose-197* UreaN-19 Creat-1.1 Na-138 K-4.6 Cl-101 HCO3-28
AnGap-14
CK(CPK)-59 CK-MB-2
cTropnT-<0.01 >> cTropnT-<0.01
Calcium-8.9 Phos-2.5* Mg-1.9
___
WBC-6.7 RBC-4.33* Hgb-13.3* Hct-42.0 MCV-97 MCH-30.7 MCHC-31.7*
RDW-14.1 RDWSD-49.7* Plt ___
Glucose-243* UreaN-23* Creat-1.2 Na-139 K-4.5 Cl-102 HCO3-27
AnGap-15
___ PTT-34.6 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO BID
2. Finasteride 5 mg PO QHS
3. Warfarin 4 mg PO DAILY16 afib
4. Aspirin 81 mg PO DAILY
5. GlipiZIDE Dose is Unknown PO BID
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Atenolol 50 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Lisinopril 10 mg PO DAILY
11. Gabapentin 600 mg PO QID
12. Pantoprazole 40 mg PO Q24H
13. Isosorbide Mononitrate 120 mg PO TID
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Finasteride 5 mg PO QHS
5. Lisinopril 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Warfarin 4 mg PO DAILY16 afib
Please get INR checked regularly
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Gabapentin 600 mg PO QID
12. Tamsulosin 0.4 mg PO BID
13. GlipiZIDE 0 mg PO DAILY
14. Outpatient Physical Therapy
Outpatient ___
Balance training
Cardiovascular disease/ICD 9 429.2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
unstable angina
SECONDARY
Atrial fibrillation on coumadin
HTN
HLD
DM2
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 // evaluate for acute process
TECHNIQUE: Chest radiograph, frontal view.
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low. Low consolidation, pneumothorax, or large pleural
effusion is identified. Cardiac silhouette is Sternotomy wires are intact.
Vascular congestion is mild.
IMPRESSION:
Mild vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with INTERMED CORONARY SYND
temperature: 98.2
heartrate: 85.0
resprate: 20.0
o2sat: 92.0
sbp: 103.0
dbp: 66.0
level of pain: 6
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital for chest pain. We gave you
medications to help your heart and treat your pain. You
underwent a cardiac catheterization that found similar cardiac
vessel disease to your prior catheterization procedure in ___.
They did not perform any further stenting of your cardiac
vessels. We think that your chest pain was caused by increased
stress to the heart in the setting of increased exertion. We
changed one of your heart rate medications (Atenolol) to a
similar medication (Metoprolol XL 50mg daily). We also changed
the dose of your blood pressure medication Isosorbide
Mononitrate to 30mg daily.
We recommend:
- Stop taking Atenolol
- Start taking Metoprolol daily
- Stop taking 120mg Isosorbide mononitrate three time a day
- Start taking 30mg Isosorbide mononitrate once a day
- Continue your home Lisinopril, Aspirin, Atorvastatin daily
- Do not lift weights (it is not good for your heart)
- Eat a heart healthy diet
- Follow up with Dr. ___ 1 week
- Please schedule outpatient physical therapy
Your medications changed. It is very important that you continue
to take the new medications. All of your medications are
detailed in your discharge medication list. You should review
this carefully and take it with you to any follow up
appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ 1mo s/p segment VIII liver resection for a benign
fibrolipomatous lesion c/b intrahepatic/subcapsular fluid
collection and reactive right pleural effusion requring
thoracentesis, presenting with right flank pain.
Ms. ___ was discharged ___ from the ___ service with PO
Augmentin for one week which she finished on ___. Prior to
discharge, her drain output was minimal, around 10 cc daily.
Today, she presents with R sided flank plan that started two
days
ago and has persisted since that time. She reports the pain is
localized to the pigtail drain site and increased with anterior
arm movement or sniffing. She also reports dull right shoulder
discomfort which she noticed around the same time. Her pigtail
drain (initially placed into the subcapsular fluid collection)
put out 15, 15, 10, 10, 10, 5, 5, 5, 0, and 0 since discharge.
Denies abdominal pain, fever, chills, shortness of breath, N/V,
or CP. She has otherwise been well since discharge - not
requiring pain medication, tolerating a regular diet, having
"normal" bowel movements, and ambulating around the house. She
was able to walk from the parking lot into the ED with no
dyspnea.
Past Medical History:
PMHJ: Obesity, OSA, GERD, Anxiety
PSH: Tubal, liver bx, ___ Exploratory laparotomy with
intraoperative ultrasound and segmental resection for segment 8
hepatic mass.
Social History:
___
Family History:
Sister with h/o schistosomiasis, mother alive at age ___ and
healthy, father alive at age ___ with Alzheimer's disease and
COPD
Physical Exam:
VS: 98.2, 70, 107/61, 18, 96% RA
Gen: NAD, AAOx3
CV: RRR
Pulm: no respiratory distress, right lung base breath sounds
diminished
Abd: soft, nontender, nondistended, drain site c/d/i
Ext: No ___ edema
Pertinent Results:
___ CT chest:
IMPRESSION:
1. Status post drainage of right hepatic collection with
minimal residual
fluid and Surgicel. Pigtail drain is in situ.
2. Interval increase in a now moderate to large right
nonhemorrhagic pleural
effusion with compressive atelectasis.
3. Left lower lobe pulmonary emboli without infarct or right
heart strain.
Medications on Admission:
APAP 650'''' PRN, clonazepam 0.5', colace 100'', sertraline 75'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Clonazepam 0.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Sarna Lotion 1 Appl TP DAILY:PRN itching
5. Sertraline 75 mg PO DAILY
6. Warfarin 3 mg PO DAILY16
7. Enoxaparin Sodium 150 mg SC DAILY PE
RX *enoxaparin 150 mg/mL 150 mg once a day Disp #*7 Syringe
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pulmonary embolus, left lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath with pleural effusion.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
A moderate to large right pleural effusion appears increased in size compared
to the prior exam. There is associated right basilar atelectasis. Mild
leftward shift of mediastinal structures appears relatively unchanged. Heart
size is likely normal. There is no pulmonary vascular congestion. Left lung
is clear. There are no acute osseous abnormalities. A pigtail catheter is
noted projecting over the right lung base.
IMPRESSION:
Interval increase in size of the moderate to large right pleural effusion with
associated right basilar compressive atelectasis.
Radiology Report
HISTORY: Status post hepatic resection and CT-guided drainage of hepatic
collection. Assess for change in effusion and fluid collection.
COMPARISON: CT abdomen ___.
TECHNIQUE: CT images were obtained through the chest and abdomen after the
uneventful intravenous administration 130 cc of Omnipaque contrast medium.
Multiplanar reformations were prepared.
FINDINGS:
CT CHEST WITH CONTRAST: The thyroid gland is normal with symmetric
enhancement. The aorta and major branches are patent and normal in caliber.
Prominent prevascular lymph nodes are notable in number but not pathologically
enlarged. A 9 mm right paratracheal node is noted. The heart and pericardium
are unremarkable without pericardial effusion. The esophagus is unremarkable.
Filling defects are noted in the left lower lobe pulmonary arteries (301:45
and 41). There is no evidence of right heart strain or infarct. A moderate to
large right pleural effusion has reaccumulated. Compressive atelectasis is
noted. There is no left pleural effusion with basal atelectasis noted.
CT ABDOMEN WITH CONTRAST: The liver is normal in attenuation with multiple
tiny hypodensities too small to be characterized but unchanged from previous
studies. The portal and hepatic veins appear patent. The gallbladder is
normal. The previously drained segment VIII resection site collection is
markedly decreased from previous examination with pigtail drain in situ,
considering that Surgicel remains in the collection as well. Minimal residual
fluid is likely present. It appears to measure approximately 4.1 x 1.7 cm
axially. Trace perihepatic free fluid is seen. Stranding in the perihepatic,
anterior epigastric and right pericolic fat is likely due to recent surgery
and removed drain. The pancreas, spleen and bilateral adrenal glands
unremarkable. Kidneys enhance and excrete contrast symmetrically. The imaged
small and large bowel are unremarkable. No pathologic lymph node enlargement
is identified. There is no free intraperitoneal air.
OSSEOUS STRUCTURES: Stranding is seen in the anterior abdominal wall soft
tissues from recent surgery. There is no suspicious lytic or blastic bone
lesions suggest osseous malignancy.
IMPRESSION:
1. Status post drainage of right hepatic collection with minimal residual
fluid and Surgicel. Pigtail drain is in situ.
2. Interval increase in a now moderate to large right nonhemorrhagic pleural
effusion with compressive atelectasis.
3. Left lower lobe pulmonary emboli without infarct or right heart strain.
Findings were discussed in person with Dr. ___ by Dr. ___ at ___ on
___.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: PAIN S/P LIVER SURGERY
Diagnosed with PULM EMBOLISM/INFARCT, PLEURAL EFFUSION NOS
temperature: 97.6
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 64.0
level of pain: 4
level of acuity: 3.0 | -___ Care Network will continue to follow you to assist with
Lovenox teaching
Please call Dr. ___ ___ if you have
any of the following:
temperature of 101 or greater, chills, nausea, vomiting,
increased right sided pain, shortness of breath, chest pain,
easy bruising, bloody stool/urine or any bleeding.
-You have been started on anticoagulation (coumadin) for a left
lower lung pulmonary embolus. This will will require blood draws
for lab monitoring of coumadin effect. Your PCP has been
contacted to manage your coumadin doses.
-you next blood draw shall be at Dr. ___ office on ___
___ am
-while the Coumadin effect is getting into the therapeutic
range, you will be on a "bridging" quick acting anticoagulant
called Lovenox. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zocor
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history for sigmoid colectomy for diverticulitis
presenting with 1 day of abdominal pain and at least 10 episodes
of vomiting that started yesterday after he ate cod. The patient
had a bowel movements this morning and is passing flatus. He
denies diarrhea, blood in his stool, or dysuria. He denies chest
pain, shortness of breath. He reports prior episodes of
abdominal
pain and nausea and even occasional vomiting but never as severe
as the current episode.
Past Medical History:
PMH:
Seizure- unable to confirm
Paranoid schizophrenia
Anxiety
GERD
Prior polysubstance abuse
HLD
Hypothyroid
HTN
PSH:
Left inguinal repair ___
Right femur surgery
Sigmoid colectomy ___
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
T 98.4 BP 127/80 HR 78 RR 18 SatO2 95% RA
General: uncomfortable, vomiting
Head: Normocephalic and atraumatic
Eyes: PERRL, EOMi
Lungs: CTAB
Cardiac: RRR, no murmur
Abdomen: Soft, tender to palpation in the RUQ and periumbilical
area, no peritoneal signs, non-distended
GU: No CVA tenderness
Musculoskeletal: No obvious deformities of limbs
Extremities: no ___ edema
Neurologic: Awake, alert, moves all extremities. Speech fluent.
Dermatologic: Skin is warm and dry
DISCHARGE PHYSICAL EXAM
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [-] murmur
Resp: [x] breaths unlabored, [x] CTAB, [-] wheezing, [-] rales
Abdomen: [x] soft, [-] distended, [-] tender, [-]
rebound/guarding.
Ext: [x] warm, [-] tender, [-] edema
Pertinent Results:
LABS
___ 06:47AM BLOOD WBC-6.8 RBC-4.38* Hgb-13.1* Hct-39.5*
MCV-90 MCH-29.9 MCHC-33.2 RDW-12.8 RDWSD-42.4 Plt ___
___ 07:22AM BLOOD WBC-7.3 RBC-4.53* Hgb-13.3* Hct-40.3
MCV-89 MCH-29.4 MCHC-33.0 RDW-12.9 RDWSD-42.4 Plt ___
___ 10:20AM BLOOD WBC-11.4* RBC-5.18 Hgb-15.3 Hct-44.9
MCV-87 MCH-29.5 MCHC-34.1 RDW-12.4 RDWSD-39.4 Plt ___
___ 10:20AM BLOOD Neuts-77.3* Lymphs-16.4* Monos-5.4
Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.81* AbsLymp-1.86
AbsMono-0.61 AbsEos-0.03* AbsBaso-0.03
___ 06:47AM BLOOD Plt ___
___ 07:22AM BLOOD Plt ___
___ 10:20AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-108* UreaN-7 Creat-0.8 Na-146
K-3.7 Cl-107 HCO3-26 AnGap-13
___ 07:22AM BLOOD Glucose-125* UreaN-11 Creat-0.8 Na-144
K-4.4 Cl-105 HCO3-26 AnGap-13
___ 10:20AM BLOOD Glucose-114* UreaN-13 Creat-1.0 Na-141
K-4.1 Cl-103 HCO3-22 AnGap-16
___ 10:20AM BLOOD ALT-13 AST-21 AlkPhos-103 TotBili-0.6
___ 06:47AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
___ 07:22AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
___ 10:20AM BLOOD Albumin-5.___BD/PELVIS ___
IMPRESSION:
1. High-grade small-bowel obstruction with transition point in
the right upper
quadrant. Increased small bowel wall thickening and mesenteric
edema and
fluid in the left lower quadrant which may suggest a coexistent
enteritis.
2. Interval development of small perihepatic ascites.
SMALL BOWEL ONLY (GASTROGRAF) ___
IMPRESSION:
Gastrografin passes through the small bowel and reaches the
colon with
redemonstration of multiple dilated loops of small bowel.
Findings are
compatible with partial small bowel obstruction.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. RisperiDONE 6 mg PO QHS
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Acetaminophen w/Codeine ___ TAB PO Q12H:PRN Pain - Severe
4. QUEtiapine Fumarate 300 mg PO QHS
5. Mirtazapine 30 mg PO QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY:PRN indigestion
8. amLODIPine 5 mg PO DAILY
9. OXcarbazepine 600 mg PO BID
10. Benztropine Mesylate 0.5 mg PO BID
11. Pravastatin 20 mg PO QPM
12. Pramipexole 0.125 mg PO QHS
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q12H:PRN Pain - Severe
2. amLODIPine 5 mg PO DAILY
3. Benztropine Mesylate 0.5 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Mirtazapine 30 mg PO QHS
7. Omeprazole 20 mg PO DAILY:PRN indigestion
8. OXcarbazepine 600 mg PO BID
9. Pramipexole 0.125 mg PO QHS
10. Pravastatin 20 mg PO QPM
11. QUEtiapine Fumarate 300 mg PO QHS
12. RisperiDONE 6 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
High grade small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with h/o diverticulitis p/w abd pain
x 1 day, n/vNO_PO contrast*** WARNING *** Multiple patients with same last
name!// eval for diverticulitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.8 s, 53.6 cm; CTDIvol = 14.8 mGy (Body) DLP = 794.0
mGy-cm.
Total DLP (Body) = 808 mGy-cm.
COMPARISON: Prior CT abdomen/pelvis dated ___.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. Otherwise, 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. Interval development of small volume
perihepatic fluid. The gallbladder is decompressed but appears normal.
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: Multiple bilateral subcentimeter cortical hypodensities are too small
to further characterize but likely renal cysts. The kidneys are of normal and
symmetric size with normal nephrogram. There is no evidence of concerning
focal renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is dilated and fluid-filled. Dilated small
bowel loops measuring up to 4.4 cm (series 601, image 33) containing multiple
air-fluid levels are present, more pronounced on prior exam. Fecalization of
small bowel loops with a transition point is seen in the right upper quadrant
(series 601, image 22). The distal ileum is collapsed. Configuration and
appearance of the small bowel appears similar compared to the prior exam
though there is increased small bowel wall thickening, mesenteric edema and
fluid in the left lower quadrant. The colon is partially collapsed but does
contain air and stool.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. High-grade small-bowel obstruction with transition point in the right upper
quadrant. Increased small bowel wall thickening and mesenteric edema and
fluid in the left lower quadrant which may suggest a coexistent enteritis.
2. Interval development of small perihepatic ascites.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with NGT placement// NGT placement
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___ chest radiograph, same day CT abdomen and pelvis
FINDINGS:
Enteric tube tip and side port terminate within the stomach. Heart size is
borderline enlarged. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
Enteric tube tip within the stomach. No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: Small bowel follow through
INDICATION: ___ year old man with SBO// Please complete gastrograffin small
bowel follow through
TECHNIQUE: Following ingestion of Gastrografin, multiple radiographs and spot
fluoroscopic images were obtained during the transit of Gastrografin through
the small bowel.
DOSE: Acc air kerma: 3 mGy; Accum DAP: 70.6 uGym2; Fluoro time: 24 second
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
Gastrografin passes through the small bowel, reaching the colon within 160
minutes which is within normal limits. There is redemonstration of multiple
dilated loops of small bowel measuring up to 4.7 cm, compatible with partial
small bowel obstruction. Otherwise, there is normal fold pattern, with no
masses or mucosal abnormality.
IMPRESSION:
Gastrografin passes through the small bowel and reaches the colon with
redemonstration of multiple dilated loops of small bowel. Findings are
compatible with partial small bowel obstruction.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:47 pm, 10 minutes
after discovery of the findings.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Lower abdominal pain, N/V
Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Unspecified abdominal pain
temperature: 98.5
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 124.0
dbp: 81.0
level of pain: 8
level of acuity: 3.0 | You were admitted to ___ with abdominal pain. CT scan showed a
small bowel obstruction. You were managed non-operatively with
bowel rest, IV fluids, and close monitoring of your abdominal
exam. A contrast study showed that contrast passed through the
area of concern and into your colon, indicating that the
obstruction had opened up. You also began to have bowel function
again. Your diet has been advanced and you are now tolerating
food without difficulty and having good bowel function. You are
ready to go home to continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex
Attending: ___
___ Complaint:
ICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of paroxysmal
atrial fibrillation on Pradaxa, non-ischemic dilated
cardiomyopathy (EF ___, and ICD placement in ___ for
primary prevention who presents after her ICD fired twice this
morning (1030 and 1100AM).
Patient reports using large amounts of alcohol (4 beers and 7
drinks) and cocaine (2 straws) on the night prior to
presentation. This morning, she was walking around her kitchen
when her ICD fired. Patient reports being lightheaded after the
first firing of the ICD. She went to sit down and had a second
firing. She has been feeling lightheaded since then. She
denies fever, chills, nausea, vomiting, chest pain, shortness of
breath, or palpitations. She did not take her medications this
morning.
Patient was taken by EMS to the ED, where she was in and out of
atrial fibrillation with rates as high as the 180s. In the ED,
intial vitals were: T 98.0 HR 89 BP 127/73 RR 18 SaO2 99% 2L.
EKG was remarkable for Afib with RVR, HR 140, no ischemia. EP
was consulted and interrogated her device, which showed rapid
Afib and two ICD shocks. They recommended beta-blockade and
amiodarone loading. They increased the detection rates on ICD.
Patient was given 1L NS, lorazepam 1 mg x 2, metoprolol tartrate
5 mg IV, metoprolol tartrate 12.5 mg po, and amiodarone 400 mg.
On the floor, patient feels well. She no longer feels
lightheaded.
ROS: 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. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension, +Dyslipidemia, +Type II
diabetes
2. CARDIAC HISTORY:
- Nonischemic dilated cardiomyopathy, EF of 25%
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: ICD placement in ___ for primary
prevention
3. OTHER PAST MEDICAL HISTORY:
- Obstructive sleep apnea
- History of ethanol and cocaine abuse
- S/p left glomus jugulare removal in ___
Social History:
___
Family History:
HTN and death due to "aneurysm" in her mother and twin sister.
Physical Exam:
EXAM (SAME ON ADMISSION AND DISCHARGE):
=========================================
VS: T 98, HR 81, BP 144/97, RR 20, SaO2 99%
GENERAL: Hispanic woman, comfortable-appearing, in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations unlabored, no accessory muscle use. No crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
================
___ 12:40PM BLOOD WBC-9.1 RBC-4.74 Hgb-13.7 Hct-42.5 MCV-90
MCH-28.8 MCHC-32.1 RDW-14.7 Plt ___
___ 12:40PM BLOOD Neuts-63.5 ___ Monos-3.3 Eos-3.5
Baso-0.5
___ 12:40PM BLOOD Glucose-87 UreaN-25* Creat-1.0 Na-143
K-4.2 Cl-99 HCO3-28 AnGap-20
___ 12:40PM BLOOD ALT-14 AST-22 LD(LDH)-206 AlkPhos-86
TotBili-0.2
___ 12:40PM BLOOD Digoxin-0.7*
___ 12:40PM BLOOD TSH-1.4
___ 12:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
================
___ 06:33AM BLOOD WBC-10.7 RBC-4.07* Hgb-12.0 Hct-37.6
MCV-93 MCH-29.6 MCHC-32.0 RDW-14.8 Plt ___
___ 06:33AM BLOOD Glucose-131* UreaN-23* Creat-1.0 Na-141
K-4.2 Cl-100 HCO3-32 AnGap-13
___ 06:33AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8
IMAGING:
=========
CXR (___):
There is mild cardiomegaly. Transvenous pacemaker lead tip is in
the right ventricle. The lungs are clear. There is no
pneumothorax or pleural effusion. There are moderate
degenerative changes in the thoracic spine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Benzonatate 100 mg PO DAILY
3. HydrOXYzine 10 mg PO Q6H:PRN itching
4. GlipiZIDE XL 5 mg PO DAILY
5. Furosemide 40 mg PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Omeprazole 20 mg PO BID
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
9. Atorvastatin 80 mg PO QPM
10. Dabigatran Etexilate 150 mg PO BID
11. Digoxin 0.25 mg PO DAILY
12. Carvedilol 12.5 mg PO BID
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash
14. hydroquinone 4 % topical bid prn rash
15. ammonium lactate 12 % topical qPM feet
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Benzonatate 100 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Dabigatran Etexilate 150 mg PO BID
5. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
6. Furosemide 40 mg PO BID
7. HydrOXYzine 10 mg PO Q6H:PRN itching
8. Lisinopril 10 mg PO DAILY
9. Omeprazole 20 mg PO BID
10. Amiodarone 400 mg PO TID Duration: 5 Days
400 mg tid through ___. Decrease to 400 mg daily on ___
and continue until EP appointment.
RX *amiodarone 400 mg 1 tablet(s) by mouth three times a day
Disp #*16 Tablet Refills:*0
11. Amiodarone 400 mg PO DAILY
Start 400 mg daily on ___ and continue until EP appointment.
RX *amiodarone 400 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
13. ammonium lactate 12 % topical qPM feet
14. GlipiZIDE XL 5 mg PO DAILY
15. hydroquinone 4 % topical bid prn rash
16. MetFORMIN (Glucophage) 500 mg PO BID
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSES:
Chronic non-ischemic dilated cardiomyopathy
Polysubstance abuse
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: Atrial fibrillation with RVR with ICD firing twice.
TECHNIQUE: Single portable frontal chest radiograph.
COMPARISON: ___
FINDINGS:
Left chest wall ICD is unchanged. Moderate cardiomegaly has improved compared
to prior study. Mediastinal silhouette and hilar contours are unremarkable.
Lungs are clear. Pleural surfaces are clear without effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with atrial fibrillation, non-ischemic
cardiomyopathy, ICD for primary prevention, presenting with ICD shocks for
atach, getting loaded with amiodarone // ?pulm fibrosisbaseline cxr for amio
initiation
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There is mild cardiomegaly. Transvenous pacemaker lead tip is in the right
ventricle. The lungs are clear. There is no pneumothorax or pleural effusion.
There are moderate degenerative changes in the thoracic spine
IMPRESSION:
No acute cardiopulmonary abnormalities
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: ICD eval
Diagnosed with ATRIAL FIBRILLATION
temperature: 98.0
heartrate: 89.0
resprate: 18.0
o2sat: 99.0
sbp: 127.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted after your ICD fired. This was
most likely due to atrial fibrillation, a fast, irregular heart
rate. After receiving medications, your heart returned to its
normal rhythm and your symptoms improved. You were started on a
new medication, called amiodarone, to help control your heart
rhythm. Your digoxin dose was decreased.
It is very important that you stop using cocaine and stop
binging on alcohol. Your abnormal heart rhythm was most likely
due to your cocaine use. If you need assistance with staying
sober, you should speak with your primary care physician.
Please see the attached medication reconcilliation for a
complete list of your current medications. You will need to see
Dr. ___ clinic) in ___ weeks.
We wish you good health!
Sincerely,
Your ___ Cardiology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / levetiracetam
Attending: ___
Chief Complaint:
S/p fall vs seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
MR. ___ is a ___ year old male who presented to the ED as
a transfer from ___. The patient was at work
today when he reports falling down and striking his head. He
does
not distinctly remember the events of his fall. The fall was
unwitnessed. ?of seizure causing fall. Patient has a history of
seizures after a similar event in ___ where the patient fell
striking his head resulting in a SAH. He takes dilantin at home
for seizures and is followed by Neurology at ___. Patient had
a
one minute seizure upon arrival to ___ and was
subsequently loaded with dilantin prior to transfer to ___.
Patient denies headache, visual changes, numbness or weakness.
Past Medical History:
___
Seizures
Social History:
___
Family History:
NC
Physical Exam:
O: T:97.7 BP: 130/70 HR:78 R16 O2Sats 97% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3 mm bilaterally EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Patient is sleep but awakes briskly to voice.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally
Toes downgoing bilaterally
On discharge:
AAO x 3, PERRLA, no pronator drift, strength ___, sensation
intact to light touch.
Pertinent Results:
CT Head ___:
No significant interval change since the previous outside CT
examination. No acute hemorrhage is seen. Bilateral
subarachnoid hemorrhage again noted with the left anterior
temporal blood products likely due to a hemorrhagic contusion
and less likely due to the subarachnoid blood
___ ECG
Sinus rhythm. Findings are within normal limits. Compared to the
previous
tracing of ___ there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 184 92 382/408 44 39 51
Medications on Admission:
Dilantin 200mg QAM, Dilantin 300mg QHS
Discharge Medications:
1. Phenytoin Sodium Extended 200 mg PO BREAKFAST
2. Phenytoin Sodium Extended 300 mg PO HS
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Patient with bilateral frontal subarachnoid hemorrhage for followup.
TECHNIQUE: Axial images of the head were obtained without contrast.
COMPARISON: Comparison was made to the outside CT examination of ___.
FINDINGS:
Bilateral subarachnoid hemorrhage is again identified was predominantly seen
in the right frontal convexity region not significantly changed from the prior
study. The left anterior temporal hemorrhagic contusion is also identified
unchanged. There is no mass effect, midline shift or hydrocephalus.
IMPRESSION:
No significant interval change since the previous outside CT examination. No
acute hemorrhage is seen. Bilateral subarachnoid hemorrhage again noted with
the left anterior temporal blood products likely due to a hemorrhagic
contusion and less likely due to the subarachnoid blood.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SDH VS EPIDURAL HEAD BLEED
Diagnosed with SUBARACHNOID HEM-NO COMA, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, TETANUS-DIPHT. TD DT
temperature: 97.7
heartrate: 78.0
resprate: 16.0
o2sat: 97.0
sbp: 130.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Continue to take your Dilantin as directed by Dr. ___.
You should follow up with him with two weeks of being
discharged. Please call his office for an appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
allopurinol / ibuprofen / acetaminophen / Cephalosporins / Zosyn
Attending: ___.
Chief Complaint:
Rash.
Major Surgical or Invasive Procedure:
Left posterior shoulder skin biospy with stitch.
History of Present Illness:
___ yo ___ speaking F with DM, HLD, HTN, gout and other
issues presents today because of facial swelling and rash with
throat and mouth pain.
Of note, she was started on allopurinol since ___. Then about a
week ago, had fatigue, cough, rhinorrhea, fever, and chill. She
went to see her doctor yesterday and was advised to started
ibuprofen and Tylenol for symptomatic relief of the presumed
viral illness. She noted facial swelling with eyelid edema, and
conjunctival injection and draining as well as oral ulcers over
a course of a few hours after taking these medications. She also
noted rash on her back and upper chest at a later time, but not
on her limbs. She reports very little itching but has a lot of
oral pain and skin stingy sensation. She reports a fever of
100.3. She was unable to sleep last night because her eyes were
burning
In the ED, initial VS were: 101.6, 83, 145/92, 14, 99% RA.
Patient was found to have oral bullae, violaceous rash to the
chest and back, no vaginal involvement. They also noted some eye
involvement. Dermatology was called who thinks this is SJS and
recommended holding allopurinol, all NSAIDs, and give 125
solumedrol for now with 125 mg daily, and to apply vaseline to
lips every ___ hours. They did not recommend any abx or ICU
level of care at this point. Ophthalmology was consulted and
said they would see the patient. Labs are significant for normal
CBC, Na 125, K 5.5, Cl 95, Bicarb 20, BUN 27, Crt 1.3, Glucose
156, ALT 101, AST 103, AP 68, Lipase 70, Tbili 0.3, Albumin 4.3,
lactate 1.5. CXR was without acute process. Patient received
methylprednisolone 125 mg IV x2 and hydromorphone 1 mg IV x 1.
VS upon transfer 101.6 95 124/71 18 97%.
Her mouth is very sore. She denies any pain with urination or in
the vaginal area. She feels very tired and there was a bit of
shortness of breath earlier, but that is a bit better now. She
vomited once on her way up from the ED, and it was slightly
blood tinged.
Past Medical History:
- DM
- HLD
- HTN
- osteoporosis
- GERD
- gout
Social History:
___
Family History:
- denies any skin condition like what she has now
- denies any family history of malignancy, autoimmune conditions
such as lupus, hypo or hyperthyroidism, T1DM
Physical Exam:
GENERAL: fatigued appearing Asian female
HEENT: face is milely swollen, sclerae is anicteric, +
conjunctival injection and mildly opaque discharge, mucous
membrane is moist but with numerous whitish erosions/ulcers,
lips are very dry and cracked with hemorrhogic crust. Face is
covered with erythematous papules that at times coalesce into
small plaques
NECK: supple, no LAD, JVD is not elevated
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses. Anterior torso has scattered
erythematous papules, mostly on the upper chest with a few
scattered on the abdomen.
GU: external genitalia appears normal, no erosion or ulcers
EXTREMITIES: no edema, 2+ pulses radial and dp
GENITAL: genital skin with ulceration and evidence of cutaneous
infalmatory involvement
NEURO: awake, A&Ox3
Back: erythematous to violaceous papules mostly on the upper
back, these lesions have central darker brownish to violaceous
centers
Skin: please note above. There is no bullae or vesicles.
Extremities are spared at this time.
Pertinent Results:
___ 06:30PM BLOOD ALT-101* AST-103* AlkPhos-68 TotBili-0.3
___ 07:24AM BLOOD ALT-79* AST-81* AlkPhos-60 TotBili-0.4
STUDIES:
___ CXR: The heart is at the upper limits of normal size.
The descending aorta is moderately tortuous. A prominent
pericardial fat pad projects along the cardiac apex. There is
no pleural effusion or pneumothorax. The lungs appear clear
aside from streaky right mid lung opacities suggesting minor
atelectasis or minor fissural thickening. There is mildly
exagerated kyphotic curvature centered along the lower thoracic
spine and a mild anterior wedge compression deformity that
appears chronic. The mid-to-upper thoracic spine is mildly
lordotic. IMPRESSION: No evidence of acute disease.
PATHOLOGY:
___ BACK SKIN BIOPSY: Interface dermatitis with keratinocyte
necrosis consistent with erythema ___
syndrome spectrum (see note). Note: Full thickness epidermal
necrosis is focally present. Close clinical follow-up to
exclude progression to toxic epidermal necrolysis is suggested.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. Acetaminophen 1000 mg PO Q8H:PRN pain or fever
3. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
4. Alendronate Sodium 35 mg PO QSUN
5. Atenolol 50 mg PO DAILY
6. GlipiZIDE 10 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO TID
10. Omeprazole 20 mg PO DAILY
11. Simvastatin 20 mg PO HS
12. Aspirin 81 mg PO DAILY
13. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
14. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. MetFORMIN (Glucophage) 850 mg PO TID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
5. Betamethasone Valerate 0.1% Cream 1 Appl TP Q 12 H
Continue until vaginal ulcers completely healed
6. Betamethasone Valerate 0.1% Ointment 1 Appl TP Q 12 H
Continue until vaginal ulcers completely healed
7. Caphosol 30 mL ORAL TID
8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID to lips
9. cycloSPORINE *NF* 0.05 % ___ Q8H Reason for Ordering: Needed
per specialist
10. fluorometholone *NF* 0.1 % ___
11. fluorometholone *NF* 1 ___
12. Lidocaine 5% Ointment 1 Appl TP BID lips
13. Lidocaine Viscous 2% 20 mL PO ___
14. Nystatin Oral Suspension 5 mL PO BID
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES Q4H
16. Sodium Chloride Nasal ___ SPRY NU TID
17. Vigamox *NF* (moxifloxacin) 0.5 % ___ BID
18. Alendronate Sodium 35 mg PO QSUN
19. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
20. Omeprazole 20 mg PO DAILY
21. Simvastatin 20 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis: ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Fever.
COMPARISONS: None.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is at the upper limits of normal size. The descending
aorta is moderately tortuous. A prominent pericardial fat pad projects along
the cardiac apex. There is no pleural effusion or pneumothorax. The lungs
appear clear aside from streaky right mid lung opacities suggesting minor
atelectasis or minor fissural thickening. There is mildly exaggerated
kyphotic curvature centered along the lower thoracic spine and a mild anterior
wedge compression deformity that appears chronic. The mid-to-upper thoracic
spine is mildly lordotic.
IMPRESSION: No evidence of acute disease.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Low lung volumes accentuate the cardiac silhouette and
bronchovascular structures, limiting assessment of cardiovascular status of
the patient. New patchy bibasilar opacities have developed, and could be due
to patchy atelectasis, aspiration, or developing infectious pneumonia. Small
pleural effusions are also noted.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: FACIAL RASH
Diagnosed with STEVENS-JOHNSON SYNDROME, ADV EFF URIC ACID METAB
temperature: 10.3
heartrate: 83.0
resprate: 14.0
o2sat: 99.0
sbp: 145.0
dbp: 92.0
level of pain: 10
level of acuity: 2.0 | Ms. ___,
You were admitted to the hospital for a reaction to
allopurinol that caused extensive skin injury. You were
evaluated and treated by the medicine service. You were also
treated by the dermatology, ophthalmology and gynecology
services. You will need to follow-up with these specialists. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
somnolence, hypothermia, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with hx of dementia (non-verbal at baseline), L
parieto-occipital intraparenchymal hemorrhage s/p G tube
placement ___ presenting with AMS and profuse diarrhea.
Her family notes that she was unable to have a bowel movement
for the prior 3 days. She received a laxative by G-tube last
night. This morning she started having constant copious tan
brown diarrhea. EMS reports that when they arrived at the
residence, her blood pressure was 80/60. In ___ it
improved to 120/P.
In the ED, initial vitals were: 92.7 105 105/71 16 76% RA
- Exam notable for: Moves hand to block when palpate abdomen,
guaiac negative rectal
- Labs notable for: WBC 3.8, Hb 12.5, K 5.0, Alb 3.1, neg UA
- Imaging was notable for: CXR neg
- Patient was given: IV Cipro, IV Flagyl, Olanzapine 5mg, Warm
IVF and bear hugger
- VS prior to transfer: T97.1 71 118/83 11 95% RA
Upon arrival to the floor, patient unable to talk, per pt's
sister, had increased BMs. Denies any sick contacts, no one with
GI illnesses at home. Doesn't remember severe diarrhea. Tried
giving risperdol last night for worsening AMS. Denies recent Abx
use.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
# hypertension
# intraparenchymal hemorrhage ___
# diabetes mellitus, type 2
# s/p g-tube placement ___
# moderate dementia
# small bowel GIST tumor s/p resection
# osteopenia
# s/p right distal radial fracture (___)
# h/o acute cholesystitis s/p open cholecystectomy (___)
# admission ___ for multiple rib fractures and
small SAH, family unaware of a fall
Social History:
___
Family History:
Non-contributory, Per family, no known family history of strokes
or
seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: 97.0 126 / 73 63 18 98 Ra
GENERAL: agitated, not opening eyes
HEENT: not opening eyes or mouth though appears dry MM
NECK: mild jvd
CARDIAC: rrr, s1/s2, no mrg
LUNGS: cta ant b/l
ABDOMEN: soft, NDNT, no rebound/guarding
EXTREMITIES: ___ ___ edema, Rt>Lt
NEUROLOGIC: spontaneously moving UEs, diff to assess iso
agitation
SKIN: G-tube w/mild surrounding erythema
DISCHARGE PHYSICAL EXAM:
========================
Vitals- ___ 92-97RA
General- nonverbal, arousable to loud voice
Lungs- rhonchorous lung sounds on left > right but appears to be
breathing comfortably and clearing secretions.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- yellow fluid around G tube (daughter attributes it to
food coming out), slight erythema, does not appear infected;
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness, no organomegaly
Ext- warm, well perfused, 2+ pulses; 2+ edema bilaterally; no
clubbing, cyanosis
Neuro- exam deferred due to somnolence and baseline dementia
Pertinent Results:
ADMISSION LABS:
___ 01:55PM BLOOD WBC-3.8* RBC-4.03 Hgb-12.5 Hct-39.7
MCV-99* MCH-31.0 MCHC-31.5* RDW-13.6 RDWSD-49.1* Plt ___
___ 01:55PM BLOOD Neuts-62.3 ___ Monos-7.9 Eos-0.3*
Baso-0.3 Im ___ AbsNeut-2.37 AbsLymp-1.10* AbsMono-0.30
AbsEos-0.01* AbsBaso-0.01
___ 01:55PM BLOOD ___ PTT-30.5 ___
___ 01:55PM BLOOD Plt ___
___ 01:55PM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-137
K-5.0 Cl-100 HCO3-27 AnGap-15
___ 01:55PM BLOOD ALT-12 AST-29 AlkPhos-99 TotBili-0.4
___ 01:55PM BLOOD Lipase-16
___ 01:55PM BLOOD Albumin-3.1* Calcium-9.4 Phos-3.6 Mg-1.7
___ 07:28PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-4.0 RBC-3.63* Hgb-11.2 Hct-35.7
MCV-98 MCH-30.9 MCHC-31.4* RDW-14.9 RDWSD-54.3* Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-138
K-4.7 Cl-102 HCO3-28 AnGap-13
___ 07:05AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8
___ 06:54AM BLOOD TSH-2.4
___ 06:54AM BLOOD T4-7.0
___ 05:15PM BLOOD Cortsol-21.9*
___ 04:45PM BLOOD Cortsol-18.0
___ 04:15PM BLOOD Cortsol-5.3
___ 06:54AM BLOOD Cortsol-4.4
___ 01:07PM BLOOD Lactate-1.0
___ MR HEAD WITH CONTRAST
1. No evidence of infarction, recent hemorrhage, or edema.
2. Chronic tissue loss of the left parietal lobe with associated
chronic blood
products, presumably due to prior hematoma.
3. Probable left frontal lobe meningioma lateral to the gyrus
rectus.
4. Please note, if there is concern for underlying
pituitary/hypothalamus
abnormality, dedicated MRI sella with contrast is recommended.
___ CT ABDOMEN AND PELVIS WITH CONTRAST
1. No obstruction or bowel wall thickening. Fluid-filled loops
of small bowel
are nonspecific but can be seen in the setting of viral
gastroenteritis. The
distal rectum is collapsed, mild apparent wall thickening likely
relates to
underdistention. No definite proctitis seen.
2. Similar to slightly increased size of a soft tissue nodule
along the
anterior urinary bladder wall compared to ___.
3. Small left pleural effusion with adjacent atelectasis.
___ CXR
No convincing evidence for pneumonia. Platelike atelectasis in
the left lower
lung.
MICRO:
___ 02:05PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
___ 2:05 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
___ 2:05 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 8:07 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 1:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate Suspension 1250 mg PO BID
2. Lisinopril 30 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. RISperidone 0.5 mg PO BID agitation
5. Senexon (sennosides) 8.6 mg oral QHS
Discharge Medications:
1. Calcium Carbonate Suspension 1250 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Senexon (sennosides) 8.6 mg oral QHS
4. HELD- Lisinopril 30 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your primary care doctor,
___
5. HELD- RISperidone 0.5 mg PO BID agitation This medication
was held. Do not restart RISperidone until discussing with PCP.
Can make somnolance worse.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Systemic inflammatory response syndrome
Gastroenteritis
Hypothermia
Secondary diagnoses:
Altered mental status
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with FTT.// pneumonia?
COMPARISON: ___
FINDINGS:
AP portable semi upright view of the chest.
Lung volumes are low with areas of linear atelectasis noted in the left lower
lung. The right lung is clear. No convincing evidence for pneumonia.
Cardiomediastinal silhouette is unchanged. No pneumothorax or large effusion.
Chronic right-sided rib deformity again noted.
IMPRESSION:
No convincing evidence for pneumonia. Platelike atelectasis in the left lower
lung.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with copious diarrhea, hypotension.
NO_PO contrast// colitis?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 4.2 s, 46.0 cm; CTDIvol = 15.3 mGy (Body) DLP = 701.3
mGy-cm.
Total DLP (Body) = 713 mGy-cm.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: There is a small left pleural effusion with adjacent atelectasis.
There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in background attenuation, with
several hypodense foci which are incompletely characterized but compatible
with simple hepatic cysts or biliary hamartomas, unchanged compared to ___. There is minimal intrahepatic biliary duct dilation, which may be
related to prior cholecystectomy, more conspicuous compared to ___. The
gallbladder is not visualized.
PANCREAS: The pancreas is atrophic but normal in attenuation, without mass,
ductal dilation, or peripancreatic stranding or fluid collection.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally.
URINARY: The kidneys are unchanged in size, with a large simple cyst arising
from the upper pole of the right kidney. There are normal nephrograms with
the kidneys excreting contrast promptly. No hydronephrosis is seen. There is
no perinephric abnormality.
GASTROINTESTINAL: A PEG tube is in place, with the balloon in the gastric
antrum. Small bowel loops are nondilated and fluid-filled, which can be seen
in the setting of viral gastroenteritis. The colon and rectum are normal in
caliber. The distal rectum is collapsed. The appendix is normal.
PELVIS: There is again a soft tissue nodule along the anterior bladder wall
measuring 1.3 x 1.6 cm (602b:35, 2:59), increased compared to ___. There
is no free fluid within the pelvis. A large lipoma extending through the
greater sciatic foramen is unchanged.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal masses
identified.
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 concerning focal lytic or sclerotic osseous lesion.
Compression deformity of the T12 vertebral body is unchanged. There is mild
anterolisthesis of the L4 on L5 vertebral bodies, also unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No obstruction or bowel wall thickening. Fluid-filled loops of small bowel
are nonspecific but can be seen in the setting of viral gastroenteritis. The
distal rectum is collapsed, mild apparent wall thickening likely relates to
underdistention. No definite proctitis seen.
2. Similar to slightly increased size of a soft tissue nodule along the
anterior urinary bladder wall compared to ___.
3. Small left pleural effusion with adjacent atelectasis.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with advanced dementia and IPH. Please
evaluate hypothalamus and pituitary for infarct/ mass causing inability to
regulate temperature/hypothermia
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
FINDINGS:
There is left parietal lobe tissue loss with chronic blood products
suggesting a prior hematoma. There is no evidence of infarction, recent
hemorrhage, or midline shift. An extra-axial mass is seen lateral to the gyrus
rectus measuring 1.8 cm x 1.7 cm x 1.0 cm (6:10, 3:9), likely a meningioma.
There is mild bilateral ethmoid sinus disease with trace nonspecific fluid
within bilateral mastoid air cells.
IMPRESSION:
1. No evidence of infarction, recent hemorrhage, or edema.
2. Chronic tissue loss of the left parietal lobe with associated chronic blood
products, presumably due to prior hematoma.
3. Probable left frontal lobe meningioma lateral to the gyrus rectus.
4. Please note, if there is concern for underlying pituitary/hypothalamus
abnormality, dedicated MRI sella with contrast is recommended.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Diarrhea, unspecified
temperature: nan
heartrate: 105.0
resprate: 16.0
o2sat: 76.0
sbp: 105.0
dbp: 71.0
level of pain: UTA
level of acuity: 2.0 | Dear Ms. ___,
You were hospitalized at ___ after you were found to have very
low body temperature in the emergency room. Your white blood
cell count, was found to be low. These two findings were
concerning for an infection. You were warmed periodically with a
warming device to keep your body temperature up. You were also
treated with five days of antibiotics for this infection. We
think that you may have had a GI infection however your stools
and labs did not reveal an obvious source of infection.
It is important that you:
[ ] Call your primary care doctor Dr. ___ to set up an
appointment for this week (phone number: ___.
[ ] Do not use risperidone unless you absolutely need to,
please discuss with your PCP as it can make you more sleepy.
[ ] Start taking metoprolol for high blood pressure, but wait
until you see Dr. ___ starting lisinopril.
It was a pleasure taking care of you! We wish you the best!
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bee Sting Kit / Shellfish Derived / Clindamycin
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ male with CLL and stage IV metastatic gastric cancer
who is C2D11 of palliative chemotherapy: Epirubicin Oxaliplatin
Capecitabine. Of note he was recent admitted ___ for diarrhea
related to enterotoxicity from chemotherapy. He was ruled out
for C dif and was treated with immodium, lomotil,opium tincture
and octreotide and his symptoms improve. Several days after
discharge diarrhea began again. He was seen in ___ clinic ___
and metformin and oral capecitabine were stopped in case these
were contributing meds.
He awoke today feeling worse, felt like he had the flu. Called
in w/ abdominal pain, chills and malaise and was referred to ED.
Temp was 99.9 at home
In the ED, initial VS were: 97.8 103 125/62 18 97% ra
Labs were notable for: WBC 5.2 Ht 27 plat 212 CEM7 wnl alb 2.8
He was given 1 L NS, his home oxycontin and prn oxycodone and
duonebs
On leaving ED spiked to 103, was 101 on arrival to floor
Per pts wife and son, two days ago he went to bathroom at least
10 times. They report he is using antimotility drugs but ___
sure which ones or w/ what frequency. Did not take any today.
No known melena or other bleeding, no vomiting, denies nausea.
is somewhat confused, able to answer questions but answers
sometimes inconsistent. initially says he has pain all over,
across upper part of chest, arms, legs, soreness. Also over L
abdomen, sharp pains coming and going. No sore throat, HA, skin
wounds, dysuria, hematuria. Has ongoing cough since paraflu dx
in ___ that is unchanged, no sputum production, no hemoptysis.
Per family he was able to get in car to come to ED today. He
denies any SOB, per wife he has been able to go upstairs at home
even earlier today, has to go up a floor to go to bathroom.
However they did note that his fingernails have been blue. No
incontinence. They report he was confused after getting ativan
in ED but throughout interview state he is now acting more like
himself.
Past Medical History:
Oncologic History:
Gastric cancer stage IV and synchronous CLL
- Long history heartburn and reflux since his ___
- ___ Started omeprazole for GI symptoms with good effect
- ___ Underwent lap banding for weight loss and reflux
- ___ Lap band ruptured due to cough
- ___ to ___ Received BR x 6 cycles for CLL
- ___ CT torso to assess response to therapy for CLL
showed only a gastrohepatic ligament.
- ___ CT torso to assess CLL showed new regions of
ill-defined hypoensity, particularly in hepatic segments V and
VI, may be due to focal fatty infiltration. However,
infiltrative disease/neoplasm is on the differential diagnosis.
Previously described gastrohepatic ligament lymph node is not
seen on the current study. Some new pulmonary nodules.
- ___ MR abdomen showed ill-defined 5.8 x 1.2 cm
hypoenhancing lesion along the proximal aspect of the lesser
curvature of the stomach, adjacent to the fundoplication site,
with enlarged gastrohepatic, gastroepiploic, and left paraaortic
lymph nodes, adjacent fat stranding, and numerous liver lesions,
concerning for metastatic gastric neoplasm. Severe hepatic
steatosis.
- ___ EGD showed an infiltrative and ulcerated 4 cm mass
with stigmata of recent bleeding of malignant appearance at the
gastroesophageal junction and lesser curve. Also found to have
esophageal candidiasis. Biopsies showed poorly differentiated
signet ring adenocarcinoma.
- ___ PET CT showed multiple foci of FDG avidity
throughout the liver are most consistent with metastatic
disease. Two subcentimeter FDG avid paraaortic lymph nodes.
Innumerable subcentimeter lung nodules and ___ opacities
in the peripheral lung parenchyma demonstrate minimal FDG
avidity
most
consistent with infection or aspiration.
- ___ EUS and biopsy of a liver lesion showed metastatic
disease
- ___ to ___ Palliative XRT
- ___ C1D1 EOX (epirubicin 50 mg/m2, oxaliplatin 130
mg/m2, capecitabine 1500 mg BID)
PAST MEDICAL HISTORY:
- Asthma/COPD
- TBM s/p tracheoplasty in ___
- C1 through C7 fusion,
- Insulin dependant diabetes.
- Depression
- HL
- Morbid obesity (BMI 38, 300 lbs)
Social History:
___
Family History:
No family hx of GI cancers
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 101.3 150/70 116 26 96%RA
GENERAL: alert, conversing appropriately but answers sometimes
inconsistent
HEENT: NC/AT, MMM no oral ulcers
CARDIAC: tachy but regular, normal S1 & S2, peripheral pulses 2+
LUNG: nonlabored, Wheezing throughout, prolonged expiratory
phase, talking in full sentences
ABD: Obese, +BS, distended but soft, tender diffusely w/o no
rebound or guarding
EXT: No lower extremity pitting edema
NEURO: ___, EOMI, face symmetric, no nystagmus, moving all
extremities against resistance, stands independently, sensation
intact to light touch, no clonus, no asterixis
SKIN: Warm and dry, without rashes; has many tattoos, buttocks
folds w/ confluent erythema but no skin wounds or decub ulcer
=================================================
DISCHARGE
Pertinent Results:
INITIAL LABS:
___ 09:30AM BLOOD WBC-5.2 RBC-3.14* Hgb-8.4* Hct-27.0*
MCV-86# MCH-26.8 MCHC-31.1*# RDW-25.1* RDWSD-73.6* Plt ___
___ 09:30AM BLOOD Neuts-73.3* Lymphs-7.3* Monos-16.5*
Eos-1.7 Baso-0.4 Im ___ AbsNeut-3.82 AbsLymp-0.38*
AbsMono-0.86* AbsEos-0.09 AbsBaso-0.02
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-187* UreaN-11 Creat-0.8 Na-133
K-3.5 Cl-97 HCO3-27 AnGap-13
___ 09:30AM BLOOD ALT-39 AST-46* AlkPhos-105 TotBili-0.4
___ 09:30AM BLOOD Lipase-7
___ 09:30AM BLOOD Albumin-2.8*
___ 10:27PM BLOOD Ammonia-21
___ 10:02PM BLOOD IgG-462*
=============================================================
MICRO:
C. DIFF: negative
=============================================================
IMAGING:
___ CXR: IMPRESSION: No acute cardiopulmonary process.
___ CTA CHEST AND CT ABDOMEN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Octreotide Acetate 100 mcg SC Q8H
2. Citalopram 40 mg PO DAILY
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
6. Lorazepam 0.5 mg PO Q8H:PRN nausea
7. Montelukast 10 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Nystatin Oral Suspension 5 mL PO BID
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
13. Pyridoxine 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. TraZODone 50-100 mg PO QHS:PRN sleep
16. Diphenoxylate-Atropine 1 TAB PO Q6H
17. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q4H
18. DiphenhydrAMINE 25 mg PO QHS:PRN allergies
19. Docusate Sodium 100 mg PO TID
20. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
21. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
22. Loratadine 10 mg PO DAILY:PRN allergy
23. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN sore
throat
24. MetFORMIN (Glucophage) 1000 mg PO BID
25. Methylnaltrexone 12 mg SUBCUT QAM:PRN constipation
26. Prochlorperazine 10 mg PO Q6H:PRN nausea
27. Senna 17.2 mg PO BID:PRN constipation
28. Pseudoephedrine 60 mg PO Q6H:PRN allergy
29. LOPERamide 2 mg PO QID
30. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Stool Softener] 100 mg 1 capsule(s) by
mouth twice a day Disp #*60 Capsule Refills:*0
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
7. Loratadine 10 mg PO DAILY:PRN allergy
8. Lorazepam 0.5 mg PO Q8H:PRN nausea
9. Montelukast 10 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
14. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Pseudoephedrine 60 mg PO Q6H:PRN allergy
17. Pyridoxine 100 mg PO DAILY
18. Senna 17.2 mg PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 tab by mouth twice a day
Disp #*60 Tablet Refills:*0
19. Tiotropium Bromide 1 CAP IH DAILY
20. Ciprofloxacin HCl 750 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
21. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*9 Tablet Refills:*0
22. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
23. DiphenhydrAMINE 25 mg PO QHS:PRN allergies
24. Diphenoxylate-Atropine 1 TAB PO Q6H
25. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
26. Methylnaltrexone 12 mg SUBCUT QAM:PRN constipation
27. TraZODone 50-100 mg PO QHS:PRN sleep
28. Nystatin Oral Suspension 5 mL PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
Metastatic gastric cancer
Secondary:
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 sob, wheezing, fever on chemo, please evaluate for
pneumonia.
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: Prior chest radiographs dating back to ___.
FINDINGS:
Chronic appearing right rib deformity or pleural thickening is unchanged from
prior studies. A left pectoral port catheter tip terminates in the mid SVC.
There is no focal consolidation, pleural effusion, pneumothorax, or pulmonary
edema. The cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: High fever, sepsis, abdominal pain, and hypoxia/cyanosis in a
patient with gastric cancer on chemotherapy.
TECHNIQUE: Helical axial MDCT images were obtained from the suprasternal
notch through the upper abdomen after the administration of IV contrast.
Reformatted images in coronal and sagittal axes were generated. Oblique MIPs
were prepared at a separate workstation. Subsequently, images were obtained
from the bases of the lungs through the pubic symphysis in the portal venous
phase, with coronal and sagittal reformats.
DOSE: This study involved 6 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
4) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.5 mGy (Body) DLP =
6.3 mGy-cm.
5) Spiral Acquisition 6.0 s, 43.1 cm; CTDIvol = 11.7 mGy (Body) DLP = 451.6
mGy-cm.
6) Spiral Acquisition 8.8 s, 61.4 cm; CTDIvol = 17.1 mGy (Body) DLP = 972.8
mGy-cm.
Total DLP (Body) = 1,433 mGy-cm. mGy-cm.
COMPARISON: CT abdomen/ pelvis from ___, as well as CTA chest from ___.
FINDINGS:
CTA thorax: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without intramural
hematoma or dissection. The pulmonary arteries are opacified to the segmental
level, without filling defect to suggest pulmonary embolism.
CT thorax: The airways are patent to the subsegmental level. Nodular
opacities in the right middle lobe measuring 3 and 5 mm are unchanged (5:189,
200 to) a punctate nodular opacity in the right upper lobe (5:161) is also
unchanged. Multiple subpleural nodular opacities in the right lower lobe are
similar in appearance. Ground-glass opacity in the apical segment of the left
lower lobe is similar to slightly decreased compared to ___, and may
represent a resolving infectious or inflammatory process. Peribronchiolar
nodularity in the bilateral lower lobes is likely related to aspiration or
small airways disease. Right hilar lymph nodes are persistent but decreased,
now measuring up to 7 mm (previously up to 1.6 cm). There is no
pathologically enlarged supraclavicular, axillary, or mediastinal lymph
node.The heart, pericardium, and great vessels are within normal limits,
though there is atherosclerosis. A left chest wall port catheter terminates
in the low SVC.Esophageal dilation is persistent.There is no pleural effusion
or pneumothorax.
CT ABDOMEN:
LIVER: The hepatic parenchyma is diffusely heterogeneous, which may be related
to contrast bolus timing. There are again multiple hypodense lesions
scattered throughout the liver, incompletely evaluated but consistent with
metastatic disease. The portal vein is patent.The nondistended gallbladder is
within normal limits, without wall thickening or pericholecystic fluid.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: The pancreas is extremely atrophic, without mass or peripancreatic
stranding or fluid collection.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI:Ill-defined hypodense wall thickening along the lesser curvature of the
stomach is consistent with known gastric cancer.The small and large bowel are
within normal limits, without wall thickening or evidence of obstruction.No
appendix is visualized, but there are no secondary signs of acute
appendicitis.
RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic
calcifications.A para-aortic lymph node measuring 11 mm (09:27) is essentially
unchanged, as is a gastrohepatic ligament lymph node, which is not as well
delineated on today's exam.
CT PELVIS: The urinary bladder appears normal.Bilateral iliac chain lymph
nodes are enlarged, measuring 1.2 cm on the left and 8 mm on the right. These
are similar compared to the most recent CT.There is no pelvic free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present.
IMPRESSION:
1. No evidence of acute pulmonary embolism. No acute intra-abdominal process
to explain the patient's presentation.
2. Ground-glass opacity in the apical segment of the left lower lobe is
similar to slightly decreased compared to ___, possibly representing an
improving infectious or inflammatory process. Likely sequela of aspiration or
small airways disease.
3. A gastric mass is grossly unchanged, better evaluated on prior MR. ___
metastatic disease and lymphadenopathy is also unchanged.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fatigue
Diagnosed with FEVER, UNSPECIFIED
temperature: 97.8
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 125.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | Dear Mr. ___,
You came to the hospital with worsening abdominal pain and
diarrhea. We also found that you had a fever. You improved with
antibiotics and you stopped having fevers and the diarrhea
improved. Please continue taking your medications and follow up
with your doctors as directed.
It was a pleasure taking care of you while you were in the
hospital.
-Your ___ care team- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Percocet
Attending: ___
Chief Complaint:
pelvic pain
Major Surgical or Invasive Procedure:
Placement of a suprapubic catheter into your bladder by
interventional radiology
History of Present Illness:
___ y/o male with PrCa, s/p XRT with intractable radiation
cystitis and prostatitis, ultimately with ileal conduit urinary
diversion and now with defunctionalized bladder unable to access
per urethra. Presents with one week severe pelvic pain radiating
to scrotum and flanks, imaging showing distended, fluid filled
bladder which could be possible etiology. Currently afebrile
with no overt clinical evidence of infection. Will plan to admit
for pain control, obtain ___ consult for small bore suprapubic
drain placement in AM.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypertension
2. Hyperlipidemia
3. Bicuspid Aortic Valve without AS
4. DM2
5. Prostate cancer s/p prostatectomy and radiation
6. Radiation cystitis resulting in recurrent hematuria
7. Circumflex artery stenting ___, and now 2 DES to ___
RCA
with 70% of mid-LAD still present
PAST SURGICAL HISTORY:
1. Radical prostatectomy by Dr. ___ in ___, Adjuvant XRT 6
months later
2. s/p penile prosthesis
3. suprabupic catheter placement on ___
4. SPT removal and ileal conduit ___
Social History:
___
Family History:
Father: MI at ___
Mother: ___ disease
Physical Exam:
N: APAP, toradol, Dilaudid IV PRN pain
CV: home atorvastatin, ISMN, metoprolol
GI: reg (carb consistent) diet, NPO after MN; Zofran PRN nausea;
bowel regimen; home omeprazole
GU: I/Os; LR 125 after MN; trial of B&O suppository for pelvic
pain
H: sqh, pboots; continue home ASA
E: home pioglitazone; hold metformin i/s/o acute
hospitalization; FSBGs ACHS, SSI
Pertinent Results:
___ 07:50AM BLOOD WBC-12.0* RBC-3.55* Hgb-10.0* Hct-32.1*
MCV-90 MCH-28.2 MCHC-31.2* RDW-13.2 RDWSD-43.7 Plt ___
___ 12:00PM BLOOD WBC-10.4* RBC-3.83* Hgb-10.9* Hct-34.6*
MCV-90 MCH-28.5 MCHC-31.5* RDW-13.1 RDWSD-43.5 Plt ___
___ 12:00PM BLOOD Neuts-80.9* Lymphs-11.0* Monos-6.5
Eos-0.6* Baso-0.5 Im ___ AbsNeut-8.42* AbsLymp-1.15*
AbsMono-0.68 AbsEos-0.06 AbsBaso-0.05
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD ___ PTT-35.5 ___
___ 12:00PM BLOOD ___ PTT-37.4* ___
___ 07:50AM BLOOD Glucose-171* UreaN-13 Creat-0.9 Na-139
K-4.5 Cl-101 HCO3-22 AnGap-21*
___ 12:00PM BLOOD Glucose-200* UreaN-13 Creat-0.9 Na-135
K-4.5 Cl-97 HCO3-23 AnGap-20
___ 12:00PM BLOOD ALT-10 AST-14 AlkPhos-110 TotBili-0.8
___ 07:50AM BLOOD Calcium-9.1 Mg-1.9
___ 12:00PM BLOOD Albumin-4.4 Calcium-9.5 Phos-2.7 Mg-2.1
___ 1:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ STAIN - UNSPUN-FINAL; FLUID
CULTURE-FINALINPATIENT
___ CULTUREBlood Culture, Routine-FINAL
Medications on Admission:
as noted in admission H&P
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H UTI
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
every twelve (12) hours Disp #*20 Tablet Refills:*0
2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydrocodone-acetaminophen 5 mg-300 mg 1 tablet(s) by mouth
p6h Disp #*15 Tablet Refills:*0
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Pioglitazone 45 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder distention requiring placement of a suprapubic drain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ with hx of prostate cancer with bilateral testicular pain,
evaluate for torsion vs epididymitis // ___ with hx of prostate cancer with
bilateral testicular pain, evaluate for torsion vs epididymitis
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
The right testicle measures: 4.2 x 2.0 x 2.5 cm.
The left testicle measures: 4.2 x 1.6 x 2.7 cm.
There is a small simple cyst at the head of the right epididymis measuring
approximately 5 mm in diameter. There is trace amount of fluid surrounding
the testicles bilaterally, which is within normal range. Otherwise, the
testicular echogenicity is normal, without concerning focal abnormalities.
The epididymides are normal bilaterally.
Vascularity is normal and symmetric in the testes and epididymides.
IMPRESSION:
1. No evidence of acute scrotal abnormalities.
2. 5 mm right epididymal head cyst.
Radiology Report
INDICATION: ___ with hx of prostate cancer now with ileal conduit with 7 days
of abdominal pain. Evaluate for abscess vs obstrctionNO_PO 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 735 mGy-cm.
COMPARISON: CT abdomen and pelvis with and without contrast ___
FINDINGS:
LOWER CHEST: Mild pulmonary emphysema is noted. There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: Liver demonstrates homogeneous attenuation throughout. A 4 mm
hypodensity in segment 6 (02:26) is too small to be fully characterized but
unchanged from prior. Intra and extrahepatic bile ducts are not dilated.
Patient is post cholecystectomy.
PANCREAS: Pancreas demonstrates homogeneous attenuation throughout.
Pancreatic duct is not dilated.
SPLEEN: Spleen is not enlarged.
ADRENALS: Bilateral adrenal glands are unremarkable.
URINARY: Right kidney lower pole renal cyst measures 3.4 cm. Left kidney
lower pole renal cyst measures 5.1 cm. Bilateral nephrograms are symmetric.
There is no hydronephrosis.
GASTROINTESTINAL: Hiatal hernia is small. Small and large bowel loops are
normal caliber. Duodenum diverticulum is noted. Right lower quadrant
ileostomy is unremarkable. Small bowel anastomosis noted in the mid abdomen.
Surgical suture is noted at the sigmoid colon in the left lower quadrant.
There is colonic diverticulosis without diverticulitis. Appendix is
unremarkable.
PELVIS: Bladder is markedly distended with mild surrounding fat stranding.
REPRODUCTIVE ORGANS: Patient is post prostatectomy. Multiple surgical clips
are noted in the pelvis. Penile implant is present.
LYMPH NODES: No pathologically enlarged lymph node is identified.
VASCULAR: There is no abdominal aortic aneurysm. Mild-to-moderate
atherosclerotic disease is noted.
BONES: Partially imaged lucent lesion in the right proximal femur measures at
least 4.6 x 2.0 cm, similar to ___.
SOFT TISSUES: No suspicious soft tissue lesion is identified. Small fat
containing umbilical hernia is noted.
IMPRESSION:
Bladder is markedly distended with mild surrounding fat stranding. Please
correlate clinically for any urinary obstruction or infection.Otherwise no
findings to explain patient's symptoms.
Radiology Report
INDICATION: Cystitis, ileal conduit, abdominal pain from dilated bladder with
closed prostatic urethra
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the
procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of IV
midazolam during which the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: As above. 20 ml of 1% lidocaine was also infused in the bladder
at the end of the case
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.9 min, 16 mGy
PROCEDURE: 1. Ultrasound guided bladder access.
2. Placement of a 8 ___ pigtail catheter.
3. Aspiration / drainage of bladder to completion.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The lower-abdomen was prepped and draped in the usual sterile
fashion.
Following the installation of 1% local anesthesia in the subcutaneous soft
tissues, a 19 gauge needle was introduced into the bladder under continuous
ultrasound guidance. Ultrasound images were stored on PACS. A ___ wire
was introduced through the needle into the bladder. After a skin incision at
the site of the needle entry, the needle was removed and sequential dilations
were performed using an 8 ___ dilator. These were then removed and a 8
___ pigtail catheter was advanced over the wire into the bladder. The wire
and inner stiffener were removed and the pigtail was formed and locked.
Contrast was injected through the syringe which showed appropriate positioning
within the bladder. Next, the bladder was completely aspirated (approximately
1.4 liters removed. The entry site was marked with a clamp and the tube was
pulled back so as to reduce curling / kinking in the empty bladder. The
pigtail string was cut, the catheter was flushed and secured with 0 silk
sutures and a Statlock device. The catheter was attached to a bag for
drainage. Sterile dressings were applied.
The patient tolerated the procedure well. No immediate complications were
noted.
FINDINGS:
1. Markedly distended bladder on ultrasound. Successful needle access and
very drak brown thin fluid removed (possible old blood) - total 1.4L
aspirated. Sample sent for microbiology, urine analysis, and cytology).
Complete decompression on ultrasound at the end of the case.
2. Successful placement of a 8 ___ pigtail drain catheter through a
suprapubic approach into the bladder. Catheter was withdrawn after complete
decompression to reduce any curling / kinking in the bladder.
IMPRESSION:
Successful placement of ___ suprapubic pigtail drain. Aspirated to completion
(1.4L dark brown fluid removed). Samples sent as above.
Gender: M
Race: SOUTH AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.7
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 162.0
dbp: 94.0
level of pain: 6
level of acuity: 3.0 | *** DO NOT LET ANYONE BUT YOUR UROLOGIST/TEAM REMOVE THE
SUPRAPUBIC TUBE/ CATHETER ***
-You will be discharged home with ___ &*** Home IV therapy
services to further assist your transition.
-Please also reference the instructions provided by nursing on
SUPRAPUBIC TUBE (SPT) hygiene and waste elimination.
For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Your SPT should be secured to the catheter secure on your thigh
at ALL times until your follow up with the surgeon.
-Follow up with UROLOGY for wound check and post-op evaluation
as directed. SPT tubes must be exchanged regularly.
-Wear Large SPT/Foley drainage bag for majority of time; leg-bag
use is only for short-term when leaving the house, etc.
-ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-___ scrotum/phallus supported/elevated. Use a
jock-supporter/strap or jockey-type briefs or tight,
tighty-whities to facilitate this; Subsequently you may
transition to loose fitting briefs or boxer-briefs for
support--they should be cotton and/or breathable.
-Do NOT use penis for intercourse/sex until explicitly advised
by your urologist that is may be ok to do so.
-You may want to coordinate your showers with your ___ provider
and the planned dressing changes.
-You may shower, but do NOT bathe, swim or otherwise immerse
your incision.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily Tylenol
dose is from 3gm to 4gm depending on your kidney function, note
that narcotic pain medication also contains Tylenol
(acetaminophen)
-Colace has been prescribed to avoid post-surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops. Colace is a
stool "softener"- it is NOT a laxative
-Resume your home medications, except as noted.
-Avoid NSAIDS/Aspirin, except as noted, for ONE week or until
you see your urologist in follow-up OR you are explicitly
advised to resume sooner by your PCP, ___ or Cardiologist.
-DO NOT RESUME medications like VIAGRA, LEVITRA or CIALIS.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Trilisate / vancomycin
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
According to the Emergency Department personnel, the ___ history
of paraplegia C4-C5 secondary to a distant fall, DMII, ETOH
related cirrhosis, h/o SBOs w/ suprapubic catheter p/w hematuria
that started after they changed his suprapubic tube this
afternoon around 2 ___. He has been having bright red blood since
then in the tube. He is not having any abdominal pain, though
somewhat tender to palpation.
.
In the ED, initial vital signs were pain 0, T 97.2, HR 103, BP
99/84, RR 16 O2 sat 94%. On arrival to ED, gross hematuria noted
in suprapubic bag, some blood around suprapubic site. CT
confirmed correct placement. K+ 6.1, gave 30g Kayexalate given,
no BM as of yet but have sent a repeat K+ 5.4. Noted to have 2
pressure ulcers 1 on right buttock and 1 on coccyx. On transfer,
vitals were Temp 97.3 Pulse 96. Respiratory Rate 26. Blood
Pressure 138/107. O2 Saturation 95.
.
On the medicine floor, the patient is a rambling historian who
basuically verifies that multiple manipulations of his
suprapubic catheter were made today and that bright red blood
was produced. He reports that his appetite has been strong and
that he has been encouraged to drink more fluids recently. His
metformin dose was also increased recently.
Past Medical History:
Quadraplegia, C4/C5 work related injury ___ years ago
Constipation, chronic
h/o Heart failure, echo ___ with EF 75%, likely diastolic, not
symptomatic
COPD
DM2-diet controlled
EtOH abuse, none for ___
Cirrhosis w/occassional ascites, splenomegaly and
thrombocytopenia
Suprapubic cath-h/o MRSA uti and pseudomonas UTI
h/o SBO ___, conservatively managed per surgery
(NGT/NPO/enemas)
h/o peritonitis ___ ago s/p laparotomy/washout, complicated
extended course (liver/renal/pulm failure)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission exam
VS - Temp 97.4F, BP 102/53, HR 98, R 20, O2-sat 97% RA
GENERAL - Alert, interactive, in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - S1, S2, no murmurs auscultated
LUNGS - Clear to anterior auscultation
ABDOMEN - Distended, surguical scars, bowel sounds positive,
erythema around entrance of suprapubic catheter
EXTREMITIES - Hands contracted, feet in protective air boots
LYMPH - no LAD
NEURO - awake, alert, CNs III-XII grossly intact, incomplete
quadriplegia
Discharge exam
O: 98.1 117/60 76 18 97%ra FBS 262
GENERAL - Alert, interactive, in NAD, extremities in decorticate
position, looks chronically ill
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, no MRG
LUNGS - Clear to auscultation in A/L fields
ABDOMEN - Distended, surgical scars, bowel sounds positive,
erythema around entrance of suprapubic catheter though does not
look like cellulitis
GU: light yellow urine, clear, no blood or clots, much improved
EXTREMITIES - Hands contracted, feet in protective air boots. 1+
pulses
BACK: stage 2 and stage 4 decubitis ulcers, look clean and w/
granuloma tissue, no signs of infection
LYMPH - no LAD
NEURO - awake, alert, CNs III-XII grossly intact, incomplete
quadriplegia
Pertinent Results:
Admission labs
___ 02:25AM BLOOD WBC-8.3# RBC-4.75# Hgb-14.1 Hct-44.3#
MCV-93 MCH-29.6 MCHC-31.7 RDW-15.7* Plt Ct-83*
___ 02:25AM BLOOD Neuts-79.6* Lymphs-14.9* Monos-4.7
Eos-0.5 Baso-0.3
___ 02:25AM BLOOD ___ PTT-33.5 ___
___ 05:35PM BLOOD ESR-46*
___ 02:25AM BLOOD Glucose-457* UreaN-35* Creat-1.1 Na-125*
K-6.1* Cl-93* HCO3-21* AnGap-17
___ 10:20AM BLOOD Albumin-2.8* Calcium-8.8 Phos-4.6*#
Mg-1.9
Other important labs
___ 05:35PM BLOOD ESR-46*
___ 07:30AM BLOOD ALT-46* AST-89* AlkPhos-87 TotBili-0.4
___ 07:30AM BLOOD %HbA1c-9.8* eAG-235*
___ 08:52AM BLOOD LDLmeas-72
___ 07:30AM BLOOD TSH-3.1
___ 07:30AM BLOOD Cortsol-9.7
___ 05:35PM BLOOD CRP-18.6*
Discharge labs
___ 07:30AM BLOOD WBC-2.2* RBC-3.96* Hgb-11.7* Hct-36.7*
MCV-93 MCH-29.5 MCHC-31.8 RDW-15.2 Plt Ct-48*
___ 07:30AM BLOOD Glucose-211* UreaN-11 Creat-0.5 Na-136
K-3.9 Cl-103 HCO3-25 AnGap-12
___ 07:30AM BLOOD ALT-46* AST-89* AlkPhos-87 TotBili-0.4
___ 07:30AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.6
Studies
ECG ___: Sinus tachycardia. Intra-atrial conduction defect.
Tracing is not significantly different from previous tracing of
___.
.
Abd/pelvic CT ___: 1. Appropriately placed suprapubic
catheter.
2. Hyperdense material in the urinary bladder, likely due to
hemorrhage/blood clot. 3. Slightly prominent ureters, with
partially visualized perinephric stranding and renal pelvices
not in the field, renal US should be considered to ensure no
obstructive process to the kidneys due to the bladder clot. High
density material in the lower right ureter may also represent
clot. 4. No free air and no free fluid.
5. Large decubitus at the right buttock to the right ischium,
unchanged since ___
.
Renal U/S ___: 1. No evidence of hydronephrosis. 2. Echogenic
material consistent with hemorrhagic debris is noted again in
the bladder with Foley catheter in place.
.
CXR ___: A spiculated and cavitary nodule in the left mid
lung at the level of the third left anterior rib measuring 2.5
cm in diameter appears slightly larger than on the prior
radiograph and corresponds to a known left upper lobe lesion on
prior CT of ___. It is morphologically concerning
for a primary lung cancer and less likely an indolent
granulomatous infection. Lungs are otherwise clear, with no new
focal areas of consolidation to suggest the presence of an acute
pneumonia. Lungs are otherwise remarkable for linear scar versus
atelectasis in the mid lung regions. Sclerosis of medial left
clavicle, likely due to prior trauma, is unchanged
.
Saccral xray ___: Diffuse osteopenia with calcification of
the intervertebral discs. There are also extensive vascular
calcification evident. Syndesmophytes are noted. Extensive
degenerative changes bilaterally in the hips, more severe on the
right. The lateral image of the sacrum is somewhat suboptimal
but no convincing evidence of osteomyelitis is seen on this
projection. There is a focal area of deformity and sclerosis in
the right inferior pubic ramus, similar in appearance to the
recent CT and consistent with chronic osteomyelitis. Soft tissue
calcifications projected over the post-sacral region, unchanged
compared to CT.
Medications on Admission:
1. Phos-NaK ___ mg Powder in Packet Sig: One (1) packet
PO twice a day: mixed with 75cc water/juice.
2. baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please at 6AM.
4. baclofen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
at 6pm please.
5. diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
6. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO every other day as needed for constipation: at 1pm.
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
10. acetamenophen Sig: Five Hundred (500) mg twice a day: 9
AM, midnight.
11. acetamenophen Sig: Three Hundred ___ (325) mg
every eight (8) hours as needed for pain or fever.
12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO once a day as
needed for pain: at 6AM.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain: at bed time.
14. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime): 6pm .
16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours).
17. carbamide peroxide 6.5 % Drops Sig: Four (4) Drop Otic DAILY
(Daily): please place 4 drops per each 2x/week ___ and
___
18. guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every
6 hours) as needed for cough.
19. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO every other day:
1 pm ___.
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO every other day:
AM ___.
22. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Medications:
1. baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO Once Daily at 6
___.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
7. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO twice a
day as needed for pain.
8. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
10. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day.
11. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO every eight (8) hours.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
14. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO once a
day.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 9 days.
17. ampicillin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 9 days.
18. insulin glargine 100 unit/mL Solution Sig: ___ (25)
units Subcutaneous twice a day.
19. Humalog 100 unit/mL Solution Sig: Per sliding scale .
Subcutaneous .
20. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
- Bladder bleed secondary to mechanical trauma from indwelling
catheter manipulation
- type 2 diabetes mellitus, with associated hyperglycemia
- MRSA and VSE urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with suprapubic tube. Please assess location.
TECHNIQUE: Contiguous MDCT images of the pelvis were obtained without
intravenous or oral contrast.
COMPARISON: CT of the abdomen, pelvis from ___.
CT OF THE PELVIS:
A suprapubic catheter is seen with the balloon in the fundus of the urinary
bladder in appropriate position. The urinary bladder is filled with
hyperdense material, likely hemorrhage or other viscous material given some
air bubbles suspended within the material. The colon also shows slightly
hyperdense content probably from oral contrast administration from a previous
outside hospital CT.
There is mild perinephric stranding at both kidneys and fullness of both
ureters. There is some high density at the lower aspect of the right ureter,
possibly some blood.
There is no free air and no free fluid in the pelvis. There is no pelvic
lymphadenopathy or pelvic hernias. There are moderate atherosclerotic
calcifications of the distal aorta and iliac arteries.
There is a large decubitus at the right buttock to the right ischium,
unchanged since ___, and present for several years.
There are moderate-to-severe degenerative changes at the hip joints and the
lower lumbar spine.
IMPRESSION:
1. Appropriately placed suprapubic catheter.
2. Hyperdense material in the urinary bladder, likely due to hemorrhage/blood
clot.
3. Slightly prominent ureters, with partially visualized perinephric
stranding and renal pelvices not in the field, renal US should be considered
to ensure no obstructive process to the kidneys due to the bladder clot. High
density material in the lower right ureter may also represent clot.
4. No free air and no free fluid.
5. Large decubitus at the right buttock to the right ischium, unchanged since
___.
Radiology Report
INDICATION: Evaluation of the patient with quadriplegia with suprapubic
catheter and hematuria for hydronephrosis.
COMPARISON: CT pelvis without contrast from the same day and CTA abdomen and
pelvis from ___.
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 10.8 cm.
Bilateral kidneys are without evidence of hydronephrosis or stones. A 0.8 x
0.8 x 0.8 cm cystic structure with peripheral echogenicity possibly the wall
is noted in the mid pole of the right kidney and not particularly concerning
in appearance. Echogenic material consistent with blood is again noted in the
bladder.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Echogenic material consistent with hemorrhagic debris is noted again in
the bladder with Foley catheter in place.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: A spiculated and cavitary nodule in the left mid lung at the level
of the third left anterior rib measuring 2.5 cm in diameter appears slightly
larger than on the prior radiograph and corresponds to a known left upper lobe
lesion on prior CT of ___. It is morphologically concerning for
a primary lung cancer and less likely an indolent granulomatous infection.
Lungs are otherwise clear, with no new focal areas of consolidation to suggest
the presence of an acute pneumonia. Lungs are otherwise remarkable for linear
scar versus atelectasis in the mid lung regions. Sclerosis of medial left
clavicle, likely due to prior trauma, is unchanged.
Radiology Report
HISTORY: ___ male with quadriplegia, indwelling suprapubic catheter,
recurrent UTIs with pseudomonas and/or MRSA, stage IV decubitus ulcer.
TECHNIQUE: Five images of the lumbosacral spine.
COMPARISON: CT pelvis ___.
FINDINGS: Diffuse osteopenia with calcification of the intervertebral discs.
There are also extensive vascular calcification evident. Syndesmophytes are
noted. Extensive degenerative changes bilaterally in the hips, more severe on
the right. The lateral image of the sacrum is somewhat suboptimal but no
convincing evidence of osteomyelitis is seen on this projection. There is a
focal area of deformity and sclerosis in the right inferior pubic ramus,
similar in appearance to the recent CT and consistent with chronic
osteomyelitis. Soft tissue calcifications projected over the post-sacral
region, unchanged compared to CT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEMATURIA
Diagnosed with HEMATURIA, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA, HYPERKALEMIA, DIABETES UNCOMPL ADULT, PARAPLEGIA NOS
temperature: 97.2
heartrate: 103.0
resprate: 16.0
o2sat: 94.0
sbp: 99.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Dear Mr ___,
It was a pleasure taking care of you at ___. You were admitted
for a bladder bleed, and high blood sugars. Your bladder bleed
was fixed by Urology, and was not bleeding at time of discharge.
You may notice discolored urine for several more days. Your high
blood sugars were treated with insulin. You will require more
insulin at home.
Your high blood sugars were the result of a urinary tract
infection. For this, you will be on antibiotics for several
days.
The following changes have been made to your medications
** START insulin glargine (long acting), take 25 units and
breakfast and dinner
** START insulin humalong (short acting), take 4 times daily per
sliding scale
** START ampicillin [antibiotic]
** START doxycycline [antibiotic]
** STOP metformin |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with past medical history
significant for atrial fibrillation (on apixiban) and HTN who
presents from home after multiple falls.
Unclear history, though speaking to patient's sons, patient, and
per review of ED history, patient has had progressive cognitive
decline over past ___ months. She has been forgetful, not sure
of date, writing ___ in her checkbook. She has also been asking
questions such as how her husband died and calling her son by
incorrect name.
Additionally she has prolonged history of left podiatric issues.
She is followed by Dr. ___ in orthopedics for medial
sesamoiditis,
clawing of the left great toe, and gastroc contracture. Per
their most recent notes she has failed conservative therapy,
planned for surgery (gastroc recession, medial sesamoidectomy,
___ lengthening, and IP vs. ___ MTP fusion) ___ however
postponed as patient continued eliquis which was to be
discontinued 1 day prior to procedure.
Per son, ___ who lives with patient, she has had difficulty
walking around ___ L foot and has had multiple falls recently.
Per his report patient was bending over to put on a sock and
fell. Patient was then brought in by EMS for further evaluation.
Per son ___ (HCP) patient had also fallen earlier in the day
when getting out of car, moving between two different surfaces.
Per patient she does not recall exactly what happened but does
remember falling to the ground with headstrike, no loss of
consciousness. She did not have any chest pain, palpitations,
lightheadedness prior to fall. She complained of nausea and had
1 episode of non bloody, non bilious emesis during her ED
course.
In the ED, initial vitals were: 99.7 88 195/115 18 100% room
air.
- Labs were significant for WBC of 9.7 (86%N), H/H 12.8/37.1,
Plt 231. INR 1.2. Chemistry panel normal, with BUN/Cr ___.
Lactate 1.1. Urinalysis with few bacteria, but otherwise
unremarkable. She had a CT head and C-spine, which were negative
for acute pathology. CXR was interpreted as pneumonia, and thus
she was given ceftriaxone and azithromycin. She was given zofran
for nausea.
Past Medical History:
- Atrial fibrillation
- HTN
- Hyperlipidemia
- Osteoarthritis
- Oseoporsis
- GERD
- Asthma
- B12 Deficiency
- Lichen Sclerosis
- Insomnia
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
Vitals: 98.6 72 124/74 18 98% on 2L
General: tired appearing older caucasian woman, oriented x 2
(place, person, not date) breathing comfortably with
intermittent dry cough, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, R pupil
2mm L pupil 3mm, round, reactive to light
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI holosystolic
murmur best appreciated at LUSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, crackles,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, L foot with flexion contracture at the IP and MTP joints
of the hallux
Neuro: CNII-XII intact, ___ strength bilateral upper
extremities, 4+/5 strength bilateral lower extremities, grossly
normal sensation, gait deferred.
DISCHARGE EXAM:
Vitals: 98.2F 141/64 70 20 96%RA
GEN: Pleasant, well-appearing elderly woman in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
NECK: Supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, II/VI holosystolic murmur
LUNGS: CTAB, no wheezes, crackles, rhonchi
ABD: Soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CN II-XII intact, grossly normal sensation, gait deferred
Pertinent Results:
LABS ON ADMISSION:
___ 01:10AM BLOOD WBC-9.7 RBC-4.02* Hgb-12.8 Hct-37.1
MCV-92 MCH-31.8 MCHC-34.5 RDW-13.6 Plt ___
___ 01:10AM BLOOD Neuts-84.6* Lymphs-8.5* Monos-5.4 Eos-1.1
Baso-0.4
___ 01:10AM BLOOD ___ PTT-29.0 ___
___ 01:10AM BLOOD Glucose-123* UreaN-20 Creat-1.1 Na-138
K-3.8 Cl-101 HCO3-27 AnGap-14
___ 09:08AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.7
___ 09:08AM BLOOD VitB12-267
___ 09:08AM BLOOD TSH-0.91
___ 09:08AM BLOOD T4-5.6
___ 04:44AM BLOOD Lactate-1.1
IMAGING:
CXR ___:
Mild cardiomegaly and pulmonary edema. No focal consolidation
present
CT Head ___:
1. No evidence for acute intracranial abnormalities.
2. Fluid in the right sphenoid sinus. Please correlate
clinically whether
active inflammation may be present.
CT C Spine ___:
1. No evidence for a fracture. No subluxation.
2. Scoliosis and multilevel degenerative disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral BID
2. Ascorbic Acid ___ mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Calcium Carbonate 1250 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Ranitidine 300 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Apixaban 2.5 mg PO BID
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. Calcium Carbonate 1250 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Ranitidine 300 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Vitamin D ___ UNIT PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
10. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Fall
Vitamin B12 deficiency
Secondary:
Atrial Fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ women with fall, now vomiting, on anticoagulation,
evaluate for intracranial bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Some images were repeated due to motion artifact. Coronal and
sagittal as well as thin bone-algorithm reconstructed images were obtained.
DOSE: DLP: 1226 mGy-cm
CTDI: 110 mGy
COMPARISON: None available.
FINDINGS:
There is no evidence of acute hemorrhage, edema, or mass effect. There is
pronounced parenchymal involutional change with prominent ventricles and
sulci. Periventricular, deep, and subcortical white matter hypodensities are
nonspecific, but likely reflect sequelae of chronic small vessel ischemic
disease in a patient of this age. The basal cisterns appear patent. There is
preservation of gray-white matter differentiation.
No fracture is seen. There is mild mucosal thickening in the partially
visualized right maxillary sinus. There is mild to moderate mucosal
thickening in the ethmoid air cells and mild mucosal thickening in the
inferior left frontal sinus. There is a fluid level in the right sphenoid
sinus. Mastoid air cells and middle ear cavities are well aerated.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. Fluid in the right sphenoid sinus. Please correlate clinically whether
active inflammation may be present.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ woman status post fall, evaluate for cervical spine
fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 37 mGy
DLP: 808 mGy-cm
COMPARISON: None
FINDINGS:
The bones are diffusely demineralized. There is no acute fracture or subluxed
malalignment. There is no evidence for prevertebral soft tissue swelling.
Dextroconvex scoliosis appears centered in the upper thoracic spine. There is
multilevel disc space narrowing, endplate sclerosis with cyst formation, and
disc osteophyte complexes indenting the ventral thecal sac at multiple levels.
There is also uncovertebral and facet osteophytes at multiple levels with
extensive multilevel bilateral neural foraminal narrowing.
There is pleural/parenchymal scarring at the lung apices bilaterally, as well
as bronchiectasis on the right.
IMPRESSION:
1. No evidence for a fracture. No subluxation.
2. Scoliosis and multilevel degenerative disease.
Radiology Report
INDICATION: ___ woman with fall and altered mental status, evaluate
for acute intrathoracic process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs with direct comparison made to
study from ___.
FINDINGS:
Diffuse prominence of interstitial markings and vascular congestion noted.
Unchanged biapical pleural thickening. The right hilum is prominent. The
heart is mildly enlarged. No focal consolidation is identified. There is no
pleural effusion or pneumothorax.
IMPRESSION:
Mild cardiomegaly and pulmonary edema. No focal consolidation present.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Altered mental status
Diagnosed with ALTERED MENTAL STATUS , HYPERTENSION NOS
temperature: 99.7
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 195.0
dbp: 115.0
level of pain: 13
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You came into
the hospital because of multiple falls. We found that this was
because of your unsteady gait and your ongoing left foot
deformities. Additionally we found that your vitamin B12 level
was low and started you on daily supplementation. You were
evaluated by physical therapy who recommended acute
rehabilitation.
Please continue to take your medications as prescribed and
follow up with your primary care physician and orthopedic
surgeon.
Be well and take care.
Sincerely,
Your ___ Care Team |
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:
___: colonoscopy with biopsies
History of Present Illness:
Ms. ___ is a ___ year-old female with a history of IBS
with primary constipation on linzess with some diarrhea at
baseline who presents with one day of acute onset RLQ pain and
diarrhea. She states the pain began suddenly at midnight last
night and comes and goes. It is severe and crampy in nature; she
initially had ___ episodes of bloody diarrhea last night and
into this morning, as well as vomiting. She has had ___
additional episodes of diarrhea since this morning which have
been non-bloody in nature and is passing flatus. She currently
denies nausea, fevers, chills, or diaphoresis.
Past Medical History:
Past Medical History:
IBS-C
Parvovirus B19
Mild intermittent asthma without complication
Past Surgical History:
Wisdom teeth
Social History:
___
Family History:
Denies family history if IBD of GI malignancy. No known serious
illness
Physical Exam:
Physical exam:
VS: 99.4 62 113/65 14 100% on room air
Gen: NAD, A&Ox3, pleasant, conversant
CV: RRR
Resp: Breathing comfortably on room air
Abd: Tender to palpation in RLQ, no rebound or guarding
Ext: Warm, well-perfused
Discharge Physical Exam:
VS: 98, 102/68, 63, 18, 100 Ra
Gen: A&O x3, ambulatory, NAD
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: WWP no edema
Pertinent Results:
CAT SCAN ABDOMEN AND PELVIS WITH CONTRAST: ___
1. Findings concerning for ileocolonic intussusception. Colon
collapsed.
2. Diffuse thickening of the transverse colon worrisome for
colitis.
ABDOMINAL XRAY: ___
No radiographic evidence of intussusception.
COLONOSCOPY: ___:
Abnormal mucosa in the colon.
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
1. Cecum, biopsy:
-Focal ischemic-type colitis, see note.
2. Ascending, biopsy:
-Focal fresh hemorrhage with rare superficial surface and crypt
neutrophils and focal crypt
regenerative changes, suggestive of a mild ischemic injury, see
note.
3. Transverse, biopsy:
-Focal fresh hemorrhage with rare superficial surface
neutrophils and focal crypt regenerative
changes, suggestive of a mild ischemic injury, see note.
4. Descending, biopsy:
-Focal fresh hemorrhage with rare superficial surface and crypt
neutrophils and focal crypt
regenerative changes, suggestive of a mild ischemic injury, see
note.
5. Sigmoid, biopsy:
-Colonic mucosa within normal limits.
6. Rectum, biopsy:
-Colonic mucosa within normal limits.
Note: Differential includes vascular insult, drugs (e.g, NSAIDS)
and infection (C. difficile). Clinical
correlation is recommended.
___ 06:55AM BLOOD WBC-3.7* RBC-3.69* Hgb-11.8 Hct-36.4
MCV-99* MCH-32.0 MCHC-32.4 RDW-12.1 RDWSD-44.0 Plt ___
___ 06:25AM BLOOD WBC-5.3 RBC-3.84* Hgb-12.3 Hct-37.5
MCV-98 MCH-32.0 MCHC-32.8 RDW-12.3 RDWSD-44.4 Plt ___
___ 04:48PM BLOOD WBC-6.8 RBC-4.57 Hgb-14.5 Hct-44.0 MCV-96
MCH-31.7 MCHC-33.0 RDW-12.2 RDWSD-42.8 Plt ___
___ 06:25AM BLOOD Neuts-48.0 ___ Monos-10.0
Eos-0.9* Baso-0.6 Im ___ AbsNeut-2.55 AbsLymp-2.14
AbsMono-0.53 AbsEos-0.05 AbsBaso-0.03
___ 04:48PM BLOOD Neuts-72.9* Lymphs-18.5* Monos-7.8
Eos-0.1* Baso-0.6 Im ___ AbsNeut-4.97 AbsLymp-1.26
AbsMono-0.53 AbsEos-0.01* AbsBaso-0.04
___ 05:09PM BLOOD ___ PTT-21.2* ___
___ 06:55AM BLOOD Glucose-81 UreaN-5* Creat-0.8 Na-141
K-4.1 Cl-109* HCO3-22 AnGap-10
___ 06:25AM BLOOD Glucose-84 UreaN-16 Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-13
___ 04:48PM BLOOD Glucose-66* UreaN-18 Creat-0.8 Na-141
K-3.9 Cl-102 HCO3-23 AnGap-16
___ 04:48PM BLOOD ALT-18 AST-28 AlkPhos-54 TotBili-0.6
___ 04:48PM BLOOD Lipase-34
___ 06:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
___ 06:25AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
___ 04:48PM BLOOD Albumin-4.6
___ 06:25AM BLOOD CRP-7.0*
___ 05:03PM BLOOD Lactate-1.3
Medications on Admission:
___
Birth Control Pill (___)
Discharge Medications:
___
Birth Control Pill (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Findings concerning for ileocolonic intussusception.
Diffuse thickening of the transverse colon worrisome for
colitis.
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: +PO contrast; History: ___ with very bad RLQ crampy pain since
last night with associated vomiting and bloody diarrhea, is also very
skinny+PO contrast// Appendicitis, colitis?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 50.7 cm; CTDIvol = 5.7 mGy (Body) DLP = 290.8
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
Total DLP (Body) = 300 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. Terminal appears to be
telescoping into the cecum/proximal ascending colon. Overall, the colon is
collapsed. The transverse colon is thickened. The appendix is normal (2:50).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
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. Findings concerning for ileocolonic intussusception. Colon collapsed.
2. Diffuse thickening of the transverse colon worrisome for colitis.
Radiology Report
INDICATION: History: ___ with rlq pain and vomiting, ?intussusception- please
obtain XR at 2345// evaluate interval reduction of intussusception
TECHNIQUE: 2 supine views of the frontal abdomen
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Enteric contrast is seen throughout the colon. No evidence of intussusception
is seen. There are no abnormally dilated loops of large or small bowel. No
free intra peritoneal air within the limitations of supine only technique.
Contrast is seen within the bladder and renal collecting systems, likely due
to recent contrast enhanced study. Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence of intussusception.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: n/v/d, RLQ abdominal pain
Diagnosed with Other specified noninfective gastroenteritis and colitis, Intussusception, Right lower quadrant pain
temperature: 99.4
heartrate: 62.0
resprate: 14.0
o2sat: 100.0
sbp: 113.0
dbp: 65.0
level of pain: 2
level of acuity: 3.0 | You were admitted to ___ with abdominal pain and were found to
have findings concerning for ileocolonic intussusception as well
as diffuse thickening of the transverse colon worrisome for
colitis. You were seen by the Gastroenterologist and underwent a
colonoscopy. They did not find any intussusception. They took
biopsies. You should follow up with your GI doctor on the biopsy
results and discuss getting an MRE in the future. You are now
tolerating a regular diet and your pain has resolved.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
-Please discuss with your gastroenterologist need for follow up
CT scan in ___ months of your abdomen to evaluate for
intussusception. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Closed reduction, right ankle.
2. Application of external fixator to right ankle.
History of Present Illness:
___ male who was walking down the driveway taking out his
recycling slipped and fell. No CP, LOC, dizziness prior to
event. Initial evaluation at ___ with attempted reduction
of Right ankle reduction.
Past Medical History:
kidney disease - Cr 2.1
HTN
psoriatic arthritis (knees)
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
RLE
External fixator and ACE in place
Fires ___
SILT s/s/dp/sp/tibial distributions.
wwp distally.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ with fx, pain // eval for fx
TECHNIQUE: AP and lateral view the right tibia and fibula and AP, lateral,
and oblique views of the right ankle.
COMPARISON: None available.
FINDINGS:
Overlying splint limits evaluation for subtle fractures. There is a
extensively comminuted distal intra-articular fibula fracture with a 1.6 cm
displaced fragment posteriorly and lateral posterior displacement of the
distal fragment. There is apex anterior angulation. The tibia is anteriorly
displaced and dislocated from the talus. A medial malleolar fracture is
minimally displaced.
IMPRESSION:
1. Fracture dislocation of the right distal tibia.
2. Comminuted intra-articular right distal fibula fracture, further detailed
above.
Radiology Report
INDICATION: preop // preop Surg: ___ (right ankle fracture)
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
A 2.3 cm poorly defined opacity in the left mid lung region is concerning for
a pulmonary nodule but difficult to assess due to overlap of adjacent rib and
scapular margins. Mediastinal contours and hila are normal. Heart is normal
in size poorly defined. No pneumothorax are pleural effusion.
IMPRESSION:
1. 7 mm nodular opacity in the left mid lung is concerning for a possible
malignant pulmonary nodule. CT chest is recommended for further evaluation.
2. No pneumonia, pulmonary edema, or pleural effusion.
RECOMMENDATION(S): Non contrast CT chest
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:04 AM, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ANKLE (2 VIEWS) RIGHT
INDICATION: ___ year old man with R ankle fx // lateral and AP
TECHNIQUE: 2 lateral views of the right ankle
COMPARISON: Right ankle radiograph from ___ at 01:58
FINDINGS:
Redemonstrated is the comminuted distal fibula fracture and fracture
dislocation of the distal tibia, further detailed in report from radiographs
from 1 hour earlier.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: ANKLE (2 VIEWS) RIGHT
INDICATION: ___ year old man with R ankle fx // lateral
TECHNIQUE: Four views of the right ankle
COMPARISON: Right ankle radiographs from ___ at 02:54 and 01:58
FINDINGS:
An overlying splint limits bony detail. There is slight improvement in
displacement of the comminuted distal fibula fracture, although it remains
displaced with apex posterior angulation. The distal tibia remains anteriorly
dislocated in relation to the talar dome. On AP view, a 2.6 cm fragment
medial to the ankle suggests interval displacement of the medial malleolus
fracture.
IMPRESSION:
1. Slightly improved displacement of the comminuted right distal fibula
fracture with persistent displacement and angulation.
2. Increased displacement of the medial malleolar fracture fragment since
initial radiograph.
3. Persistent anterior dislocation of the distal tibia in relation to the
talus.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:07 AM, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: 7 intra op fluoro spot images of the right ankle
INDICATION: Right ankle fracture, fixation
TECHNIQUE: 7 intraoperative fluoro spot images of the right ankle
COMPARISON: Earlier today, ___ at 04:40
FINDINGS:
7 intraoperative images were acquired without a radiologist present.
Fluoroscopy time was 27.3 seconds.
Images show fixation of the ankle in this patient with medial malleolar
fracture and prior dislocation of the tibia in relation to the talus. Again
seen distal fibular fracture.
Please refer to the operative note for details of the procedure.
IMPRESSION:
Please refer to the operative note for details of the procedure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Ankle injury, Transfer
Diagnosed with Displaced segmental fracture of shaft of right fibula, init, Fall on same level, unspecified, initial encounter
temperature: 98.0
heartrate: 103.0
resprate: 18.0
o2sat: 98.0
sbp: 152.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NON WEIGHT BEARING RIGHT LOWER EXTREMITY IN EXTERNAL FIXATOR
- KEEP ELEVATED WITH FOOT ABOVE KNEE WHICH SHOULT BE ABOVE LEVEL
OF HEART
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take LVNX daily for 2 weeks
WOUND CARE:
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- NON WEIGHT BEARING RIGHT LOWER EXTREMITY IN EXTERNAL FIXATOR
- KEEP ELEVATED WITH FOOT ABOVE KNEE WHICH SHOULD BE ABOVE LEVEL
OF HEART
Treatment Frequency:
ACTIVITY AND WEIGHT BEARING:
- NON WEIGHT BEARING RIGHT LOWER EXTREMITY IN EXTERNAL FIXATOR
- KEEP ELEVATED WITH FOOT ABOVE KNEE WHICH SHOULD BE ABOVE LEVEL
OF HEART
Pin care per ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / ceftriaxone
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
Femoral central venous line ___
History of Present Illness:
___ nursing home resident with ___ dementia, afib on eliquis,
indwelling foley for neuropathic bladder, CKD stage 3, Crohn's,
transferred from ___ for hematuria, altered mental
status, fever, soft blood pressures c/f sepsis.
History from patient is limited due to his baseline cognitive
function. Per transfer paperwork, pt had foley catheter replaced
this AM at nursing home and was noted to have hematuria at that
time. Later this afternoon patient was incontinent of bowels and
noted to be extremely lethargic and not oriented to self or
place, which is reportedly different from his baseline. He also
may have had a syncopal episode vs worsened lethargy while on
the toilet. BPs noted to be ___. A large amount of hematuria
was noted in foley. He was then brought to ___ where
he was noted to have temp of 102.8 and rigors. Lactate >6 at
OSH. At ___ received 1g vancomycin, 1L NS. His EKG
showed "0.5-1mm STE inferiorly with Q waves, deep ST depressions
V2-V5, TWI V6, no prior for comparison". ___ interventional
cardiology was contacted, who deferred catheterization given
critical illness. Transferred here for further workup.
ED Course notable for:
Initial vitals 100.1 82 101/60 18 94% RA
Labs notable for:
WBC 6.2 -> 16.4 -> 21
H/H 10.1/31.4 -> 7.7/24.2 -> 8.8/26.8
Plts 70 -> 56 -> 64
Trop T 0.16 -> 0.31 -> 0.31
143 107 39
------------< 74
4.0 22 2.7
144 112 44
------------< 59
4.0 17 2.9
Lactate 3.4 -> 2.6 -> 3.8
UA with small leuks, mod blood, trace protein, 158 RBCs, 16
WBCs, few bacteria
Blood cultures at ___ growing GNRs in ___ bottles
- CXR: Low lung volumes with patchy bibasilar airspace
opacities, potentially atelectasis, with aspiration or infection
not excluded in the correct clinical setting.
- Consults: urology - no record of them seeing him in dash, but
CBI was initiated
Pt received
3L IVF (and an additional 1L at ___
Vancomycin (at ___
Zosyn
1000mg IV Tylenol
2g IV Magnesium
25g 50% dextrose
Pt with persistent hypotension with systolics in the ___. Pt
defervesced with 1g IV Tylenol. Given persistent elevated
lactate and hypotension pt had CVL placed and was started on
levophed just prior to transfer.
On arrival to the MICU, pt is resting comfortably. He answers
yes/no to most questions, even if not yes/no questions. Able to
say he is from ___. Denies any pain. Not on levophed on
arrival.
Past Medical History:
Unspecified dementia without behavioral disturbances
Chronic kidney disease
Vitamin D deficiency
History of stroke, unclear if residual defects
Unspecified hearing loss
Primary hypertension
Anemia
Bradycardia
Crohn's disease
Chronic atrial fibrillation
Social History:
___
Family History:
Reviewed and assessed as not relevant for current admission
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in metavision
GENERAL: resting comfortably, NAD, AAOx1, answers some but not
all questions appropriately
HEENT: Sclera anicteric, dry MM, 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, bilateral feet with significant onychomycosis, R femoral
line present
GU: foley in place draining bloody urine, blood present at
meatus
SKIN: grossly intact
NEURO: CN ___ grossly intact, MAE, follows commands
DISCHARGE PHYSICAL EXAM
Vitals:
24 HR Data (last updated ___ @ 513)
Temp: 97.5 (Tm 98.2), BP: 149/83 (145-168/68-89), HR: 63
(59-68), RR: 20 (___), O2 sat: 95% (95-97), O2 delivery: Ra
General: Comfortably lying in bed, NAD. A&Ox2.
CV: Regular rate and rhythm, normal S1, + S2
Lungs: Clear to auscultation bilaterally, no appreciable rales,
wheezes or rhonci
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: Foley in place, draining without hematuria
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. L
wrist swelling resolved.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, grossly normal movements in all four
extremities.
Pertinent Results:
LABS ON ADMISSION:
___ 07:45PM WBC-6.2 RBC-3.40* HGB-10.1* HCT-31.4* MCV-92
MCH-29.7 MCHC-32.2 RDW-14.4 RDWSD-48.6*
___ 07:45PM NEUTS-96.8* LYMPHS-2.2* MONOS-0.5* EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-6.23* AbsLymp-0.14* AbsMono-0.03*
AbsEos-0.00* AbsBaso-0.00*
___ 07:45PM ___ PTT-28.5 ___
___ 07:45PM GLUCOSE-74 UREA N-39* CREAT-2.7* SODIUM-143
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14
___ 07:45PM ALT(SGPT)-23 AST(SGOT)-77* ALK PHOS-103 TOT
BILI-1.0
___ 07:45PM LIPASE-69*
___ 07:45PM cTropnT-0.16*
___ 08:01PM LACTATE-3.4*
RELEVANT STUDIES:
3 Blood cultures, all growing enterobacter
Negative urine culture
CXR ___: Low lung volumes with patchy bibasilar airspace
opacities, potentially atelectasis, with aspiration or infection
not excluded in the correct clinical setting.
TTE ___: Mild symmetric left ventricular hypertrophy with
normal cavity size and moderate regional systolic dysfunction
c/w CAD in a PDA distribution. Mild to moderate aortic
regurgitation.Mild to moderate mitral regurgitation. Mild
tricuspid regurgitation. Mild pulmonary artery systolic
hypertension.
CXR ___: Left perihilar consolidation in the previously
collapsed left lower lobe could be a large pneumonia. Right
upper lobe is clear, lower lobe and perhaps middle lobe
substantially atelectatic. Small right pleural effusion is new.
Left pleural effusion is presumed, small or moderate in volume.
Moderate cardiomegaly has increased since ___. no
pneumothorax.
TEMPORARY TRANSAMINITIS WITH CTX:
___ 05:14AM BLOOD ALT-47* AST-54* LD(LDH)-206 AlkPhos-302*
TotBili-0.6
___ 04:47AM BLOOD ALT-67* AST-86* LD(LDH)-220 AlkPhos-348*
TotBili-0.6
___ 05:21AM BLOOD ALT-87* AST-139* AlkPhos-384* TotBili-0.5
___ 05:42AM BLOOD ALT-122* AST-223* AlkPhos-368*
TotBili-0.3
___ 05:22AM BLOOD ALT-213* AST-600* LD(___)-421*
AlkPhos-441* TotBili-0.3
___ 04:56AM BLOOD ALT-52* AST-138* AlkPhos-262* TotBili-0.3
___ 05:43AM BLOOD ALT-41* AST-102* AlkPhos-272*
___ 05:15AM BLOOD ALT-28 AST-58* AlkPhos-237* TotBili-0.8
LABS ON DISCHARGE:
___ 05:14AM BLOOD WBC-7.1 RBC-2.80* Hgb-8.0* Hct-24.9*
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.8 RDWSD-45.2 Plt ___
___ 05:14AM BLOOD Glucose-89 UreaN-35* Creat-1.7* Na-143
K-5.2 Cl-109* HCO3-23 AnGap-11
___ 05:14AM BLOOD ALT-47* AST-54* LD(LDH)-206 AlkPhos-302*
TotBili-0.6
___ 01:46AM BLOOD CK-MB-2 cTropnT-0.19*
___ 05:14AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. HydrALAZINE 10 mg PO QHS
7. HydrALAZINE 20 mg PO BID
8. Mirtazapine 15 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
6. Apixaban 2.5 mg PO BID
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
8. HydrALAZINE 10 mg PO QHS
9. HydrALAZINE 20 mg PO BID
10. Mirtazapine 15 mg PO QHS
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
===================
Gram Negative ___ Acquired Pneumonia, unspecified organism
Atrial Fibrillation with rapid ventricular rate
Hypernatremia
Acute on chronic anemia
Secondary Diagnosis:
=====================
Dementia
Neurogenic Bladder, chronic indwelling catheter
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 new R PICC// R DL Power PICC 40cm ___
___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the right atrium, approximately 4
cm beyond the cavoatrial junction. There is no pneumothorax identified.
The lung volumes are low with right greater than left basilar
atelectasis/consolidation. A small right pleural effusion is also present.
The size of the cardiac silhouette is within limits.
IMPRESSION:
The tip of a right PICC line projects over the right atrium, approximately 4
cm beyond the cavoatrial junction. No pneumothorax.
NOTIFICATION: The findings were discussed with ___, R.N. by ___
___, M.D. on the telephone on ___ at 5:03 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW STUDY
INDICATION: ___ year old man with h/o dementia, afib, chronic foley, recent dx
of PNA, GNR bacteremia. Has been hypernatremic likely ___ decreased po fluid
intake. Concerned for coughing during feeds. Evaluation for aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 04:56 min.
COMPARISON: None.
FINDINGS:
There was penetration and aspiration of thin liquids during consecutive sips
by straw and cup. There was significant delayed oral transit with pudding
consistency.
IMPRESSION:
Penetration and aspiration with thin liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with recent GNR infection, new AST/ALT
elevations// concern for dilation, new liver pathology, evaluate for contour
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: No prior imaging available for comparison at the time of
dictation.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: The gallbladder is contracted (the patient reportedly ate prior
to the exam). There is no evidence of gallstones.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
body and tail obscured by overlying bowel gas.
SPLEEN: The spleen was incompletely visualized secondary to difficulty in
patient positioning. Limited assessment is unremarkable.
KIDNEYS: The kidneys are not well evaluated.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
OTHER: There is a small right pleural effusion.
IMPRESSION:
1. Hepatic parenchyma is within normal limits. No suspicious lesions.
2. No evidence of intra or extrahepatic biliary dilatation.
3. Small right pleural effusion.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with initial concern for IV infiltration, now
with persistent left sided edema without resolution.// evaluate for evidence
of clot, fluid collection
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. A venous catheter is seen in the right subclavian
vein. The left brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation. There is extensive subcutaneous
edema in the left cephalic vein region, but no fluid collection. The left
cephalic vein is not seen.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity. Left
cephalic vein not seen with edema within this area.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dementia, hypotention, afib// For dobhoff
placement For dobhoff placement
IMPRESSION:
Comparison to ___. Low lung volumes. New retrocardiac atelectasis.
The tip of the top of catheter projects over the mouth, no feeding tube is
seen in the esophagus. No pneumothorax or other complications.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ nursing home resident with PMH dementia, afib on eliquis,
indwelling foley for neuropathic bladder, CKD stage 3, Crohn's, transferred
from ___ for hematuria, altered mental status, fever, soft blood
pressures c/f sepsis. Now with worsening sats.// evaluate for PNA, pulm edema
TECHNIQUE: Portable semi upright view of the chest
COMPARISON: Chest radiograph from ___
FINDINGS:
There is increased volume loss in the right lower lung with a moderate right
pleural effusion. Superimposed pneumonia cannot be excluded in the
appropriate clinical setting. No pneumothorax. The left lung appears grossly
clear. The cardiac silhouette is partially obscured by right lower lobe
opacities, but likely unchanged. Mild atherosclerotic calcifications are seen
in the aortic knob.
IMPRESSION:
Increased volume loss in the right lower lung with moderate right pleural
effusion. Superimposed pneumonia cannot be excluded in the appropriate
clinical setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ nursing home resident with PMH dementia, afib on eliquis,
indwelling foley for neuropathic bladder, CKD stage 3, Crohn's, transferred
from ___ for hematuria, altered mental status, fever, soft blood
pressures c/f sepsis. Now with worsening O2 sats, increased work of
breathing.// evaluate for pulmonary edema, effusion, PNA evaluate for
pulmonary edema, effusion, PNA
IMPRESSION:
Left pleural effusion is large. Left perihilar consolidation is unchanged.
Right basal consolidation is unchanged. There is interval decrease in right
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dementia CKD and afib now with sepsis,
worsening oxygen requirement with left lower lobe collapse on ultrasound
___ morning.// ?left lower lobe collapse ?left lower lobe collapse
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left perihilar consolidation in the previously collapsed left lower lobe could
be a large pneumonia. Right upper lobe is clear, lower lobe and perhaps
middle lobe substantially atelectatic. Small right pleural effusion is new.
Left pleural effusion is presumed, small or moderate in volume. Moderate
cardiomegaly has increased since ___. no pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematuria, Syncope
Diagnosed with Weakness, Syncope and collapse
temperature: 100.1
heartrate: 82.0
resprate: 18.0
o2sat: 94.0
sbp: 101.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
Why was I admitted to the hospital?
___ were admitted to the hospital because ___ were having fevers
at home and there was blood in your urine.
What was done for me while I was in the hospital?
We treated an infection in your urine and blood with IV
antibiotics. Our urology team evaluated ___ and exchanged your
foley after clearing out the clot. ___ were experiencing
breathing which was because of pneumonia which was also treated
with antibiotics. We encouraged ___ to eat and drink in order to
increase your strength.
What should I do when I leave the hospital?
Please continue taking your medications as prescribed. It is
very important that ___ drink water regularly. If ___ notice
that ___ are having fevers or feeling like ___ are having
trouble breathing, please return to the hospital.
We wish ___ the best!
Your ___ treatment team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
none [NGT placement]
History of Present Illness:
___ h/o stage IIIC, pT3 N2b Mx appendiceal cancer status
post right hemicolectomy in ___ followed by six cycles of
adjuvant FOLFOX completed on ___, complicated by port
infection s/p port removal. Patient has no evidence of disease
on
followup imaging, but did have evidence of incidental PEs,
status
post six months of anticoagulation and port removal.
He was recently admitted to the ___ surgical service on ___
for crampy abdominal pain after eating followed by nausea,
vomiting and obstipation. CT scan at the time showed a high
grade
SBO with a transition point at his prior anastomosis. An NGT was
placed and he resolved his obstruction quickly, and so was
discharged on ___. He now returns with ___ day of recurrent
symptoms, with abdominal pain similar to his prior SBO, nausea,
vomiting and bloating. He last passed flatus yesterday and had a
small bowel movement this morning, but had not had any bowel
function since the onset of his pain. KUB in the ED showed
dilated loops with air-fluid levels consistent with recurrent
SBO. An NGT was placed.
Past Medical History:
Appendiceal carcinoma
Hypertension
Osteoarthritis
Degenerative joint disease
Hyperlipidemia
Diabetes
Incidental PEs s/p 6 months of anticoagulation
Tibial fracture, chronic back/hip pain
SURGICAL HISTORY:
Hemicolectomy, multiple orthopedic procedures: R TKR, L knee
arthroscopy, B/l rotator cuff, Tibia surgery, Hand surgery,
Pelvic surgery, 3 spine surgeries
Social History:
___
Family History:
Mother: ___ at ___ yo.
Father: ___ at ___ yo.
Malignancies: 2 brothers with prostate cancer
Physical Exam:
Admit PE:
VS: 97.4 60 176/83 18 99% RA
General: alert, oriented X3; in no acute distress
HEENT: atraumatic, normocephalic, oral mucosa mildly dry
Resp: clear breath sounds bilaterally
CV: RRR, no murmurs, rubs, or gallops
Abd: soft, protuberant, non-tender
Extr: atraumatic, skin intact
Discharge PE:
VS: 98.5 126/68 67 18 97% RA
General: NAD, A&Ox3
Resp: CTAB, no W/R/C
CV: RRR, no M/R/G
Abd: soft, NT/ND, no rebound or guarding
Ext: no CCE, WWP
Pertinent Results:
___ 10:48PM BLOOD WBC-13.0*# RBC-4.73 Hgb-13.8 Hct-41.9
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.4 RDWSD-43.3 Plt ___
___ 10:15AM BLOOD WBC-7.0 RBC-4.49* Hgb-13.2* Hct-39.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.3 RDWSD-43.4 Plt ___
___ 05:59AM BLOOD WBC-4.3 RBC-3.99* Hgb-11.4* Hct-35.8*
MCV-90 MCH-28.6 MCHC-31.8* RDW-13.2 RDWSD-43.3 Plt ___
___ 10:48PM BLOOD Glucose-191* UreaN-24* Creat-1.0 Na-137
K-4.2 Cl-100 HCO3-22 AnGap-19
___ 10:15AM BLOOD Glucose-188* UreaN-22* Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-23 AnGap-16
___ 05:59AM BLOOD Glucose-133* UreaN-15 Creat-0.8 Na-137
K-3.7 Cl-103 HCO3-25 AnGap-13
ABDOMEN (SUPINE & ERECT) Study Date of ___ 11:11 ___
Multiple dilated loops of mid abdominal small bowel are noted,
along with
numerous air-fluid levels on the upright view. No free air is
seen.
Fecalized material is noted within right upper quadrant loops,
similar
compared to the prior CT. Surgical material is noted in the
right lower
quadrant. A partially cannulated left posterior acetabular
screw is noted.
Severe degenerative changes of the hips and lower lumbar spine
are present.
IMPRESSION: Findings are compatible with small-bowel
obstruction.
CHEST (PORTABLE AP) Study Date of ___ 1:04 AM
A nasogastric tube courses through the esophagus, and although
it is very
difficult to clearly visualize, it appears to terminate below
the level of the diaphragm. The distal side hole port cannot be
identified. The visualized lungs are clear. The
cardiomediastinal silhouette is stable.
IMPRESSION: NG tube courses below the level of the diaphragm,
although distal side hole port is not visualized. Advancement
of ___ centimeters would ensure appropriate positioning.
Medications on Admission:
-Lipitor 10 mg qd
-Fentanyl 50 mcg/hr TD patch q72 hrs
-Glipizide 5 mg bid
-Losartan 25 mg qd
-Metformin 1000 mg bid
-Oxycodone 10 mg q6h prn: pain
-Cyanocobalamin - dosage uncertain -
-Multivitamin - dosage uncertain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 10 mg PO QPM
3. Fentanyl Patch 50 mcg/h TD Q72H
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN hip pain
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. GlipiZIDE 5 mg PO BID
7. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with SBO, NGT // eval NGT position
TECHNIQUE: Single upright portable radiograph the chest is obtained.
COMPARISON: Chest radiographs: ___.
FINDINGS:
A nasogastric tube courses through the esophagus, and although it is very
difficult to clearly visualize, it appears to terminate below the level of the
diaphragm. The distal side hole port cannot be identified. The visualized
lungs are clear. The cardiomediastinal silhouette is stable.
IMPRESSION:
NG tube courses below the level of the diaphragm, although distal side hole
port is not visualized. Advancement of ___ centimeters would ensure
appropriate positioning.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 176.0
dbp: 83.0
level of pain: 10
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___ and
underwent management of your bowel obstruction with nasogastric
decompression and bowel rest/IV hydration. You are recovering
well and are now ready for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / aspirin
Attending: ___.
Chief Complaint:
Chest pain, hypoxia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ y/o male with PMHx HTN, ESRD on dialysis MWF, depression,
hyperlipidemia who presented to the ED from his assisted living
facility with chest pain and hypertension. Initial VS from SNF
during episode of CP were 180/90, 102, 22, 96.6dF. Given SL NTG
with minimal relief and had increasing BPs to 200/100, put on
4LNC and satting 89-91% and continued to c/o CP. He was supposed
to go to ___ where he gets the majority of his care however
the ambulance brought him to ___ instead.
He was initially started on 2LNC, but his hypoxia progressed and
he became agitated so he was given lorazepam 1mg IV and started
on CPAP. A CXR was obtained which was consistent with pulmonary
edema. Labs showed H&H of 8.8/27.5, Cr of 6.0 w/ BUN 34, trop
of 0.3 with CK of 92, MB of 3. He was given nitro SL 0.4mg and
lorazepam 2mgx1. On transfer, vitals were: 97.8 99 169/89 10
100%.
On arrival to the MICU, patient was actively undergoing dialysis
and he became increasingly agitated and removed his CPAP mask.
Currently doing well on 2LNC. Does not appear to be having chest
pain currently.
Past Medical History:
-Depression
-Hyperlipidemia
-HTN
-ESRD on dialysis MWF
-Hx stroke
-Hx GI bleed
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.2 BP: 175/102 P: 97 R: 18 O2: 98% on 2LNC
General: Nonverbal, does opens eyes to command
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
Chest: Left HD access site without erythema or induration, right
tunneled PICC site without erythema or induration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, RUE fistula with bruit
Neuro: Unable to participate with complete neuro exam due to
mental status, but moving left sided extremities equally
.
DISCHARGE PHYSICAL EXAM
VSS
General: NAD, AAOX2,known prior weakness from CVA
CV: RRR, no RMG
Lungs: CTAB, no WRR
Abdomen: NDNT, active BS X4, no HSM
.
Pertinent Results:
ADMISSION LABS
___ 10:15AM BLOOD WBC-9.4 RBC-2.74* Hgb-8.8* Hct-27.5*
MCV-100* MCH-32.2* MCHC-32.1 RDW-17.8* Plt ___
___ 10:15AM BLOOD Neuts-73.8* Lymphs-16.7* Monos-6.6
Eos-2.5 Baso-0.3
___ 10:15AM BLOOD Glucose-110* UreaN-34* Creat-6.0* Na-142
K-4.1 Cl-99 HCO3-30 AnGap-17
___ 10:00AM BLOOD cTropnT-0.30*
___ 10:15AM BLOOD CK(CPK)-92
.
___ EKG
Sinus tachycardia. Otherwise, within normal limits and no
significant change
from ___ other than increase in sinus rate.
.
___ CXR
IMPRESSION:
Improving pulmonary edema and persistent pleural effusions.
.
Time Taken Not Noted Log-In Date/Time: ___ 8:58 pm
BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
___ 4:36 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Atorvastatin 20 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Lorazepam 0.5 mg PO BID
7. Lorazepam 0.5 mg PO Q4H:PRN anxiety/combativeness
8. Nephrocaps 1 CAP PO DAILY
9. Calcium Acetate 667 mg PO TID W/MEALS
10. OxycoDONE (Immediate Release) 5 mg PO TID
11. Diltiazem 90 mg PO QID
12. Acetaminophen 650 mg PO Q4H:PRN pain, fever
13. Bisacodyl ___AILY:PRN constipation
Give if no results from MOM
14. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheeze
15. Nitroglycerin SL 0.4 mg SL PRN chest pain
Every five minutes as needed for chest pain. Up to 3 doses then
call MD
16. Docusate Sodium (Liquid) 100 mg PO DAILY
17. Nafcillin 2 g IV Q4H
stopping ___. Metoprolol Succinate XL 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Atorvastatin 20 mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Bisacodyl ___AILY:PRN constipation
Give if no results from MOM
5. Citalopram 20 mg PO DAILY
6. Diltiazem 90 mg PO QID
7. Docusate Sodium (Liquid) 100 mg PO DAILY
8. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheeze
9. Lisinopril 40 mg PO DAILY
10. Lorazepam 0.5 mg PO BID
11. Lorazepam 0.5 mg PO Q6H:PRN anxiety/combativeness
12. Nafcillin 2 g IV Q4H
stopping ___. Nephrocaps 1 CAP PO DAILY
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
Every five minutes as needed for chest pain. Up to 3 doses then
call MD
15. Omeprazole 20 mg PO DAILY
16. OxycoDONE (Immediate Release) 5 mg PO TID
17. Tiotropium Bromide 1 CAP IH DAILY
18. Labetalol 200 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: flash pulmonary edema secondary to
hypertension
End-stage renal disease
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
CHEST, TWO VIEWS: ___
HISTORY: ___ male with chest pain. End-stage renal disease on
hemodialysis.
FINDINGS: AP and lateral views of the chest. No prior. There are bilateral
parenchymal opacities identified and a small-to-moderate right pleural
effusion. Cardiac silhouette is slightly enlarged. Calcification in the
region of the right hilum could represent a calcified lymph node. Dual-lumen
central venous line is seen with tip in the right atrium. Additional
right-sided central line is seen with tip in the mid SVC. Osseous and soft
tissue structures are notable for inferior subluxation of the right humeral
head with respect to the glenoid which is incompletely characterized on this
exam.
IMPRESSION: Diffuse bilateral parenchymal opacities and right effusion.
Overall, suggestive of moderate pulmonary edema. Component of infection is
also possible and clinical correlation is suggested.
Radiology Report
PA AND LATERAL CHEST OF ___
COMPARISON: Chest radiographs of ___.
FINDINGS: Stable mild cardiomegaly and persistent pulmonary vascular
engorgement, but improvement in degree of pulmonary edema. Small bilateral
pleural effusions are unchanged.
IMPRESSION:
Improving pulmonary edema and persistent pleural effusions.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, CHEST PAIN NOS, END STAGE RENAL DISEASE
temperature: 98.2
heartrate: 96.0
resprate: 24.0
o2sat: 98.0
sbp: nan
dbp: nan
level of pain: 8
level of acuity: 2.0 | You were admitted with shortness of breath and chest pain. You
were found to have fluid in your lungs (pulmonary edema). This
improved with dialysis. This occurred because you had very high
blood pressures. We changed your medications to help better
control your blood pressure.
We reviewed your recent hospital course and noticed that you had
a blood infection that may have spread to your heart. We
discussed investigating this further but it appears that it did
not comply with your current goals of care. You will continue on
your antibiotics per your prior plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / bumetanide
Attending: ___.
Chief Complaint:
Hypotension, active bleeding
Major Surgical or Invasive Procedure:
___ Left lower extremity debridement
History of Present Illness:
___ year old female with history of PE on Coumadin, pulmonary
hypertension, and cor pulmonale who presented to another
hospital with bleeding from a leg wound, now transferred to
___ for further mgmt.
She initially presented to ___ after hitting her leg against a
dresser causing a large skin tear with profuse bleeding. Per
EMS, estimated blood loss of 2L. Upon presentation to OSH, blood
pressure was 63/38 (baseline SBP 80-90s). Labs were notable for
H/H 5.1/___.4 and INR 3.2. Foam gel was placed over the skin tear
with compression. The patient was given 2 units RBC, 2.5L IVF,
and fentanyl x 2 prior to transfer.
Upon arrival to the ED, initial vitals were: 97.2 ___ 20
97% RA. Exam was notable for 8cm skin tear to left shin with
oozing, but no evidence of arterial bleed. Pulses were intact.
Labs were notable for WBC 7.9, H/H 6.0/19.6, plt 59, INR 2.4, Na
125, HCO3 19, Cr 1.2.
On arrival to the MICU, patient was only complaining of lower
left leg pain. Denies any lightheadedness, dizziness or
headache.
Prior Pertinent History:
She has had several admissions (5 since ___ recently
with refractory peripheral edema. She has also had worsening
renal function on the most recent two admissions, with a cr up
to 2.7 which improved with dopamine.
Most recent right heart catheterization was on ___: RA 17
mmHg, PA ___ (27) mmHg, PAWP 19 mmHg, CO 5.3 L/min, CI 2.9
L/min/m2, PVR 121 dsc (1.5 ___. Aortic pressure 81/50. Mild LV
systolic dysfunction (EF 40-45% on transthoracic echocardiogram,
but given septal wall motion abnormality related to RV
pressure/volume overload, the EF is difficult to estimate), she
underwent a coronary angiogram at that time which was completely
normal. Most recent echocardiogram from ___ now reveals an
EF of ___ (on direct comparison, slightly reduced from prior
in ___, RV is severely dilated and there is severe RV
dysfunction, flattened septum throughout the cardic cycle,
severe TR and marked RA dilation.
She has had significant diuretic resistance and hyponatremia.
Prior admissions has required high doses of loop diuretics of
Lasix ___ in addition to metolazone (baseline sodium
123-125) which would worsen hyponatremia (to around 118) and she
has required tolvaptan 30mg po bid in addition (has not had any
neurologic compromise with hyponatremia). Her outpatient
diuretic regimen is torsemide 150mg po bid, spironolactone 50mg
daily, metolazone prn, and tolvaptan 30mg po bid.
Most recent admission is ___ for weight gain and increase
in lower extremity edema, poor appetite. Cr was 2.0. She
underwent ultrafiltration and was started on dopamine at 2mcg
and renal function has improved to 1.1 and she has diuresed 10 L
LOS and has had a 20 lb weight loss (171 lbs on ___ to 151
lbs on ___. Now off of dopamine as of ___ a.m.
On a prior admission with renal dysfunction (cr 2.7) and edema
we placed a PA line and attempted dobutamine which did not
increase her cardiac output, reduce filling pressures, or allow
for improvement in renal function or augmentation of diuresis.
Low dose dopamine at 2mcg had then been attempted and led to a
normalization of renal function.
Past Medical History:
- History of PE on warfarin
- RV failure, evaluated at ___ for heart-lung transplant but
deemed not eligible.
- Pulmonary hypertension, CTPH
Social History:
___
Family History:
non-contributory
Physical Exam:
***ADMISSION PHYSICAL EXAM***
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, loud S1, no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, pulsatile
liver. Port in place at left chest all.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 3+
bilateral edema to the knee.
SKIN: LLE dressing in place. DP and ___ pulses intact
bilaterally, strength intact bilaterally, sensation intact
bilaterally
Neurologic: A&Ox3
***DISCHARGE PHYSICAL EXAM***
VS: Tc 98 Tm 98.8 BP 82-101/51-60 HR 100-112 RR 16 93%/1L
I/O: ___
LOS:
from ___: +12,442 -11,730 (net +712 ml_
from ___: 3622/4550 (net out 928 ml since admission)
Dry Weight: 155-160 lbs, Current wt 162 lbs
(bed scale) 72.1 kg <-71.6 kg<-70 kg<-75.1 kg
Standing weight ___: 76.6 kg (168 lbs)->73.7 kg
Tele: HR up to 135, accelerated junctional rhythm, sinus tachy
with ___ AVB/Wenkebach
General: NAD, comfortable lying down
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: Supple, no LAD. JVP elevated >10cm, unchanged exam, with
prominent venous pulsations over neck
CV: tachycardic, irregular rhythm, normal S1+S2. ___ systolic
murmur over LUSB and apex, Palpable PMI over RLSB.
Lungs: CTAB No wheezes, rales, or rhonchi.
Abdomen: Softer abdomen, minimally tender today. +BS.
GU: Foley in place
Ext: 2+ pitting edema over bilateral legs and dorsum of feet.
Left lower calf covered with ACE bandage over post-surgical
dressing,
Skin: Hyperpigmentation and multiple bruises over all 4
extremities
Pertinent Results:
ADMISSION LABS:
___ 06:00AM BLOOD WBC-7.9 RBC-2.22* Hgb-6.0* Hct-19.6*
MCV-88 MCH-27.0 MCHC-30.6* RDW-18.4* RDWSD-59.1* Plt Ct-59*
___ 06:00AM BLOOD ___ PTT-38.0* ___
___ 06:00AM BLOOD Glucose-127* UreaN-44* Creat-1.2* Na-125*
K-3.6 Cl-90* HCO3-19* AnGap-20
___ 11:49PM BLOOD Calcium-7.9* Phos-4.8* Mg-1.7
___ 11:49PM BLOOD Hapto-85
___ 07:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
DISCHARGE LABS:
___ 04:40AM BLOOD WBC-5.9 RBC-3.15* Hgb-9.0* Hct-27.9*
MCV-89 MCH-28.6 MCHC-32.3 RDW-17.6* RDWSD-55.5* Plt Ct-72*
___ 04:40AM BLOOD Glucose-64* UreaN-31* Creat-0.9 Na-126*
K-3.8 Cl-88* HCO3-24 AnGap-18
___ 04:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1
MICRO:
- C Diff assay ___: pending
- MRSA SCREEN (Final ___: No MRSA isolated
IMAGING and OTHER STUDIES:
___ TTE: The left atrium is elongated. The right atrium is
markedly dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. LV systolic function
appears depressed (LVEF = 30%) secondary to ventricular
interaction with marked septal flattening and paradoxical septal
excursion/displacement. The right ventricular free wall is
hypertrophied. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is partial flail of a tricuspid valve leaflet.
Severe [4+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The pulmonic valve leaflets
are thickened
___ CXR: No relevant change as compared to ___, 05:31. Massive cardiomegaly. No pulmonary edema. No
larger pleural effusions. Mild atelectasis in the retrocardiac
lung regions. The central venous access line is in unchanged
position.
___ ECG: Baseline artifact makes interpretation difficult.
Possible sinus tachycardia with premature atrial contractions
versus atrial fibrillation. Right bundle-branch block.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing earlier the same day no significant change.
___ Abdominal Ultrasound: Mild splenomegaly. 1.4 splenule
incidentally noted. Trace ascites in the left upper quadrant.
___ EKG: The underlying rhythm is likely atrial fibrillation
with right bundle-branch block and moderately controlled
ventricular response. Compared to the previous tracing of
___ there is no diagnostic interim change
___ CXR: Cardiomegaly is severe, unchanged. Central venous
line tip terminates in the right atrium. Right pleural effusion
is in part loculated. Right basal opacity might represent a
combination of pleural effusion and consolidation, more
conspicuous than on the prior radiograph. There is no
pneumothorax
OLDER RECORDS for reference:
___ Right heart cath: RA 17, PA ___ (27), PAWP 19, CP 5.3
L/min, PVR 121 dxc, mild LV dysfunction (EF 40-45% on TTE)
Normal angiogram at this time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. bosentan 125 mg oral BID
2. Cetirizine 5 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Vitamin D ___ UNIT PO 1X/WEEK (TH)
6. Escitalopram Oxalate 10 mg PO DAILY
7. Ferrous Sulfate 325 mg PO TID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. melatonin 3 mg oral QHS
10. Metolazone 5 mg PO DAILY
11. mometasone 50 mcg inhalation DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Potassium Chloride 20 mEq PO BID
15. Spironolactone 25 mg PO DAILY
16. Tolvaptan 60 mg PO DAILY
17. Torsemide 200 mg PO BID
18. Warfarin 7.5 mg PO DAILY16
19. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
20. LOPERamide 2 mg PO QID:PRN diarrhea
21. Treprostinil Sodium 5120.5 nanograms/kg/minute IV DRIP
INFUSION
Discharge Medications:
1. Treprostinil Sodium 49 nanograms/kg/minute IV DRIP INFUSION
RX *treprostinil sodium [Remodulin] 1 mg/mL 49 nanograms/kg/min
Infusion continuous Disp #*30 Vial Refills:*3
2. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*3
3. Rolling Walker
Dx: Right Heart Failure ICD 10 I50.9
Px: Good
length:13 months
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
5. bosentan 125 mg oral BID
6. Cetirizine 5 mg PO DAILY
7. Digoxin 0.125 mg PO EVERY OTHER DAY
8. Ferrous Sulfate 325 mg PO TID
9. Escitalopram Oxalate 10 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Metolazone 5 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Potassium Chloride (Powder) 20 mEq PO BID
16. Spironolactone 25 mg PO DAILY
17. Tolvaptan 60 mg PO DAILY
18. Torsemide 200 mg PO BID
19. melatonin 3 mg oral QHS
20. mometasone 50 mcg inhalation DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. Warfarin 7.5 mg PO DAILY16
23. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Decompensated Right Sided Congestive Heart Failure
- Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
- Atrial Fibrillation/Second Degree AV Block with Junctional
Escape
-Left Lower extremity bleeding s/p debridement
Secondary Diagnosis:
-Thrombocytopenia of unclear etiology
-Anemia of Chronic disease
-Asthma
-Insomnia
-Chronic Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with Pulm HTN, s/p 2.5L and 1U PRBC // Eval for Pulm Edema
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
There is moderate to severe enlargement of the cardiac silhouette. There is
prominence of the interstitial markings without large effusion or confluent
consolidation. Median sternotomy wires are intact. There is a left-sided
venous catheter identified extending to the midline but the tip is not clearly
delineated. No acute osseous abnormalities.
IMPRESSION:
Moderate to severe enlargement of the cardiac silhouette, potentially due to
cardiomegaly although pericardial effusion would be possible. Vascular
congestion without evidence of overt pulmonary edema.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN PORT
INDICATION: ___ from AHJ, PMH of PE on Coumadin, Rt sided CHF with pHTN,
evaluated at BWH for heart/lung transplant with thrombocytopenia. // Please
eval spleen.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the left upper
quadrant were obtained.
COMPARISON: None.
FINDINGS:
Targeted sagittal and transverse images of the left upper quadrant were
obtained for evaluation of the spleen. The spleen appears normal in
echogenicity with no focal lesions identified. There is mild splenomegaly
measuring up to 13.0 cm. A 1.4 cm splenule is incidentally noted. Trace
ascites is identified in the left upper quadrant adjacent to the spleen.
IMPRESSION:
1. Mild splenomegaly.
2. 1.4 splenule incidentally noted.
3. Trace ascites in the left upper quadrant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, PHT presents with LLL bleed //
please assess for interval change please assess for interval change
COMPARISON: Chest radiograph ___.
IMPRESSION:
Mild to moderate pulmonary edema, more pronounced in the right lung, has
worsened slightly since ___. Severe cardiomegaly and mediastinal
venous engorgement are also slightly worse. Pleural effusion is presumed but
not substantial. There is no pneumothorax. Left jugular line ends in the
right atrium. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PHT, CHF, with bleeding // please assess
for interval change with diuresis please assess for interval change with
diuresis
IMPRESSION:
No relevant change as compared to ___, 05:31. Massive
cardiomegaly. No pulmonary edema. No larger pleural effusions. Mild
atelectasis in the retrocardiac lung regions. The central venous access line
is in unchanged position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dCHF, with new RLL crackles on exam. No
clinical signs of infection // Any acute intrapulmonary process or evidence
of increased pulmonary edema? Any acute intrapulmonary process or evidence
of increased pulmonary edema?
COMPARISON: ___
IMPRESSION:
Cardiomegaly is severe, unchanged. Central venous line tip terminates in the
right atrium. Right pleural effusion is in part loculated. Right basal
opacity might represent a combination of pleural effusion and consolidation,
more conspicuous than on the prior radiograph. There is no pneumothorax.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: L Leg pain, Hypotension
Diagnosed with Iron deficiency anemia secondary to blood loss (chronic), Long term (current) use of anticoagulants, Personal history of pulmonary embolism
temperature: 97.2
heartrate: 110.0
resprate: 20.0
o2sat: 97.0
sbp: 81.0
dbp: 43.0
level of pain: 4
level of acuity: 1.0 | Dear Ms. ___,
You were admitted to ___ on ___ after you had
significant bleeding from your left leg, and underwent
debridement on ___. You were initially monitored in the ICU
given your low blood counts. Once you were stable, you were
restarted on your heart failure medications.
Your discharge weight was 162.4 lbs which is still slightly up
from your reported dry weight of 158-160 lbs. We recommend you
weigh yourself everyday, and call Dr. ___ your weight
increases by 3 lbs. Please also call Dr. ___ for an
appointment within a week (perhaps on ___ when you see
Dr. ___.
We wish you the best
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o LFT abnormalities and ETOH abuse p/w palpitations x
2 days. 2 days PTA patient was shoveling and noticed
palpitations, shortness of breath and diaphoresis with
shoveling. Patient had mild chest pressure after going inside to
sit down. Symptoms lasted less than 5 minutes. Patient denied
arm pain/discomfort, jaw discomfort shortness of breath resolved
prior to chest symptoms. Pt. reports two episodes yesterday,
first when he went from sitting to standing and felt SOB with
heart "fluttering", which resolved with rest. Second episode
later yesterday while climbing stairs, and again resolved with
rest. Describes the episodes also having associated symptoms of
dyspnea, sweating, chest tightness (but not chest pain), and
palpitations. Denies syncope or falls. Patient had atypical
cheat pain a few years ago. He had negative stress test ___ years
ago in ___.
Pt. had labs sent several days ago for his PCP which showed
elevated triglycerides to the 1500s. This morning he went for
repeat labs and did not eat anything. He was feeling dizzy after
the labs were drawn and came to the ED because his father forced
him to in the setting of symptoms the previous 2 days. He always
gets dizzy with blood draws. He had not yet eaten or drunk
anything when the ED labs were drawn here at ___. Of note, pt.
describes drinking alcohol about 1 week ago after ___ years of
alcohol abuse.
Patient had normal Cr function 2 days ago. Denies recent NSAID
use. Has only bee using prescribed meds as listed below. Denies
urinary symptoms or decreased urine output. Denies flank pain.
Pt. presented to the ED with vitals: 98.3 86 126/80 18 100%. He
was found to have ___ with Cr 2.3 (baseline 1.0). Elevated LFTs
ALT 114, AST 122. Plt of 83. ___ troponin negative. EKG showed
NSR with PVCs. Renal ultrasound showed normal renal ultrasound
with normal renal arterial flow. Pt. was admitted for evaluation
of ___.
On floor patient's only symptom is feeling a little sweaty.
Denies shortness of breath, chest pain, fever, chills, night
sweats, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, orthopnea, PND, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Pt. had a negative stress test ___ years ago. Last HbA1C was 6.2
on ___.
ROS: per HPI. 10-point review of systems was negative.
Past Medical History:
HTN
HLD
Alcoholic steatoheaptitis
ETOH abuse
GERD
Social History:
___
Family History:
Mother: DM2, CRF on hemodialysis, HTN
Father ___, prostate cancer
Sister: PE, ___
Physical Exam:
Admission EXAM:
Vitals- 97.8 110/69 HR 97-102 18 97%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no hepatosplenomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge EXAM:
Vitals- 97.3 120/67 70 (70-102) 16 97%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no hepatosplenomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Initial Labs:
___ 12:58PM BLOOD WBC-4.2 RBC-4.10* Hgb-13.2* Hct-38.6*
MCV-94 MCH-32.2* MCHC-34.2 RDW-12.8 Plt Ct-83*
___ 12:58PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 12:58PM BLOOD Plt Smr-LOW Plt Ct-83*
___ 09:11AM BLOOD Creat-2.4*# Na-137 K-2.7* Cl-95* HCO3-21*
AnGap-24*
___ 09:11AM BLOOD Glucose-132*
___ 10:35AM BLOOD Glucose-130* UreaN-18 Creat-2.3*# Na-133
K-3.1* Cl-92* HCO3-25 AnGap-19
___ 10:35AM BLOOD ALT-114* AST-122* AlkPhos-45 TotBili-1.1
___ 09:30PM BLOOD CK(CPK)-590*
___ 09:11AM BLOOD Lipase-44
___ 10:35AM BLOOD cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:11AM BLOOD Phos-3.7 Mg-1.5* Cholest-292*
___ 10:35AM BLOOD Albumin-4.8
___ 09:11AM BLOOD Triglyc-231* HDL-78 CHOL/HD-3.7
LDLcalc-168*
___ 09:11AM BLOOD Acetone-NEG Osmolal-278
___ 10:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:42AM BLOOD Lactate-1.9
___ 01:45PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Discharge Labs:
___ 06:55AM BLOOD WBC-3.5* RBC-3.84* Hgb-12.4* Hct-37.4*
MCV-97 MCH-32.4* MCHC-33.3 RDW-12.8 Plt Ct-86*
___ 06:55AM BLOOD Plt Ct-86*
___ 06:55AM BLOOD ___ PTT-30.1 ___
___ 06:55AM BLOOD Glucose-118* UreaN-17 Creat-1.2# Na-138
K-3.3 Cl-100 HCO3-25 AnGap-16
___ 06:55AM BLOOD ALT-106* AST-110* AlkPhos-40 TotBili-0.8
___ 06:55AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.1
___ 12:49AM URINE Hours-RANDOM UreaN-168 Creat-34 Na-LESS
THAN K-4 Cl-LESS THAN
___ 09:11AM BLOOD PYRUVATE-PND
___ 09:11AM BLOOD LACTATE-PND
CXR ___:
IMPRESSION: No acute cardiopulmonary abnormality.
US Kidney ___:
Normal renal ultrasound with normal renal arterial flow.
EKG: NSR with PVCs, poor R wave progression V1-v2, T wave
inversion v4-v6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARtia XT (diltiazem HCl) 300 mg oral QAM
2. Diovan (valsartan) 240 mg oral QAM
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
4. CARtia XT (diltiazem HCl) 300 mg oral QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Palpitations/Atypical Chest pain
Acute kidney injury
Hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Palpitations.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph, two views.
FINDINGS: Heart size is normal. Cardiomediastinal silhouette and hilar
contours are unremarkable. Lungs are clear. Pleural surfaces are clear
without effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary abnormality.
Radiology Report
HISTORY: New renal failure. Evaluate for renal arterial flow or obstruction
TECHNIQUE: Grayscale and Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
The right kidney measures 10.8 cm and the left kidney measures 11 cm. There
is no hydronephrosis, stones or masses. Renal echogenicity and
corticomedullary architecture is within normal limits. The bladder is
moderately well seen and normal in appearance. There are 2 small simple cysts
on the right kidney the largest of which measures 2.1 x 2 x 2.1 cm in the
lateral aspect.
Doppler:
The resistive indices of the intrarenal arteries on the right ranges from
0.59-0.65, within the normal range. Acceleration times and peak systolic
velocities of the right main renal artery are normal. Vascularity symmetric
throughout the right kidney. The right renal vein is patent and shows normal
waveform.
The resistive indices of the intrarenal arteries on the left ranges from
0.59-0.61, within the normal range. Acceleration times and peak systolic
velocities of the main renal artery on the left are normal. Vascularity is
symmetric throughout the left kidney. The left renal vein is patent and shows
normal waveforms.
IMPRESSION:
Normal renal ultrasound with normal renal arterial flow.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: PALPITATIONS
Diagnosed with PALPITATIONS, SHORTNESS OF BREATH
temperature: 98.3
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of episodes
of chest tightness, shortness of breath, and abnormal creatinine
values. Your low creatinine (kidney inury) is likely due to
dehyration, but we are not certain exactly what caused it as you
said you drank enough water. Your creatinine value corrected by
the morning of discharge after IV fluids. It is unclear why you
had the chest tightness and shortness of breath. During the
hospital stay, some of the most serious and acute causes of
these symptoms were ruled out using EKG, cardiac telemetry, and
blood tests. Your symptoms did not recur during the hospital
stay, even after walking up several flights of stairs (which
provoked one of your initial episodes).
We recommend that you follow-up closely with your primary care
doctor in the next ___ weeks to setup a treadmill stress-test to
test for other possible causes of your symptoms.
Please do not take your Diovan (valsartan) again until you
follow up with your doctor. You blood pressure while a little
high in the hospital in the was in the 120-140s range and is
safe.
We wish you the best!
Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex / Demerol
Attending: ___
Chief Complaint:
aphasia, numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ PMH A1 pipeline embolization, stroke, CAD presents with
worsening of aphasia. She was at her baseline state of health
until with last known normal on ___ evening when she went to
sleep. She has baseline aphasia due to previous stroke. When her
daughter saw her ___ evening, around 7pm, she noted that
since the last time she had seen her ___ evening), she
didn't
seem right. She was bumping and tripping into things, couldn't
speak as well as she normally could, reported some R arm
numbness
and her leg seemed stiffer on the right. Her daughter did not
see
her on ___ at all, and is not sure how she was doing. There
was a caregiver who saw her, but she was recently hired, and is
not familiar with what she is like at baseline and otherwise.
She had last taken her ___ 1 hour prior to coming to the
hospital. There has not been any recent fevers, chills, nausea,
vomiting, diarrhea or concern for any dehydration.
She follows with Dr. ___ in stroke clinic, last saw her last
month. At the last visit, it had been recommended that she stop
___, with a plan to continue on full dose aspirin only, as
it
was thought that there was not additional benefit of using
anticoagulation over antiplatelet. After stopping ___, her
daughter notes that she had an episode of R facial droop,
headache, and tightness in the R leg several weeks ago, and
because of that daughter resumed her ___ in addition to 162
mg aspirin. She had resumed this on ___.
ROS:
unable to state
Past Medical History:
coronary artery disease status post cath
obstructive sleep apnea on CPAP
elective left pipeline embolization of Left A1 segment aneurysm
(___)
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM
===============
Vitals: T: BP: HR: RR: SaO2:
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: 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 self. Unable to state age or
year. Follows some commands correctly, has trouble with complex
commands. Mimics. Names half of items on stroke card. Appears
frustrated when attempting to name others, stating she knows
what
they are. Able to identify when given MC options. Able to read
around half of the sentences on stroke card. Repetition, omits
some words. No dysarthria. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. BTT b/l.
V: Facial sensation intact to light touch.
VII: R facial droop
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.
Unable to participate in confrontational testing.
Able to keep both arms raise dfor 10 seconds, legs for 5
seconds.
Briskly antigravity in all limbs with resistance provided in
all,
no clear asymmetry.
-Sensory: No deficits to light touch, pinprick, throughout. No
extinction to DSS
-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
==============
Vitals: ___ 0750 Temp: 98.2 PO BP: 154/78 HR: 61 RR: 20 O2
sat: 95% O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Extremities: no edema
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, hospital,
___.
Follows midline commands. Impaired repetition. No neglect.
-Cranial Nerves: PERRL and brisk. EOMI without nystagmus.
Question for VF deficit in RUQ of left eye. Facial sensation
intact to light touch bilaterally, symmetric at rest and upon
activation. Hearing intact to conversation. Palate elevates
symmetrically. Trapezii strength ___ bilaterally. Tongue
protrudes midline with good movement both left and right. Some
dysarthria.
-Motor: Normal bulk and tone throughout. Slight pronation seen
in
RUE. No adventitious movements, such as tremor or asterixis
noted. Full throughout.
-Sensory: No deficits to light touch bilaterally.
-Reflexes: Deferred.
-Coordination: Finger tap rhythmic and smooth bilaterally.
-Gait: Narrow based, walked to bathroom without assistance.
Pertinent Results:
ADMISSION LABS
==============
___ 09:45PM BLOOD WBC-6.7 RBC-4.26 Hgb-13.1 Hct-39.9 MCV-94
MCH-30.8 MCHC-32.8 RDW-12.1 RDWSD-42.3 Plt ___
___ 09:45PM BLOOD Neuts-52.3 ___ Monos-7.1 Eos-2.4
Baso-0.6 Im ___ AbsNeut-3.48 AbsLymp-2.48 AbsMono-0.47
AbsEos-0.16 AbsBaso-0.04
___ 09:45PM BLOOD ___ PTT-43.4* ___
___ 09:45PM BLOOD Plt ___
___ 09:45PM BLOOD UreaN-16
___ 09:45PM BLOOD ALT-36 AST-40 AlkPhos-108* TotBili-1.0
___ 09:45PM BLOOD Lipase-43
___ 09:45PM BLOOD Albumin-4.5
___ 09:46PM BLOOD Glucose-96 Creat-0.8 Na-142 K-3.8 Cl-103
calHCO3-29
DISCHARGE LABS
===============
___ 05:25AM BLOOD WBC-6.3 RBC-4.18 Hgb-12.9 Hct-39.6 MCV-95
MCH-30.9 MCHC-32.6 RDW-12.0 RDWSD-41.5 Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-93 UreaN-15 Creat-0.7 Na-142
K-4.2 Cl-104 HCO3-29 AnGap-9*
___ 05:25AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
IMAGING
=======
MR HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Sequela of prior infarction involving the left frontal,
parietal, and
temporal lobes with volume loss
CTA HN
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Encephalomalacia of the left frontal, left parietal, and left
temporal
lobes.
3. Postprocedural changes of pipeline stent placement of the
left A1 segment. Although In-Stent stenosis cannot be
evaluated, there is normal contrast opacification of the left A2
segment.
4. Small caliber left M1 segment with asymmetrically decreased
arborization of the left MCA branches. This could relate to
changes of chronic infarction versus blockage of blood flow by
the stent itself.
5. Unchanged 2 mm area of contrast opacification in the left A1
segment
aneurysm compatible with residual filling.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ 5 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. FLUoxetine 20 mg PO BID
5. Famotidine 20 mg PO BID
6. VitaJoy Daily D (cholecalciferol (vitamin D3)) 5000 mg oral
DAILY
7. Aspirin 162 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. ___ 5 mg PO BID
3. Aspirin 162 mg PO DAILY
4. Famotidine 20 mg PO BID
5. FLUoxetine 20 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. VitaJoy Daily D (cholecalciferol (vitamin D3)) 5000 mg oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#TIA
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 HEAD NECK.
INDICATION: ___ female with STROKE.
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
intravenous administration of 55 mL of Omnipaque 350 nonionic contrast.
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 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
702.4 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 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
4) Spiral Acquisition 4.5 s, 35.7 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,134.0 mGy-cm.
Total DLP (Head) = 4,375 mGy-cm.
COMPARISON: CT head without contrast dated ___ and ___.
CTA head with contrast dated ___.
MRI head dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
High attenuation in the region of the left A1 segment is compatible with
pipeline stent placement.
There is no evidence of acute territorial infarction or intracranial
hemorrhage. There is encephalomalacia in the left frontal, left parietal, and
left temporal lobes from prior infarction. There is ex vacuo dilatation of
the left lateral ventricle. Otherwise, the ventricles and sulci are
age-appropriate in size and configuration. No midline shift. There are
patchy areas of hypoattenuation in the periventricular and subcortical white
matter, which are nonspecific, but likely relate to chronic small vessel
ischemic changes.
There is moderate mucosal thickening of the ethmoid sinuses. The mastoid air
cells are clear. The intraorbital contents are unremarkable.
CT PERFUSION:
The CBF <30% volume is 0 mL. No evidence of core infarction.
The T-max >6.0 seconds volume is 3 mL.
Small patchy areas of increased T-max in the left parietal temporal lobes.
Findings could reflect ischemic changes, especially given the prior left MCA
distribution infarction.
CTA HEAD:
There are postprocedural changes of pipeline stent placement in the left A1
segment extending from the left paraclinoid internal carotid artery to the
junction of the left A1 and A2 segments. There is contrast opacification
distal to the pipeline stent, however, in-stent stenosis cannot be evaluated.
In comparison to prior exam dated ___, there is unchanged 2 mm area of
contrast opacification within the left A1 segment aneurysm (image 237 of
series 4) compatible with residual filling.
There is diminished contrast opacification of the left MCA branches with a
small caliber of opacification of the left M1 segment. There is asymmetric
decreased arborization of the left MCA branches.
Otherwise, the right MCA and posterior cerebral circulation demonstrate normal
contrast opacification without evidence of focal stenosis or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
Focal irregularity at the origin of the right vertebral artery may be
secondary to volume averaging and tortuosity (series 4 image 62), or component
of atherosclerosis.
There is a 2 mm curvilinear filling defect along the anterior aspect of the
left internal carotid artery. This is unchanged compared to ___, and
likely represents curvature of the vessel. Otherwise, the carotid and
vertebral arteries and their major branches appear normal with no evidence of
stenosis or occlusion. There is no evidence of internal carotid stenosis by
NASCET criteria.
OTHER:
Respiratory motion limits evaluation of the lung parenchyma. No suspicious
pulmonary nodules are evident. The thyroid is unremarkable.
There are a number of subcentimeter bilateral cervical chain lymph nodes, but
otherwise no lymphadenopathy by CT size criteria. The largest is a right
level 2A lymph node measuring 1.3 x 0.8 cm. Probable intraparotid lymph
nodes.
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Encephalomalacia of the left frontal, left parietal, and left temporal
lobes.
3. Postprocedural changes of pipeline stent placement of the left A1 segment.
Although In-Stent stenosis cannot be evaluated, there is normal contrast
opacification of the left A2 segment.
4. Small caliber left M1 segment with asymmetrically decreased arborization of
the left MCA branches. This could relate to changes of chronic infarction
versus blockage of blood flow by the stent itself.
5. Unchanged 2 mm area of contrast opacification in the left A1 segment
aneurysm compatible with residual filling.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with previous pipeline embolization presents
with worsening aphasia. 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 dated ___.
CTA head and neck with contrast dated ___.
FINDINGS:
Susceptibility artifact in the region of the left A1 segment consistent with
pipeline stent placement limits assessment.
There is no evidence of acute infarction or intracranial hemorrhage. There is
volume loss and encephalomalacia with surrounding FLAIR hyperintense signal
abnormalities involving the left frontal, left parietal, and left temporal
lobes with ex vacuo dilatation of the left lateral ventricle. The ventricles
and sulci are otherwise age-appropriate with no midline shift.
Patchy to confluent areas of T2 and FLAIR hyperintense signal abnormalities
in the periventricular and subcortical white matter are nonspecific, but
likely reflect chronic small vessel ischemic changes.
There is moderate mucosal thickening of the ethmoid sinuses. The mastoid air
cells are clear. The intraorbital contents are unremarkable.
The left MCA flow voids are diminished compared to the right.
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Sequela of prior infarction involving the left frontal, parietal, and
temporal lobes with volume loss.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with stroke, new RLE warmth and pain// r/o
thrombus
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal compressibility and color flow of the right common femoral,
femoral, and popliteal veins. Normal color flow is demonstrated in the
posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) RIGHT PORT
INDICATION: ___ year old woman with right knee pain// fx?
TECHNIQUE: Frontal and lateral portable views of the right knee were obtained
COMPARISON: None
FINDINGS:
No fracture or dislocation is seen. There is tricompartmental degenerative
change around the knee, most pronounced over the medial compartment where it
is moderate in extent as evidence by joint space loss and large osteophyte
formation. Densities within the menisci likely reflect chondrocalcinosis.
There is no knee joint effusion. There is normal osseous mineralization. No
suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
Tricompartmental degenerative change most pronounced over the medial
compartment where it is moderate in extent. Chondrocalcinosis of the menisci.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Aphasia, Numbness
Diagnosed with Cerebral infarction, unspecified
temperature: 97.5
heartrate: 59.0
resprate: 18.0
o2sat: 98.0
sbp: 172.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were hospitalized due to symptoms of weakness, difficulty
speaking resulting from a TRANSIENT ISCHEMIC ATTACK, a condition
where a blood vessel providing oxygen and nutrients to the brain
is transiently blocked. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) brain stent
2) high cholesterol
We are changing your medications as follows:
1) increasing your cholesterol lowering medication,
atorvastatin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
positive blood culture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is a ___ female who underwent URS/LL for obstructing
right sided ureteral stone ___. She was discharged following
the
procedure. One of her blood cultures taken in the ED on ___
resulted as ___ for GNR and the patient was called by the ED to
return to admission while sensitivities pended
To summarize her recent course in detail:
The patient developed severe right flank pain and nausea on a
drive up to ___ over the weekend and went to the ___ on ___ where she was found to have a UTI
(Pan-sensitive Klebsiella) and an obstructing 3mm right UVJ
stone. She was discharged home with antibiotics. She has
continued to have some right flank pain and nausea. She had a
temp of 100.3 at home this morning and elected to come to the ED
for evaluation. She presently has ___ pain after 15mg of
Toradol. She presently has no nausea. She denies hematuria,
dysuria, urgency or frequency.
on ___ in ED:
___ 8.8
Cr 1.3
UA: Notable for 7WBC, no Bacteria, blood or nitrites
Given overall clinical picture and patient's desire to have the
stone removed, we elected to take her to the OR for a right
sided
stent and ureteroscopy. The operation went well without
complication. She received perioperative Ceftriaxone. She was
discharged home following the operation.
now on her return to the ED she reports no fevers, chills,
nausea. She has some mild right flank pain from the surgery. She
does report feeling like she had a UTI with urinary frequency
and
some mild dysuria however she attributed this to the stent.
Notably, her UA in the ED was grossly positive for bacteria, WBC
and nitrites.
Past Medical History:
HSV of oral mucosa
Social History:
Occasional alcohol.
non smoker
Physical Exam:
General: A&Ox3, NAD
Cards: no respiratory distress, RRR
Abd: Soft, NT, ND, no CVA tenderness
ext: WWP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q8H
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. Oxybutynin 5 mg PO TID
4. Phenazopyridine 100 mg PO TID
5. LORazepam 0.5 mg PO Frequency is Unknown
6. ValACYclovir 500 mg PO Q24H
7. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Complete entire 11 day course of antibiotic. Do not drink
alcohol while taking antibiotics.
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*22 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO/NG BID Duration: 7 Days
Please take complete ___o not drink alcohol while
on this medication.
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
3. LORazepam 0.5 mg PO QHS:PRN anxiety
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
5. Acyclovir 500 mg PO Q24H
6. Oxybutynin 5 mg PO TID
7. Phenazopyridine 100 mg PO TID
8. Tamsulosin 0.4 mg PO QHS
9. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Bacteremia with Klebsiella
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 dyspnea// ?pneumonia ?pneumothorax
COMPARISON: Prior exam from ___
FINDINGS:
PA and lateral views of the chest provided. A pigtail catheter partially seen
projecting over the right upper abdomen likely represents a right ureteral
stent. Lungs are clear. No focal consolidation, large effusion,
pneumothorax. Cardiomediastinal silhouette is normal. Bony structures are
intact.
IMPRESSION:
No acute findings in the chest.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Calculus of kidney
temperature: 97.7
heartrate: 73.0
resprate: 20.0
o2sat: 100.0
sbp: 119.0
dbp: 74.0
level of pain: 3
level of acuity: 3.0 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent. You may aslo experience some
pain associated with spasm of your ureter.
-The kidney stone may or may not have been removed AND/or there
may be fragments/others still in the process of passing.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
AVOID lifting/pushing/pulling items heavier than 10 pounds
(or 3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may shower normally but do NOT immerse your nephrostomy
-Do not drive or drink alcohol while taking narcotics or
antibiotics and do not operate dangerous machinery
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
postpartum severe preeclampsia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ s/p SVD on ___ who presents to ___ ED as a
transfer from ___ ED with concern for post partum
pre-eclampsia given severe range blood pressures and persistent
headache. The patient had an uncomplicated vaginal
delivery on ___ with an uncomplicated post partum course. She
reports a new onset posterior headache starting three days ago.
She notes seeing intermittent black and white spots, increasing
in frequency over the last three days. Her headache became
progressively worse over the course of the last three days,
prompting her presentation to the ED. Per the transfer
documentation from ___, she was found to be hypertensive to the
200's/100's. She was given 10mg IV labetalol, started on
magnesium with a 6gm bolus -> 2gm/hr maintenance rate, 15mg IV
toradol and 4mg morphine. She underwent a non-contrast CT of her
head, which was negative for acute intracranial processes or
hemorrhage. ___ labs were all WNL. She reported mild improvement
in her headache, then was transferred to ___ for further
management.
Here, she notes evolution of her headache from the back of her
head to the front of her head, now with worsening visual
symptoms. She felt like she was just "seeing spots" before, but
now she states she is unable to see her phone to type or focus
long enough to participate in a neurological exam. She denies
chest pain or shortness of breath, denies upper abdominal pain
or new swelling of her extremities. She denies abdominal
cramping,
her lochia is minimal requiring ___ pads per day. She has been
breastfeeding. Her newborn son is doing well and is currently
being cared for by the father of the baby. She is noticeably
concerned and agitated by her current visual symptoms.
Past Medical History:
___:
- ___
-3 TAB (___) for undesired pregnancy
-NSVD x 3 ___ no hx of pre-eclampsia or HTN
disorders; most recent SVD uncomplicated at term
GynHx:
-History of +HPV ___
-Denies history of fibroids
-D&C x 2
-H/o Chlamydia ___
PMH:
- Congenital Heart Defect, repaired at birth.
- Depression (previously on Prozac and Ativan prior to
pregnancy)
PSH:
-congenital cardiac surgery (further details unknown to patient
and not available)
-D&C x 2
Physical Exam:
Physical Exam on Discharge:
VS: Afebrile, VSS
Neuro/Psych: NAD, Oriented x3, Affect Normal
Heart: RRR
Lungs: CTA b/l
Abdomen: soft, appropriately tender, fundus firm
Pelvis: minimal bleeding
Extremities: warm and well perfused, no calf tenderness, no
edema
Pertinent Results:
=======================================
Labs
=======================================
___ 06:34AM BLOOD WBC-6.6 RBC-4.19 Hgb-13.0 Hct-39.2 MCV-94
MCH-31.0 MCHC-33.2 RDW-15.1 RDWSD-52.5* Plt ___
___ 09:30AM BLOOD WBC-7.9 RBC-3.95 Hgb-12.6 Hct-37.3#
MCV-94 MCH-31.9 MCHC-33.8 RDW-15.0 RDWSD-52.3* Plt ___
___ 09:30AM BLOOD Neuts-56.5 ___ Monos-7.9 Eos-2.5
Baso-0.5 Im ___ AbsNeut-4.47 AbsLymp-2.50 AbsMono-0.63
AbsEos-0.20 AbsBaso-0.04
___ 09:30AM BLOOD ___ PTT-28.1 ___
___ 06:34AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-22 AnGap-17
___ 09:30AM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-138
K-3.4 Cl-104 HCO3-20* AnGap-17
___ 06:34AM BLOOD ALT-32 AST-21
___ 09:30AM BLOOD ALT-29 AST-21 AlkPhos-108* TotBili-0.2
___ 06:34AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.7 Cholest-209*
___ 09:35AM BLOOD %HbA1c-5.0 eAG-97
___ 06:34AM BLOOD Triglyc-221* HDL-57 CHOL/HD-3.7
LDLcalc-108
___ 09:35AM URINE Color-Straw Appear-Clear Sp ___
___ 09:35AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 09:35AM URINE RBC-2 WBC-8* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
___ 07:32PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
=======================================
Microbiology
=======================================
___ 9:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=======================================
Imaging
=======================================
MRI/MRV Head (___)
1. There are punctate periventricular and subcortical T2/FLAIR
nonenhancing
white matter hyperintensities nonspecific in a patient of this
age, however
not in a distribution typical for PRES. Differential
considerations include
sequela of chronic headache such as migraine, prior trauma,
infectious/inflammatory etiology or small vessel ischemic
disease.
2. No acute infarct or intracranial hemorrhage.
3. The dural venous sinuses are patent on MP-RAGE and MRV.
Echocardiography (___)
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Doppler parameters are
most consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. There is no
mitral valve prolapse. No mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal.
Renal artery Doppler (___)
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman postpartum day 6 with new onset hypertension,
severe persistent headache and scotomata// r/p venous sinus thrombosis or PRES
TECHNIQUE: Phase contrast MRV of the head performed. Sagittal and axial T1
weighted imaging were performed along with diffusion imaging.
After administration of 8 mL of Gadavist intravenous contrast, axial imaging
was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: Outside hospital CT head of ___.
FINDINGS:
MRI BRAIN:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The
sulci, ventricles and cisterns are within expected limits for the patient's
age. There are punctate periventricular and subcortical T2/FLAIR nonenhancing
white matter hyperintensities, nonspecific in a patient of this age, however
not in a distribution typical for PRES. Incidental note is made of a partial
empty sella. The major intracranial flow voids are preserved. The dural
venous sinuses are patent on postcontrast MP-RAGE. There is mild mucosal
thickening of the ethmoid air cells and maxillary sinuses. The orbits are
unremarkable without evidence of increased CSF space in the optic nerve sheath
complex. Trace fluid signal is noted in the left mastoid tip.
MRV brain: The internal cerebral veins, vena ___, straight sinus, torcula,
bilateral transverse and sigmoid sinuses as well as superior sagittal sinus
are unremarkable. The left transverse sinus is hypoplastic relative to the
right. The visualized internal jugular veins are patent.
IMPRESSION:
1. There are punctate periventricular and subcortical T2/FLAIR nonenhancing
white matter hyperintensities nonspecific in a patient of this age, however
not in a distribution typical for PRES. Differential considerations include
sequela of chronic headache such as migraine, prior trauma,
infectious/inflammatory etiology or small vessel ischemic disease.
2. No acute infarct or intracranial hemorrhage.
3. The dural venous sinuses are patent on MP-RAGE and MRV.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old woman with persistently elevated BP// eval for renal
artery stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: Ultrasound ___
FINDINGS:
The right kidney measures 10.9 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.59-0.61. The resistive indices on the
left range from 0.55-0.61. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 74
centimeters/second. The peak systolic velocity on the left is 114
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache, Hypertension
Diagnosed with Unspecified maternal hypertension, comp the puerperium
temperature: 97.7
heartrate: 72.0
resprate: 19.0
o2sat: 96.0
sbp: 120.0
dbp: 85.0
level of pain: 5
level of acuity: 2.0 | You are leaving against medical advice.
Check you BPs daily and do not take BP medication if you feel
dizzy of blood pressure is below 120/70.
___ will come to your house to check your blood pressure.
Follow-up in our clinic on ___ or ___ to check-in.
Cardiology will call you to make an appointment for follow-up. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male ___ speaking male with cirrhosis
(___) s/p OLT ___, ESRD on HD, and diabetes who
presents with left arm pain. Of note, he was admitted from
___ where he was found to have CONS bacteremia, which
was thought to be ___ infected ___ catheter. This was
subsequently removed. ID did not see him in house however there
were plans for him to f/u in ___ clinic as an outpatient. TTE was
completed which did not show e/o endocarditis. During this
admission, he complained of left UE pain. DVT was ruled out and
XR was negative acute process. He was ultimately discharged on
ibuprofen.
Since discharge, he continued to left shoulder and right hip
pain. He reports that the pain was so bad that he missed
dialysis yesterday. Upon further questioning, it appears that
the pain has been going on for ___ months. It started when they
began dialysis. Denies any trauma. States that is worse with
movement. Denies any swelling or redness of joint. With regards
to his right hip, it too started ___ months ago. Denies any
inciting event. On day prior to admission, patient developed a
fever to 100.3. Denied any infectious symptoms. Given his
symptoms he presented to the ED for evaluation.
In the ED, triage vitals were 97 79 130/66 99%. Labs were
notable for Cr of 15.8, Hct 28.0, and Vanc 22.4 (drawn at
dialysis). Given history of fevers, patient was then admitted to
the ET. VS prior to leaving the ED were 98 72 108/50 12 98% RA.
He was taken to dialysis prior to coming to the floor. His
fistula was accessed. He received oxycodone amd tylenol. He
received 500mg of vanco. They removed 2L over 4 hours.
Currently, he reports ___ shoulder pain.
ROS: per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- ___ cirrhosis
- Ascites
- Wilsons disease
- ESRD on HD ___,
- Metabolic syndrome, DMII
- Obesity
- Gout
- Nodular lesion in stomach (negative biopsy)
- Hemorrhoids
- Right inguinal hernia repair, cirumcision ___ OLT,
___ washout
Social History:
___
Family History:
Dad died of ___ disease.Mom with HTN, HLD, CAD
Physical Exam:
ADMISSION
VS: 98.3 109/62 83 18 100% RA
GENERAL: Well appearing in NAD. Comfortable
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with ___ excess sounds appreciated
LUNGS: CTA b/l with ___ wheezing, rales, or rhonchi.
ABDOMEN: Soft, mildly TTP in LUQ. ___ HSM or tenderness
appreciated.
BACK: ___ spinous process tenderness
EXTREMITIES: mpedema b/l. Warm and well perfused, ___ clubbing or
cyanosis. Limited ROM of right hip on active motion ___ pain,
full ROM on passive; Left shoulder joint with restricted ROM, ___
swelling or redness
NEUROLOGY: ___ asterixis
DISCHARGE
VS: 98.2 124/64 75 19 100% RA
GENERAL: Well appearing in NAD. Comfortable. Receiving dialysis.
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with ___ excess sounds appreciated
LUNGS: CTA b/l with ___ wheezing, rales, or rhonchi.
ABDOMEN: Soft, mildly TTP in LUQ. ___ HSM or tenderness
appreciated.
BACK: ___ spinous process tenderness
EXTREMITIES: ___ edema b/l. Warm and well perfused, ___ clubbing
or cyanosis. Increased ROM of right hip, full ROM on passive;
Left shoulder joint with restricted ROM improved.
NEUROLOGY: ___ asterixis
Pertinent Results:
ADMISSION
___ 09:20AM WBC-4.9 RBC-3.01* HGB-9.6* HCT-28.0* MCV-93
MCH-31.8 MCHC-34.2 RDW-13.7
___ 09:20AM NEUTS-73.3* ___ MONOS-4.7 EOS-1.5
BASOS-0.6
___ 09:20AM PLT COUNT-174
___ 09:20AM ___ PTT-35.9 ___
___ 09:20AM CALCIUM-9.0 PHOSPHATE-6.0*# MAGNESIUM-2.4
___ 09:20AM GLUCOSE-108* UREA N-69* CREAT-15.8*#
SODIUM-139 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-23*
___ 09:35AM LACTATE-1.4
___ 01:00PM VANCO-22.4*
___ 01:00PM ALT(SGPT)-9 AST(SGOT)-16 ALK PHOS-126 TOT
BILI-0.3
DISCHARGE
___ 05:45AM BLOOD WBC-3.3* RBC-2.84* Hgb-8.8* Hct-26.9*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.8 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-34.2 ___
___ 05:45AM BLOOD Glucose-86 UreaN-25* Creat-8.3*# Na-142
K-4.5 Cl-98 HCO3-33* AnGap-16
___ 05:45AM BLOOD ALT-11 AST-18 AlkPhos-98 TotBili-0.6
___ 05:45AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.0
___ 05:45AM BLOOD tacroFK-9.0
CXR ___: The heart is normal in size. The mediastinal and
hilar contours appear within normal limits. There is ___ pleural
effusion or pneumothorax. Slight residual left lower lung
opacity remains but improved since the prior examination from
___, with ___ definite new focal opacity. An
exostosis along the course of the superior right second rib
appears unchanged. IMPRESSION: Substantial improvement in left
lower lung opacity.
LEFT ARM DUPLEX ___: Normal Doppler waveform with normal
respiratory phasicity and normal compressibility of the left
internal jugular vein, subclavian vein, axillary vein, brachial
vein, as well as the left cephalic vein. Normal compressibility
of the left basilic vein, which demonstrates high velocity flow,
most likely related to patient's known created left arm
arteriovenous fistula for hemodialysis. ___ evidence of left
upper extremity deep venous
thrombosis. IMPRESSION: ___ evidence of left upper extremity DVT.
MICRO
___ CULTURE: pending
___ CULTURE: pending
___ CULTURE: pending
___ CULTURE: pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Doxercalciferol 0 UNIT PO 3X/WEEK (___)
with dialysis
4. Azathioprine 50 mg PO DAILY
5. ChlorproMAZINE 25 mg PO Q8:PRN nausea
6. Docusate Sodium 100 mg PO BID prn constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 100 mg PO DAILY
9. Tacrolimus 4 mg PO Q12H
10. traZODONE 25 mg PO HS:PRN insomnia
11. Omeprazole 40 mg PO DAILY
12. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush
13. Vancomycin 1000 mg IV HD PROTOCOL
Discharge Medications:
1. Ethyl Chloride ___ seconds SPRAY QDIALYSIS pain
RX *ethyl chloride 100 % Spray ___ seconds Prior to dialysis
Disp #*1 Each Refills:*2
2. Azathioprine 50 mg PO DAILY
RX *azathioprine 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID prn constipation
4. Tacrolimus 4 mg PO Q12H
RX *tacrolimus 1 mg 4 capsule(s) by mouth twice daily Disp #*120
Capsule Refills:*0
5. traZODONE 25 mg PO HS:PRN insomnia
6. ChlorproMAZINE 25 mg PO Q8:PRN nausea
7. Doxercalciferol 0 UNIT PO 3X/WEEK (___)
with dialysis
8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
9. Acetaminophen 500 mg PO Q6H:PRN pain
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
11. Ferrous Sulfate 325 mg PO DAILY
12. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush
13. Omeprazole 40 mg PO DAILY
14. EMLA *NF* (lidocaine-prilocaine) 2.5-2.5 % Topical before
dialysis
RX *lidocaine-prilocaine 2.5 %-2.5 % Apply small to moderate
amount before dialysis Disp #*2 Tube Refills:*1
15. Outpatient Physical Therapy
Evaluation and treatment.
ICD-9: 719.41 (Pain in joint, shoulder region)
ICD-9: 719.45 (Pain in joint, pelvic region and thigh)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Left shoulder adhesive capsulitis
- Right hip pain
Secondary
- End stage renal disease on hemodialysis
- Staph epidermidis bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Left shoulder pain and fever.
COMPARISONS: ___ and ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is no pleural effusion or pneumothorax.
Slight residual left lower lung opacity remains but improved since the prior
examination from ___, with no definite new focal opacity. An
exostosis along the course of the superior right second rib appears unchanged.
IMPRESSION: Substantial improvement in left lower lung opacity.
Radiology Report
HISTORY: ___ year old man with CoNS bacteremia, persistent left arm / shoulder
pain, ESKD on dialysis. REASON FOR THIS EXAMINATION: rule out DVT
COMPARISON: Upper extremity venous duplex Doppler ultrasound ___
FINDINGS:
Normal Doppler waveform with normal respiratory phasicity and normal
compressibility of the left internal jugular vein, subclavian vein, axillary
vein, brachial vein, as well as the left cephalic vein. Normal
compressibility of the left basilic vein, which demonstrates high velocity
flow, most likely related to patient's known created left arm arteriovenous
fistula for hemodialysis. No evidence of left upper extremity deep venous
thrombosis.
IMPRESSION:
No evidence of left upper extremity DVT.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: L ARM PAIN
Diagnosed with JOINT PAIN-SHLDER, JOINT PAIN-PELVIS
temperature: 97.0
heartrate: 79.0
resprate: nan
o2sat: 99.0
sbp: 130.0
dbp: 66.0
level of pain: 8
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking are of you in the hospital. You were
admitted for left arm / shoulder pain, and were found to have
musculoskeletal cause of your pain. We did not think your left
shoulder or right hip was infected. An ultrasound of the veins
in the left arm and shoulder did not reveal any blood clots. You
were treated with physical therapy, tylenol, and tramadol. You
also had a known bloodstream infection, for which you received
vancomycin at hemodialysis. Blood cultures drawn during this
admission did not show active infection. Please follow up in
infectious disease and orthopedics clinics for further
management. You should also get outpatient physical therapy.
You have received vancomycin at dialysis for 2 weeks, and will
stop antibiotic therapy. This was done in order to see if you
have an underlying bloodstream infection.
Please follow up with physical therapy as an outpatient. A
script has been provided for these sessions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
___: Coronary artery bypass grafting x3 with the left
internal mammary artery to left anterior descending artery,
and reverse saphenous vein graft to the posterior descending
artery and distal circumflex artery.
___ Cardiac catheterization
History of Present Illness:
___ year old female, with prior history of CVA, SVT, and ovarian
cancer, who now presented with increased substernal chest pain
with exertion. She had a nuclear stress test ___ which showed
mild reversible inferolateral defect in
the setting of considerable soft tissue attenuation. She
subsequently underwent a cardiac catheterization today and was
found to have two vessel disease (mid LAD, mid RCA) and is now
being referred to cardiac surgery for surgical
revascularization.
Denies any other associated symtoms besides exertional angina,
denies fevers, chills, SOB, nausea, vomiting, weight loss.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes Mellitus
CVA x 2 (first in ___ in BI records, another reportedly after
that) with residual intermittent L facial droop, intermittent
diplopia
Low grade Ovarian Cancer (caught incidentally during BSO)
SVT
COPD
Gastritits
ILD, pulmonary fibrosis
Past Surgical History:
Hysterectomy and BSO for fibroids
Social History:
___
Family History:
Father died of an aneurysmal bleed. Brother with strokes in
their ___.
Physical Exam:
Admit PE:
Pulse:69 Resp:16 O2 sat:97/RA
B/P Right:135/62 Left:146/79
Height:58" Weight:79.5 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [c] EOMI [c]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [c]
Heart: RRR[x] Irregular [] Murmur [] grade ______
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm[x], well-perfused[x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: P Left: P
DP Right: P Left: P
___ Right: P Left: P
Radial Right: P Left: P
Carotid Bruit Right: none Left: none
Discharge PE:
Physical Exam
Pulse: Resp: O2 sat:/RA
B/P:
Height:58" Weight: (preop 79.5 kg)
General:Obese, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [c] EOMI [c]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear with decreased bases bilaterally [x]
Heart: RRR[x] Irregular [] Murmur [] grade ______
Sternum: healing well, no erythema or drainage
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm[x], well-perfused[x]
Right Leg Incision: healing well, no erythema or drainage
Edema: 1+ BLE
Neuro: Grossly intact [x]
Pulses:
DP Right: P Left: P
___ Right: P Left: P
Radial Right: P Left: P
Discharge examination
98.8 - 98/62 - 86 - 20 - 92% RA
Alert and oriented x3 non focal generalized weakness
RRR no murmur or rub
CTA except basilar crackles left base
Abd soft nt nd
Ext warm
Prevna intact on sternal incision
Pertinent Results:
Studies:
Cardiac Catheterization: ___ ___: normal
LAD: 50% ostial and 40% mid stenosis.
LCX: 30% stenosis in proximal segment.
Ramus: small caliber branch with 40% ostial stenosis.
RCA: 40% proximal and long 80% mid stenosis.
Cardiac ___ ___
The left atrial volume index is moderately increased. Mild
symmetric left ventricular hypertrophy with normal cavity size,
and regional/global systolic function (biplane LVEF = 62 %).
There is mild (non-obstructive) focal hypertrophy of the basal
septum. Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. 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
leaflets are mildly thickened. There is no mitral valve
prolapse.
Trivial mitral regurgitation is seen. There is moderate
pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No source of cardiac embolization identified. Mild
symmetric left ventricular hypertrophy with normal left
ventricular cavity size and preserved biventricular global and
regional systolic function. Moderate tricuspid regurgitation and
moderate pulmonary artery systolic hypertension.
Chest xray ___ ___
Bibasilar atelectasis.
Stress Test ___ ___
No anginal type symptoms or significant ST segment changes.
Nuclear report sent separately.
Cardiac Perfusion ___ ___
IMPRESSION: Mild reversible inferolateral defect in the setting
of considerable soft tissue attenuation. Normal wall motion.
Normal EF.
PA/LAT CXR ___:
Lung volumes remain low. There are bilateral small pleural
effusions with
associated atelectasis. Superimposed infection cannot be
excluded. Even
allowing for the projection, the heart is enlarged. There is
prominence of pulmonary vasculature consistent with mild
pulmonary vascular congestion but no frank pulmonary edema.
Left lower lobe atelectasis. No pneumothorax seen.
IMPRESSION: Small bilateral pleural effusions are similar in
degree when compared to the prior study.
TEE, Intraoperative ___: (*PRELIMINARY*)
The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the left atrial appendage. The interatrial
septum is aneurysmal.There is a chiari network in right
atriumThere is moderate symmetric left ventricular hypertrophy.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The ascending thoracic aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. Mild (1+) mitral regurgitation is seen.
There is mild tricuspid regurgitaion.There is no pericardial
effusion.
Post bypass
Biventricular function is preserved.There are no new wall
motion abnormality. The rest of the exam is normal.the thoracic
aorta I normal.
Labs:
Admit:
___ 11:24AM BLOOD WBC-11.3* RBC-4.35 Hgb-11.9 Hct-36.9#
MCV-85 MCH-27.4 MCHC-32.2 RDW-13.3 RDWSD-40.8 Plt ___
___ 09:00PM BLOOD WBC-10.5* RBC-3.73* Hgb-10.3* Hct-31.6*
MCV-85 MCH-27.6 MCHC-32.6 RDW-13.4 RDWSD-41.4 Plt ___
___ 11:24AM BLOOD ___ PTT-31.6 ___
___ 08:50AM BLOOD Ret Aut-2.9* Abs Ret-0.11*
___ 12:53PM BLOOD ___ 11:24AM BLOOD Glucose-130* UreaN-19 Creat-0.7 Na-142
K-4.0 Cl-105 HCO3-22 AnGap-19
___ 11:24AM BLOOD cTropnT-<0.01
___ 05:13PM BLOOD cTropnT-<0.01
___ 11:24AM BLOOD proBNP-226
___ 08:50AM BLOOD calTIBC-312 Ferritn-84 TRF-240
___ 11:24AM BLOOD D-Dimer-415
___ 04:30AM BLOOD %HbA1c-7.0* eAG-154*
Discharge:
___ 06:24AM BLOOD WBC-10.9* RBC-3.60* Hgb-10.2* Hct-31.5*
MCV-88 MCH-28.3 MCHC-32.4 RDW-13.3 RDWSD-42.4 Plt ___
___ 06:24AM BLOOD ___
___ 06:24AM BLOOD Glucose-136* UreaN-20 Creat-0.8 Na-138
K-4.6 Cl-102 HCO3-25 AnGap-16
___ 04:30AM BLOOD ALT-28 AST-34 LD(LDH)-179 AlkPhos-77
TotBili-0.3
___ 06:24AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Dipyridamole-Aspirin 1 CAP PO BID
4. Omeprazole 20 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Meclizine 25 mg PO Q8H:PRN vertigo
9. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. medication
Aggrenox stopped as started on Coumadin for atrial fibrillation
- discussed with neurology
If ever comes off Coumadin will need to consider restarting
Aggrenox would recommend discussing with neurology before any
further changes
2. Furosemide 40 mg PO DAILY Duration: 7 Days
3. Heparin 5000 UNIT SC BID
4. Tiotropium Bromide 1 CAP IH DAILY
___ MD to order daily dose PO DAILY16
goal INR ___ dose to be decided by rehab provider next INR draw
___. Pravastatin 40 mg PO QPM
7. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*10 Capsule Refills:*0
9. Docusate Sodium 100 mg PO BID
10. Aspirin EC 81 mg PO DAILY
11. Amiodarone 400 mg PO BID
___ mg twice a day four days then decrease to 400 mg daily for 1
week then decrease to 200 mg daily
12. Omeprazole 20 mg PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
14. Acetaminophen 325-650 mg PO Q4H:PRN pain or fever
15. Metoprolol Tartrate 50 mg PO Q8H
16. Meclizine 25 mg PO Q8H:PRN vertigo
17. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Coronary artery disease s/p revascularization
Postoperative atrial fibrillation
Secondary:
Hypertension
Hyperlipidemia
Diabetes Mellitus
CVA x 2 (first in ___ in BI records, another reportedly after
that) with residual intermittent L facial droop, intermittent
diplopia
Low grade Ovarian Cancer (caught incidentally during BSO)
SVT
Chronic obstructive pulmonary disease
Gastritits
ILD, pulmonary fibrosis
Hysterectomy and BSO for fibroids
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with acetaminophen and oxycodone
Sternal Incision - Prevna dressing intact please remove ___ pm
then wound can be open to air any questions please contact
cardiac surgery
Right Leg Incision - healing well, no erythema or drainage
Edema - 1+ BLE
Stage 2 on buttock covered with mepilex
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph
FINDINGS:
Cardiac silhouette size is borderline enlarged. The aorta is tortuous.
Mediastinal and hilar contours are otherwise unchanged. Pulmonary vasculature
is within normal limits. Linear and streaky bibasilar airspace opacities are
compatible regions of atelectasis. No focal consolidation, pleural effusion
or pneumothorax is identified. There are no acute osseous abnormalities.
IMPRESSION:
Bibasilar atelectasis.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with 3 vessel disease being evaluated for CABG
// eval for stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: CTA head and neck of ___.
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque in
the carotid bulb and ICA.
The peak systolic velocity in the right common carotid artery is 55 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 37, 42, and 54 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 20 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 237 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild heterogeneous atherosclerotic plaque in
the carotid bulb and ICA.
The peak systolic velocity in the left common carotid artery is 60 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 61, 54, and 56 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 28 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 55 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
1. <40% stenosis in the right and left internal carotid arteries.
2. Increased velocities in the right external carotid artery are suggestive
of stenosis.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman s/p CABG // FAST TRACK EARLY EXTUBATION
CARDIAC SURGERY Contact name: ___: ___ FAST TRACK
EARLY EXTUBATION CARDIAC SURGERY
IMPRESSION:
In comparison with the preoperative study of ___, there has been a CABG
procedure performed with intact midline sternal wires. Endotracheal tube tip
lies approximately 3 cm above the carina. Right IJ catheter extends to the
right atrium. Nasogastric tube extends well into the distal stomach. Left
chest tube is in place and there is no pneumothorax.
There are very low lung volumes which accentuate the transverse diameter of
the heart and pulmonary vascular congestion. Bibasilar atelectatic changes
are seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p CABG // Eval for effusions Eval for
effusions
COMPARISON: Prior chest radiographs ___ in ___.
IMPRESSION:
Since ___, ET tube has been removed. Small lung volumes have improved
and previous mild pulmonary edema has resolved. Moderate enlargement of the
cardiac silhouette has increased slightly but there is no mediastinal widening
to suggest bleeding.
Left pneumothorax is minimal, along the left lower lateral costal pleural
surface. Midline and left pleural drains still in place. No appreciable
pleural effusion.
Right jugular line ends low in the right atrium, as before.
Radiology Report
INDICATION: ___ year old woman s/p CABG // eval for pneumo
COMPARISON: ___
FINDINGS:
As compared to chest radiograph ___ can, pleural drain and mediastinal
drains have been removed. Possible instead left apical pneumothorax. The lung
volumes have decreased with moderate cardiomegaly. Trace bilateral pleural
effusions and higher it content a as not changed.
IMPRESSION:
Possible left tiny apical pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with s/p CABG // f/u effusions, atx
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: Chest radiographs ___
FINDINGS:
Lung volumes remain low. There are bilateral small pleural effusions with
associated atelectasis. Superimposed infection cannot be excluded. Even
allowing for the projection, the heart is enlarged. There is prominence of
pulmonary vasculature consistent with mild pulmonary vascular congestion but
no frank pulmonary edema. Left lower lobe atelectasis. No pneumothorax seen.
IMPRESSION:
Small bilateral pleural effusions are similar in degree when compared to the
prior study.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion, Chest pain
Diagnosed with Chest pain, unspecified, Dyspnea, unspecified
temperature: 97.8
heartrate: 110.0
resprate: 28.0
o2sat: 99.0
sbp: 190.0
dbp: 109.0
level of pain: 0
level of acuity: 2.0 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Prevna dressing to sternal wound please remove ___ pm and
leave wound open to air. Any questions or concerns please
contact cardiac surgery office |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Morphine Sulfate / Sulfa (Sulfonamide Antibiotics) /
Reglan / Codeine / Aspirin / Flagyl / Albuterol / Lidocaine /
Azathioprine / Iodine / Enbrel / Zithromax / Depo-Medrol /
Polocaine / Plavix / Shellfish / Peanuts
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of HFpEF, DM2,
PE/DVT, AF and seronegative arthropathy who presents for chest
pain, dizziness. Reports chest pain for 3 days. Trigger for O2
sat 87% in triage. Patient reports she has been having chest
pain
on the left side. Reports it feels like a pressure. Reports she
also feels very lightheaded. Reports she feels very short of
breath. She is hard to tell if the shortness of breath of the
chest pain are worse. Reports has been going on for the last 3
days. Reports she also is having some issues with her vertigo
although not as bad as the chest pain or shortness of breath.
Denies fever, chills.
No diaphoresis. No fevers chills or hemoptysis. Some acute on
chronic wheezing. No abdominal pain. Chronic leg swelling with
no
acute changes. No pleuritic pain.
In the ED:
Initial vital signs were notable for:
96.8 |64 |121/67| 87% RA
Labs were notable for:
14.7>- 10.3/35.1-< 568
N:86.9 L:7.4 M:4.2 E:0.5 Bas:0.3 ___: 0.7 Absneut: 12.78
Abslymp: 1.09 Absmono: 0.62 Abseos: 0.08 Absbaso: 0.05
ALT: 35 AP: 105 Tbili: 0.5 Alb: 3.4
AST: 109
133 | 92 | 20
-------------<265 AGap=15
6.6 | 26 | 1.1
Ca: 9.4 Mg: 2.2 P: 3.4
Lactate:3.5
pH 7.47
pCO2 41
pO2 84
HCO3 31
proBNP: 186
Trop-T: <0.01
Studies performed include:
CXR:
IMPRESSION:
Mild to moderate pulmonary vascular congestion. No definite
focal consolidation.
Patient was given:
___ 13:58 IH Ipratropium Bromide Neb 1 NEB
___ 14:55 PO PredniSONE 60 mg
___ 14:55 PO Acetaminophen 1000 mg
Consults:
Vitals on transfer:
98.7 |100 |126/81 | 18 |97% RA
Upon arrival to the floor, patient reports that she has had
worsened shortness of breath over the past three days. She has
had associated pleuritic chest pain. She has had bilateral lower
extremity pain which has increased over the past two days with
increased warmth of lower extremities. She has had cough that
had
not been productive. She has had no fevers. She has been
experiencing for days of diarrhea which improved today. She has
intermittent epigastric abdominal pain. She has had no nausea or
vomiting. She has been having burning with urination. No
increased frequency or hesitancy.
Past Medical History:
DM2
HTN
HLD
Seronegative nonerosive inflammatory arthropathy, on
steroids for more than ___ years.
Pulmonary embolism and DVT (___) on lifelong warfarin.
Peripheral neuropathy/carpal tunnel syndrome
Left rotator tendinopathy
Fibromyalgia
Raynaud's
Obstructive sleep apnea on CPAP
Liver steatosis
Gout
Osteoporosis.
Costochondritis
GERD.
Irritable bowel syndrome
vertigo
Morbid obesity
History of spinal stenosis
Sciatica
Thyroid Nodules
Social History:
___
Family History:
Mother - cellulitis, CHF, DVT
Father - DVT, CHF, DM
Physical Exam:
Admission:
========================
VITALS: 24 HR Data (last updated ___ @ 2118)
Temp: 99.4 (Tm 99.4), BP: 133/82, HR: 109, RR: 18, O2 sat:
94%, O2 delivery: RA, Wt: 308.2 lb/139.8 kg
General: Obese, alert and cooperative, and appears to be in no
acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation. EOMI. Vision is grossly
intact, hearing grossly intact. Nares patent with no nasal
discharge. Oral cavity and pharynx are without inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is
irregular.
Pulmonary: Referred upper airway sounds. Diffuse end expiratory
wheezes. No increased work of breathing.
Abdomen: Normoactive bowel sounds. Obese. Soft, nondistended.
Mildly tender to palpation in epigastrium. No guarding or
rebound. No masses.
Musculoskeletal: ROM intact in spine and extremities. No joint
erythema or tenderness.
Extremities: 1+ edema to knees bilaterally. Bilaterally lower
extremities with tenderness to palpation in anterior shin and
along calf musculature.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type III. Lower extremities with chronic stasis
change. RUE with red to violaceous purpuric lesion.
Discharge:
General: Pleasant, markedly obese, no distress.
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Resp: Limited air movement. Prominent upper airway / vocal
wheezes on expiration. No crackles appreciated. Breathing
comfortably.
CV: RRR, no rubs, murmurs, gallops.
GI: Protuberant and obese. Soft, non-tender, non-distended,
bowel
sounds present.
Extremities: warm, well perfused, 2+ pulses. Very swollen lower
extremities, R > L. Redness and warm on calves, more prominent
on
R lower ext. No palpable cords. Exquisite tenderness to light
touch, bilaterally. Unchanged from yesterday
Neuro: alert and oriented x 3. Moving 4 extremities with
purpose.
Pertinent Results:
Admission:
___ 02:21PM ___ PO2-84* PCO2-41 PH-7.47* TOTAL
CO2-31* BASE XS-5 COMMENTS-GREEN TOP
___ 02:21PM LACTATE-3.5* K+-3.9
___ 01:58PM GLUCOSE-265* UREA N-20 CREAT-1.1 SODIUM-133*
POTASSIUM-6.6* CHLORIDE-92* TOTAL CO2-26 ANION GAP-15
___ 01:58PM estGFR-Using this
___ 01:58PM ALT(SGPT)-35 AST(SGOT)-109* ALK PHOS-105 TOT
BILI-0.5
___ 01:58PM cTropnT-<0.01
___ 01:58PM proBNP-186
___ 01:58PM ALBUMIN-3.4* CALCIUM-9.4 PHOSPHATE-3.4
MAGNESIUM-2.2
___ 01:58PM WBC-14.7* RBC-5.16 HGB-10.3* HCT-35.1 MCV-68*
MCH-20.0* MCHC-29.3* RDW-19.1* RDWSD-45.3
___ 01:58PM NEUTS-86.9* LYMPHS-7.4* MONOS-4.2* EOS-0.5*
BASOS-0.3 IM ___ AbsNeut-12.78* AbsLymp-1.09* AbsMono-0.62
AbsEos-0.08 AbsBaso-0.05
___ 01:58PM PLT COUNT-568*
___ 01:58PM ___ PTT-25.9 ___
Discharge:
___ 06:27AM BLOOD WBC-14.8* RBC-4.73 Hgb-9.5* Hct-33.2*
MCV-70* MCH-20.1* MCHC-28.6* RDW-19.6* RDWSD-47.5* Plt ___
___ 06:50AM BLOOD Neuts-78.0* Lymphs-14.9* Monos-6.2
Eos-0.2* Baso-0.1 Im ___ AbsNeut-11.23* AbsLymp-2.15
AbsMono-0.90* AbsEos-0.03* AbsBaso-0.02
___ 06:27AM BLOOD Plt ___
___ 06:27AM BLOOD ___
___ 06:27AM BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-95* HCO3-32 AnGap-12
___ 06:50AM BLOOD ALT-21 AST-17 LD(LDH)-204 AlkPhos-84
TotBili-0.4
___ 06:27AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
___ 02:21PM BLOOD ___ pO2-84* pCO2-41 pH-7.47*
calTCO2-31* Base XS-5 Comment-GREEN TOP
Imaging:
IMAGING: Reviewed in OMR
- CXR ___:
Mild to moderate pulmonary vascular congestion. No definite
focal consolidation.
- ___ ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Micro:
- Urine culture pending
- Blood culture negative
- C. diff negative.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Famotidine 20 mg PO BID
3. Gabapentin 600 mg PO DAILY
4. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing
5. mometasone 200 mcg/actuation inhalation BID
6. Montelukast 10 mg PO DAILY
7. Nortriptyline 20 mg PO QHS
8. Omeprazole 40 mg PO DAILY
9. PredniSONE 10 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. TraMADol 50 mg PO QID
12. Warfarin 5 mg PO 6X/WEEK (___)
13. Warfarin 2.5 mg PO 1X/WEEK (SA)
14. docusate sodium 50 mg/5 mL oral DAILY
15. Febuxostat 40 mg PO DAILY
16. Klor-Con 10 (potassium chloride) 60 mEq oral TID
17. Bumetanide 6 mg PO BID
18. HumuLIN R U-500 (Conc) Kwikpen (insulin regular hum U-500
conc) 500 unit/mL (3 mL) subcutaneous TID W/MEALS
19. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
Discharge Medications:
1. U-500 Conc 60 Units Breakfast
U-500 Conc 50 Units Lunch
U-500 Conc 35 Units Dinner
2. PredniSONE 40 mg PO DAILY
Take 40 mg on ___ and ___, then return to 10 mg daily on ___.
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Bumetanide 6 mg PO BID
5. docusate sodium 50 mg/5 mL oral DAILY
6. Famotidine 20 mg PO BID
7. Febuxostat 40 mg PO DAILY
8. Gabapentin 600 mg PO DAILY
9. HumuLIN R U-500 (Conc) Kwikpen (insulin regular hum U-500
conc) 500 unit/mL (3 mL) subcutaneous TID W/MEALS
10. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing
11. Klor-Con 10 (potassium chloride) 60 mEq oral TID
12. mometasone 200 mcg/actuation inhalation BID
13. Montelukast 10 mg PO DAILY
14. Nortriptyline 20 mg PO QHS
15. Omeprazole 40 mg PO DAILY
16. Spironolactone 100 mg PO DAILY
17. TraMADol 50 mg PO QID
18. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
19. Warfarin 5 mg PO 6X/WEEK (___)
20. Warfarin 2.5 mg PO 1X/WEEK (SA)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary:
Heart failure with preserved ejection fraction
Type 2 Diabetes
Adrenal Insufficiency
History of DVT and PE
Chronic venous insufficiency with stasis dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cp and sob// pna?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates in the low SVC/cavoatrial junction without
evidence of pneumothorax. Cardiac silhouette size is top-normal, likely
accentuated by AP technique. Mediastinal contours are unremarkable. There is
mild to moderate pulmonary vascular congestion. No large pleural effusion is
seen. No definite focal consolidation is seen.
IMPRESSION:
Mild to moderate pulmonary vascular congestion. No definite focal
consolidation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with history of DVT/PE presenting with
worsening ___ pain// Please evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dizziness, Dyspnea
Diagnosed with Chest pain, unspecified, Heart failure, unspecified
temperature: 96.8
heartrate: 64.0
resprate: nan
o2sat: 87.0
sbp: 121.0
dbp: 67.0
level of pain: 9
level of acuity: 1.0 | Dear,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a COPD exacerbation.
What was done for me while I was in the hospital?
- We treated your COPD exacerbation with antibiotics and
medications to help you breath.
What should I do when I leave the hospital?
-Please note any new medications in your discharge worksheet
-Your appointments are as below:
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levaquin / Bactrim / Penicillins / Tetracyclines / codeine
Attending: ___.
Chief Complaint:
help in gaining weight
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with a history of anorexia, chronic kidney disease,
presenting with electrolyte abnormalities and acute on chronic
renal failure is here for help in gaining weight.
Patient reports that she had the flu in ___ and lost ___
pounds but has been unable to regain her weight. She has been
taking in only 700 calories per day. She feels ill when eating
more than this. She denied suicidal ideation. Denies chest pain,
shortness of breath, nausea, vomiting, abdominal pain. According
to the patient she was started on oral vancomycin yesterday for
a urinary tract infection. No resp symptoms. She is here hoping
to have intravenous nutrition because she is having a hard time
gaining weight. She has had anorexia since she was ___, has been
hospitlized and been on eating d/o protocols before. Denies any
bullemia currently (has h.o bullemia in her ___ She drinks a
lot of diet sprite every day has not been eating mnuch recently
In the ED, initial vital signs were 98.1 62 132/72 20 100%. Labs
were notable for a creatinine of 2.5 (baseline 1.5), K 3.2,
bicarb 10 and WBC 15.5 (70% N, 12%Eos). Urinalysis was
concerning for infection and patient received IV ceftriaxone x
1. Patient received 1L NS and was admitted for further
management. was given 1 L NS in ER
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anorexia since age ___, used to have bullemia in her ___, used to
binge eat, has been hospitilized for anorexia
Chronic kidney disease (baseline 1.5)
Hypothyroidism
s/p CCY
Depression
Osteoporosis
Irritable bowel syndrome
h/o GI polyps
h/o nephrolithiasis
Social History:
___
Family History:
Lynch syndrome- brother died in his ___
Heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- 97.5 125/75 58 16 100%RA
Weight: 35.7kg (___), 34.6kg (___)
General: very cachectic, looks older than age
HEENT: EOMI
CV: RRR, no murmers
Lungs: clear to auscultation
Abdomen: non distended, very thin, non tender
Ext: no edema, warm ext
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T97.8 50-63 ___ 16 100RA
Weight: 38.2kg
General: very cachectic, looks older than age
HEENT: EOMI, Clear oropharynx
CV: Bradycardic, regular rhythm, no murmurs
Lungs: clear to auscultation bilaterally, no wheezes, rhonchi or
crackles
Abdomen: non distended, very thin, soft, no TTP, BS present
Ext: legs elevated with compression stockings in place without
c/c/e
Pertinent Results:
ADMISSION LABS:
==============
___ 04:30PM BLOOD WBC-15.1*# RBC-3.82* Hgb-11.2* Hct-35.2*
MCV-92 MCH-29.4 MCHC-31.9 RDW-15.7* Plt ___
___ 04:30PM BLOOD Glucose-86 UreaN-63* Creat-2.5* Na-135
K-3.2* Cl-106 HCO3-10* AnGap-22*
___ 04:30PM BLOOD ALT-22 AST-27 AlkPhos-124* TotBili-0.1
___ 04:30PM BLOOD Albumin-3.9
___ 05:55AM BLOOD Calcium-8.2* Phos-5.9* Mg-1.9
___ 06:05AM BLOOD Calcium-7.0* Phos-3.9# Mg-1.8 Iron-30
___ 01:38PM BLOOD Calcium-7.0* Phos-3.0 Mg-1.7
___ 06:05AM BLOOD calTIBC-226* VitB12-834 Folate-14.9
Ferritn-36 TRF-174*
___ 02:24PM BLOOD Type-ART pO2-180* pCO2-16* pH-7.18*
calTCO2-6* Base XS--20
DISCHARGE LABS:
==============
___ 06:15AM BLOOD WBC-5.5 RBC-2.71* Hgb-8.1* Hct-25.2*
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.0 Plt ___
___ 06:15AM BLOOD Glucose-82 UreaN-64* Creat-1.2* Na-141
K-4.0 Cl-109* HCO3-22 AnGap-14
___ 06:15AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.6
___ 07:18AM BLOOD ___ pO2-159* pCO2-40 pH-7.29*
calTCO2-20* Base XS--6 Comment-GREEN TOP
URINE:
======
___ 06:35PM URINE Color-Straw Appear-Clear Sp ___
___ 06:35PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 06:35PM URINE RBC-2 WBC-49* Bacteri-FEW Yeast-NONE
Epi-0
___ 06:35PM URINE Eos-NEGATIVE
___ 08:29PM URINE Eos-NEGATIVE
___ 08:29PM URINE CastHy-1*
___ 09:37PM URINE 24Creat-304
MICROBIOLOGY:
=============
URINE CULTURE ___ (Final ___: <10,000 organisms/ml.
ECG:
====
___
Sinus bradycardia. QS deflections in leads VI-V3 consistent with
prior
anteroseptal myocardial infarction. Right axis deviation. No
previous tracing available for comparison. Clinical correlation
is suggested.
IMAGING:
========
___ Renal US: Findings compatible with medullary
nephrocalcinosis, for which the differential diagnosis includes
entities such as medullary sponge kidney, type 1 renal tubular
acidosis, and hyperparathyroidism. Scattered nonobstructing
renal calculi are seen bilaterally, measuring up to 7 mm in the
right interpolar region, not significantly changed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO ___
2. Dexilant *NF* (dexlansoprazole) 60 mg Oral BID
3. Potassium Chloride 40 mEq PO BID
Hold for K >
4. Sertraline 50 mg PO DAILY
5. Sodium Bicarbonate 650 mg PO TID
6. Vancomycin Oral Liquid ___ mg PO BID
7. Pravastatin 20 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO TUES, THURS, SAT, SUN
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO ___
2. Levothyroxine Sodium 75 mcg PO TUES, THURS, SAT, SUN
3. Pravastatin 20 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Sodium Bicarbonate 650 mg PO TID
6. Multivitamins 1 TAB PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
take daily for constipation.
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Primary Diagnoses:
1. Acute on chronic kidney disease
2. Anorexia nervosa
3. Metabolic acidosis
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: History of severe anorexia and nephrolithiasis with acute on chronic
renal disease and severe acidemia. Assess for nephrolithiasis.
COMPARISON: Complete GU ultrasound from ___. Renal ultrasound
from ___.
FINDINGS:
The right kidney measures 9.1 cm and the left kidney measures 7.7 cm. There
is redemonstration of echogenic renal pyramids bilaterally, suggestive of
medullary nephrocalcinosis. There are several nonobstructing calculi in both
kidneys. The largest stone on the right is in the interpolar region and
measures 7 mm, not significantly changed. Scattered nonobstructing stones on
the left are punctate in size, similar to prior. There is no hydronephrosis
or suspicious focal renal mass. A 5 x 8 x 8 mm right upper pole cyst is not
significantly changed in size compared to the prior ultrasound from ___. The bladder is unremarkable.
IMPRESSION:
Findings compatible with medullary nephrocalcinosis, for which the
differential diagnosis includes entities such as medullary sponge kidney, type
1 renal tubular acidosis, and hyperparathyroidism. Scattered nonobstructing
renal calculi are seen bilaterally, measuring up to 7 mm in the right
interpolar region, not significantly changed.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: anorexia/renal failure
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOKALEMIA, URIN TRACT INFECTION NOS, ANOREXIA NERVOSA
temperature: 98.1
heartrate: 62.0
resprate: 20.0
o2sat: 100.0
sbp: 132.0
dbp: 72.0
level of pain: nan
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You came to the hospital
because you wanted help in gaining weight. You were seen by the
psychiatrists, nutritionists, and social worker and did very
well with the protocol. Your electrolyte abnormalities and
kidney dysfunction all improved with nutrition and hydration.
It will be very important to avoid ibuprofen and other
anti-inflammatories as they can further damage your kidneys.
We also strongly encourage that you meet with a nutritionist (to
be scheduled), a psychiatrist, and your PCP closely as an
outpatient, to continue all of the wonderful progress you made
while in the hospital. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose intolerant
Attending: ___.
Chief Complaint:
___ Labs
Major Surgical or Invasive Procedure:
ERCP with balloon sweep and sphincterotomy
History of Present Illness:
___ yo female w/ h/o amyloid heart disease, systolic and
diastolic CHF (EF=45-50%), a-fib/flutter, CKD, presents from
___, where she has been living due to
declining mental/functional status. Over the last week she has
had worsening mental status and daily labs which show that she
has been hypernatremic (Na 152-160s despite 1L ___ NS) and
rising BUN.
In the ED, initial VS were: 12:30 (unable) 97.0 95 104/73 99%
2L NP. Patient was not responsive to questions and no further
history was taken. She had a CT abdomen/ pelvis done which
showed prelim: ___ common iliac artery aneurysms and small
pericardial effusion. A UA showed a UTI. Patient was given
zosyn 2.25g IV at 1415 and 1L NS.
Of note, pt has been an Atrius patient since ___ after
transferring care from ___. At ___, she was found
to have insignificant coronary artery disease. She had a right
atrial pressure elevated at 16 mmHg, pulmonary capillary wedge
of 24 and elevated pulmonary artery pressure of 60/23. A right
ventricular biopsy was not performed but, because of
echocardiographic features suggestive of amyloidosis a fat pad
biopsy was done. This stained positive for amyloid. Subsequent
investigations demonstrated that she had normal serum free light
chains, no abnormal bands on
immunofixation and genetic testing that demonstrated a
substitution of isoleucine for valine in position 122 consistent
with the ___ variant of amyloidogenic mutant transthyretin.
The assumption was, based on this,(and on the echocardiographic
findings) was that she had amyloid cardiomyopathy.
On arrival to the MICU, patient's VS 98.7, 127/94, 91, 100% RA.
Patient is interactive stating "hi" although is slow to respond
to questions. She is also contracted and shifted over to one
side of the bed, although she doesn't report specific pain, she
grimaces when attempts are made at moving.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: ___ cath: clean
coronaries
-PACING/ICD: None
-Atrial fibrillation/flutter
-Amyloid Heart Disease
-Systolic and diastolic CHF (EF=45-50%)
3. OTHER PAST MEDICAL HISTORY:
-Hypothyroidism
-Gout
-CKD (1.5-1.8 per previous discharge summary from ___
-Dementia
-? COPD
-Depression
-Uses a walker.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7, 127/94, 91, 100% RA
Pulsus of 0.
General: Alert, oriented, in semi fetal position in bed.
HEENT: Sclera anicteric, oropharynx with dry mucus membranes
with milky film, likely partially treated thrush, EOMI, PERRL.
Well healed scar along left neck.
Neck: supple, although patient resists moving it, JVP at ___
with positive kussmal's, no LAD
CV: Irregular 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: foley
Ext: Right Knee: increased effusion with knee mildly ballotable,
full range of motion by exam, but tender to touch. No overlying
erythema.
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, no cogwheeling. aaoX1
Pertinent Results:
ADMISSION LABS:
___ 12:50PM BLOOD WBC-20.4*# RBC-6.01* Hgb-14.8 Hct-49.5*
MCV-82 MCH-24.6* MCHC-29.9* RDW-20.9* Plt ___
___ 12:50PM BLOOD Glucose-169* UreaN-114* Creat-2.3*
Na-156* K-4.6 Cl-117* HCO3-26 AnGap-18
___ 12:50PM BLOOD Calcium-8.4 Phos-4.4 Mg-2.4
___ 08:50AM BLOOD ___ pO2-51* pCO2-40 pH-7.39
calTCO2-25 Base XS-0
___ 01:03PM BLOOD Lactate-3.3*
___ CT AP
Moderate cardiomegaly with small pericardial effusion. Severe
calcified atherosclerotic disease of the aorta and its branches.
Aneurysmal dilatation of common iliac arteries. The right
common iliac artery
measures 2.1 and left common iliac artery measures 1.9 cm. The
right internal iliac artery is dilated to 3.9 x 2.8 cm. The
right common femoral artery is dilated measuring 1.4 cm.
Bilateral renal cysts. Trace bilateral pleural effusions with
adjacent atelectasis.
___ RUQ U/S
Moderate extrahepatic biliary dilatation, may be postsurgical;
however
given history transaminitis and mild pancreatic ductal
dilatation, consider correlation with MRCP to exclude
obstruction. Mild right-sided hydronephrosis, this could also be
evaluated at the time of MRCP.
___ ERCP
-Normal major papilla
-Difficult scope position
-Cannulation of the biliary duct was successful and deep with a
sphincterotome
-The CBD was dilated to 15 mm. No filling defects seen
-A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
-Sludge was extracted successfully with balloon sweep
-Otherwise normal ercp to third part of the duodenum
CT T-spine (to assess for vertebral compression fracture):
1. Diffuse osteopenia with chronic anterior wedge deformity of
several mid-thoracic vertebrae and resultant kyphosis, as on the
radiographs dated ___.
2. No acute-appearing vertebral compression or thoracic spinal
canal compromise.
3. Apparent multifactorial spinal canal stenosis at the L3-L4
level, incompletely characterized.
4. Significant bilateral pleural effusions with associated
subsegmental atelectasis.
CXR (to confirm PICC placement):
1. Right PICC with tip projecting in the right atrium 9 cm
caudal to the carina. If placement of the tip at the low SVC is
desired, withdrawal of the catheter by 5 cm is required -> done
by IV nurse
2. Interval development of mild pulmonary edema with increasing
layering effusions.
.
___ CXR: PICC in R.SVC
___ 07:30AM BLOOD WBC-9.2 RBC-4.77 Hgb-11.5* Hct-39.8
MCV-83 MCH-24.1* MCHC-28.9* RDW-22.1* Plt ___
___ 07:45AM BLOOD WBC-7.9 RBC-4.96 Hgb-12.1 Hct-41.5 MCV-84
MCH-24.4* MCHC-29.2* RDW-21.5* Plt ___
___ 05:30AM BLOOD WBC-9.2 RBC-5.06 Hgb-12.3 Hct-42.4 MCV-84
MCH-24.3* MCHC-29.0* RDW-20.9* Plt ___
___ 05:45AM BLOOD WBC-8.4 RBC-4.75 Hgb-11.4* Hct-39.3
MCV-83 MCH-24.0* MCHC-29.1* RDW-20.4* Plt ___
___ 12:55PM BLOOD WBC-10.0 RBC-4.80 Hgb-11.6* Hct-39.7
MCV-83 MCH-24.2* MCHC-29.2* RDW-21.3* Plt ___
___ 06:50AM BLOOD WBC-12.6* RBC-4.97 Hgb-11.8* Hct-41.4
MCV-83 MCH-23.7* MCHC-28.5* RDW-20.1* Plt ___
___ 06:45AM BLOOD WBC-10.8 RBC-4.71 Hgb-11.1* Hct-38.8
MCV-82 MCH-23.6* MCHC-28.7* RDW-20.3* Plt ___
___ 03:30AM BLOOD WBC-13.0* RBC-5.28 Hgb-12.5 Hct-44.2
MCV-84 MCH-23.7* MCHC-28.3* RDW-20.0* Plt ___
___ 12:50PM BLOOD WBC-20.4*# RBC-6.01* Hgb-14.8 Hct-49.5*
MCV-82 MCH-24.6* MCHC-29.9* RDW-20.9* Plt ___
___ 07:45AM BLOOD ___
___ 05:30AM BLOOD ___
___ 05:45AM BLOOD ___
___ 12:55PM BLOOD ___ PTT-49.2* ___
___ 06:50AM BLOOD ___
___ 03:30AM BLOOD ___ PTT-40.5* ___
___ 05:50PM BLOOD ___ PTT-53.1* ___
___ 12:33AM BLOOD ___
___ 12:50PM BLOOD ___ PTT-61.1* ___
___ 07:30AM BLOOD Glucose-130* UreaN-34* Creat-1.0 Na-144
K-4.2 Cl-108 HCO3-25 AnGap-15
___ 08:50PM BLOOD Na-144 K-4.0 Cl-109*
___ 07:45AM BLOOD UreaN-33* Creat-0.9 Na-145 K-3.9 Cl-111*
HCO3-26 AnGap-12
___ 03:30PM BLOOD UreaN-36* Creat-1.0 Na-151* K-3.4 Cl-115*
HCO3-25 AnGap-14
___ 03:28PM BLOOD Na-148* Cl-115*
___ 02:15PM BLOOD Na-148* K-6.3* Cl-116*
___ 05:30AM BLOOD Glucose-157* UreaN-35* Creat-0.9 Na-149*
K-5.3* Cl-115* HCO3-26 AnGap-13
___ 02:14PM BLOOD K-6.6*
___ 05:45AM BLOOD Glucose-180* UreaN-43* Creat-0.8 Na-149*
K-6.2* Cl-116* HCO3-27 AnGap-12
___ 06:50AM BLOOD Glucose-172* UreaN-75* Creat-1.3* Na-146*
K-4.1 Cl-111* HCO3-23 AnGap-16
___ 06:45AM BLOOD Glucose-63* UreaN-92* Creat-1.7* Na-146*
K-4.5 Cl-111* HCO3-23 AnGap-17
___ 12:55PM BLOOD ALT-37 AST-48* AlkPhos-152* TotBili-2.6*
___ 06:50AM BLOOD ALT-47* AST-59* AlkPhos-165* TotBili-3.2*
___ 06:45AM BLOOD ALT-51* AST-63* AlkPhos-144* TotBili-3.8*
.
___ 12:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 4 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ ___ @2340.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Date 6 Lab # Specimen Tests Ordered By
All ___ All BLOOD CULTURE MRSA
SCREEN URINE All EMERGENCY WARD INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL EMERGENCY
___ 07:30AM BLOOD WBC-9.2 RBC-4.77 Hgb-11.5* Hct-39.8
MCV-83 MCH-24.1* MCHC-28.9* RDW-22.1* Plt ___
___ 06:33AM BLOOD ___ PTT-34.8 ___
___ 02:15PM BLOOD ___ PTT-150* ___
___ 10:55AM BLOOD Na-143 K-4.3 Cl-108
___ 06:33AM BLOOD Glucose-130* UreaN-36* Creat-1.1 Na-145
K-5.4* Cl-108 HCO3-27 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Warfarin 2.5 mg PO DAILY16
6. Acetaminophen 650 mg PO Q4H:PRN pain
7. Torsemide 40 mg PO DAILY
hold for SBP <95
8. BuPROPion 75 mg PO DAILY
9. TraMADOL (Ultram) 25 mg PO Q8H
Hold for sedation, RR<12
10. Nystatin Oral Suspension 5 mL PO QID
11. Bisacodyl 10 mg PR HS:PRN constipation
12. Fleet Enema ___AILY:PRN constipation
13. Senna 1 TAB PO DAILY:PRN constipation
14. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation QID:PRN wheezing, dyspnea
15. traZODONE 12.5 mg PO QID:PRN anxiety
16. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. BuPROPion 75 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Senna 1 TAB PO DAILY:PRN constipation
8. Simvastatin 40 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Meropenem 500 mg IV Q8H
Last day of therapy is ___
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
12. Fleet Enema ___AILY:PRN constipation
13. Metoprolol Succinate XL 25 mg PO DAILY
14. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation QID:PRN wheezing, dyspnea
15. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
16. traZODONE 12.5 mg PO QID:PRN anxiety
17. Warfarin 1 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
E. coli septicemia from UTI
Common bile duct obstruction
Advanced dementia
Amyloidosis complicated by chronic systolic/diastolic CHF
atrial flutter
Malnutrition, hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam dated ___.
CLINICAL HISTORY: Altered mental status, assess pneumonia.
FINDINGS: AP supine portable chest radiograph was provided. The heart is
moderately enlarged. The lungs are clear. No effusion or pneumothorax though
the left CP angle is excluded. No overt signs of pulmonary edema. Bony
structures intact.
IMPRESSION: Cardiomegaly. Otherwise, unremarkable.
Radiology Report
INDICATION: Patient with abdominal tenderness, altered mental status.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained without intravenous or oral contrast. Coronally and sagittally
reformatted images are provided.
FINDINGS:
CT OF THE ABDOMEN:
The heart is moderately enlarged. There is small pericardial effusion. Trace
bilateral pleural effusions are present with bibasilar dependent atelectasis.
Evaluation of visceral organs is limited due to lack of intravenous contrast.
Within this limitation, the liver demonstrates homogeneous attenuation. There
is no evidence of intrahepatic biliary ductal dilatation. Hepatic capsular
punctate calcifications are noted (2:32). The gallbladder is surgically
absent. The spleen is unremarkable. The pancreas appears atrophic without
ductal dilatation or peripancreatic fluid collection. The adrenal glands are
slightly prominent without focal nodular lesions. There is no evidence of
hydronephrosis. There is a 3.1 x 3.2 cm hypodense lesion arising from the
interpolar region of the left kidney measuring 13 Hounsfield units in
attenuation, compatible with a cyst (2:24). There is an additional exophytic
2 x 2.2 cm hypodense lesion of the right kidney measuring up to 20 Hounsfield
units in attenuation, compatible with an additional cyst (2:24).
Imaged small and large bowel loops are normal in caliber without evidence of
bowel wall thickening or obstruction. There are scattered retroperitoneal
lymph nodes which do not meet CT criteria for pathologic enlargement. There
is no mesenteric lymphadenopathy. Intra-abdominal aorta is notable for
extensive calcified atherosclerotic disease. The distal intra-abdominal aorta
just above its bifurcation measures 1.9 cm (601B:22). The right common iliac
artery is dilated measuring 2.1 cm. The right internal iliac artery is
aneurysmal measuring 3.9 x 2.8 cm in maximum diameter (2:49). The left common
iliac artery measures 1.9 cm (601B:23).
CT OF THE PELVIS:
___ catheter is in place. Small amount of gas within the bladder likely
relates to Foley placement. There is trace amount of free fluid. The rectum,
uterus, and sigmoid colon are unremarkable. There is no free air within the
pelvis. There is no pelvic or inguinal lymphadenopathy. Right common femoral
artery is dilated measuring 1.4 cm (2:74).
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
1. Moderate cardiomegaly with small pericardial effusion.
2. Severe calcified atherosclerotic disease of the aorta and its branches.
Aneurysmal dilatation of common iliac arteries. The right common iliac artery
measures 2.1 and left common iliac artery measures 1.9 cm. The right internal
iliac artery is dilated to 3.9 x 2.8 cm. The right common femoral artery is
dilated measuring 1.4 cm.
3. Bilateral renal cysts.
4. Trace bilateral pleural effusions with adjacent atelectasis.
Radiology Report
HISTORY: Sepsis, right upper quadrant ultrasound as patient has transaminitis
and abdominal pain.
TECHNIQUE: Grayscale and color Doppler evaluation of the upper abdomen.
COMPARISON: None contrast CT of the abdomen and pelvis ___.
FINDINGS:
There is mild pancreatic ductal dilatation in the body extending towards the
tail measuring 3.3 mm in maximum diameter.
No focal liver lesions. There is trace intrahepatic biliary dilatation and
marked dilation of the extrahepatic common bile duct the extrahepatic common
bile ducts are markedly dilated measuring up to 1.3 cm.
Normal appearance of the spleen. Bilateral renal cysts are noted, not
significantly changed from comparison CT with the largest measuring the 4 cm
on the left. There is mild right-sided hydronephrosis. A 7 mm echogenic
focus in the left kidney corresponds to a hyperdense lesion on the comparison
CT and may represent milk of calcium within a hyperdense cyst.
IMPRESSION:
1. Moderate extrahepatic biliary dilatation, may be postsurgical; however
given history transaminitis and mild pancreatic ductal dilatation, consider
correlation with MRCP to exclude obstruction.
2. Mild right-sided hydronephrosis, this could also be evaluated at the time
of MRCP.
Radiology Report
HISTORY: Sepsis, to assess for pneumothorax.
FINDINGS: In comparison with study of ___, there is again substantial
enlargement of the cardiac silhouette without definite vascular congestion,
pleural effusion, or acute focal pneumonia. Specifically, there is no
evidence of pneumothorax.
Radiology Report
CT OF THE THORACIC SPINE WITHOUT CONTRAST, ___
HISTORY: ___ female with dementia, cholangitis, E. coli sepsis,
delirium and mid- upper thoracic spine pain on palpation; evaluate for
thoracic compression fracture.
TECHNIQUE: Helical 3.75-mm axial MDCT sections were obtained from the C5
through the L3 level without IV contrast administration; sagittal and coronal
reformations were prepared, and all images are viewed in bone, soft tissue and
lung window on the workstation.
FINDINGS: The study is compared with the (limited) thoracic radiographs dated
___. There is no prior cross-sectional imaging study of the thoracic
spine on record.
As on the radiographs, there is marked diffuse osteopenia. Likely related to
this, there is relatively slight anterior wedging of the T5 through T9
vertebrae with resultant accentuated kyphosis at this level. However,
allowing for this background, no acute-appearing compression, retropulsion or
significant spinal canal compromise is seen. Noted is underlying DISH
involving the thoracic spine. Also noted is multifactorial degenerative
disease involving the included upper lumbar spine, including facet arthrosis,
ligamentum flavum thickening and disc bulging producing moderately severe
spinal canal stenosis, particularly at the L3-L4 level (2:123-125).
The remainder of the examination is notable for moderately large bilateral
pleural effusions and associated subsegmental atelectasis, larger than on the
abdominal NECT dated ___. There is also a pericardial effusion, very
incompletely imaged. There is extensive atherosclerotic mural calcification
involving the thoraco-abdominal aorta and its included branches, without focal
aneurysmal dilatation; calcifications in the kidneys are also likely vascular,
with incidentally noted low-attenuation lesion in the dorsal aspect of the
right renal upper pole, likely a simple cyst, as on the previous CT.
IMPRESSION:
1. Diffuse osteopenia with chronic anterior wedge deformity of several
mid-thoracic vertebrae and resultant kyphosis, as on the radiographs dated
___.
2. No acute-appearing vertebral compression or thoracic spinal canal
compromise.
3. Apparent multifactorial spinal canal stenosis at the L3-L4 level,
incompletely characterized.
4. Significant bilateral pleural effusions with associated subsegmental
atelectasis.
Radiology Report
INDICATION: Right PICC placement.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph.
FINDINGS: There has been interval placement of a right PICC with the tip
terminating in the right atrium, 9 cm caudal to the carina. Significant
enlargement of the cardiac silhouette is unchanged compared to prior study
with development of mild interstitial edema. Small bilateral layering
effusions are slightly increased. There is no pneumothorax.
IMPRESSION:
1. Right PICC with tip projecting in the right atrium 9 cm caudal to the
carina. If placement of the tip at the low SVC is desired, withdrawal of the
catheter by 5 cm is required.
2. Interval development of mild pulmonary edema with increasing layering
effusions.
Results were discussed over the telephone by ___ with Dr. ___
___ at 12:20 and ___ of IV therapy at 12:24 on ___
at time of initial review.
Radiology Report
INDICATION: PICC placement.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph.
FINDINGS: There has been interval placement of a right PICC with the tip
projecting over the mid SVC. There is otherwise no significant change
compared to ___ with persistent bilateral layering effusions and mild
interstitial edema.
IMPRESSION: Right PICC with tip projecting over the mid SVC. Persistent
bilateral effusions and mild interstitial edema.
Results were discussed over the telephone with Dr. ___ by ___
___ at 1:34 p.m. on ___ at the time of initial review.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABNL LABS
Diagnosed with HYPEROSMOLALITY, ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPOTHYROIDISM NOS
temperature: 97.0
heartrate: 95.0
resprate: nan
o2sat: 99.0
sbp: 104.0
dbp: 73.0
level of pain: 13
level of acuity: 2.0 | You were admitted to the hospital with a severe urinary tract
infection and blood infection, which improved with antibiotics.
You also had a bile duct blockage that was fixed with endoscopy.
Your lab tests reflected malnutrition and electrolytes that
showed dehydration, and you need to have someone help you eat
your meals to prevent worsening malnutrition.
Please see below for your follow up appointments and
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. |