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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 distention
Major Surgical or Invasive Procedure:
___ PROCEDURES:
1. Exploratory laparotomy.
2. Bilateral rectus abdominis component-separation repair
of abdominal wall defect.
3. Small-bowel resection with primary anastomosis x1.
4. A 10 x 14 inch polypropylene mesh onlay performed in the
manner of STOPPA.
History of Present Illness:
___ M s/p exploratory laparotomy, small bowel decompression,
rectosigmoid colectomy, appendectomy, colorectal anastomosis for
obstructing colon adenocarcinoma (pT3N2b, stage IIIc) in ___
who presents to the ED with symptoms of bloating, abdominal pain
and distention x6 days. He was seen by his PCP today who ordered
a KUB demonstrating dilated loops of bowel and presented to the
ED at his PCP's request for a CT scan given concern for a small
bowel obstruction. He reports ___ pain currently which has been
up to a ___, continued bloating and gas pains. No nausea, no
emesis. He is tolerating PO, although his appetite is decreased
and he is passing flatus and having bowel movements. Last BM
this AM.
Past Medical History:
Past Medical History: Colon Cancer-pT3N2b, stage IIIc S/P
resection, chemo x2 and cyberknife treatment (Met found in ___
in aortal caval LN). Last CT showed no evidence of recurrence in
___ of ___. HTN, HLD
Past Surgical History: ___- exploratory laparotomy, small bowel
decompression, rectosigmoid colectomy, on-table colonic lavage,
appendectomy, colorectal anastomosis, and rigid sigmoidoscopy
Repair of left inguinal hernia ___ Port-a-cath placement ___,
removal ___ and replacement ___ Knee surgery as a teen
Social History:
___
Family History:
Father- prostate CA, DM, Heart Disease, Mother ___ CA & Kidney
CA
Physical Exam:
ON ADMISSION ___:
Vitals: T 97.9 HR 65 BP 144/100 RR 16 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, distended, nontender, no rebound or guarding,
normoactive bowel sounds, large midline hernia- partially
reducible
EXT: No ___ edema, ___ warm and well perfused
ON DISCHARGE ___:
VS: T 98.4, HR 81, BP 136/71, RR 18, SaO2 99% RA
Pertinent Results:
CBC:
___ 03:15PM BLOOD WBC-8.6 RBC-4.90 Hgb-15.1 Hct-45.2 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.4 Plt ___
___ 10:00PM BLOOD WBC-9.0 RBC-4.48* Hgb-14.0 Hct-40.5
MCV-90 MCH-31.2 MCHC-34.6 RDW-14.3 Plt ___
___ 10:10PM BLOOD WBC-9.3 RBC-4.44* Hgb-13.7* Hct-40.4
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.7 Plt ___
___ 08:00AM BLOOD WBC-11.4* RBC-4.15* Hgb-13.0* Hct-37.7*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.6 Plt ___
___ 03:31AM BLOOD WBC-10.6 RBC-3.55* Hgb-11.1* Hct-32.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___
___ 05:17AM BLOOD WBC-12.1* RBC-3.80* Hgb-11.8* Hct-35.9*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.7 Plt ___
___ 01:26PM BLOOD WBC-7.2 RBC-3.44* Hgb-10.7* Hct-31.6*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___
___ 04:59AM BLOOD WBC-8.8 RBC-3.57* Hgb-11.0* Hct-32.3*
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt ___
___ 07:49AM BLOOD WBC-10.4 RBC-3.70* Hgb-11.6* Hct-34.4*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.1 Plt ___
___ 07:03AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.5* Hct-34.0*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.8 Plt ___
___ 07:56AM BLOOD WBC-8.8 RBC-3.89* Hgb-11.9* Hct-35.9*
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.8 Plt ___
CHEMISTRY:
___ 03:15PM BLOOD UreaN-12 Creat-1.1
___ 10:00PM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
___ 10:00PM BLOOD Albumin-4.4
___ 10:10PM BLOOD Glucose-155* UreaN-12 Creat-1.1 Na-140
K-4.6 Cl-107 HCO3-25 AnGap-13
___ 10:10PM BLOOD Calcium-6.9* Phos-4.3 Mg-1.3*
___ 08:00AM BLOOD Glucose-161* UreaN-16 Creat-1.2 Na-139
K-4.2 Cl-104 HCO3-27 AnGap-12
___ 08:00AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.5
___ 03:31AM BLOOD Glucose-109* UreaN-20 Creat-1.1 Na-139
K-4.1 Cl-106 HCO3-27 AnGap-10
___ 05:17AM BLOOD Glucose-112* UreaN-15 Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 05:17AM BLOOD Calcium-8.3* Phos-2.3*# Mg-2.1
___ 01:26PM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-142
K-3.4 Cl-102 HCO3-26 AnGap-17
___ 01:26PM BLOOD Calcium-8.2* Phos-2.0* Mg-1.9
___ 12:08PM BLOOD Glucose-116* UreaN-7 Creat-0.6 Na-139
K-3.5 Cl-100 HCO3-28 AnGap-15
___ 12:08PM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9
___ 04:59AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-141
K-3.2* Cl-99 HCO3-28 AnGap-17
___ 04:59AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
___ 07:49AM BLOOD Glucose-116* UreaN-6 Creat-0.8 Na-143
K-4.3 Cl-99 HCO3-30 AnGap-18
___ 07:49AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.2
___ 07:03AM BLOOD Glucose-120* UreaN-6 Creat-0.7 Na-141
K-4.2 Cl-101 HCO3-30 AnGap-14
___ 07:03AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1
___ 07:56AM BLOOD Glucose-112* UreaN-6 Creat-0.7 Na-142
K-4.3 Cl-101 HCO3-28 AnGap-17
___ 07:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Valcyte (valGANciclovir) 500 mg oral DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Valcyte (valGANciclovir) 500 mg oral DAILY
3. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tablet by mouth at bedtime Disp
#*60 Tablet Refills:*1
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth DAILY Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink or drive while taking narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
7. Cephalexin 500 mg PO Q6H Duration: 4 Doses
Take for 1 more day - 1 tab every 6 hours
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Large ventral hernias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Postoperative day 6 status post complex ventral hernia repair
with mesh and small bowel resection. Patient now presenting with ileus.
Evaluate for source of ileus, intra-abdominal fluid collection or obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
after the uneventful administration of 130 ml of Omnipaque. Coronal and
sagittal reformations were provided and reviewed. Gastrografin as oral
contrast anterior abdomen. Cutaneous laparotomy staples are noted. A small
fluid collection beneath the incision measuring 3.1 x 2.3 cm is likely a
postoperative seroma. Administered.
DOSE: DLP: 1073.52 mGy-cm
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Oral contrast has progressed to the proximal jejunum. Dilated loops of small
bowel range in size up to the 4.6 cm. There is a transition in small bowel
caliber seen in the left lower quadrant (602b:65). The distal loops of small
bowel are decompressed. A small amount of contrast is seen in the colon from
prior CT examination. Findings are consistent with a small bowel obstruction.
This is thought to be from an adhesion given the adjacent narrowing and
angulation without obstruction seen on the nearby and proximal jejunum (2:63).
There is a trace amount of mesenteric edema, presumably from recent surgery.
There is no bowel wall edema. There is no extraluminal contrast.
The imaged lung bases show bibasilar atelectasis. There is no pleural
effusion. The included portion of the heart is normal in size and there is no
pericardial effusion.
A small focus of air seen in the anterior abdomen is probably within the
rectus sheath (02:58). There is no definite free air. 2 subcutaneous drains
terminate in the subcutaneous fat of the anterior abdominal wall.
The liver enhances homogeneously without focal lesions. The gallbladder is
normal and there is no intra or extrahepatic biliary ductal dilation. The
spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance
symmetrically and excrete contrast without hydronephrosis.
The aorta is normal caliber. The portal vein, splenic vein and superior
mesenteric vein are patent.
The bladder, prostate and rectum are normal. There is no pelvic or inguinal
sidewall lymphadenopathy.
There are no lytic or blastic osseous lesions.
IMPRESSION:
1. Complete obstruction with transition in the left lower quadrant. Given the
adjacent narrowing and angulation without obstruction on the nearby the
jejunum, this is felt to be secondary to an adhesion. No bowel wall edema or
intra-abdominal free air.
2. Bilateral subcutaneous drains are well positioned.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
via telephone on ___ at 2:04 ___, 15 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Abdominal distention
Diagnosed with INTESTINAL OBSTRUCT NOS, HX OF COLONIC MALIGNANCY
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 143.0
dbp: 98.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ was admitted from the emergency department on
___. He was initially seen at his PCP's office where a
KUB was done showing distended loops of bowel concerning for
small bowel obstruction. On evaluation in the ED, CT scan of the
abdomen showed a complex network of ventral hernias with
multiple loops of bowel incarcerated within the hernia. He was
admitted to the Acute Care Surgery team for management and
operative discussion/planning.
Mr. ___ was taken to the OR on ___ and underwent an
exploratory laparotomy with bilateral rectus abdominis component
separation repair of abdominal wall defect with polypropylene
mesh and small bowel resection with primary anastomosis,
performed by Dr. ___. He tolerated the procedure well without
any complications and was taken to the post-anesthesia care unit
in stable condition. At the end of the procedure, Mr. ___ had 2
JP drains in the space overlaying the mesh and an NG tube for
decompression of the stomach.
In the immediate post-operative period, Mr. ___ at an epidural
for pain control and foley catheter while he had an epidural.
The NG tube was removed a few days after the operation and he
was started on sips of clears, awaiting return of bowel
function. However, after a few days, Mr. ___ became
increasingly distended and had an episode of emesis. He was
again kept NPO, started on IV fluids, and given a PCA for pain
control temporarily. An NGT had to be placed to decompress the
stomach after a second episode of bilious vomiting. Once he
began passing flatus, he was started on a clear diet and diet
was advanced as tolerated while he continued to pass flatus.
During the recovery period, he was also started antibiotics for
some mild non-demarcatable erythema noted over the incision,
especially given the risk of mesh infection. The JP drains
remained serosanguinous in output.
On discharge, Mr. ___ continued to pass flatus, although he had
not had a bowel movement. He was tolerating a regular diet
without any nausea and vomiting and continued on a bowel
regimen. He was eager to be discharged and acknowledge that
should he not have a bowel movement in 48 hours, he should call
the clinic or return to the ED. He was given instructions for
medications and scheduled to follow-up early next week for
staple removal and JP drain removal and then another 2 weeks
after for follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors / Bactrim / Hydrochlorothiazide / Aricept
Attending: ___.
Chief Complaint:
Slammed into door, sustaining injuries including C4 vertebral
fracture, retroperitoneal hematoma, retropharyngeal hematoma.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of AFib (on warfarin), cognitive
impairment with h/o recurrentfalls, CAD s/p remote CABG ___
ago), CKD (baseline Cr 1.5),
diffuse esophageal spasm, HTN, and ?COPD here after slamming
into
door with active extravastation... retropharyngeal hematoma
requiring intubation.
Patient was walking in the dark and slammed into a door at
home,
hitting her face. She had a L eyelid laceration, paramedics came
to see her, and she ultimately declined ED admission. 45min
afterwards, she felt short of breath and felt like her "airway
was closing" prompting arrival to ED. The patient then underwent
emergent intubation for airway protection. Her INR was 1.8 and
was given K centra and 10 IV vitamin K.
Past Medical History:
# CAD s/p CABG
# HTN
# Mitral Regurgitation
# Chronic Afib: On warfarin
# CKD
# Hx.of UTIs (typically EColi, variable resistance, most recent
pan-sensitive ___
# Osteopenia
# Mild Peripheral Neuropathy: previously on gabapentin, did not
tolerate ___ cognitive issues
# Possible Cognitive Impairment (undergoing neuropsych
evaluation ___
Social History:
___
Family History:
Father died suddenly of a cerebral hemorrhage when pt. was ___.
Otherwise, non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
Temp: 97.6 HR: 87 BP: 158/94 Resp: 18 O(2)Sat: 94 Normal
Constitutional: Comfortable
Chest: neck with left sided ttp and fullness; OP clear and
patent; no bruit on neck exam; from ; no c-spine TTP; ?some
dysphonation but daughter says no different than usual voice
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Non-tender, Soft, Non-distended
Skin: Warm and dry
Neuro: right elbow hematoma with sts; from; nvi right hand
Psych: Normal mood, Normal mentation; CN intact; PERRL 4 mm
___: No petechiae
physical examination upon discharge: ___:
GENERAL: NAD
vital signs: 98.6, hr=97, bp=150/81, rr=18 98% room air
HEENT: Ecchymosis left side face, left cheek bone, left neck
CV: Irreg.
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: ecchymosis ant. aspect right lower leg, ecchymosis right
thigh, no calf pain bil, + dp bil
NEURO: alert and oriented x3, speech clear, no tremors
Pertinent Results:
CBC
___ 05:45AM BLOOD WBC-10.5* RBC-3.04* Hgb-9.3* Hct-28.7*
MCV-94 MCH-30.6 MCHC-32.4 RDW-14.6 RDWSD-47.9* Plt ___
___ 05:45AM BLOOD WBC-10.8* RBC-3.10* Hgb-9.4* Hct-28.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.1 RDWSD-46.3 Plt ___
___ 05:21AM BLOOD WBC-12.3* RBC-3.02* Hgb-9.2* Hct-28.1*
MCV-93 MCH-30.5 MCHC-32.7 RDW-14.1 RDWSD-47.0* Plt ___
___ 03:38AM BLOOD WBC-14.0* RBC-3.13* Hgb-9.5* Hct-28.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.9 RDWSD-45.4 Plt ___
___ 03:03AM BLOOD WBC-9.4 RBC-3.19* Hgb-9.6* Hct-29.5*
MCV-93 MCH-30.1 MCHC-32.5 RDW-14.1 RDWSD-47.7* Plt ___
___ 02:21AM BLOOD WBC-8.7 RBC-2.91* Hgb-8.9* Hct-27.1*
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.5 RDWSD-48.8* Plt ___
___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___
___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___
___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___
___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___
___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___
___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___
___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___
___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___
___ 07:40AM BLOOD WBC-9.7 RBC-3.35* Hgb-10.3* Hct-30.7*
MCV-92 MCH-30.7 MCHC-33.6 RDW-14.2 RDWSD-47.0* Plt ___
___ 01:54AM BLOOD WBC-12.3* RBC-3.47* Hgb-10.7* Hct-32.1*
MCV-93 MCH-30.8 MCHC-33.3 RDW-14.4 RDWSD-47.9* Plt ___
___ 06:15PM BLOOD WBC-12.4* RBC-3.93 Hgb-12.1 Hct-36.1
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.0 RDWSD-47.0* Plt ___
___ 01:50PM BLOOD WBC-11.6* RBC-3.92 Hgb-12.1 Hct-35.8
MCV-91 MCH-30.9 MCHC-33.8 RDW-13.9 RDWSD-46.3 Plt ___
___ 08:30AM BLOOD WBC-14.4*# RBC-4.80 Hgb-14.7 Hct-42.6
MCV-89 MCH-30.6 MCHC-34.5 RDW-13.8 RDWSD-44.8 Plt ___
CHEST (PORTABLE AP) Study Date of ___ 8:30 AM
FINDINGS:
AP portable upright view of the chest. Midline sternotomy wires
and
mediastinal clips again noted. Overlying EKG leads are present.
The heart is stably mildly enlarged. Prominence of the
superior mediastinum reflects known hematoma in the
retropharyngeal space extending into the superior mediastinum as
seen on same-day neck CT. Lungs are clear bilaterally. Bony
structures appear intact.
CT HEAD W/O CONTRAST Study Date of ___ 8:32 AM
IMPRESSION:
1. No acute hemorrhage or fracture.
2. Chronic small vessel disease.
3. Small left ___ hematoma.
CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___
8:45 AM
IMPRESSION:
Massive pre-vertebral hematoma with associated hyper extension
teardrop
fracture at C4 without alignment abnormality or distraction.
Recommend urgent CTA to assess active bleeding.
CTA NECK W&W/OC & RECONS Study Date of ___ 9:21 AM
IMPRESSION:
1. Extensive retropharyngeal hematoma spanning from C2 through
T1, measuring 4.6 x 2.6 cm axially with active extravasation.
Unclear whether this represents active extravasation from
prevertebral artery versus
retropharyngeal branch artery, although the associated vessel
does appear to be likely prevertebral (series 2, image 144).
Consultation with neurosurgery is recommended.
2. An additional linear focus of hyperdensity along the lateral
aspect of the hematoma inferiorly (series 2, image 103) cannot
be connected to a larger vessel. This could represent venous
hemorrhage. Close attention on ___ is recommended.
3. Additional findings described above.
CT CHEST W/O CONTRAST Study Date of ___ 4:25 ___
IMPRESSION:
1. A large retropharyngeal hematoma extends into the superior
mediastinum, not appreciably changed compared to the earlier
same day neck CTA. There is mild mass effect on the posterior
wall of the trachea, but no significant luminal narrowing.
2. Somewhat nodular opacification focally within the anterior
right lower lobe probably reflects atelectasis. However,
recommend three-month ___ chest CT to assess stability.
CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___
4:25 ___
IMPRESSION:
1. Re-demonstration of retropharyngeal hematoma extending from
C2 through the right aspect of the posterior mediastinum,
slightly decreased in size from the prior study with
non-visualized hematocrit levels previously seen, likely
secondary to mass effect from endotracheal tubes and intubation.
2. The hematoma extends to the posterior mediastinum. The
component in the mediastinum appears more prominent when
compared to prior examination. This could represent
redistribution, however the findings could represent continued
active extravasation and close interval ___ is recommended
to document stability/growth.
Portable TTE (Complete) Done ___ at 12:00:00 ___ FINAL
IMPRESSION: Borderline LV systolic function secondary to septal
dyssynchrony. Bi-leaflet MVP with moderate mitral regurgitation.
Mild pulmonary hypertension.
CHEST (PORTABLE AP) Study Date of ___ 4:50 AM
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Lungs clear. Moderate cardiomegaly is chronic. No pulmonary
edema or pleural effusion.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 9:19 ___
IMPRESSION:
1. Acute fracture involving the anterior C4 vertebral body with
pre-vertebral soft tissue edema and probable injury to the
anterior longitudinal ligament as well the as the inter-spinous
ligament.
2. Edema within the C6-C7 intervertebral disc space with
probable osseous
edema of the superior C7 vertebral body.
3. Re-demonstration of retropharyngeal hematoma.
4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3.
5. Multilevel degenerative changes as detailed above, with
moderate spinal
canal stenosis at C4-C5 through C6-C7 levels with spinal cord
remodeling,
without definite cord edema.
CHEST (PORTABLE AP) Study Date of ___ 4:54 AM
IMPRESSION:
In comparison with the study ___, the monitoring support
devices are
essentially unchanged. Cardiac silhouette remains mildly
enlarged without
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
CHEST PORT. LINE PLACEMENT Study Date of ___ 10:53 ___
IMPRESSION:
Compared to chest radiographs since ___, most recently
___
through ___ at 05:33.
Combination of small to moderate pleural effusions and moderate
bibasilar
atelectasis has increased since earlier in the day. Moderate
cardiomegaly is chronic. There is also very mild ___
edema.
Indwelling cardiopulmonary support devices in standard
placements.
CHEST (PORTABLE AP) Study Date of ___ 5:31 AM
IMPRESSION:
Lines and tubes are in standard position. Bibasilar opacities
have markedly improved. Bilateral effusions have improved.
Cardiomegaly, tortuous aorta and prominent hila bilaterally are
stable. There is no evident pneumothorax. Sternal wires are
intact.
VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 11:37 AM
IMPRESSION:
No aspiration. Penetration with thin and nectar consistencies.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
CT HEAD W/O CONTRAST Study Date of ___ 5:41 ___
IMPRESSION:
1. Findings most consistent with severe chronic small vessel
ischemic changes in the absence of acute symptoms. No
intracranial hemorrhage.
2. Para-nasal sinus disease, suggestive of acute sphenoid
sinusitis in the
absence of recent intubation.
___: CXR;
In comparison with the study ___, the right IJ catheter
has been
removed. Continued enlargement of the cardiac silhouette in a
patient with previous CABG procedure an intact midline sternal
wires. Mild elevation of pulmonary venous pressure with small
bilateral pleural effusions and compressive atelectasis at the
bases.
No definite acute focal pneumonia.
___ 5:24 am 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
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. irbesartan 300 mg oral DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Warfarin 2.5 mg PO 2X/WEEK (WE,SA)
6. Aspirin 81 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO QHS
5. Heparin 5000 UNIT SC BID
___ d/c after ambulatory
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Multivitamins W/minerals Liquid 15 mL PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID:PRN swish
may diconstinue when no signs or symptoms
9. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours
Disp ___ Milliliter Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Warfarin 2.5 mg PO 2X/WEEK (WE,SA)
ON HOLD UNTIL ___ WITH ___. ___
12. amLODIPine 5 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 10 mg PO QPM
15. Fish Oil (Omega 3) 1000 mg PO BID
16. irbesartan 300 mg oral DAILY
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Omeprazole 20 mg PO DAILY
20. Warfarin 5 mg PO 5X/WEEK (___)
ON HODL UNTIL FOLLOW UP WITH ___. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
retropharyngeal hematoma
C4 vertebral body fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall
COMPARISON: Same-day neck CTA and chest radiograph from ___
FINDINGS:
AP portable upright view of the chest. Midline sternotomy wires and
mediastinal clips again noted. Overlying EKG leads are present. The heart is
stably mildly enlarged. Prominence of the superior mediastinum reflects known
hematoma in the retropharyngeal space extending into the superior mediastinum
as seen on same-day neck CT. Lungs are clear bilaterally. Bony structures
appear intact.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with history of headstrike on Coumadin// eval for
intracranial hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of large vascular territory
infarction,hemorrhage,edema,or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes. Again demonstrated,
is severe periventricular and subcortical white matter hypodensities,
consistent with chronic microvascular ischemic disease. Bilateral basal
ganglia and thalamic hypodensities are also noted similar to prior.
There is no fracture. Mild mucosal thickening of the sphenoid sinus. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. There is a small ___ and preseptal
hematoma without underlying fracture or signs of globe injury.
IMPRESSION:
1. No acute hemorrhage or fracture.
2. Chronic small vessel disease.
3. Small left ___ hematoma.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST
INDICATION: ___ year old woman with history of neck fullness on Coumadin with
concern for collection// eval for hematoma
TECHNIQUE: Multidetector CT through the neck performed without contrast with
multiplanar reformations
DOSE: Total DLP (Body) = 310 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a massive midline prevertebral hematoma approximately 12.8 cm in
craniocaudal dimension and 6.8 (TR) x 4.4 (AP) cm. Urgent CTA is required to
assess active bleeding, ? carotid injury. There is associated mass-effect on
the airway most pronounced at the level of the epiglottis. Consider urgent
intubation for airway protection.
An acute hyperextension fracture is noted at the anterior inferior corner of
C4 without distraction or alignment abnormality. Fracture is best appreciated
on the sagittal reformats, series 602b image 28 through 31. There is minimal
anterolisthesis of C2 on C3 which is likely chronic/related to degeneration.
Disc disease is most notable spanning C4 through C7 with loss of disc space,
disc osteophyte complexes which result in mild to moderate central spinal
canal narrowing. In addition, uncovertebral joint hypertrophy noted at
multiple levels results in severe neural foraminal narrowing at C4-5 and C5-6
on the left. The lung apices notable for emphysema. Prevertebral hematoma
extends to the level of the superior mediastinum. Thyroid is unremarkable.
IMPRESSION:
Massive prevertebral hematoma with associated hyper extension teardrop
fracture at C4 without alignment abnormality or distraction. Recommend urgent
CTA to assess active bleeding.
RECOMMENDATION(S):
-Intubation for airway protection.
-C-spine collar placement given acute fracture at C4.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: History: ___ with head strike with prevertebral hematoma on CT//
eval for dissection or active extravasation in the neck
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
2) Spiral Acquisition 4.3 s, 33.7 cm; CTDIvol = 35.2 mGy (Head) DLP =
1,186.8 mGy-cm.
Total DLP (Head) = 1,219 mGy-cm.
COMPARISON: CT neck of ___
FINDINGS:
There is a retropharyngeal hematoma spanning from the level of C2 to T1,
measuring 12.3 cm with max diameter measuring 4.6 x 2.9 cm on the axial
dimension, overall similar in prior examination. Of note, there is a fluid
fluid level within the ___ the hematoma (series 2, image 135). At the
level C3-4 disc space, there is vigorous, active extravasation of intravenous
contrast into the hematoma (2:150). The hematoma appears to be connected to a
small prevertebral arterial vessel (series 2, image 144) although this region
of enhancement cannot be definitively connected to a larger vessel. The
expanded hematoma displaces the esophagus anteriorly and somewhat narrows the
airways, though the central airways remain patent. The retroperitoneal
hematoma extends into the mediastinum to the level of pulmonary artery
bifurcation. There is trace linear hyperdensity, likely representing
additional site of extravasation (series 2, image 103) at the level of the
thyroid gland, without definitive source.
There is layering fluid in the sphenoid sinus. Mild mucosal thickening is
seen in the posterior ethmoid air cells. The visualized paranasal sinuses,
mastoid air cells, middle ear cavities are otherwise patent. Moderate
calcifications are seen at the bilateral carotid siphons. While this exam is
not tailored for intracranial contents, the visualized circle of ___
appears patent. No territorial infarct is seen. Prominent left periorbital
hematoma and soft tissue stranding is noted.
By NASCET criteria, there is no significant stenosis of the ICA bilaterally.
The left vertebral artery is diminutive throughout its course, likely
congenital variation.
Degenerative changes of the cervical spine with disc space and vertebral body
height loss, most severe at C4 through C7 is noted. C4 anterior teardrop
fracture is better visualized on prior examination.
IMPRESSION:
1. Extensive retropharyngeal hematoma spanning from C2 through T1, measuring
4.6 x 2.6 cm axially with active extravasation. Unclear whether this
represents active extravasation from prevertebral artery versus
retropharyngeal branch artery, although the associated vessel does appear to
be likely prevertebral (series 2, image 144). Consultation with neurosurgery
is recommended.
2. An additional linear focus of hyperdensity along the lateral aspect of the
hematoma inferiorly (series 2, image 103) cannot be connected to a larger
vessel. This could represent venous hemorrhage. Close attention on followup
is recommended.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___ resident by ___,
M.D. on the telephone on ___ at 10:03 am, 5 minutes after discovery of
the findings.
The findings were discussed with ___, M.D. by ___, M.D. on the
telephone on ___ at 10:30 am, 30 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with s/p intubation// Eval ETT
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. There has been interval placement of
an endotracheal tube with its tip positioned 3.2 cm above the carina. An OG
tube courses into the left upper abdomen with its tip excluded from view.
Midline sternotomy wires and mediastinal clips are again noted. There is
mediastinal widening which is reflective of known prevertebral/mediastinal
hematoma, appears increased from prior. The heart remains stably enlarged.
Lungs are clear. Bony structures are intact.
IMPRESSION:
Interval intubation with appropriately positioned ET tube. OG tube positioned
appropriately. Expanding mediastinal hematoma.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
INDICATION: ___ year old woman with retropharyngeal hematoma// ?interval
change
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 27.7 cm; CTDIvol = 5.4 mGy (Body) DLP = 148.6
mGy-cm.
Total DLP (Body) = 149 mGy-cm.
COMPARISON: CT neck ___
FINDINGS:
In comparison with the recent CT neck, there is interval decrease in size of a
retropharyngeal hematoma which now measures 4.2 x 1.7 cm, previously 4.6 x 2.9
cm. The previously seen hematocrit levels are not visualized on this study.
This could be secondary to mass effect from intubation and the endotracheal
tubes. The hematoma extends from C2 through visualized right aspect of the
posterior mediastinum. However, the extent of hematoma within the mediastinum
appears more prominent when compared to prior examination and findings remain
concerning for active extravasation versus redistribution secondary to mass
effect from the intubation. There is stranding within the soft tissues of the
lower neck.
There are subcentimeter cervical lymph nodes, possibly reactive. There are
vascular calcifications of the aorta and origins of the great vessels. The
thyroid gland appears unremarkable. There are multilevel degenerative changes
of the cervical spine. There is dependent atelectasis within the visualized
lung apices.
IMPRESSION:
1. Redemonstration of retropharyngeal hematoma extending from C2 through the
right aspect of the posterior mediastinum, slightly decreased in size from the
prior study with nonvisualized hematocrit levels previously seen, likely
secondary to mass effect from endotracheal tubes and intubation.
2. The hematoma extends to the posterior mediastinum. The component in the
mediastinum appears more prominent when compared to prior examination. This
could represent redistribution, however the findings could represent continued
active extravasation and close interval followup is recommended to document
stability/growth.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old woman with retropharyngeal hematoma.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Same day neck CTA
FINDINGS:
HEART AND VASCULATURE: The there is severe cardiomegaly. Patient appears
status-post CABG with median sternotomy wires and mediastinal clips. Native
coronary calcifications are severe. The aorta is normal in caliber. Aortic
arch and great vessel origin calcifications are moderate to severe.
MEDIASTINUM: The mediastinal portion of a large retropharyngeal hematoma
appears no larger than the earlier same day head and neck CTA. The hematoma
is smaller at the level of thoracic inlet than it is either superiorly or
inferiorly. Inferior to the level of thoracic inlet, the hematoma spans 6.2 x
3.7 cm, terminating approximately 1 cm superior to the carina (series 602,
image 64).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: The mediastinal hematoma exerts mild mass effect on the
posterior wall of the trachea, though no significant narrowing is noted. An
endotracheal tube tip terminates approximately 2 cm above the level of the
carina. There is a somewhat nodular area of probable atelectasis in the
anterior right lower lobe abutting the major fissure (series 302, image 158).
There is linear atelectasis or scarring elsewhere at lung bases. There is
mild pleural thickening and punctate pleural calcifications.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: There is a 1.6 cm cyst in hepatic segment VII. An enteric catheter
courses below the diaphragm and outside the field of view, at least to the
level of the gastric body.
BONES: No thoracic spine rib fractures visualized. The known cervical spine
fracture was not included within the field of view on this examination.
IMPRESSION:
1. A large retropharyngeal hematoma extends into the superior mediastinum, not
appreciably changed compared to the earlier same day neck CTA. There is mild
mass effect on the posterior wall of the trachea, but no significant luminal
narrowing.
2. Somewhat nodular opacification focally within the anterior right lower lobe
probably reflects atelectasis. However, recommend three-month follow-up chest
CT to assess stability.
RECOMMENDATION(S): Somewhat nodular opacification focally within the anterior
right lower lobe probably reflects atelectasis. However, recommend three-month
follow-up chest CT to assess stability.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation// Tube placement, evidence of
atelectasis or pneumonia Tube placement, evidence of atelectasis or
pneumonia
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Lungs clear. Moderate cardiomegaly is chronic. No pulmonary edema or pleural
effusion.
ET tube in standard placement. Nasogastric drainage tube ends in the upper
stomach.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with mechanical fall and retropharyngeal
hematoma. Evaluate for fracture.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: CT neck ___
FINDINGS:
There is redemonstration of retropharyngeal hematoma (06:24). There is linear
STIR hyperintensity extending through anterior C4 vertebral body through the
anterior osteophyte extending into the intervertebral disc space, with mild
intervertebral disc edema. There is mild prevertebral soft tissue edema with
questionable injury to the anterior longitudinal ligament. There is also
edema along the inter spinous process and ligamentum nuchae, more significant
at C4/C5 level, there is fluid within the C6-C7 intervertebral disc space with
STIR hyperintensity of the superior C7 vertebral body endplate without
definite T1 hypointensity, possibly related to marrow edema. Patient is
intubated with presence of an enteric tube.
There is 5 mm retrolisthesis of C4 on C5 and 2 mm anterolisthesis of C 2 on
C3. There is loss of intervertebral disc space at C4-C5 through C6-C7 levels
with disc desiccation related to degenerative process.
C2-C3: There is no spinal canal stenosis or neural foraminal narrowing.
C3-C4: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate left and mild right neural foraminal narrowing without
spinal canal stenosis or cord edema.
C4-C5: There is a disc bulge with facet and uncovertebral joint arthropathy
causing moderate spinal canal stenosis with remodeling of spinal cord without
cord edema. There is moderate to severe right and mild left neural foraminal
narrowing.
C5-C6: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate spinal canal stenosis with remodeling of the ventral
with remodeling and flattening of the spinal cord (07:27) with moderate
bilateral neural foraminal narrowing.
C6-C7: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate spinal canal stenosis with remodeling of the ventral
spinal cord without cord edema. There is moderate left and no right neural
foraminal narrowing.
C7-T1: There is no spinal canal stenosis or neural foraminal narrowing.
IMPRESSION:
1. Acute fracture involving the anterior C4 vertebral body with prevertebral
soft tissue edema and probable injury to the anterior longitudinal ligament as
well the as the interspinous ligament.
2. Edema within the C6-C7 intervertebral disc space with probable osseous
edema of the superior C7 vertebral body.
3. Redemonstration of retropharyngeal hematoma.
4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3.
5. Multilevel degenerative changes as detailed above, with moderate spinal
canal stenosis at C4-C5 through C6-C7 levels with spinal cord remodeling,
without definite cord edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with interval change// interval change
IMPRESSION:
In comparison with the study ___, the monitoring support devices are
essentially unchanged. Cardiac silhouette remains mildly enlarged without
evidence of vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new R IJ CVL// assess for CVL location
Contact name: ___: ___ assess for CVL location
IMPRESSION:
Compared to chest radiographs since ___, most recently ___
through ___ at 05:33.
Combination of small to moderate pleural effusions and moderate bibasilar
atelectasis has increased since earlier in the day. Moderate cardiomegaly is
chronic. There is also very mild perihilar edema.
Indwelling cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with retropharyngeal hematoma, intubated// eval
for interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Lines and tubes are in standard position. Bibasilar opacities have markedly
improved. Bilateral effusions have improved. Cardiomegaly, tortuous aorta
and prominent hila bilaterally are stable. There is no evident pneumothorax.
Sternal wires are intact.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with feeding needs// eval dobhoff placement
COMPARISON: Chest x-ray is ___
FINDINGS:
Portable AP semi upright views of the chest were provided.
Dobhoff tube is seen being advanced through the esophagus and ultimately coils
at the GE junction. A enteric feeding tube courses below the diaphragm, but
terminates beyond the field of view of the image. A right internal jugular
central venous catheter terminates in the distal SVC. Endotracheal tube
terminates 2.3 cm above level of carina. There is mild pulmonary vascular
congestion. There is moderate cardiomegaly, stable. There is bibasilar
atelectasis.
IMPRESSION:
Interval placement of Dobhoff feeding tube which coils at the GE junction and
should be repositioned. No other significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with retropharyngeal hematoma// Assess for
interval change Assess for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild cardiomegaly improved, lungs grossly clear, small bilateral pleural
effusions new or newly apparent. No pneumothorax. Right jugular line ends in
the low SVC..
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with dobhoff placement// dobhoff placement
TECHNIQUE: Chest single view
COMPARISON: ___ 12:23
FINDINGS:
Under radiograph taken at 19:24 feeding tube tip is coiled in the proximal
stomach.
On the radiograph taken at 19:32, feeding tube has been pulled back, with tip
in the distal esophagus.
Heart size, mild pulmonary vascular congestion are stable. Mild basilar
opacities have increased, consider worsening edema or atelectasis. Small
bilateral pleural effusions are likely. No pneumothorax.
IMPRESSION:
On the second radiograph, feeding tube tip is in distal esophagus, should be
advanced.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old woman with retropharyngeal hematoma// ability to eat
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 02:16 min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration. Penetration is seen thin and
nectar consistencies, which cleared with subsequent swallow.
IMPRESSION:
No aspiration. Penetration with thin and nectar consistencies.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with RP bleed with C4 VB fx., now with
increased neck pain and post. head pain// evaluate for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Again seen is confluent periventricular and subcortical, brainstem white
matter hypodensities, nonspecific, however likely sequela of severe chronic
small vessel ischemic disease in the absence of acute symptoms, similar..
Bilateral basal ganglia and thalamic hypodensities are also unchanged, thought
to represent a combination of prominent perivascular spaces and chronic
lacunar infarcts. Tiny chronic right cerebellar infarct, stable.
There is no evidence of acute fracture. There is moderate opacification with
fluid in the sphenoid sinus. Submucosal retention cyst in the left maxillary
sinus is. Trace fluid in the inferior left mastoid 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 unremarkable.
Dense calcifications in the carotid siphons are noted.
IMPRESSION:
1. Findings most consistent with severe chronic small vessel ischemic changes
in the absence of acute symptoms. No intracranial hemorrhage.
2. Paranasal sinus disease, suggestive of acute sphenoid sinusitis in the
absence of recent intubation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recent trauma to neck now w/ low-grade
fevers and leukocytosis// rule out pneumonia
IMPRESSION:
In comparison with the study ___, the right IJ catheter has been
removed. Continued enlargement of the cardiac silhouette in a patient with
previous CABG procedure an intact midline sternal wires. Mild elevation of
pulmonary venous pressure with small bilateral pleural effusions and
compressive atelectasis at the bases.
No definite acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Eyelid laceration
Diagnosed with Unsp disp fx of fourth cervical vertebra, init for clos fx, Walked into furniture, initial encounter
temperature: 97.6
heartrate: 87.0
resprate: 18.0
o2sat: 94.0
sbp: 158.0
dbp: 94.0
level of pain: 5
level of acuity: 3.0 | ___ year old female with past medical history notable for afib on
warfarin and recurrent falls. Per report of primary team, she
suffered a fall earlier and struck her head on a doorknob. She
initially was able to get up and refused transfer to the
hospital, but later (<1 hour after), she noticed swelling in her
neck and difficulty breathing.
She was brought to the emergency room where a CT scan of the
neck was done, which showed a large prevertebral retropharyngeal
hematoma with active extravasation of contrast. She was
intubated in the emergency room. The patient was admitted to
the MICU for monitoring and pulmonary toilet.
On arrival to the MICU, the neurosurgical, ENT, and spine teams
were consulted, who did not initially plan for surgical
intervention. The ACS team was consulted given multiple other
areas with evidence of trauma, and recommended transfer to the
TSICU. Imaging of the neck showed active extravasation, venous
vs arterial but the source was unclear. Per Neurosurgery/ENT,
there was no clear surgical intervention to be performed. An MRI
of the neck was done which demonstrated an acute fracture
involving the anterior C4 vertebral body. The patient was
placed in a soft collar for comfort but later discontinue
because the spine was stable and there was only 1 column injury.
An oral-gastric tube was placed for the initiation of tube
feedings. Prior to extubation, the patient underwent a bronch
which demonstrated tracheomalacia. She had pneumonia from group
B strep and was started a 7 day course of antibiotics:
ceftriaxone and azithromycin, which was changed to ancef when
culture date was obtained.
The patient was successfully weaned and extubated on ___. To
provide nutrition after removal of the oral gastric tube, the
patient was evaluated by Speech and Swallow and underwent a
Video swallow. She was transitioned to a soft diet. Because of
the patient's underlying cardiac history, she underwent an
echocardiogram which showed an EF 50-55%, and 2+ MR.
___ patient was transferred to the surgical floor on ___. Her
hematocrit remained stable. On ___, she reported increased neck
and posterior head pain. The Neurosurgery service was
re-consulted and recommended a non-contrast head cat scan which
showed severe chronic small vessel ischemic changes with no
acute process. The patient was given pain medication and warm
compresses and her neck pain decreased in intensity. In
preparation for discharge, she was evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility.
The patient was discharged on HD # 11. Her vital signs were
stable and she was afebrile. She was voiding without difficulty
and had return of bowel function. Her appetite continued to be
decreased and she was provided with nutritional supplements.
She had no difficulty with swallowing. Her hematocrit and white
blood cell count stabilized. Appointments for ___ were
made in the acute care clinic. Discharge instructions were
reviewed and questions answered.
Her anticoagulation was held during this admission, and should
not be continued until discussion with her PCP at ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Paxil
Attending: ___.
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
endoscopic ultrasound with biopsy
History of Present Illness:
___ yo M with PMH of DM2, CAD s/p CABG, ischemic cardiomyopathy
with LVEF 20%, atrial fibrillation on Coumadin, and a recent
history of pancreatitis, cholecystitis, and c. diff colities at
___ who presents from rehab with 2 day history of bloody
bowel movements and an E. coli UTI.
With respect to his stools, patient has been having large-volume
frankly bloody bowel movements. Records do not report melanotic
or black stool.
With respect to his UTI, patient has also been having increased
frequency for the last 2 days for which UA and urine culture was
sent yesterday. UCx returned positive for E. coli today. Patient
spiked to 101.5 today at rehab. Notably, patient has been on
vancomycin PO for recurrent C. diff.
In the ED, initial vitals signs were 97.4, 85, 101/48, 18, 96%
RA. Labs were remarkable for H/H 9.6/29.8, Na 126, INR 2.8,
lactate 3.2 initially which downtrended to 1.6 with IVF. UA
grossly positive. CT abdomen/pelvis showed no obvious source of
GI bleed. During CT scan, patient became hypotensive to 86/40
for which he received 2 L IVF and 1 unit pRBCs given continued
BRBPR in the ED. This resulted in increase in blood pressures.
Patient also received ceftriaxone and Flagyl as well as vitamin
K and FFP for INR. Decision was made to admit to the FICU given
concern for continued hemodynamic instability.
Review of systems:
(+) Per HPI, (+) weight loss 30 lbs since ___. (+)
diarrhea.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain, palpitation. Denies nausea, vomiting.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
- CAD s/p NSTEMI in ___. CABG in ___ (SVG to LAD and Cx to
PDA). PCI in ___ with 90% stenosis of SVG to LAD and OM2
patent with moderate diffuse disease. Stented proximal ramus.
- VFib arrest in ___ s/p ICD and upgrade to BiV in ___
- Ischemic cardiomyopathy with LVEF of 20%
- Atrial fibrillation on Coumadin
- Stable infrarenal AAA
- Irritable bowel syndrome
- ___ esophagus/esophagitis
- Recent pancreatitis
- Current C. diff colitis
- BPH s/p TURP
- Depression
Social History:
___
Family History:
No history of bleeding. No known family history of heart
disease, CA, DM or HTN.
Physical Exam:
Admission Physical Exam:
Vitals- afebrile, 81, 102/43, 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes
CV: Distant heart sounds; Regular rate and rhythm
Abdomen: soft, (+) LLQ tenderness, non-distended, hypoactive
bowel sounds
GU: foley draining faintly bloody urine; (+) blood around
urethral meatus
Ext: warm, well perfused, no edema
Rectal: maroon stool; no hemorrhoids appreciated
Pertinent Results:
PATHOLOGIC DIAGNOSIS:
Esophageal biopsy: Squamous epithelium with active esophagitis
and
foreign pigmented material associated with an inflammatory
exudate. The
foreign material stains strongly for iron and could represent
part of
an iron pill. A rare yeast form is seen in the exudate on GMS
and PAS
stain.
Final Report
INDICATION: Patient with history of C. diff. colitis and
abdominal pain and
bloody bowel movements.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired images through the abdomen and pelvis
was obtained.
Coronally and sagittally reformatted images are provided. 30 cc
of IV
contrast was administered when primary team requested mesenteric
CTA.
Therefore, no true pre-contrast sequence is available. Arterial
and venous
phases were subsequently obtained.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases are clear. The liver demonstrates homogeneous
enhancement.
There is a 12 mm hyperenhancing lesion in segment VII/VIII
(5b:80), most
likely flash-filling hemangioma, unchanged since ___ exam.
There is no
evidence of intrahepatic biliary ductal dilatation. Biliary
stent is
unchanged in position. There is expected pneumobilia
predominantly in the
left hepatic lobe. The portal vein is patent. The gallbladder
is surgically
absent. There is a small hiatal hernia. The spleen is normal
in size. The
pancreas enhances homogeneously without main pancreatic ductal
dilatation.
Focal fatty deposition within the pancreatic head is unchanged
(5b:215).
There is a 1.7 x 1.6 cm hypodensity in the uncinate process of
the pancreas,
which is more conspicuous since priors. The adrenal glands are
unremarkable.
The kidneys enhance and excrete contrast symmetrically without
hydronephrosis
or suspicious renal masses. Subcentimeter renal hypodensities
are too small
to characterize and are most likely cysts.
There is small amount of ascites, increased since prior study.
There is no
mesenteric or retroperitoneal lymphadenopathy. Aorta
demonstrates extensive
calcified atherosclerotic disease with multiple infrarenal
fusiform aneurysms,
the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal
changes extend
to the bilateral iliac vessels, the left measuring 1.6 and the
right measuring
2.2 cm. The right external iliac artery measures 11 mm, and
appears ectatic.
There is moderate narrowing at the origin of the celiac axis.
The SMA is
patent.
There is marked bowel wall edema involving nearly entire colon,
which most
likely relates to patient's known Clostridium difficile
infection. There are
multiple colonic diverticula. There are focal areas of
hyperintensity within
the descending and sigmoid colon (5b:244, 288), which appear
hyperdense on the
arterial phase. However, no significant progression of
hypodensities is seen
within the bowel. The evaluation is limited given lack of
pre-contrast
sequence.
CT OF THE PELVIS: A foley catheter is within the bladder.
Small amount of
air within the bladder likely relates to Foley placement. The
rectum,
prostate gland and seminal vesicles are unremarkable. There is
small amount
of free fluid. There is no free air. No pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony
lesion. Prior
right eigth rib fracture is noted.
IMPRESSION:
1. Limited evaluation due to lack of pre-contrast sequence.
Focal areas of
hyperdensity within the descending and sigmoid colon without
definite
progression, are felt to be hight density intraluminal contents
unlikely to
represent GI bleed; however, this cannot be definitely excluded
due to
limitation of the study.
2. Diffuse colonic edema, compatible with patient's known
history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely
flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the
pancreas, more
conspicuous since prior studies, which can be further assessed
with MRCP, if
patient's pacemaker is MR compatible. Otherwise, consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta
with associated
aneurysmal changes, stable.
8. Small hiatal hernia.
The study and the report were reviewed by the staff radiologist.
===========================
LABS ON ADMISSION:
===========================
___ 04:45PM BLOOD WBC-4.5 RBC-2.88* Hgb-9.6* Hct-29.8*
MCV-104* MCH-33.5* MCHC-32.3 RDW-17.3* Plt ___
___ 04:45PM BLOOD Neuts-86.8* Lymphs-7.9* Monos-4.6 Eos-0.4
Baso-0.3
___ 04:45PM BLOOD ___ PTT-28.2 ___
___ 04:45PM BLOOD Glucose-160* UreaN-22* Creat-1.0 Na-126*
K-4.3 Cl-85* HCO3-31 AnGap-14
___ 11:05PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7
___ 04:45PM BLOOD Albumin-2.7*
___ 04:45PM BLOOD ALT-16 AST-30 AlkPhos-139* TotBili-0.7
___ 04:45PM BLOOD Lipase-32
___ 05:01PM BLOOD Lactate-3.2*
___ 07:11PM BLOOD Lactate-1.6 K-3.6
===========================
LABS ON DISCHARGE:
===========================
===========================
OTHER RESULTS:
===========================
___ CT Ab/Pelvis
IMPRESSION: PRELIM READ
1. Limited evaluation due to lack of pre-contrast sequence.
Focal areas of
hyperdensity within the descending and sigmoid colon without
definite
progression, are felt unlikely to represent GI bleed; however,
this cannot be definitely excluded due to limitation of the
study.
2. Diffuse colonic edema, compatible with patient's known
history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely
flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the
pancreas, more
conspicuous since prior studies, which can be further assessed
with MRCP, if patient's pacemaker is MR compatible. Otherwise,
consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta with
associated aneurysmal changes, stable.
8. Small hiatal hernia.
PRIOR GI PROCEDURES:
___ Colonoscopy -
Diverticulosis of the sigmoid colon
Grade 2 internal hemorrhoids
Polyps in the colon
There was a blue lesion at 60cm which may have been trauma or an
old scar.
___ EGD -
Normal mucosa in the whole examined duodenum
Normal mucosa in the whole stomach
Small hiatal hernia
There was a ''pocket'' in the distal esophagus where the lumen
took a sharp turn. There was a presbyesophagus more
proximally.The Z-line was slightly irregular, but there was no
definite ___ esophagus. No biopsies were done due to the
anticoagulation.
Otherwise normal EGD to third part of the duodenum
___ 06:50AM BLOOD WBC-7.9 RBC-2.97* Hgb-9.9* Hct-29.8*
MCV-100* MCH-33.2* MCHC-33.1 RDW-17.8* Plt ___
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-131*
K-3.9 Cl-95* HCO3-29 AnGap-11
___ 05:09AM BLOOD CA ___ -Test
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 300 mg PO QPM
5. Allopurinol ___ mg PO QPM
6. Torsemide 20 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Aspirin 81 mg PO DAILY
11. Digoxin 0.125 mg PO DAILY
12. Metoprolol Tartrate 50 mg PO BID
13. Vancomycin Oral Liquid ___ mg PO Q6H
14. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
15. Warfarin 5 mg PO DAILY16
16. Gabapentin 600 mg PO BID
17. Docusate Sodium 100 mg PO BID
18. Omeprazole 40 mg PO DAILY
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Allopurinol ___ mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 50 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness
9. Torsemide 20 mg PO DAILY
10. Vancomycin Oral Liquid ___ mg PO Q6H
11. Warfarin 3 mg PO DAILY16
12. Docusate Sodium 100 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Finasteride 5 mg PO DAILY
15. Gabapentin 300 mg PO QPM
16. Gabapentin 600 mg PO BID
17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
18. Pravastatin 40 mg PO DAILY
19. Omeprazole 40 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
e. coli septicemia
e coli uti
gi bleeding
ischemic colitis
acute blood loss anemia
chronic systolic chf
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: Patient with history of C. diff. colitis and abdominal pain and
bloody bowel movements.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired images through the abdomen and pelvis was obtained.
Coronally and sagittally reformatted images are provided. 30 cc of IV
contrast was administered when primary team requested mesenteric CTA.
Therefore, no true pre-contrast sequence is available. Arterial and venous
phases were subsequently obtained.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases are clear. The liver demonstrates homogeneous enhancement.
There is a 12 mm hyperenhancing lesion in segment VII/VIII (5b:80), most
likely flash-filling hemangioma, unchanged since ___ exam. There is no
evidence of intrahepatic biliary ductal dilatation. Biliary stent is
unchanged in position. There is expected pneumobilia predominantly in the
left hepatic lobe. The portal vein is patent. The gallbladder is surgically
absent. There is a small hiatal hernia. The spleen is normal in size. The
pancreas enhances homogeneously without main pancreatic ductal dilatation.
Focal fatty deposition within the pancreatic head is unchanged (5b:215).
There is a 1.7 x 1.6 cm hypodensity in the uncinate process of the pancreas,
which is more conspicuous since priors. The adrenal glands are unremarkable.
The kidneys enhance and excrete contrast symmetrically without hydronephrosis
or suspicious renal masses. Subcentimeter renal hypodensities are too small
to characterize and are most likely cysts.
There is small amount of ascites, increased since prior study. There is no
mesenteric or retroperitoneal lymphadenopathy. Aorta demonstrates extensive
calcified atherosclerotic disease with multiple infrarenal fusiform aneurysms,
the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal changes extend
to the bilateral iliac vessels, the left measuring 1.6 and the right measuring
2.2 cm. The right external iliac artery measures 11 mm, and appears ectatic.
There is moderate narrowing at the origin of the celiac axis. The SMA is
patent.
There is marked bowel wall edema involving nearly entire colon, which most
likely relates to patient's known Clostridium difficile infection. There are
multiple colonic diverticula. There are focal areas of hyperintensity within
the descending and sigmoid colon (5b:244, 288), which appear hyperdense on the
arterial phase. However, no significant progression of hypodensities is seen
within the bowel. The evaluation is limited given lack of pre-contrast
sequence.
CT OF THE PELVIS: A foley catheter is within the bladder. Small amount of
air within the bladder likely relates to Foley placement. The rectum,
prostate gland and seminal vesicles are unremarkable. There is small amount
of free fluid. There is no free air. No pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion. Prior
right eigth rib fracture is noted.
IMPRESSION:
1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of
hyperdensity within the descending and sigmoid colon without definite
progression, are felt to be hight density intraluminal contents unlikely to
represent GI bleed; however, this cannot be definitely excluded due to
limitation of the study.
2. Diffuse colonic edema, compatible with patient's known history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more
conspicuous since prior studies, which can be further assessed with MRCP, if
patient's pacemaker is MR compatible. Otherwise, consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta with associated
aneurysmal changes, stable.
8. Small hiatal hernia.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.4
heartrate: 85.0
resprate: 18.0
o2sat: 96.0
sbp: 101.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | ___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with
LVEF 20%, atrial fibrillation on Coumadin, and a recent history
of pancreatitis, cholecystitis, and c. diff colitis presents
with BRBPR and UTI and admitted initially to the MICU due to
transient hypotension while in the ED.
# BRBPR/GI bleeding - Pt. presented with 2 day history of large
bloody bowel movements. Rectal exam revealed maroon stools.
Despite bloody bowel movements, H/H relatively stable on
admission at 9.6/29.8 from 10.6/32.1 one month prior. Pt.
responded appropriately to 1U PRBC in the ED. Pt. had one
episode of hypotension that resolved with transfusion and IVF.
No evidence of source on CT ab/pelvis, though limited by lack of
PO contrast. EGD without clear source of bleed in ___.
Colonoscopy ___ did show hemorrhoids as well as sigmoid
diverticuli. Pt's INR was reversed in the ED with vitamin K and
FFP. Pt. was seen by GI who felt that bleed most likely
diverticular vs ischemic colitis. Pt. remained hemodynamically
stable without further drop in H/H and so was transferred to the
floor on hospital day 2 He got one additional unit of RBC and
hemoglobin prior to discharge was 9.6.
#Pancreas lesion: not consistent with solid mass on endoscopic
ultrasound. Underwent pancreas biopsy that did not show
malignancy. He will have f/u with Dr. ___ adv endoscopy
team for biliary stent removal and can discuss future imaging of
abd at that time. CA ___ tumor marker normal level.
- ERCP in 6 weeks
- CT pancreas protocol in 4 weeks, follow up with Dr. ___
___
# Hypotension: Pt. transiently hypotensive to 86/40 while
undergoing CT scan in the emergency department. Hypotension
resolved with administration of IVF and blood transfusion. He
never required pressors. Given blood loss and bacteremia,
hypotension was likely related to combination of hypovolemia and
possibly sepsis. Pt. had no further episodes of hypotension.
# E. coli bacteremia and UTI - Per nursing home report, culture
from the day prior to admission was growing E. coli, though pt.
had not yet been initiated on antibiotics. UA grossly positive
on arrival to ___. Pt. initiated on ceftriaxone. Blood and
urine cultures, however, grew E. coli resistant to ceftriaxone
and so pt. transitioned to meropenem. He received 9 day of
antibiotics from first day of negative blood culture on ___ to
end on ___. PICC line placed in mid line position to be removed
prior to discharge.
# C. difficile colitis: Per reports, pt. has history of
recurrent C. diff. Pt. admitted on PO vancomycin (DAY ___
END ___. However, consider extending course given recent
treatment with Meropenem for UTI
# Hyponatremia: Pt. hyponatremic on admission with Na 126.
After IVF and blood transfusion, sodium improved to 130.
# DM2: At home, pt. is not on insulin, though he is covered by
low dose sliding scale at rehab. Pt. was continued on insulin
sliding scale during this admission.
# Cardiac disease: Pt. with atrial fibrillation (CHADS2 of 4; on
Coumadin), CAD, and CHF (EF 20%). Pt's INR was reversed on
admission due to active GI bleed with 10 IV vitamin K and FFP.
His home torsemide was held in setting of hypotension and then
resumed at lower dose. Coumadin resumed prior to discharge. He
was continued on home aspirin, digoxin, metoprolol, and
pravastatin.
- Torsemide may require uptitration
# Gout: Continued home prednisone and allopurinol.
# BPH: Continued home finasteride.
# Transitional issues:
- Contact: ___ (wife) ___
- Code: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Supraventricular tachycardia ablation (___)
History of Present Illness:
___ man, past medical history of hypertrophic
cardiomyopathy status post alcohol septal ablation, presents
with
epigastric gas-like pain. He states he usually goes away with
antacids. States that it "feels like gas-like pain" but when
further asked, agreed that it felt like palpitations. No
lightheadedness or dizziness. Some mild increased fatigue
recently. No chest pain, chest pressure, SOB, DOE, ___ edema,
orthopnea, dizziness, lightheadedness, syncope, or falls. Had an
episode two months prior where he woke up trying to catch his
breath.
He was seen by his PCP in office for a routine follow-up
regarding this discomfort. They did an EKG and it showed that he
was in a rapid supraventricular rhythm. Therefore he was
transferred here. The patient states he has had these sensations
on and off for over a month and a half at this time.
Patient last saw his EP specialist, Dr. ___, in clinic in
___. Per note: "At present, he appears to be
asymptomatic to his LVOT obstruction and does not have
exertional
symptoms. However, given his occasional indigestion with
activity, I will have him undergo stress testing. I will also
have him repeat a Holter monitor. Holter/stress showed SR as
underlying rhythm, rare APDs, frequent multiform VPDs and 3-beat
run of VT is noted. He reported feeling well during monitoring
period. No changes were made to his management.
In the ED, EKG interpreted as supraventricular tachyarrhythmia,
likely atrial flutter. Given IV diltiazem 15 mg. Immediately
converted into sinus rhythm.
Past Medical History:
___ s/p colectomy w/ ileoanal anastomosis, asthma, anxiety,
hypertrophic cardiomyopathy, recurrent GI bleeds in ___ (source
never identified despite extensive workup, including Spirus
enteroscopy, Meckel's scan, multiple CTAs and routine standard
upper and lower endoscopy; ultimately thought to be a SB AVM)
PSH: colectomy w/ileoanal anastomosis, ileostomy takedown
Social History:
___
Family History:
Notable for a brother with ulcerative colitis who died of an
MI
at age of ___, uncle with colon cancer, Brother with prostate and
gastric cancer, and sister with breast cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: T 97.6 BP 145/90 HR 59 RR 18 96%Ra
GENERAL: well developed, well nourished in NAD
HEENT: sclera anicteric, MMM
NECK: JVP at at level of clavicle, no LAD
CARDIAC: RRR, no mrg, heart sounds soft
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, MAE anti-gravity
DISCHARGE EXAM:
GENERAL: well developed, well nourished in NAD
HEENT: sclera anicteric, MMM
NECK: JVP flat while lying at 30 degrees, no LAD
CARDIAC: RRR, heart sounds soft. No HCOM murmur with valsava.
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present
GU: After EP study, bilateral femoral access points evaluated.
There is no underlying hematoma, no bruit auscultated
bilaterally. Sites are covered with clean dry gauze.
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, MAE anti-gravity
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-11.9* RBC-5.04 Hgb-15.4 Hct-49.4
MCV-98 MCH-30.6 MCHC-31.2* RDW-12.9 RDWSD-46.4* Plt ___
___ 06:50PM BLOOD Glucose-120* UreaN-12 Creat-1.1 Na-146
K-4.2 Cl-109* HCO3-26 AnGap-11
___ 06:50PM BLOOD CK-MB-17* MB Indx-6.0 cTropnT-0.03*
PERTINENT RESULTS:
TTE: ___
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional
systolic function. Global systolic function is hyperdynamic. No
valvular ___ or resting/inducible
intracavitary gradient. Mildly dilated aortic arch
DISCHARGE LABS:
___ 07:51AM BLOOD WBC-7.6 RBC-5.21 Hgb-16.2 Hct-49.4 MCV-95
MCH-31.1 MCHC-32.8 RDW-12.7 RDWSD-44.3 Plt ___
___ 07:51AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-141
K-4.4 Cl-107 HCO3-23 AnGap-11
___ 05:10AM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-0.03*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 120 mg PO Q24H
2. Amitriptyline 10 mg PO QHS
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 30 Days
2. Amitriptyline 10 mg PO QHS
3. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
====================
-Supraventricular tachycardia due to atrioventricular node
re-entrant tachycardia (AVNRT)
SECONDARY DIAGNOSIS/ES:
========================
-Troponin elevation (demand myocardial infarction)
-Hypertrophic cardiomyopathy
-Hypertension
-Ulcerative colitis
-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: History: ___ with tachycardia, palpitations// assess for pna
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are lower compared to the previous exam. There is mild cardiac
enlargement, slightly increased from the prior exam. The aorta is mildly
tortuous. Mediastinal and hilar contours are otherwise unremarkable.
Pulmonary vasculature is not engorged. Lungs appear clear. No pleural
effusion or pneumothorax. No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Palpitations
Diagnosed with Unspecified atrial flutter
temperature: 96.0
heartrate: 161.0
resprate: 18.0
o2sat: 99.0
sbp: 141.0
dbp: 112.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a pleasant ___ y/o gentleman with a PMH of
hypertrophic cardiomyopathy s/p ETOH septal ablation, ulcerative
colitis s/p total protocolectomy, and hypertension, who
presented with several weeks of palpitations, found to be in
supraventricular tachyarrhythmia most likely c/w AVNRT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
intraparenchymal hemorrhage with intraventricular hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male on Coumadin who lives in assisted living who
suffered
a witnessed fall today. He was being transferred from his
wheelchair to bed when he fell onto his left side and struck his
head this morning at 8:45am. It is unclear whether the patient
had loss of consciousness at the time of the fall. A cranial CT
was done at 1pm that revealed a hemorrhage into an old stroke
bed.
Patient's INR was 3.0 at presentation. He was given Kcentra and
vitamin K.
Patient's son endorses a seizure history and states that he had
a
seizure last week.
Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension
2. CARDIAC HISTORY:
-CABG: ___
-PERCUTANEOUS CORONARY INTERVENTIONS: ___
- embolic stroke in ___ after PCI c/b hemorrhagic conversion
after receiving TPA
- psoriasis
- hypothyroid
- afib
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. His son does
have CAD and is s/p MI with stent placement in his ___.
Physical Exam:
On Admission:
O: T:38.4 BP:100 /65 HR:72 R18 O2Sats 95
Gen: WD/WN, comfortable, NAD.
HEENT:Left eye ecchymosis
Neck: Trauma collar
Cardiac: Irregular
Abd: Soft,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, but arousable
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3mm
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: Left upper and lower extremity contracture from previous
stroke, right side full strength.
C/o left hip pain with palpation
On Discharge:
Left periorbital ecchymosis, Alert and oriented x3, left side
contracted and plegic, R side 4+/5 throughout
Pertinent Results:
___ 09:06AM PLT COUNT-189
___ 09:06AM ___ PTT-31.5 ___
___ 02:06PM WBC-10.9# RBC-4.46* HGB-12.9* HCT-41.8 MCV-94
MCH-28.9 MCHC-30.8* RDW-15.6*
___ NCHCT
1. Right frontal intraparenchymal hemorrhage in the region of
encephalomalacia related to prior right MCA infarct. Hemorrhage
extending into the bilateral lateral ventricles and the third
ventricle. Small left frontal contusion versus subarachnoid
hemorrhage.
2. Segmental fracture of the left zygomatic arch.
___ CT Cspine
No evidence of acute fracture or dislocation.
___ Chest Xray
No definite acute cardiopulmonary process.
___ Hip Films
1. Apparent foreshortening of the right femoral neck, not well
assessed on
this study, although this does not appear to be the patient's
site of concern.
2. No evidence of acute fracture or dislocation of the left
hip.
___ Pelvis AP film
1. Apparent foreshortening of the right femoral neck, not well
assessed on
this study, although this does not appear to be the patient's
site of concern.
2. No evidence of acute fracture or dislocation of the left
hip.
___ CT SINUS/MANDIBLE/MAXIL
Segmental fracture of the left zygomatic arch and possible
nondisplaced
fracture of the lateral wall of left orbit.
___ ___
Large parenchymal hemorrhage in the right MCA territory at the
site of prior infarction with overall minimal change from prior
exam. Intraventricular hemorrhage again noted without evidence
of obstructive hydrocephalus or herniation. Left zygomatic arch
fracture.
HEAD CT ___:
Final read pending at time of discharge:
Stable IPH with improved IVH and stable ventricular size.
Medications on Admission:
Lisinopril 2.5mg', Keppra 500mg ___, wed, ___ and ___,
Metoprolol succ ER 12.5 mg ', Aspirin 81mg',Levothyroxine
75mcg',
fish oil, atorvastatin 80mg', Coumadin 2mg', metamucil '
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain or fever > 101.4
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO DAILY
4. LeVETiracetam 500 mg PO BID
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
intraparenchymal hemorrhage
IVH
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: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ year old man with zygomatic arch fx // other fx?
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal and sagittal reformatted images were obtained and reviewed.
DOSE: DLP: 583.83 mGy-cm; CTDI: 25.94 mGy
COMPARISON: Comparison is made with CT head from ___.
FINDINGS:
Segmental fracture of the left zygomatic arch is again seen, similar to prior
head CT. There is also a possible nondisplaced fracture of the lateral wall of
the left orbit. No other fracture or dislocation is seen. Mucosal thickening
is seen in the bilateral maxillary sinuses and ethmoid air cells. Otherwise,
the visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The ostiomeatal units are patent bilaterally.
Limited views of the brain again demonstrate intracranial bleed, better
characterized on recent head CT.
IMPRESSION:
Segmental fracture of the left zygomatic arch and possible nondisplaced
fracture of the lateral wall of left orbit.
Radiology Report
INDICATION: ___ male with intracranial hemorrhage, evaluate for
evolution.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 1226 mGy-cm
COMPARISON: Head CT ___.
FINDINGS:
Encephalomalacia in the right MCA territory again noted, compatible with a
chronic infarction ,which can be seen extending back to ___. Acute hemorrhage
within this region of encephalomalacia is again noted (in the right temporal
and frontal lobes as well as the rt basal ganglia) extending into the right
lateral ventricle. There has been minimal increase in overall volume of
hemorrhage from previous study. Intraventricular hemorrhage extends into the
lateral ventricles and third ventricle without significant change in
ventricular size or evidence of obstructive hydrocephalus. Subarachnoid
hemorrhage in the right temporal lobe is unchanged (2 a: 13). Ex vacuo
dilation of the right ventricle is unchanged. Minimal hyperdensity previously
seen adjacent to the left inferior frontal lobe, thought to represent a tiny
component of subarachnoid hemorrhage is not clearly visualized on this exam.
There remains no shift of midline structures. Basal cisterns remain patent.
Again seen, is an acute segmental fracture through the left zygomatic arch.
There is mild mucosal thickening of the maxillary sinuses. The remaining
sinuses are clear. Postsurgical changes in the calvarium noted on the right
side.
IMPRESSION:
Large parenchymal hemorrhage in the right MCA territory at the site of prior
infarction with overall minimal change from prior exam. Intraventricular
hemorrhage again noted without evidence of obstructive hydrocephalus or
herniation. Left zygomatic arch fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with IVH, IPH // Eval for interval change;
assess for increase vent size; pls do ___ AM
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 55 mGy
DLP: 1003.42 mGy-cm
COMPARISON: CT head without contrast ___
FINDINGS:
In comparison the previous examination, again seen is a large intraparenchymal
hemorrhage on chronic encephalomalacia with interventricular hemorrhage
unchanged from the previous examination with stable midline shift and mass
effect. There is again demonstrated fractures the left zygomatic arch and
patient is status post craniotomy.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Atherosclerotic mural calcification of the vertebral and internal carotid
arteries is noted.
The globes are unremarkable.
IMPRESSION:
Unchanged intraparenchymal hemorrhage and left zygomatic fractures from
previous examination. No new areas of hemorrhage or infarction.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Eye pain
Diagnosed with BRAIN HEM NEC W/O COMA, FX MALAR/MAXILLARY-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT
temperature: 38.4
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 100.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted from the emergency department to the
surgical intensive care unit on ___ after being adminstered
Kcentra and vitamen K. His aspirin and coumadin were held. A
trauma evaluation was started which included a dedicated CT
SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic
surgery was asked to consult regarding.
___, the patient's exam remained stable. Plastic surgery
reviewed the CT of the sinus which showed segmental fracture of
the left zygomatic arch and possible nondisplaced fracture of
the lateral wall of left orbit. Plastics recommended that the
patient follow up with them in clinic following discharge from
the hospital. He had a repeat NCHCT which showed a stable bleed
interval.
On ___, patient was stable and transferred to the floor.
On ___, the patient remained neurologically stable and was
pending a bed to rehab.
On ___, patient was stable on examination. Repeat head CT was
performed and showed stable ventricular size and improved IVH.
He was accepted at rehab and was discharged in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Non - healing left toe amp site with dry gangrene
Major Surgical or Invasive Procedure:
___ LLE angiogram
___ LLE TMA
History of Present Illness:
Mr. ___ is a ___ gentleman with a complex vascular
history who has undergone multiple bilateral lower extremity
procedures. He has a history of end-stage renal disease and is
currently being dialyzed through a right groin tunneled
catheter. He presents with dry gangrene of his remaining three
toes on his left foot. We have planned for left lower extremity
angiogram via the right groin with further intervention to be
dictated by our findings.
Past Medical History:
- ESRD for ___ years. Per medical records, ESRD was ___ severe
HTN, though pt reports it followed a gunshot wound to the chest
(with possible hypotension and ischemic ATN). He has since
required HD, w/ multiple past IV access procedures. Currently
undergoes dialysis MWF at ___ in ___
- Status post DDRT in ___ (at ___.
___ RRT in the interim, but graft failed ___ years later.
- Hypertension
- Parathyroid hyperactivity with "soft bones". Parathyroid was
surgically removed ___ years ago.
- Status post GSW to right chest ___ years ago. The apical
portion of the right lung is removed.
Social History:
___
Family History:
Denies premature coronary artery disease
Physical Exam:
ON ADMISSION:
Phys Ex:
VS - 98.4 80 96/54 20 97% RA
Gen - in mild distress ___ pain
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
MSK & extremities/skin - s/p R BKA, L ___ toe amp w/ dry eschar
over wound (picture uploaded to ___), b/l palpable femoral
pulses(faint), dopplerable L AT and ___ signals
ON DISCHARGE:
Pertinent Results:
___ 05:12AM BLOOD WBC-8.3 RBC-3.66* Hgb-10.5* Hct-34.5*
MCV-94 MCH-28.7 MCHC-30.4* RDW-17.5* RDWSD-59.6* Plt ___
___ 05:18AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.9* Hct-35.6*
MCV-94 MCH-28.9 MCHC-30.6* RDW-17.6* RDWSD-60.0* Plt ___
___ 05:24PM BLOOD Neuts-70.5 Lymphs-15.8* Monos-7.9 Eos-3.3
Baso-0.6 NRBC-0.4* Im ___ AbsNeut-7.89* AbsLymp-1.77
AbsMono-0.89* AbsEos-0.37 AbsBaso-0.07
___ 05:12AM BLOOD Plt ___
___ 05:12AM BLOOD ___ PTT-33.7 ___
___ 05:12AM BLOOD Glucose-76 UreaN-48* Creat-9.7*# Na-138
K-5.0 Cl-95* HCO3-24 AnGap-19*
___ 05:18AM BLOOD Glucose-90 UreaN-37* Creat-7.7*# Na-136
K-4.9 Cl-95* HCO3-26 AnGap-15
___ 05:12AM BLOOD Calcium-9.0 Phos-7.8* Mg-2.0
___ 05:18AM BLOOD Calcium-9.0 Phos-6.7* Mg-2.0
___ 06:45AM BLOOD Vanco-22.8*
___ 05:03AM BLOOD Vanco-10.5
___ 05:33PM BLOOD Creat-8.3* K-3.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 100 mg PO TID:PRN pain
3. Omeprazole 20 mg PO DAILY
4. Percocet (oxyCODONE-acetaminophen) ___ mg oral TID:PRN
pain
5. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
6. Aspirin 81 mg PO DAILY
7. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Nephrocaps 1 CAP PO DAILY
RX *B complex with C 20-folic acid [Mynephrocaps] 1 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3
3. Percocet (oxyCODONE-acetaminophen) 1 tab mg oral TID:PRN
pain
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Gabapentin 100 mg PO TID:PRN pain
7. Omeprazole 20 mg PO DAILY
8. Senna 17.2 mg PO DAILY
9. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PERIPHERAL VASCULAR DISEASE
CHRONIC RENAL FAILURE
GANGRENE, dry
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pre-op // PNA
TECHNIQUE: AP view of the chest.
COMPARISON: Chest CT from ___ and chest x-ray from ___.
FINDINGS:
Surgical material projects over the right upper lung as seen previously. The
lungs are clear without consolidation, effusion, or edema. Mild cardiomegaly
is again noted. Old healed right-sided rib fractures are noted as well as a
median sternotomy. Inferior approach central venous catheter tip projects
over the right atrium. Resorption of the distal right clavicle is noted,
chronic.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ male with left foot pain // osteo, fracture
TECHNIQUE: 3 nonweightbearing views of the left foot. Please note
COMPARISON: None
FINDINGS:
Status post resection of the first digit to the proximal aspect of the
proximal phalanx. The osteotomy is irregular and uncorticated, consistent
with recent resection. Apparent linear lucency extending toward the base of
the medial aspect of the remaining proximal phalanx could be artifactual due
to overlying skin defect, although fracture or osteomyelitis would be
difficult to exclude. Soft tissue swelling and apparent skin defects are seen
about the stump. No subcutaneous gas is identified. No dislocation is seen.
There is mild osseous demineralization throughout. There are mild
degenerative changes throughout the foot. Extensive vascular calcifications
are seen.
IMPRESSION:
Status post resection of the first digit with expected postsurgical changes.
Apparent linear lucency extending from the osteotomy toward the base of the
remaining proximal phalanx could be artifactual due to overlying skin defect,
although fracture or osteomyelitis would be difficult to exclude.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ HTN, ESRD on HD after failed renal transplant (___), and
extensive vascular surgical history w/ open L toe amp wound, s/p L pop/AT
stent // st depression st depression
IMPRESSION:
Comparison to ___. Stable postoperative right apical changes.
Stable sternotomy wires and inferior vena cava device. Borderline size of the
cardiac silhouette. Stable subtle ___ bronchial opacities, new as compared
to the previous examination, and potentially reflecting mild interstitial
edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with Local infection of the skin and subcutaneous tissue, unsp
temperature: 98.5
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 91.0
dbp: 47.0
level of pain: 9
level of acuity: 3.0 | Patient underwent LLE angiogram with popliteal artery and
anterior tibialis artery stent on ___. It was decided to
pursue a LLE transmetatarsal amputation and was added on for
___. The patient was NPO prior to ___ procedure, but the
case had to bumped to ___ due to limited OR availability.
Surgery was rescheduled for ___. Patient received dialysis
on the morning of his procedure, which he has getting every 3
days. After induction of general anesthesia for LLE
transmetatarsal amputation, anesthesia noticed low blood
pressure and ST depressions. At this time, it was decided to
hold off on the procedure and consult cardiology. Cardiology
stated that the event was most likely secondary to demand
ischemia due to no EKG changes post operatively. However, they
wanted to assess patients cardiac status through cardiac
catheterization. He was added on for ___. Patient was unable
to undergo cardiac catheterization and was reschedule for
___. It was on ___ that patient decided he wanted to
leave the hospital and come back at another time for the cardiac
procedure. This was against medical advice and patient
understood. He was advised to continue aspirin and plavix. He
was written a script for Augmentin PO for 2 weeks. Patient was
contacted by vascular and cardiac surgery for follow up
appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Celexa / latex / morphine
Attending: ___.
Chief Complaint:
Abdominal Pain due to Hemmorhagic Ovarian Cyst
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female who presents with a known hemorrhagic ovarian
cyst with severe left lower quadrant pain which radiates to the
back which began while in exercise class today while performing
a pushup. She apparently felt a popping sensation in the LLQ and
the severe pain shot to her left inguinal crease to her left
labia. She felt the sensation of liquid there, but was dry.
Since then she has had intermittant nausea and severe sharp
shooting pain.
She states that about 1 week prior to admission her stools
became quite pale ___ like") and had one bout of diarhea. She
states the pain did not worsen with eating. The stools have
continued very pale.
The patient is at the end of her mestrual period, and she notes
that it was one day late. In the ED her initial vitals were
98.2, 85, 105/68, 20, 96%. She underwent an ultrasound (pelvic
and transvaginal) along with a CT Abdoment/Pelvis without any
explanation of the pain. In addition she was seen by OBGYN
consult in the ED, although there is no consult note on the
dashboard or OMR, it appears that they felt the cyst would not
be explaining this. In the ED she was given fentanyl, dilaudid,
ondansetron, ketorolac x2 and promethazine without relief. She
arrives on the ward dry heaving in ___ pain.
Past Medical History:
Chronic Stable Asthma
ADHD
Peptic ulcer disease
Appendectomy
Tonsillectomy
Social History:
___
Family History:
Father: ___ Cancer
Mother: DM, DVT
Physical Exam:
PHYSICAL EXAM:
VSS: 98.2, 98/62, 80, 18, 100%RA
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Moderate LLQ TTP, + Left CVAT, - rebound, - guarding, +BS,
- distension
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE EXAM:
Stable vitals
Soft abdomen with volunatary guarding
Pertinent Results:
___ 01:00AM BLOOD WBC-8.1 RBC-4.23 Hgb-13.3 Hct-39.1 MCV-92
MCH-31.4 MCHC-34.0 RDW-12.3 RDWSD-41.5 Plt ___
___ 01:00AM BLOOD Neuts-42.0 ___ Monos-9.0 Eos-3.1
Baso-1.0 Im ___ AbsNeut-3.38 AbsLymp-3.61 AbsMono-0.73
AbsEos-0.25 AbsBaso-0.08
___ 01:00AM BLOOD Glucose-105* UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-23 AnGap-18
___ 01:00AM BLOOD ALT-19 AST-19 LD(LDH)-135 AlkPhos-61
TotBili-0.1
___ 01:00AM BLOOD Albumin-4.5
___ 01:17AM BLOOD Lactate-1.8
___ 04:05AM URINE Color-Straw Appear-Clear Sp ___
___ 04:05AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:05AM URINE RBC-16* WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
___ 04:05AM URINE UCG-NEGATIVE
PELVIS U.S., TRANSVAGINAL Study Date of ___ 1:56 AM
PELVIS, NON-OBSTETRIC Study Date of ___ 1:56 AM
IMPRESSION:
1. 12 mm left ovarian dermoid.
2. Otherwise normal ovaries without evidence of torsion.
3. Millimetric anterior wall fibroid.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:01 AM
IMPRESSION:
1. No acute CT findings of the abdomen and pelvis.
2. 9 mm left ovarian dermoid as seen on same-day ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed for pain Disp #*50 Tablet Refills:*0
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg 1 tab by mouth once every 4 hours as needed
for anxiety/pain Disp #*24 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
for pain Disp #*28 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*5
Capsule Refills:*0
6. Metoclopramide 10 mg PO Q8H:PRN nausea
RX *metoclopramide HCl 10 mg 1 tab by mouth every 8 hours as
needed for nausea Disp #*21 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed for nausea Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Renal colic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History of ovarian cyst presenting with pelvic pain.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Pelvic ultrasound ___.
FINDINGS:
The uterus is anteverted and measures 9.1 x 3.0 x 4.7 cm. The endometrium is
homogenous and measures 4 mm. 5 mm anterior wall fibroid as seen previously.
12 mm left ovarian dermoid. The ovaries are otherwise normal. Ovarian
vascularity is preserved. There is trace free fluid.
IMPRESSION:
1. 12 mm left ovarian dermoid.
2. Otherwise normal ovaries without evidence of torsion.
3. Millimetric anterior wall fibroid.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: Left lower quadrant pain and tenderness to palpation.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: DLP: 484.91 mGy cm
COMPARISON: Same-day pelvic ultrasound.
FINDINGS:
Heart size is normal without significant pericardial fluid. Imaged lung bases
are clear.
CT abdomen with contrast:
Millimetric hypodensity in hepatic segment 8 is too small to fully
characterize but likely represents a biliary hamartoma. Liver otherwise
enhances homogeneously without suspicious focal mass or biliary dilatation.
Gallbladder is unremarkable. Portal vein is patent.
Spleen, pancreas and adrenal glands are unremarkable. Kidneys present
symmetric nephrograms and excretion of contrast without focal lesion or
hydronephrosis.
Stomach, duodenum and small bowel loops are unremarkable without evidence of
obstruction. Large bowel is thin-walled and unremarkable without pericolonic
fat stranding or fluid collection.
Abdominal aorta is normal caliber. No mesenteric or retroperitoneal
lymphadenopathy. No ascites, pneumoperitoneum or abdominal hernia.
CT pelvis with contrast:
Uterus, right ovary and rectum are unremarkable. Small free pelvic fluid. 9
mm fat density left ovarian lesion corresponding to dermoid seen on same-day
ultrasound. No free pelvic air. No inguinal or pelvic sidewall
lymphadenopathy by CT size criteria.
Bones and soft tissues:
No suspicious focal bone lesion.
IMPRESSION:
1. No acute CT findings of the abdomen and pelvis.
2. 9 mm left ovarian dermoid as seen on same-day ultrasound.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.2
heartrate: 85.0
resprate: 20.0
o2sat: 96.0
sbp: 105.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | 1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with
vomitting: Pain was out of proportion to exam, requiring
dilaudid PCA for HD 2, however patient eventually felt it may be
more anxiety related, was switched to oral oxycodone tylenol
motrin. Renal stone is most likely given clinical picture of
writhing ___ pain, though exams reviewed with radiology and no
evident stone, good ureteral perfusion jets to bladder
indicating no osbstruction, no other intraab pathology.
Discharged hospital day three with tamsulosin. Tolerating PO.
2. Chronic Stable Asthma
- Albuterol
3. ADHD
- Currently off all amphetamines (stopped 4 months prior to
admit)
Full Code
Ambulation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ - Pipeline embolization for R ICA pseudoaneurysm
History of Present Illness:
___ is a ___ year old female with PMH of PCOMM
aneurysm s/p clipping on ___ with Dr. ___ unsecured
left para-opthalmic artery aneurysm. She had been having
headaches for one week prior to presentation that significantly
worsened on day of presentation with associated nausea and
vomiting. NCHCT at OSH showed acute SAH with IVH. She was
transferred to ___ for further evaluation and treatment.
Past Medical History:
HTN
high cholesterol
SAH
PCOMM aneurysm s/p coiling ___
4mm L para ophthalmic artery aneurysm (unsecure)
Social History:
___
Family History:
Brother exp MI in his ___
Physical Exam:
On Arrival:
-----------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic but follows exam with redirection.
___ speaking but daughter at bedside translating.
Orientation: Oriented to person, hospital, and month/year.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Upon Discharge:
---------------
She is awake, alert, and cooperative with the exam. She is
___ speaking. She's oriented to self, location, and date.
PERRL, EOMI. Left nasolabial fold flattening. Tongue midline. No
pronator drift. She moves all extremities with ___ strength.
Groin site soft and nontender. Dorsalis pedis pulses palpable
and equal bilaterally.
Pertinent Results:
Please see all pertinent results in OMR
Medications on Admission:
Alendronate 70 mg tablet. 1 (One) tablet(s) by mouth once a week
ATORVASTATIN - Atorvastatin 20 mg tablet. 1 tablet(s) by mouth
every night BUTALBITAL-Butalbital-acetaminophen-caffeine 50
mg-325 mg-40 mg tablet. 1 (One) tablet(s) by mouth every six (6)
hours as needed for headache
Cyclobenzaprine 5 mg tablet. 1 tablet(s) by mouth every 8 hours
as needed for muscle spasms
Fluticasone 50 mcg/actuation nasal spray,suspension. 2
(Two)sprays b/l nostrils once daily
Anusol-HC 2.5 % topical cream with perineal applicator. apply to
rectum 2 times daily as needed for hemorrhoids
MELOXICAM - Dosage uncertain
Ranitidine 150 mg capsule. 1 (One) capsule(s) by mouth 2 times
daily
Acetaminophen 500 mg tablet. 2 (Two) tablet(s) by mouth up to 3
times daily as needed
Adult Low Dose Aspirin 81 mg tablet,delayed release. 1 tablet(s)
by mouth once a day
CALCIUM 600 + D(3) - Calcium 600 + D(3) 600 mg calcium-200 unit
capsule. 1 (One) capsule(s) by mouth 2 times daily
Cholecalciferol (vitamin D3) 2,000 unit capsule. 1 (One)
capsule(s) by mouth once daily
Loratadine 10 mg capsule. 1 (One) capsule(s) by mouth once daily
as needed
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Taper 1
This is dose # 2 of 4 tapered doses
4. Dexamethasone 1 mg PO Q8H Duration: 6 Doses
Taper #3
This is dose # 4 of 4 tapered doses
5. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
Taper #2
This is dose # 3 of 4 tapered doses
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Heparin 5000 UNIT SC BID
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
9. Neutra-Phos 2 PKT PO BID
10. NiMODipine 60 mg PO Q4H
11. Senna 17.2 mg PO QHS:PRN constipation
12. TiCAGRELOR 90 mg PO BID
13. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
Reason for PRN duplicate override: switching tyelenol
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Calcium Carbonate 500 mg PO BID
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Loratadine 10 mg PO DAILY
19. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Right ICA pseudoaneursym
Hypertension
Headache
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with subarachnoid hemorrhage, aneurysm clipping.
Question of worsening hydrocephalus.
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 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
702.4 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP =
16.3 mGy-cm.
3) Spiral Acquisition 4.3 s, 33.5 cm; CTDIvol = 30.8 mGy (Head) DLP =
1,033.0 mGy-cm.
Total DLP (Head) = 1,752 mGy-cm.
COMPARISON: CT head done ___
Cerebral angiogram done ___
CTA done ___.
FINDINGS:
CT HEAD:
Surgical clips and embolization coils in the area of the right suprasellar
cistern results in a large amount of beam hardening artifact making evaluation
of this area difficult.
Hemorrhage is noted in the left lateral ventricle near the foramina ___
as well as in the third and fourth ventricles, similar to the earlier same-day
CT. Subarachnoid hemorrhage in the suprasellar cistern, anterior
interhemispheric fissure, left sylvian fissure, and left-sided sulci is stable
compared to the earlier same-day CT. Mild hydrocephalus is stable compared to
the earlier same-day CT but new compared to ___.
Right frontotemporal extra-axial collection measuring 3 mm in diameter and
postsurgical right frontotemporal craniotomy changes appear similar compared
to most recent CT. There is mild mucosal thickening in the ethmoid air cells.
CTA HEAD AND NECK:
Hyperdense embolization coil and surgical clip is noted in the region of the
right posterior communicating artery and M1 segment of the right middle
cerebral artery which results in a large amount of beam hardening artifact,
making the previously treated aneurysm arising from the communicating segment
of the right ICA difficult to re-evaluate.
The 2 mm medially projecting aneurysm measured rising from the clinoid segment
of the left ICA appear similar compared to prior, image 3:198.
Within the limitations of the study there is no acute arterial occlusion. No
ICA stenosis by NASCET criteria. Mild calcific atherosclerotic changes of the
carotid siphons bilateral. The vertebral arteries are patent without evidence
for flow-limiting stenosis.
OTHER:
The visualized portion of the lungs are clear. 7 mm hypodense nodule in the
left lobe of thyroid does not meet size criteria for further evaluation by
ultrasound according to the ACR guidelines. There is no lymphadenopathy by CT
size criteria.
IMPRESSION:
-Intraventricular and subarachnoid hemorrhage are stable compared to the
earlier same-day noncontrast head CT.
-Mild hydrocephalus, stable compared to the earlier same-day CT, but new
compared to ___.
-Revaluation of the previously treated right supraclinoid ICA aneurysm is
limited by streak artifact from surgical clips and endovascular coils. Please
refer to the subsequent cerebral angiography results for further detail.
-Stable 2 mm left ICA clinoid segment aneurysm.
NOTIFICATION: According to notes on OMR dated ___ at 17:22 the
neurosurgery team was aware of the subarachnoid and intraventricular
hemorrhage.
Radiology Report
EXAMINATION: Right common carotid artery angiogram.
Left common carotid artery angiogram.
Left vertebral artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old woman with SAH/IVH, hydrocephalus and known PCOMM
aneurysm s/p coiling ___, also with Left para ophthalmic artery aneurysm
(unsecure)// diagnostic with possible intervention
ANESTHESIA: General endotracheal anesthesia was maintained by separate
anesthesia provider throughout the entirety of the case. The anesthesia
provider also monitored the patient's hemodynamic and respiratory parameters.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 6 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right common carotid artery. AP, oblique and lateral views of the
anterior cerebral circulation were obtained. Subsequently, 3D rotational
images were performed requiring post processing on an independent workstation
under concurrent physician supervision and used in the interpretation and
reporting of the procedure.
Catheter was then pulled back in the aorta and used to select the left common
carotid artery. AP, oblique and lateral views of the anterior cerebral
circulation were obtained. The catheter was then pulled back in the aorta and
the left subclavian artery was selected. AP and lateral road map imaging was
undertaken. Next, the left vertebral artery was selected. AP and lateral
views were taken from this vessel for the posterior cerebral circulation. All
the Ace runs were medically necessary for management planning.
5000 units of heparin were given, and in collaboration with our colleagues in
anesthesia subsequent doses were given to target ACT ___. Also 15 mg of
IV Integrilin was given. An OG tube was inserted in verified via chest x-ray
and used to gave 300 mg of aspirin and 180 mg of Birlinta.
Diagnostic catheter was exchanged to 6 ___ Benchmark Delivery Catheter
which was mounted over an angled exchange length wire slowly and carefully
with continuous fluoro. Then it was positioned at a satisfactory position in
the right internal carotid artery, new road maps were taken. Subsequently,
Phenom micro catheter was advanced on a synchro 2 wire until it was parked in
a satisfactory position in the middle cerebral artery (M1/M2 junction)
carefully and slowly under direct fluoro.
A new angio run was done at this point. Measurements were obtained for the
pipeline, the synchro 2 wire was pulled out and the pipeline embolization
device was advanced until the tip was visualized at the M1 segment of the MCA,
the Phenom and the device were then slowly Re treated into the internal
carotid artery an slow and careful deployment of the pipeline device was done
across the pseudoaneurysm, once we reached the satisfactory apposition against
the wall of the artery the pipeline device was completely deployed. A new
angio run was done at this point confirming patency of the artery. The
microcatheter was retrieved. New magnified and de-magnified angio runs were
taken which confirmed the patency of the artery and the excellent positioning
of the pipeline device and significant reduction of flow into the
pseudoaneurysm.
The catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently 6 ___ Angio-Seal was put in. At the conclusion of the
procedure, there is no evidence of thromboembolic complication and the patient
was at his neurologic baseline.
COMPARISON: ___
PROCEDURE: Diagnostic cerebral angiogram +pipeline embolization of a right
internal carotid artery communicating segment pseudoaneurysm.
FINDINGS:
Right common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. An ICA communicating segment
pseudoaneurysm was identified, measuring around 4 mm in maximum diameter.
Post pipeline embolization, successful deployment of the stent across the neck
of the aneurysm with no InStent narrowing or stenosis. Significantly improved
distal M1 vasospasm likely secondary to manipulation. Otherwise, vessel
caliber smooth and tapering. Normal arterial, capillary, and venous phase.
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Stable appearance of the previously noted
2-3 mm aneurysm in the pARA-CLINOIDAL segment of the ICA. Otherwise, vessel
caliber smooth and tapering. Normal arterial, capillary, and venous phase . No
vascular abnormalities identified .
Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral
SCA and bilateral PCAs are well-visualized. The right ___ is not well
visualized as there was no cross-filling to the right vertebral artery. No
vascular abnormalities identified, vessel caliber smooth and tapering.
Arterial, capillary, venous phases were normal .
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___,
was present for the entirety of the procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
Right ICA communicating segment pseudoaneurysm was identified, measuring
around 4 mm in maximum diameter. Post pipeline embolization, successful
deployment of the stent across the neck of the aneurysm with no InStent
narrowing or stenosis. Significantly improved distal M1 vasospasm likely
secondary to manipulation.
RECOMMENDATION(S):
1. Continue on dual antiplatelet.
2. Follow-up angiogram within 4 weeks.
3. Tight blood pressure control for the next few days.
4. Subarachnoid hemorrhage management as per usual protocol.
Radiology Report
INDICATION: ___ year old woman with SAH// Assess ETT position and OGT position
and for any pulmonary congestion
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the endotracheal tube projects 2.2 cm from the carina and the tip
of the feeding tube projects over the stomach. There are low bilateral lung
volumes. New streaky opacities in the left lower lung may reflect atelectasis
or aspiration. The right lung is grossly clear. No pleural effusion or
pneumothorax. The size of the cardiac silhouette is within normal limits.
Radiology Report
INDICATION: ___ year old woman with SAH// New NGT please assess position
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the nasogastric tube the AA projects over the distal stomach. The
tip of the endotracheal tube projects 2 cm from the carina.
No focal consolidation, pleural effusion or pneumothorax. The size of the
cardiac silhouette is within normal limits..
IMPRESSION:
The tip of the nasogastric tube projects over the distal stomach. The tip of
the endotracheal tube projects 2 cm from the carina.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with Low grade SAH// POD 2 from pipline of R
ICA pseudo-aneurysm.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CTA head and neck dated ___ and CT head from outside
facility also dated ___.
FINDINGS:
Metallic clips and embolization coils with associated artifact are again noted
adjacent to the right suprasellar cistern. Assessment of the posterior fossa
and adjacent structures is limited.
Since the prior examination, there is increased high-density layering
hemorrhage within the occipital horns of both lateral ventricles (02:15) and
the superior aspect of the third ventricle (02:16). There has been interval
slight increased prominence of the bilateral frontal horns of the lateral
ventricles and temporal horn of the right lateral ventricle. The temporal
horn of the left lateral ventricle is likely stable from prior.
Subarachnoid hemorrhage involving the bilateral parasagittal frontal lobes and
right frontal lobe appears stable (02:12, 02:14). Previously described
subarachnoid hemorrhage in the suprasellar cistern is less evident suggesting
evolution.
Right frontal temporal postsurgical changes are re-demonstrated with decreased
prominence of the right frontotemporal extra-axial collection measuring 1-2
mm, previously 3 mm. No definite new hemorrhage or infarct. No midline shift.
IMPRESSION:
1. Interval new intraventricular hemorrhage and slight worsening of
hydrocephalus.
2. No midline shift or evidence of infarct.
3. Redemonstrated embolization coils and surgical clips limiting assessment of
surrounding structures.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 4:02 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with SAH/IVH s/p PCOMM aneurysm clipping//
hemorrhage or infarct
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP: 752.1 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Surgical hardware streak artifact limits examination.
Patient is status post metallic clips and embolization coil placement in the
right suprasellar region, consistent with history of right communicating
artery aneurysm clipping. The right internal carotid artery stent at the
clinoid is also noted.
While there is stable ventriculomegaly and near complete effacement of
cerebral gyri and sulci, pre-existing layering intraventricular hyperdensity
has resolved.
There remains stable ovoid hyperdensity along the posterior midline of the
interventricular septum measuring 1.4 x 1.0 cm.
Patient is status post right temporal craniotomy with stable postsurgical
changes. Bilateral mastoid air cells are underpneumatized. Otherwise, the
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Surgical hardware streak artifact limits examination.
2. Within limits of study, no evidence of new or enlarging hemorrhage and no
definite evidence of territorial infarct. Please note MRI of the brain is
more sensitive for the detection of acute infarct.
3. Interval resolution of layering intraventricular hemorrhage.
4. Grossly stable ventriculomegaly with near complete effacement of the sulci.
5. Grossly stable intraventricular septum 1.4 cm probable blood products
compared to ___ prior exam, new compared to ___
prior.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ s/p pipeline embo of R ICA pseudoaneurysm on ___ now with
worsening HA, agitation and new R Ptosis. Eval for etiology of neurologic
symtpoms.// Evaluate for etiology of neurologic symptoms and new R ptosis.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Spiral Acquisition 2.5 s, 19.6 cm; CTDIvol = 27.6 mGy (Head) DLP = 539.9
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Head) DLP = 2.8
mGy-cm.
4) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 51.1 mGy (Head) DLP =
25.6 mGy-cm.
Total DLP (Head) = 1,316 mGy-cm.
COMPARISON: CT head without contrast ___., CTA head neck ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Status post right-sided craniotomy. Metallic clips and embolization coils
with associated streak artifact are present adjacent to the right suprasellar
cistern. The patient is status post right paraclinoid pipeline carotid artery
stent placement. Right parasellar aneurysm clip. Otherwise, no significant
change in the blood products (0.1 cm AP x 1.4 cm TV) in the interventricular
septum since ___. There is no new intracranial hemorrhage.
There is no large territorial infarct.
Stable moderate hydrocephalus with mild periventricular low-attenuation
changes may be from periventricular edema, with possible contribution from
chronic small vessel ischemic changes. Trace intraventricular blood products
within occipital horn, similar.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is within spasm at the bilateral M1, A1, proximal ACA segments,,
bilateral PCA similar compared with ___, apparent compared with
___. There is mild parenchymal edema, without definite areas of
ischemia.
The vessels of the circle of ___ and their principal intracranial branches
appear normal with no evidence of stenosis, occlusion, or aneurysm. The dural
venous sinuses are patent.
IMPRESSION:
1. No significant change in size of the interventricular hemorrhage.
2. Unchanged moderate hydrocephalus, suggestion of periventricular edema.
3. Intracranial arterial vasospasm, similar to ___ exam..
Suggestion of areas of parenchyma edema, without definite ischemia.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for evaluation of previously
ruptured right posterior communicating artery aneurysm in the setting of new
right eye ptosis.
During the procedure the following vessels were selectively catheterized
angiograms performed:
Right internal carotid artery
Three-dimensional rotational angiography of the right internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Left common femoral artery
Ultrasound-guided access to the left common femoral artery
INDICATION: This ___ female who suffered a subarachnoid hemorrhage in
posterior communicating artery aneurysm rupture several months ago. She
underwent coiling at that time. Angiogram at follow-up in ___ showed
residual aneurysm that underwent clipping. There is a drop to of rupture
during the clipping. She presented several days after with a new headache.
There is evidence of residual aneurysm near the clip versus dissection. She
was treated with a pipeline embolization device. This morning she presented
with new headache and additional right-sided ptosis. She underwent a CTA that
was unrevealing but had significant artifact related to the coils and clips
and pipeline. For that reason angiogram was undertaken.
ANESTHESIA: The patient was somewhat somnolent at baseline and received 2 mg
of Versed for the procedure. She did not received 2 agents. Her respiratory
in hemodynamic parameters were continuously monitored by a trained an
independent observer.
TECHNIQUE: Diagnostic cerebral angiogram, single-vessel
COMPARISON: Multiple previous angiograms.
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. An interpreter
was present for the duration of the procedure. Versed was administered.
Bilateral groins were prepped and draped in standard sterile fashion. A
time-out was performed. In light of her many recent procedure she has several
palpable Angio-Seal device is in the right groin. For this reason the left
groin was used for access. The left common femoral artery was identified
using anatomic and radiographic landmarks. The left common femoral artery was
accessed using standard micropuncture technique after infiltration of local
anesthetic using ultrasound guidance. A long 5 ___ sheath was introduced,
connected to continuous heparinized saline flush, and secured.
Next a stiff ___ 2 catheter was introduced. It was advanced over 038
glidewire through the aorta into the aortic arch. It was used to select the
right common carotid artery. The wire was removed. A roadmap was performed.
The wire was introduced and used to select the right internal carotid artery.
The catheter was positioned over the wire in the right internal carotid
artery. The wire was removed. Vessel patency was confirmed via hand
injection. Three-dimensional rotational images well as standard AP and
lateral and high magnification oblique views were obtained.
Next the diagnostic catheter was removed. Left t common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Angio-Seal evolution. The patient
was removed from the fluoroscopy table remained at her 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:
Ultrasound the left common femoral artery: There is a single noncompressible,
arterial, pulsatile lumen. There is evidence of access of the wire into the
lumen
Right internal carotid artery: Vessel caliber smooth and regular. There is
opacification of the anterior and middle cerebral arteries and their distal
territories. There is no evidence of a residual filling of the previous
posterior communicating artery aneurysm. There is artifact related to the
previous coil and clip. There is a pipeline device located across the neck of
the previous aneurysm. There is no evidence of endoleak. There is no InStent
stenosis. There is no residual filling on the three-dimensional image as
well.
Left common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
.
IMPRESSION:
___ 1, no residual filling of previously ruptured, coiled, clipped,
and pipelined right posterior communicating artery aneurysm.
RECOMMENDATION(S):
1. Continue aspirin and relate to. Plans for remote treatment of
contralateral ICA aneurysm on the left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with subarachnoid hemorrhage S/P pipeline
embolization of pseudoaneurysm with leukocytosis// rule out pneumonia rule
out pneumonia
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Heart size top-normal. Lungs clear. No pleural abnormality.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with subarachnoid hemorrhage now S/P pipeline
embolization of R ICA pseudoaneurysm with leukocytosis// 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, 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: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Headache
temperature: 97.0
heartrate: 75.0
resprate: 18.0
o2sat: 95.0
sbp: 123.0
dbp: 58.0
level of pain: 7
level of acuity: 2.0 | Ms ___ is a ___ yo female who presented with a headache.
Initial CT at OSH showed a SAH with IVH and she was transferred
to ___ for further evaluation.
#SAH/IVH from pseudoaneurysm
CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA
pseudoaneurysm. She was admitted to the Neuro ICU for close
neuro monitoring and strict blood pressure control <140. She was
taken to angio suite on ___ and underwent pipeline
embolization of R ICA pseudoaneurysm. Please see operative
report for full details. R groin was angiosealed and she was
transported to ICU intubated. She was started on Keppra 1 g Q12H
BID for 7 days for seizure ppx and nimodipine 60 mg q4h for 21
days for vasospasm ppx. She was successfully extubated. She was
continued on ASA/Brilinta. She remained in ICU for close BP
monitoring and vasospasm watch. Head CT ___ showed slight
worsening of hydrocephalus but she remained neurologically
stable. She had continued nausea and was started on decadron
with improvement. She was transferred to the step down unit on
___. She was evaluated by physical therapy ___, who
recommended rehab at discharge. On ___, she became very
agitated and complained of a headache and had new right ptosis.
She underwent STAT CTA brain, which was negative for acute
findings. She underwent cerebral angiogram which showed complete
resolution of the aneurysm. Physical therapy and occupational
therapy were consulted for disposition planning and recommended
discharge to rehab. On day of discharge, her pain was well
controlled with oral medications. She was tolerating a diet and
getting out of bed with assistance. Her vital signs were stable
and she was afebrile. She was discharged to rehab in a stable
condition.
#Hypertension
She was started on PO labetalol for blood pressure control,
which was titrated and eventually discontinued.
#Leukocytosis
WBC uptrended and she was afebrile. UA was negative. CXR showed
minimal atelectasis and incentive spirometry was encouraged.
LENIs were negative for DVT. WBC downtrended to normal.
#Diarrhea
She had multiple episodes of loose stool. She was negative for
C. difficile. Bowel regimen was liberalized to PRN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
seasonal
Attending: ___
Chief Complaint:
Shortness of breath and leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with PMHx new diagnosis CHF (EF 55%),
hypertension, spinal stenosis, anxiety, depression, alcohol
abuse, and chronic macrocytic anemia presenting with 1 week of
worsening dyspena on exertion. He was seen in his PCP's office
on ___, was started on furosemide and told to go to the ED
for worsening anemia. He was not able to make it to the ED as
recommended, and has had worsening DOE, leg, scrotal, and
abomdinal edema despite diuretics. In the ED, he was afebrile,
hypertensive to 142/68, and SaO2 96% on RA. Labs remarkable for
Na+119, proBNP 9033, HCT 23 (MCV 99), INR 1.2, trop <0.01.
Received 40mg IV furosemide, albuterol and ipratropium, nebs.
On ROS, he notes progressive SOB and edema of his legs for the
past 3 months. He reports 3 weeks of non-bloody diarrhea without
sick contacts, recent abx use, no laxative use. He reports a
chronic cough that he attributes to smoking, but has noted
increased phlegm over several weeks. Reports slightly decreased
appetite, weight gain of unknown amount over several months.
Denies fevers, chills, night sweats, headache, sinus tenderness,
rhinorrhea, congestion, chest pain, chest tightness,
palpitations, nausea, vomiting, hematemesis, constipation,
abdominal pain, dysuria, arthralgias, myalgias.
On the floor patient reports trouble breathing mostly with
transfers, and less so at rest. He denies a history of blood
transfusions. No other complaints. States he feels very tired
right now.
Past Medical History:
Alcohol abuse
CHF
Grand mal seizure (presumed d/t EtOH) several years ago
Macrocytic anemia, likely due to ETOH use (normal B12, folate,
iron studies, BM Bx)
Mild proteinuria
Mild bicuspid aortic stenosis
Moderate mitral regurgitation
Moderate tricuspid regurgitation
Peripheral vascular disease
Spinal stenosis c/b neurogenic claudication, s/p L2-5
Laminectomy with L3-5 fusion; C5-6 and C6-7 discetomy and fusion
Chronic back pain (treated w regular injections)
Fatty liver disease
Chronic Hepatitis B
Essential HTN
Hiatal hernia with reflux
Allergic rhinitis
Psoriasis
h/o Hyponatremia, possibly beer potomania
Adjustment disorder with mixed anxiety/depression
Erectile dysfunction
Gastritis
S/P closed scapula fracture
Adenomatous and benign colonic polyps
Social History:
___
Family History:
No known history of CAD, HTN, DM. Father had alcohol abuse and
subsequent cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.5, 156/80, 98, 20, 100% on 2L NC
Weight: 88.6kg
I/O: 2250 UOP since 10mg IV lasix (in 6 hours)
GEN: NAD, alert, oriented, conversant and appropriate
HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry,
oropharynx clear, poor dentition without gum erythema or lesions
NECK: supple, JVD mildly elevated, no LAD
RESP: good effort, no accessory muscle use, rales ___ way up, no
rhonchi, occasional expiratory wheeze
CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early
systolic murmur at RUSB
ABD: soft, distended, non-tender, 1+ abdominal pitting edema to
umbillicus, organomegaly not appreciated, + BS
EXT: warm, well-perfused, 2+ pitting edema b/l ___, dry and
thickened skin on anterior tibia b/l
NEURO: aaox3, CNII-XII intact, mild dysmetria, normal rapid
alternating movements, gait deferred
DISCHARGE PHYSICAL EXAM:
VS: 98.3 132/71 81 20 96% on RA
Weight: 87.0
I/O: 500+sips/3150
GEN: NAD, alert, oriented, conversant and appropriate
HEENT: NC/AT, PERRL, sclera anicteric, conjunctival pale, MMM,
oropharynx clear, poor dentition without gum erythema or lesions
NECK: supple, no JVD elevation, no LAD
RESP: good effort, no accessory muscle use, rales at bases, no
rhonchi, bilateral short expiratory wheeze
CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early
systolic murmur at RUSB
ABD: soft, obese, non-tender, 1+ abdominal pitting edema at
flanks to umbillicus, organomegaly not appreciated, + BS
EXT: warm, well-perfused, 1+ pitting edema b/l ___, dry and
thickened skin on anterior tibia b/l
NEURO: aaox3, CNII-XII intact, moving all 4 extremities
Pertinent Results:
ADMISISON LABS:
=======================
___ 05:30PM BLOOD WBC-6.0 RBC-2.33* Hgb-7.5* Hct-23.0*
MCV-99* MCH-32.4*# MCHC-32.8 RDW-18.2* Plt ___
___ 05:30PM BLOOD Neuts-68.7 ___ Monos-6.9 Eos-3.9
Baso-0.7
___ 05:30PM BLOOD ___ PTT-35.9 ___
___ 05:30PM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-119*
K-4.7 Cl-84* HCO3-25 AnGap-15
___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3
___ 05:30PM BLOOD Lipase-41
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033*
___ 05:30PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.9
Mg-1.0*
___ 05:30PM BLOOD VitB12-GREATER THAN ___ 05:30PM BLOOD TSH-2.0
___ 05:38PM BLOOD Lactate-0.9
IMAGING/STUDIES:
========================
___ CXR:
Interval increase in pulmonary vascular congestions,
interstitial edema, small bilateral pleural effusions R>L
___ ECG:
Poor baseline, NSR at 75bpm, normal axis, IVCD, 1mm STE in V2
that is new from ___
___ RUQ US:
FINDINGS:
The liver shows no evidence of focal lesions or textural
abnormality. Doppler assessment of the main, right, and left
portal vein show patency and hepatopetal flow. There is no
ascites. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The common bile duct measures 0.6 cm. The
gallbladder is normal without evidence of stones or gallbladder
wall thickening. Pancreatic head and body are unremarkable; the
pancreatic tail is not well visualized secondary to overlying
bowel gas. The spleen measures 8.3 cm and has a homogeneous
echotexture. The right and left kidneys are normal without
mass, hydronephrosis or stones. The right kidney measures 12.9
cm in the left kidney measures 13.3 cm. The aorta is of normal
caliber throughout, without evidence of atherosclerotic plaques.
The visualized portions of the inferior vena cava appear
normal. Incidental note is made of a right pleural effusion.
IMPRESSION:
1. No focal liver masses.
2. Patent hepatic vasculature with hepatopetal flow.
PERTINENT LABS
=================================
___ 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-1+
___ 06:10AM BLOOD Ret Aut-4.0*
___ 06:10AM BLOOD LD(LDH)-193
___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3
___ 05:30PM BLOOD Lipase-41
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033*
___ 06:10AM BLOOD calTIBC-273 Hapto-270* Ferritn-149
TRF-210
___ 05:30PM BLOOD TSH-2.0
___ 05:38PM BLOOD Lactate-0.9
DISCHARGE LABS
==================================
___ 06:25AM BLOOD WBC-7.2 RBC-2.54* Hgb-8.2* Hct-24.3*
MCV-96 MCH-32.3* MCHC-33.7 RDW-16.9* Plt ___
___ 06:25AM BLOOD Glucose-107* UreaN-20 Creat-0.7 Na-129*
K-4.3 Cl-88* HCO3-33* AnGap-12
___ 06:25AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
2. ClonazePAM 1 mg PO TID
3. Loratadine 10 mg PO DAILY:PRN allergic rhinitis
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Baclofen 10 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Citalopram 40 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Metoprolol Tartrate 50 mg PO BID
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 1 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. Loratadine 10 mg PO DAILY:PRN allergic rhinitis
9. Metoprolol Tartrate 50 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
13. Vitamin D 1000 UNIT PO DAILY
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
15. Aspirin 81 mg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Nicotine Patch 21 mg TD DAILY
18. Torsemide 60 mg PO DAILY
19. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: diastolic CHF exacerbation
Secondary: peripheral edema, macrocytic anemia, alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Dyspnea on exertion, here to evaluate for fluid overload or
pneumonia.
COMPARISON: Prior chest radiograph dated ___ and ___.
TECHNIQUE: Upright AP and lateral radiographs of the chest.
FINDINGS: There is interval increased mild pulmonary vascular
congestion/interstitial edema from the remote prior study. Small bilateral
pleural effusions on the right greater than left are present. There is no
pneumothorax. Mild biapical scarring appears symmetrical. Increased
opacification at the right lung base is most likely reflective of atelectasis.
The cardiac silhouette is moderately enlarged but stable. The mediastinum is
prominent, likely related to a combination of tortuous vessels and technique.
Anterior cervical spine fixation hardware is redemonstrated. There are
multiple old fracture deformities of the bilateral clavicles and right
posterior ribs.
IMPRESSION: Mild pulmonary vascular congestion/interstitial edema and small
bilateral pleural effusions.
Radiology Report
HISTORY: ___ year old man with chronic Hepatitis B, alcohol abuse, presenting
___ and abdominal edema, hyponatremia. Evaluate for evidence of cirrhosis and
patency of hepatic vasculature.
TECHNIQUE: Gray scale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
The liver shows no evidence of focal lesions or textural abnormality. Doppler
assessment of the main, right, and left portal vein show patency and
hepatopetal flow. There is no ascites.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
common bile duct measures 0.6 cm. The gallbladder is normal without evidence
of stones or gallbladder wall thickening. Pancreatic head and body are
unremarkable; the pancreatic tail is not well visualized secondary to
overlying bowel gas. The spleen measures 8.3 cm and has a homogeneous
echotexture. The right and left kidneys are normal without mass,
hydronephrosis or stones. The right kidney measures 12.9 cm in the left
kidney measures 13.3 cm. The aorta is of normal caliber throughout, without
evidence of atherosclerotic plaques. The visualized portions of the inferior
vena cava appear normal.
Incidental note is made of a right pleural effusion.
IMPRESSION:
1. No focal liver masses.
2. Patent hepatic vasculature with hepatopetal flow.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS
temperature: 97.3
heartrate: 78.0
resprate: 20.0
o2sat: 95.0
sbp: 147.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ male with history of CHF, hypertension, and
macrocytic anemia of unknoen etiology, admitted with volume
overload and dyspnea, concerning for acute diastolic CHF
exacerbation, exacerbated by worsening chronic macrocytic
anemia. Symptoms improved with diuresis and two blood
transfusions. Electrolytes repleted during diuresis, likely
worsened in setting of some chronic malnutrition. Discharged to
short term rehab with improved edema and on room air.
ACTIVE ISSUES
# Diastolic heart failure exacerbation
CXR, BNP, history and exam suggestive of volume overload
secondary to diastolic CHF exacerbation; patient with primarily
right-sided heart failure; echo in ___ with LVEF 55%,
moderate MR. ___ with IV lasix. Fluid restricted to
2000cc/day. There was a concern for cirrhosis contributing to
edema with his low albumin and elevated INR in setting of
chronic hepatitis B and EtOH abuse, but RUQ US did not indicate
evidence of a cirrhotic liver. Dyspnea is also worsened by
concomittant anemia and his severe pulmonary hypertension.
Fatigue and shortness of breath improved with RBC transfusions,
as below. On ___ he was transitioned from IV furosemide to PO
torsemide and was able to maintain diuresis. On ___ his foley
catheter was removed and he was able to urinate. He already has
outpatient follow-up scheduled in cardiology clinic.
# Hyponatremia:
Sodium was 119 on admission. Pt has h/o hyponatremia during past
hospitalizations, thought to have beer potomania at that time.
His current hyponatremia was secondary to hypervolemia in
setting of dCHF exacerbation. There could also be a component of
chronic, mild hyponatremia in the setting of citalopram use. His
Na+ slowly trended up with diuresis. Na+ at discharge was 129.
# Macrocytic Anemia:
This is a chronic issue for him. Workup to date revealed normal
B12, folate, iron studies, ___ only with a few colonic
adenomatous polyps in ___, and BM Bx without hypocellularity
and no evidence MDS. ___ without signs of active bleeding,
stool guiac negative. Likely secondary to chronic EtOH abuse.
Received two transfusions of 1U PRBC each for HCT < 21 with
improvement in fatigue. HCT stabilized for several days prior to
discharge. H/H at discharge was 8.2/24.3
# Alcohol Abuse:
Pt has h/o alcohol abuse with prior episode of DT's requiring
intubation for airways protection. H/O fatty liver per medical
record. Unclear how much he drinks, states that he doesn't drink
every day, cannot quantify how much beer, but states that he
drinks to take the edge off of his back pain. He received IV
thiamine and folate x 5 days, continued on home B12 and MVI.
CIWA protocol used, but patient did not score nor receive any
benzodiazepines.
# Tobacco Abuse
He was started on a nicotine patch while hospitalized.
# Severe pulmonary hypertension
Noted on echo in ___, unclear etiology, may be secondary to
chronic hypoxemia from smoking, left-sided valvular disease
(MR), or pulmonary arterial hypertension. Would recommend
oupatient PFTs and perhaps RHC as outpatient when seeing
cardiology.
# Diarrhea: Nonbloody, no recent abx use. No recent travel or
sick contacts. ___ be malabsorptive or in setting of poor
nutrition. C. diff was ordered to be collected but patient did
not have diarrhea once admitted.
CHRONIC ISSUES
# Spinal Stenosis: pt has severe spinal stenosis s/p several
surgeries and now physically disabled. He takes oxycontin for
his pain and seen at ___ steroid injections,
and has h/o opioid abuse in past but not currently abusing it.
Continued on home oxycodone.
# Proteinuria: documented in past PCP ___. Unclear etiology.
Pr/Cr 1.8. Should have outpatient follow-up.
# Depression/Anxiety:
Continued on citalopram and clonazepam.
# Gastritis, GERD:
Continued on omeprazole.
# Hypertension:
Continued on metoprolol and lisinopril
TRANSITIONAL ISSUES
- Alcohol abuse history - unclear exactly how much he is
currently drinking, was on CIWA scale here and highest score was
3 and did not required benzodiazepines; should be followed over
the next several days for any signs of withdrawal
- Required daily IV magensium during aggressive IV furosemide
diuresis, please check Chem-10 within the 48 hours after arrival
to rehab (on ___ and replete electrolytes as necessary. He may
need daily oral magnesium.
-Foley catheter was removed on ___, able to urinate, watch over
next day for any signs of urinary retention
- Being discharged on 60mg PO torsemide - titrate his diuretic
dosing as an outpatient as needed
- Recommend outpatient PFTs given severe pulmonary HTN on
echocardiogram
- Started on 81mg ASA daily given PVD
- Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Minocin / hydrocodone / nifedipine / ibuprofen
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with a past medical history of T4N0M0 Stage IIIA
poorly differentiated adenosquamouscarcinoma of the lung s/p
right pneumonectomy ___, adjuvant cisplatin/gemcitabine
___ now on active surveillance, recent admission for CAP
(D/C
___ on cefpodox/azithro through ___, on enoxaparin since
___ for PE, now presents with headache and gait imbalance.
The history is obtained with pt and her son who lives with her.
He states that ___ days ago his wife started noticing that the
patient had her head tilted to the right side and they also
noted
over the past ___ days that things had to be repeated to her and
she was having trouble understanding things though not overtly
confused and disoriented otherwise. She also noted headaches
starting about 2 days ago which are intermittent and mostly
located over the left temple though some right sided neck pain
is
associated. She denies any visual changes/diplopia. Denies
fever/nausea/vomiting. She has baseline dyspnea on exertion
after
her pneumonectomy, and cough at baseline, but these things have
not worsened. She recalls no trauma or head strike. No report of
syncope. She also denies diarrhea/dysuria/abd pain/chest pain.
ED COURSE:
v/s 97.8 94 130/96 18 100% RA . Exam was notable for left facial
droop and head tilt to left. Labs were unremarkable, including
LFTS, CBC, chem, coags, trop (in ED she reported having had
chest
pain at home), and UA. noncon CT had showed interval development
of multiple intracranial mass lesions with associated vasogenic
edema new from ___, rec MRI. Vasogenic edema from left
temporal/parietal lobe mass results in effacement of temporal
horn of left lateral ventricle. CXR no acute process.
Neurosurgery was consulted and they felt that this was c/w brain
mets of known lung cancer, no indication for neurosurgical
intervention at this time. SHe received 1g apap, 2.5mg
olanzapine, 120mg lovenox at 10 AM, 100mcg levothyroxine.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ woman who in started to experience non-productive
cough in ___, and subsequently developed hemoptysis on
___ when she went to ___ too be
evaluated. There she had a chest CT which showed a 4.4 x 4.2 cm
right hilar/right middle lobe lung mass surrounding the right
pulmonary artery and nearly collapsing the right bronchus
intermedius; also, there was a 1.0 x 1.6 cm right lower lobe
spiculated nodule and a 0.7 cm 4R lymph node and a 2.0 x 1.1 cm
right adrenal nodule.
She had a bronchoscopy ___ with biopsy of the right lower
lobe lung mass which showed non-small cell carcinoma with CK5/6
positive, P63 positive, TTF-1 negative, napkin A negative,
supporting squamous cell carcinoma. Washings from the RLL were
positive for malignant cells compatible with carcinoma.
On ___ a head CT was negative for metastases. PET-CT on
___ showed a 5 x 5.4 cm right parahilar mass with an SUV of
18.2 with partial collapse of the RML; there was extension of
the
mass to the right upper lobe bronchus and mild mass effect on
the
RLL bronchus; there was a 1.7 x 1.5 cm ground-glass opacity in
the RLL with an SUV of 2.8, concerning for metastasis; there was
a 2.1 x 1.7 cm right paratracheal lymph node with an SUV of 3.3;
a prevascular lymph node measuring 1.8 x 1.1 cm with an SUV of
2.3; there was a 1.8 x 1.3 cm subcarinal lymph node with an SUV
of 3.2; there were no abdominal, pelvic or bone metastases.
On ___ she underwent an EBUS-guided of 11L, 7L, and 4R LNs
that were negative for malignancy; biopsy of the RML lung mass
showed invasive poorly differentiated non-small cell carcinoma
with cytokeratin 7 positive and focal positivity for CK5/6 and
TTF-1; napsin was negative and the differential diagnosis was
felt to be adenosquamous carcinoma versus high-grade
mucoepidermoid carcinoma; RLL FNA was positive for malignant
cells compatible with nonsmall cell carcinoma.
On ___ she had a cervical mediastinoscopy; biopsy from the
4R station showed four lymph nodes, which were negative and
biopsy from the level 7 station also showed four lymph nodes,
which were negative.
On ___ he had a right pneumonectomy. Her tumor was 8.2 cm
in
greatest diameter. In addition, she did have a separate tumor
nodule in the right lower lobe, which was a squamous cell
carcinoma 1.5 cm unclear whether this represents a second
primary or a satellite lesion. There was also adjacent lung
parenchyma with atypical adenomatous hyperplasia, multiple lymph
nodes were negative. All margins were negative. No LVI, no
visceral pleural involvement.
She recovered reasonably well from her surgery. Was started on
Adjuvant Cisplatin and Gemcitabine on ___ and completed on
___. Her treatment was complicated by pulmonary embolism in
___ and she was started on enoxaparin.
Past Medical History:
1. Bipolar disorder
2. Schizophrenia
3. Hypothyroidism
4. Vasculitis
5. GERD.
6. Lung cancer, as above.
7. Right adrenal nodule - not FDG avid
8. Pulmonary embolism on anticoagulation
Social History:
___
Family History:
- Father died at age ___ from heart disease.
- Mother died at age ___ from complications of diabetes mellitus
- Maternal aunt had throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
Neurological Examination: Her ___ Performance Score is
70.
She is oriented to name and place. She does not know the year,
month is ___ then ___ is summer. 6 quarters in $1.75.
There is no right-left confusion, finger agnosia, no apraxia,
clock drawing is normal, she can copy two intersecting
pentagons.
She is inattentive. She is dysarthric with nonfluent aphasia.
She
can name, repeats with mild paraphasic errors, comprehends,
reads, writes. Her recent recall is fair. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 to 2
mm bilaterally. Extraocular movements are full; there is no
nystagmus, no ptosis, no diplopia. Visual field are full. She
has a mild left UMN facial. Facial sensation is intact
bilaterally. Her hearing is intact bilaterally. Her tongue is
midline. Palate goes up in the midline. Sternocleidomastoid and
upper trapezius are strong. Motor Examination: She has left
upper extremity pronation. Tone
is increased in the left lower extremity. Her muscle strengths
are ___ at all muscle groups except 4+/5 hip left knee flexion.
Her reflexes are 1+ on the right upper and lower extremity and
2+
on the left upper and lower extremity. Ankle jerk are absent.
Left toe up going and right down going. Sensory examination is
intact in all modalities except proprioception in left great toe
is not intact.
She does not have a sensory level. Coordination examination does
not reveal dysmetria but she is tremulous in left upper
extremity
on finger to nose. Her gait is steady but cautious. She cannot
tandem. She does not have a Romberg.
DISCHARGE PHYSCIAL EXAM:
VITAL SIGNS: 97.7 122/80 77 18 95%RA
General: NAD
HEENT: MMM, no OP lesions
CV: RRR, NL S1S2
PULM: decreased on R, L clear, nonlabored
GI: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: speech is slow w/ some dysarthria. Oriented to person and
place, not to date. EOMI, sl left facial droop but raises bilat
w/ smile, tongue midline. no
nystagmus strength is ___ of the proximal and distal upper and
lower extremities. sensation intact to light touch, mild
dysmetria w/ finger-to-nose but only in R upper motion, gait
slow and cautious but steady, cannot perform tandem gait. visual
fields full to confrontation
Pertinent Results:
ADMISSION LABS:
___ 02:00AM BLOOD WBC-8.5 RBC-4.10 Hgb-11.5 Hct-36.5 MCV-89
MCH-28.0 MCHC-31.5* RDW-14.9 RDWSD-48.5* Plt ___
___ 02:00AM BLOOD Neuts-54.2 ___ Monos-8.5 Eos-3.5
Baso-0.4 Im ___ AbsNeut-4.60 AbsLymp-2.79 AbsMono-0.72
AbsEos-0.30 AbsBaso-0.03
___ 02:00AM BLOOD ___ PTT-24.5* ___
___ 02:00AM BLOOD Glucose-108* UreaN-27* Creat-0.8 Na-137
K-3.6 Cl-99 HCO3-27 AnGap-15
___ 02:00AM BLOOD ALT-36 AST-27 AlkPhos-93 TotBili-0.3
___ 02:00AM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.2 Mg-1.8
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-21.9* RBC-4.58 Hgb-12.9 Hct-39.6
MCV-87 MCH-28.2 MCHC-32.6 RDW-15.6* RDWSD-49.4* Plt ___
___ 05:37AM BLOOD Glucose-134* UreaN-41* Creat-0.7 Na-135
K-4.3 Cl-97 HCO3-27 AnGap-15
___ 05:37AM BLOOD ALT-41* AST-23 AlkPhos-53 TotBili-0.3
___ 05:37AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
PERTINENT IMAGING:
BRAIN MRI W/ & W/O CONSTRAST ___
There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within
the right
superior cerebellar cortex which demonstrates adjacent vasogenic
edema and mild mass effect on the fourth ventricle (see900:52).
.
There is an adjacent ventral small 5 mm enhancing nodule
(see900:50).
There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the
posterior left mesial temporal cortex left forceps major with
adjacent FLAIR signal hyperintense vasogenic edema extending
into the posterior temporal and occipital lobes across the
splenium. There is associated mass effect on the occipital
horn left lateral ventricle (see900:69).
There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally
enhancing mass at the lateral right precentral gyrus which
demonstrates adjacent vasogenic edema and mass effect
(see900:90). There is a small amount of central hemorrhage seen
on the gradient echo sequence.
There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid
enhancing mass at the posterior right superior frontal gyrus
which demonstrates adjacent
vasogenic edema which extends throughout the precentral gyrus.
There is a subependymal focus of gradient echo hypointensity
with petechial hemorrhage at the right lateral ventricular atria
(see6:15). There is no evidence of acute infarct. There is
stable prominence of the ventricles and cortical sulci. The
extra-axial spaces are unremarkable. The orbits, calvarium, and
soft tissues are unremarkable. The paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
Enhancing masses within the right frontal, left temporal, and
right cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. These are new in
comparison to ___.
CT chest w/ contrast ___
IMPRESSION:
1. Marked improvement of previous ground-glass opacities,
consistent with
resolving infectious/inflammatory etiology. There is no
evidence for
intrathoracic malignancy.
CT ab/pelvis w/ contrast ___
IMPRESSION:
1. Interval decrease in the size of the right adrenal nodule.
2. Colonic diverticulosis without diverticulitis.
MRI C/T/L spine ___
IMPRESSION:
1. No evidence of metastases to the cervical, thoracic or
lumbar spine.
2. No abscess, osteomyelitis/discitis or cord signal
abnormalities.
3. Mild degenerative changes without significant spinal canal
narrowing.
Mild right neural foraminal narrowing at C5-C6 and C6-C7 as
described above.
4. Benign appearing superior endplate compression deformities at
T12 and L1.
CXR ___
FINDINGS:
Post pneumonectomy appearance of the right hemi thorax is stable
compared to the prior radiograph. Left lung remains
hyperexpanded but grossly clear, and there is no evidence of
left pleural effusion. Cardiomediastinal contours
remain shifted to the right and are unchanged in appearance. .
IMPRESSION:
No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
2. Levothyroxine Sodium 100 mcg PO DAILY
3. OLANZapine 2.5 mg PO QAM
4. OLANZapine 5 mg PO QPM
5. Loratadine 10 mg PO DAILY:PRN allergies
6. Senna 8.6 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Enoxaparin Sodium 120 mg SC QDAY
Start: ___, First Dose: Next Routine Administration Time
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Loratadine 10 mg PO DAILY:PRN allergies
5. OLANZapine 2.5 mg PO QAM
6. OLANZapine 2.5 mg PO QPM
7. Senna 8.6 mg PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN headache
9. Dexamethasone 4 mg PO Q12H
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Omeprazole 40 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Brain metastases
Cerebral edema
History of lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA
x2days // ? pneumonia, acute cardiopulm process
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___ and chest radiograph dated ___.
FINDINGS:
Patient is status post total right pneumonectomy, with expected postoperative
changes, including rightward shift of the mediastinal structures. Right-sided
Port-A-Cath ends in the low SVC. Cardiac and mediastinal contours are
unchanged. No left-sided consolidation, pneumothorax, or pleural effusion.
IMPRESSION:
No pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA
x2days // ? pneumonia, acute cardiopulm process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 54.5 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: MR head dated ___.
FINDINGS:
There has been interval development of multiple intracranial mass lesions,
including 2 in the right frontal lobe measuring 2.6 x 2 cm (2:21) and 2.1 x
1.8 cm (603b:41), as well as a second in the left temporoparietal lobe, which
measures 2.5 x 2 cm. These areas are surrounded by a large amount of
vasogenic edema. An additional area vasogenic edema is seen in the right
cerebellum. There is no evidence of intracranial hemorrhage. Vasogenic edema
on the left temporoparietal lobe results in effacement of the temporal horn of
the left lateral ventricle. The basal cisterns appear patent.
No fracture is identified. Visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
2. Vasogenic edema from the left temporal parietal lobe mass results in
effacement of the temporal horn of the left lateral ventricle.
RECOMMENDATION(S):
1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
NOTIFICATION: Wet read was discussed with Dr. ___ by Dr. ___ telephone
at 3:32 am on ___, approximately 10 min after discovery.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ female with newly diagnosed lung cancer found to have
metastasis on prior head CT now experiencing a new neurological deficits.
Evaluate intracranial disease.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: ___ noncontrast head CT.
___ contrast-enhanced head MRI.
___ noncontrast head CT.
FINDINGS:
There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within the right
superior cerebellar cortex which demonstrates adjacent vasogenic edema and
mild mass effect on the fourth ventricle (see900:52). .
There is an adjacent ventral small 5 mm enhancing nodule (see900:50).
There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the posterior left
mesial temporal cortex left forceps major with adjacent FLAIR signal
hyperintense vasogenic edema extending into the posterior temporal and
occipital lobes across the splenium. There is associated mass effect on the
occipital horn left lateral ventricle (see900:69).
There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally enhancing mass at the
lateral right precentral gyrus which demonstrates adjacent vasogenic edema and
mass effect (see900:90). There is a small amount of central hemorrhage seen on
the gradient echo sequence.
There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid enhancing mass at
the posterior right superior frontal gyrus which demonstrates adjacent
vasogenic edema which extends throughout the precentral gyrus.
There is a subependymal focus of gradient echo hypointensity with petechial
hemorrhage at the right lateral ventricular atria (see6:15). There is no
evidence of acute infarct. There is stable prominence of the ventricles and
cortical sulci. The extra-axial spaces are unremarkable. The orbits,
calvarium, and soft tissues are unremarkable. The paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
Enhancing masses within the right frontal, left temporal, and right cerebellar
cortices with adjacent vasogenic edema and mass effect, consistent with
metastatic disease. These are new in comparison to ___.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: ___ year old woman with metastatic nsclc and new brain mets,
hoping to obtain MRI spine to evaluate for mets // ****please obtain MRI of
whole spine to evaluate for mets along spine ****please obtain MRI of whole
spine to evaluate for mets al
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
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 7 mL of Gadavist contrast
agent.
COMPARISON: ___ chest radiograph. CT Torso ___.
FINDINGS:
Cervical spine:
Alignment of the cervical spine is normal. Intervertebral disc and marrow
signal intensity is normal. No cord signal abnormalities are identified.
There is no evidence of infection or neoplasm. Notable degenerative changes
within the cervical spine include:
At C3-C4, there is a tiny midline disc protrusion that does not result in
significant spinal canal or neural foraminal narrowing.
At C5-C6, there is a right intervertebral osteophyte that results in mild
narrowing of the right neural foramen. No spinal canal narrowing at this
level.
At C6-C7, there is also mild narrowing of the right neural foramen which may
be due to a combination of a right intervertebral osteophyte and a small right
paracentral disc protrusion.
Thoracic spine:
Alignment of the thoracic spine is normal. Intervertebral disc and marrow
signal intensity are normal. No cord signal abnormalities are identified.
Conus medullaris terminates at T12. There is no infection or neoplasm within
thoracic spine. No spinal canal or neuroforaminal narrowing. Incidental note
is made of a tiny syrinx (4:11).
Lumbar spine:
Alignment of the lumbar spine is normal. Superior endplate compression
deformities are noted at T12 and L1 (901: 10), without marrow signal
abnormalities throughout the lumbar spine. Notable degenerative changes in
the lumbar spine including mild disc bulge at L4-L5 and L5-S1, without spinal
canal or neural foraminal narrowing. No evidence of infection or neoplasm.
OTHER: Limited images of the posterior fossa demonstrate no gross
abnormalities. Right pneumonectomy changes are noted. There are several left
renal cysts, one of which contains a fluid level. These findings are better
characterized on the recent CT chest/abdomen/pelvis performed on the same
date.
IMPRESSION:
1. No evidence of metastases to the cervical, thoracic or lumbar spine.
2. No abscess, osteomyelitis/discitis or cord signal abnormalities.
3. Mild degenerative changes without significant spinal canal narrowing.
Mild right neural foraminal narrowing at C5-C6 and C6-C7 as described above.
4. Benign appearing superior endplate compression deformities at T12 and L1.
Radiology Report
INDICATION: ___ year old woman with metastatic nsclc with new brain mets,
hoping to evaluate for other mets // worsening mets?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: This study involved 8 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 = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
5) Stationary Acquisition 6.3 s, 0.2 cm; CTDIvol = 106.6 mGy (Body) DLP =
21.3 mGy-cm.
6) Spiral Acquisition 6.4 s, 75.1 cm; CTDIvol = 7.3 mGy (Body) DLP = 516.7
mGy-cm.
7) Spiral Acquisition 2.8 s, 34.6 cm; CTDIvol = 5.3 mGy (Body) DLP = 158.1
mGy-cm.
8) Spiral Acquisition 1.5 s, 20.1 cm; CTDIvol = 5.9 mGy (Body) DLP = 89.8
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: Comparison is made to prior from ___.
FINDINGS:
LOWER CHEST: Please refer to dedicated chest CT for complete report.
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: There is interval decrease in the size of the right adrenal nodule,
which measures 1.1 x 1.1 cm in the current study compared to prior measurement
of 1.1 x 1.4 cm. The left adrenal is unremarkable.
URINARY: Normal appearance of the right kidney. Multiple cysts are
appreciated within the left kidney. No evidence of hydronephrosis on either
side. The bladder is unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
extensive colonic diverticulosis. No evidence of diverticulitis in the
current study. 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.
Prominent right external iliac lymph node, measuring up to 1.0 cm in short
axis.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: Vertebral body compression at T12 and L1.
Degenerative changes within the spine. Multiple subcutaneous soft tissue
stranding in the anterior abdominal wall from injections.
IMPRESSION:
1. Interval decrease in the size of the right adrenal nodule.
2. Colonic diverticulosis without diverticulitis.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with metastatic non small cell lung cancer
with new brain metastases. Question intrathoracic metastases. The patient
had ground-glass opacities on passed chest CT, questioning infectious or
malignant etiology.
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 axial maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: See abdomen/pelvic CT
COMPARISON: CT chest dated ___.
FINDINGS:
Neck/cardiomediastinal: The thyroid is unremarkable. There is no axillary or
supraclavicular lymphadenopathy. Subcentimeter mediastinal lymph nodes are
unchanged in size. A right Port-A-Cath terminates in the superior cavoatrial
junction. The heart is normal in size. The aorta is normal in caliber. The
main pulmonary artery is normal in caliber without intraluminal filling
defect. There is no pericardial effusion.
Airway/lungs: The patient is post right pneumectomy. The right bronchial
stump has a normal postoperative appearance. Postoperative change of right
intercostal muscle flap remain. The pleural rind surrounding the contents of
the pneumonectomy space is stable from prior. The ground-glass and nodular
opacities throughout the left lung have markedly improved. A region of linear
opacity in the left upper lobe remains (05:18), likely atelectasis. A
calcified granuloma in the left lower lobe is stable (05:20).
Abdomen: Infra-diaphragmatic structures will be reported separately.
Cardiac thoracic cage/soft tissues: There are no suspicious blastic or lytic
lesions.
IMPRESSION:
1. Marked improvement of previous ground-glass opacities, consistent with
resolving infectious/inflammatory etiology. There is no evidence for
intrathoracic malignancy.
2. Please see abdomen/ pelvic CT for additional findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hx lung cancer new brain mets, SOB,
leukocytosis // eval for effusion, pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
Post pneumonectomy appearance of the right hemi thorax is stable compared to
the prior radiograph. Left lung remains hyperexpanded but grossly clear, and
there is no evidence of left pleural effusion. Cardiomediastinal contours
remain shifted to the right and are unchanged in appearance. .
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: L Weakness, Confusion, Chest pain
Diagnosed with BRAIN CONDITION NOS
temperature: 97.8
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 96.0
level of pain: nan
level of acuity: 2.0 | ___ y/o female with history of T4N0M0 Stage IIIA poorly
differentiated adenosquamouscarcinoma of the lung s/p right
pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now
on active surveillance, on enoxaparin since
___ for PE, now presents with headache and gait imbalance
found to have multiple brain mets.
# Metastatic NSCLC with new CNS mets- MRI shows new enhancing
masses within the right frontal, left temporal, and right
cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. Exam with multiple
neurologic deficits includiong R facial droop and dysarthria.
CT shows significant edema. Pt also w/ ongoing short term
memory/cognitive difficulty
-Neuro-oncology and radiation oncology consulted. Patient
started whole brain radiation ___, plan for total of 10
fractions (currently ___ completed, will complete on ___.
- dexamethasone for edema now reduced to 4mg BID, further taper
per rad onc. On PPI while on steroids
- MRI spine to evalaute for mets in the spine or leptomeningeal
disease - none seen.
- CT torso to evaluate systemic disease was negative.
- she will have follow up brain MRI in ___
Patient did have improvement in coordination and headaches w/
initiation of steroids and WBRT. She was evaluated by physical
therapy and is able to ambulate independently however continues
to struggle with short term memory, completing tasks/directions.
Due to this patient requires ___ supervision for safety. She
will be discharged to ___ in ___ for further
rehabilitation and possibly long-term care.
#Leukocytosis - likely ___ dex, persistently elevated w/o signs
systemic infxn. surveillance urine/blood cx NGTD on repeat
exams. CXR ___ shows only stable pneumonectomy, clear on L. did
improve w/ reduced dex dose.
# h/o PE - no evidence of bleeding on head CT or MRI. Able to
anticoagulate per neuro-onc
-continue home lovenox.
# Hypothyroidism - on Levothyroxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Cardiac Catheterization with no PCI
History of Present Illness:
___ PMH HLD, HTN, DM, CAD s/p IMI and CABG in ___ followed by
PCI of SVG-OM that same year, p/w atypical chest pain for 1.5
weeks. Patient reports one and a half weeks of crescendo chest
pain that comes and goes. Prain pressure-like, in L isde of
chest, occurring ___ times a day and lasting ___, no clear
inciting or relieving factors. With associated flushing and mild
headache, radiation to back and arm, facial numbness. Not
exertional or pleuritic. Pain worse on ___ so took nitro
with no/little relief. Different from reflux pain, but similar
to the pain she felt prior to needing a stent in ___. No
association with eating or BMs. She denies fevers, chills,
shortness of breath, diaphoresis, abdominal pain, nausea,
vomiting. Significantly, patient reports this chest pain pattern
is very similar to that which she had prior to her last
cath/stent in ___
In the ED initial vitals were: 98.6 164/55 66 14 100/RA
EKG: TWI in III, aVF, STD in II similar to prior without new
ischemic changes.
Labs/studies notable for:
10.2>12.8/40.0<225
136 | 100 | 17
---------------<246
4.6 | 25 | 0.7
Trop <0.01 x2
INR 0.9
UA benign
CXR: no acute process
Patient was given: Nitro SL .4 x 2, ASA 324, APAP 1g, MS 2mg x2,
Insulin 40, metformin 1g, Plavix 75, asa 81, lisinopril 5, metop
succinate 75, imdur 120 and 30, fluoxetine 40, omeprazole 40
On the floor, patient reports mild pressure but otherwise
feeling well.
ROS:
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Denies exertional buttock
or calf pain.
On further review of systems, 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. Denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
PAST MEDICAL HISTORY:
1. CAD, inferior wall MI ___, CABG: LIMA-LAD, SVG-OM,
SVG-PDA in ___. Symptoms: chest pressure, LUE/jaw
discomfort. SVG-OM DES 11.10.
2. Obesity. BMI 35.9
3. DLD: 12.15 TC108.TG136.H22.L59. atorva 80mg, fish oil.
4. Insulin-requiring diabetes, HbA1c 8.9, ___. Dx ___
5. Family history of pCAD (father, brother)
6. ___ (metoprolol, isosorbide, lisinopril)
Other Relevant Medical Issues:
- Prior tobacco abuse.
- Depression.
- GERD.
- Obstructive sleep apnea, intolerant of CPAP.
HOME MEDS:
The Preadmission Medication list is accurate and complete
1. Lisinopril 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Estrogens Conjugated 1 gm VG 1X/WEEK (FR)
5. FLUoxetine 40 mg PO DAILY
6. econazole 1 % topical DAILY
7. Glargine 40 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM
9. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM
10. MetFORMIN (Glucophage) 500 mg PO QHS
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
14. Omeprazole 40 mg PO BID
15. Aspirin 81 mg PO DAILY
16. Vitamin D Dose is Unknown PO DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. Loratadine 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Psyllium Powder 1 PKT PO Frequency is Unknown
21. Calcium Carbonate 1500 mg PO DAILY
ALLERGIES: NKDA
SOCIAL HISTORY: ___
FAMILY HISTORY:
Dad- MI @___
Sister: MI in ___
Brother: sudden cardiac death from MI @___
Most family members with DM.
PHYSICAL EXAM:
VS: 97.6 132/63 57 16 96/RA; admission weight 96.6kg
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
CHEST: No chest wall deformities, scoliosis or kyphosis; has
sternotomy scar. Resp were unlabored, no accessory muscle use.
No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Past Medical History:
1. CAD, inferior wall MI ___, CABG: LIMA-LAD, SVG-OM,
SVG-PDA in ___. Symptoms: chest pressure, LUE/jaw
discomfort. SVG-OM DES 11.10.
2. Obesity. BMI 35.9
3. DLD: 12.15 TC108.TG136.H22.L59. atorva 80mg, fish oil.
4. Insulin-requiring diabetes, HbA1c 8.9, 12.15. Dx ___
5. Family history of pCAD (father, brother)
6. ___ (metoprolol, isosorbide, lisinopril)
Other Relevant Medical Issues:
- Prior tobacco abuse.
- Depression.
- GERD.
- Obstructive sleep apnea, intolerant of CPAP.
Social History:
___
Family History:
Has son with unknown type of congenital heart disease-"hole in
heart." Father with MI, age ___, CABG, PPM, deceased in ___
from melanoma. Three siblings, one brother with sudden cardiac
death after MI age ___. Older sister with silent MI in her ___.
Most family members with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.6 132/63 57 16 96/RA; admission weight 96.6kg
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
CHEST: No chest wall deformities, scoliosis or kyphosis; has
sternotomy scar. Resp were unlabored, no accessory muscle use.
No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
==========================
VS: T 98.1 120-140/51-63 HR 56-63 RR 18 98%
tele: sinus rhythm, sinus brady
GENERAL: WDWN in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
CHEST: No chest wall deformities, scoliosis or kyphosis; has
sternotomy scar. Resp were unlabored, no accessory muscle use.
No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
NEURO: Oriented x3.
PSYCH: Mood, affect appropriate.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:03AM cTropnT-<0.01
___ 06:44AM URINE HOURS-RANDOM
___ 06:44AM URINE UHOLD-HOLD
___ 06:44AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:44AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:44AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 06:44AM URINE MUCOUS-RARE
___ 03:00AM GLUCOSE-246* UREA N-17 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
___:00AM estGFR-Using this
___ 03:00AM cTropnT-<0.01
___ 03:00AM WBC-10.2* RBC-4.44 HGB-12.8 HCT-40.0 MCV-90
MCH-28.8 MCHC-32.0 RDW-12.5 RDWSD-41.2
___ 03:00AM NEUTS-59.8 ___ MONOS-8.4 EOS-2.5
BASOS-0.3 IM ___ AbsNeut-6.08 AbsLymp-2.90 AbsMono-0.85*
AbsEos-0.25 AbsBaso-0.03
___ 03:00AM PLT COUNT-225
___ 03:00AM ___ PTT-28.1 ___
INTERIM LABS:
=============
___ 07:00AM BLOOD WBC-8.7 RBC-4.58 Hgb-13.0 Hct-41.6 MCV-91
MCH-28.4 MCHC-31.3* RDW-12.3 RDWSD-40.6 Plt ___
___ 07:10AM BLOOD WBC-7.9 RBC-4.72 Hgb-13.3 Hct-43.2 MCV-92
MCH-28.2 MCHC-30.8* RDW-12.3 RDWSD-41.2 Plt ___
___ 07:00AM BLOOD Glucose-214* UreaN-16 Creat-0.7 Na-137
K-4.2 Cl-101 HCO3-24 AnGap-16
___ 07:10AM BLOOD Glucose-185* UreaN-15 Creat-0.7 Na-139
K-4.4 Cl-105 HCO3-23 AnGap-15
___ 09:03AM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:10AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0
MICRO:
======
UCx negative
STUDIES/IMAGING:
================
CXR ___: The lungs are well expanded and clear. There is no
pleural abnormality. The moderate cardiomegaly is unchanged
from prior exam. The mediastinal and hilar contours are stable.
Median sternotomy wires and surgical clips are aligned and
intact. The osseous structures are unremarkable.
ETT ___:
INTERPRETATION: ___ yo woman with HL, HTN and DM, s/p IMI and
CABG in
___ followed by PCI of SVG-OM that same year was referred to
evaluate
an atypical chest discomfort. The patient completed 9.25 minutes
of a
modified ___ protocol representing an average exercise
tolerance; ~
___ METS. The exercise test was stopped due to fatigue. The
patient
denied any chest, back, neck or arm discomforts during the
procedure. At
peak exercise, 0.5-1 mm upsloping ST segment depressions were
noted
inferolaterally. Immediately post-exercise, a horizontal ST
morphology
was noted in these same leads. The ST segment changes resolved
with rest
and returned to standing baseline by 4 minutes post-exercise.
The rhythm
was sinus with rare isolated APBs. The blood pressure increased
with
exercise, however the response was blunted. In the presence of
beta
blocker therapy, the peak exercise heart rate was somewhat
blunted.
CATH ___:
Coronary Anatomy Dominance: Right
LMCA: The LMCA was calcified with mild plaquing proximally.
LAD: The proximal and mid LAD were heavily calcified. The
proximal LAD had diffuse mild plaquing to 40% mid vessel
involving the origin of D1 mildly. The mid LAD had a 75%
stenosis with competitive flow seen distally.
LCX: The proximal CX was calcified. The proximal CX tapered to
40%. A small long (<2 mm in diameter) OM1 had a proximal 70%
stenosis. The AV groove CX was occluded mid vessel.
RCA: The RCA was heavily calcified. There was a proximal 70%
stenosis and a mid vessel chronic total occlusion. There was
faint filling of the mid-distal RCA via vasa and other
right-to-right collaterals.
SVG-RPDA: The SVG had a corkscrew turn near ostially. The SVG
had mild plaquing and grafted onto a large RPDA with retrograde
perfusion of the large distal RCA system into multiple RPLs.
There was NO retrograde perfusion of the mid RCA.
SVG-LPL: The SVG had mild plaquing, especially ostially. The
grafted LPL (also <2 mm in diameter) had serial 70% and 75%
stenoses. There was retrograde perfusion down the distal AV
groove CX.
LIMA-LAD: The LIMA-LAD was patent onto the mid LAD with
competitive flow seen retrogradely in the mid LAD. The apical
LAD had diffuse plaquing.
Impressions:
1. Native three vessel coronary artery disease with chronic
total occlusion of the CX and RCA, unrevascularized native OM1
disease and LPL disease downstream of the SVG (both of these in
vessels <2 mm in diameter and thus too small for PCI).
2. Systemic systolic arterial hypertension.
3. Moderate-severe left ventricular diastolic heart failure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Estrogens Conjugated 1 gm VG 1X/WEEK (FR)
5. FLUoxetine 40 mg PO DAILY
6. econazole 1 % topical DAILY
7. Glargine 40 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM
9. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM
10. MetFORMIN (Glucophage) 500 mg PO QHS
11. Metoprolol Succinate XL 75 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
14. Omeprazole 40 mg PO BID
15. Aspirin 81 mg PO DAILY
16. Cyanocobalamin 1000 mcg PO DAILY
17. Loratadine 10 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Psyllium Powder 1 PKT PO Frequency is Unknown
20. Calcium Carbonate 1500 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Glargine 40 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Psyllium Powder 1 PKT PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Carbonate 1500 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. econazole 1 % topical DAILY
10. Estrogens Conjugated 1 gm VG 1X/WEEK (FR)
11. FLUoxetine 40 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM
13. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM
14. Loratadine 10 mg PO DAILY
15. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
16. MetFORMIN (Glucophage) 500 mg PO QHS
17. Metoprolol Succinate XL 75 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. Omeprazole 40 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Unstable Angina, s/p catheterization
-Coronary Artery Disease s/p CABG
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain // Evaluate for ACS
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
The lungs are well expanded and clear. There is no pleural abnormality. The
moderate cardiomegaly is unchanged from prior exam. The mediastinal and hilar
contours are stable. Median sternotomy wires and surgical clips are aligned
and intact. The osseous structures are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 98.6
heartrate: 66.0
resprate: 14.0
o2sat: 100.0
sbp: 164.0
dbp: 55.0
level of pain: 5
level of acuity: 2.0 | ___ year-old woman with diabetes mellitus and known CAD S/P CABG
in ___ (LIMALAD, SVG-PDA, SVG-OM/LPL) and post-CABG PCI of
SVG-OM who presented with 1.5 weeks of chest squeezing radiation
at rest and with exertion to both arms similar to her prior
acute coronary syndrome symptoms.
# Unstable Angina
# Coronary Artery Disease s/p CABG
Patient presents with chest pain at rest. She had no biomarker
evidence of myocardial infarction. She exercised to ___ METs on
a non-imaging stress test without symptoms and initially
nondiagnostic 0.5-___epressions which became
horizontal during recovery. She was thus referred for coronary
and bypass graft angiography which showed native three vessel
coronary artery disease with chronic total occlusion of the CX
and RCA, unrevascularized native OM1 disease and LPL disease
downstream of the SVG (both of these in vessels <2 mm in
diameter and thus too small for PCI). No lesions suitable for
PCI as native OM1 and grafted LPL <2 mm in diameter.
Interventional cardiology recommend ___ medical
therapy and reinforcement of secondary preventative measures
against CAD and hypertension. Patient was continued on home
cardiac medications (ASA, Plavix, metoprolol, atorvastatin and
isosorbide mononitrate). Ultimately, lisinopril was increased
from 5 mg to 10 mg daily. Metoprolol was not uptitrated due to
patients HR (50-60s). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / Clozaril / Lactose
Attending: ___
Chief Complaint:
Jaw swelling/pain
Major Surgical or Invasive Procedure:
Periapical Incision & Drainage (___)
Foley inserted ___
History of Present Illness:
Ms. ___ is a ___ year old woman with history of diabetes and
schizophrenia who presents with jaw swelling.
Patient states that she started to develop pain and swelling in
her jaw for the past 3 days, that first started on R lower
chin/jaw, but then continued to involve the entire right side
including her cheek. She reports pain when opening her mouth and
eating, so she has not eaten since the pain started. She denies
any drooling and is able to manage secretions. She has
significant pain inside her mouth. Denies any recent dental
work, or difficulty breathing. Denies fevers/chills, cough, N/V,
chest pain, abdominal pain, constipation, diarrhea, dysuria,
rash, sick contact.
In the ED, initial vital signs were:
97.2 108 134/89 18 98% RA
- Exam notable for: Tenderness under her tongue.
- Labs were notable for WBC 7.4, bicarb 25, cr 0.7, lactate 0.9
- Studies performed include CT Neck which showed soft tissue
stranding anterior to the mandible without definite abscess.
- Patient was given 2L NS, 1G acetaminophen, 3G unasyn
- Vitals on transfer:
99.6 99 ___ 100% RA
Upon arrival to the floor, the patient was comfortable, but
complaining of lower jaw pain
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
HLD
DM II
Morbid Obesity
Schizophrenia
Hx of Carcinoid: carcinoid: colon - excised ___ ___ -
colonoscopy ___ - BX neg in area of tumor, colonic polyp -
hyperplasia -
colonoscopy ___ - Dr. ___ all WNL, showing no
more
carcinoid tissue: ___: Re- referred to Dr. ___
s/p R total shoulder ___
GERD
OSA on CPAP
LV systolic dysfunction
Hyperprolactinemia: ___ Endocrine f/u
Social History:
___
Family History:
N/A
Physical Exam:
ON ADMISSION:
Vitals- 99.7 165/80 103 18 100%
GENERAL: obese ___ woman laying in bed comfortably in NAD.
Unable to enunciate words well. No muffled speech
HEENT: poor dentition, tenderness across the anterior neck,
mandible with increased involvement on the right side. Most
tender on the anterior inferior periodontal region. PERRL. EOMI.
Unable to open mouth wide to evaluate oropharynx. No peripheral
LAD
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion.
No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait
deferred
ON DISCHARGE:
PHYSICAL EXAM:
Vitals- 98.6 ___-100% ra
I/O: 540/1330mL. Bladder scan - 700cc
GENERAL: obese ___ woman laying in bed comfortably in NAD.
HEENT: poor dentition, mildly tender across the anterior chin, R
cheek. Still tender in the mouth, but improved. PERRL. EOMI.
Large tongue Unable to open mouth wide to evaluate oropharynx.
No peripheral LAD
CARDIAC: RR, normal rate, no murmurs/rubs/gallops. No JVD.
LUNGS: CTAB w/appropriate breath sounds appreciated in all
fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, nd nt to deep palpation in all
four quadrants. Tympanic to percussion. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait
deferred
Rectal: good rectal tone. No external hemorrhoids. Brown stool
GU: Foley in place
Pertinent Results:
ON ADMISSION
======================
___ 09:00AM WBC-7.4# RBC-3.92 HGB-11.5 HCT-37.4 MCV-95
MCH-29.3 MCHC-30.7* RDW-14.1 RDWSD-49.2*
___ 09:00AM GLUCOSE-110* UREA N-19 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18
___ 09:00AM NEUTS-74.6* LYMPHS-17.2* MONOS-7.3 EOS-0.4*
BASOS-0.1 IM ___ AbsNeut-5.51# AbsLymp-1.27 AbsMono-0.54
AbsEos-0.03* AbsBaso-0.01
___ 09:00AM PLT COUNT-255
___ 10:35AM LACTATE-0.9
ON DISCHARGE
___ 07:50AM BLOOD WBC-3.5* RBC-4.07 Hgb-11.9 Hct-39.7
MCV-98 MCH-29.2 MCHC-30.0* RDW-13.5 RDWSD-48.4* Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-86 UreaN-24* Creat-0.7 Na-141
K-4.4 Cl-101 HCO3-30 AnGap-14
IMAGING:
CT NECK W/ CONTRAST (___):
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass, and
no areas of
focal mass effect.
Soft tissue stranding is noted anterior to the mandible. This
extends just to
the level of the mental protrude , without extension to the
subcutaneous fat
adjacent to the mandibular body. Lucencies identified in the
right incisor
(2: 53) suggestive of periapical infection. No definite
abscess is
identified.
Thyroid gland is diffusely enlarged.
IMPRESSION:
1. Soft tissue stranding anterior to the mandible without
definite abscess.
2. Right mandibular incisor. Apical infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO Frequency is Unknown
2. Benztropine Mesylate 2 mg PO QHS
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 300 mg PO QHS
8. Lisinopril 40 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. OLANZapine 35 mg PO QHS
11. Omeprazole 20 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 17.2 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. TraZODone 100 mg PO QHS
16. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
17. Mylanta 30 mL ORAL TID:PRN nausea/heartburn
18. Gabapentin 600 mg PO TID
19. Chlorthalidone 25 mg PO DAILY
20. Simvastatin 40 mg PO QPM
21. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*20 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*8 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 1 Week
RX *chlorhexidine gluconate 20 % 15mL twice a day Refills:*0
4. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Benztropine Mesylate 2 mg PO QHS
6. BuPROPion (Sustained Release) 300 mg PO QAM
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Gabapentin 300 mg PO QHS
12. Gabapentin 600 mg PO TID
13. Loratadine 10 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Mylanta 30 mL ORAL TID:PRN nausea/heartburn
16. OLANZapine 35 mg PO QHS
17. Omeprazole 20 mg PO BID
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO DAILY
20. Sertraline 100 mg PO DAILY
21. Simvastatin 40 mg PO QPM
22. TraZODone 100 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Periapical Abscess
Multiple Dental Carries
Urinary Retention
SECONDARY:
Schizophrenia
Obstructive Sleep Apnea
Hypertension
Diabetes
Gastroesphageal reflux
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: History: ___ with pain, swelling of L lower chin, tender under
tongue. // ___?
TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 36.1 cm; CTDIvol = 18.7 mGy (Body) DLP = 676.6
mGy-cm.
Total DLP (Body) = 677 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass, and no areas of
focal mass effect.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears normal. There is no lymphadenopathy by
CT criteria. The neck vessels are patent.
Soft tissue stranding is noted anterior to the mandible. This extends just to
the level of the mental protrude , without extension to the subcutaneous fat
adjacent to the mandibular body. Lucencies identified in the right incisor
(2: 53) suggestive of periapical infection. No definite abscess is
identified.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
Thyroid gland is diffusely enlarged.
IMPRESSION:
1. Soft tissue stranding anterior to the mandible without definite abscess.
2. Right mandibular incisor. Apical infection.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Jaw pain, Mouth pain
Diagnosed with Cellulitis of face, Chronic apical periodontitis
temperature: 97.2
heartrate: 108.0
resprate: 18.0
o2sat: 98.0
sbp: 134.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | ___ yo F with PMH diabetes and schizophrenia admitted for acute
jaw pain/swelling, found to have a periapical abscess in the
mandibular anterior vestibule. CT scan revealed no drainable
fluid collection in the neck. Patient was started on IV unasyn
for oral infection. ___ was consulted who observed a fluctuant
lesion at the apex of ___ and performed a beside incision and
drainage. Patient received panoramic radiograph of her teeth.
The dentistry team recommended that she gets full teeth
extraction to be done at outpatient ___ clinic. Patient was
transitioned to PO augmentin (last dose on ___. Patient
also found to be retaining urine with bladder scan>1000cc of
urine. Patient was straight cathed was monitored by bladder
scan, found to have increasing PVR and so a foley was placed.
Patient to follow up with urologist for urodynamic study.
# Dental Infection:
Jaw swelling/pain suspicious for periodontal infection. Patient
started on IV unasyn. ___ was consulted who observed a
fluctuant lesion at the apex of ___ and performed a beside
incision and drainage. Patient received panoramic radiograph of
her teeth. The dentistry team recommended that she gets full
teeth extraction to be done at outpatient ___ clinic. Patient
was transitioned to PO augmentin (last dose on ___.
Patient's jaw swelling/pain improved and she was able to
tolerate soft PO food.
#Urinary retention
Patient found to have poor urine output while hospitalized.
Patient was straight cathed for 1100cc. Patient's urine output
was monitored and patient had increasing PVR >500cc, so a foley
was placed. Unclear etiology for her urinary retention. Patient
on olanzapine, which has anticholinergic effects. UA negative.
No evidence of cord compression or peripheral neuropathy.
Patient discharged on foley with outpatient urology appointment.
# Hypertension:
Patient's blood pressure was in the low 100's-110's. Held home
chlorthalidone and decreased lisinopril to 20mg. Patient's BP
continued to be in relatively low, so she was discharged on 10mg
lisinopril to have outpatient followup for blood pressure
# OSA: Stable. Patient on CPAP at night
# Schizophrenia: Stable. Continued home olanzapine, wellbutrin,
sertraline, cogentin, gabapentin
# Diabetes: Held metformin. Patient was on insulin sliding
scale, but did not require any insulin.
# GERD: Continued home omeprazole 20mg BID
# COPD: stable. Continued Fluticasone Propionate 110mcg 2 PUFF
IH BID, albuterol neb PRN q6h
TRANSITIONAL ISSUES
=======================
[]ensure patient has appointment with ___ (___) to get
full teeth extraction (___). Patient needs to call
EXACTLY AT 7AM to get appointment same day (___)
[]f/u jaw pain/swelling
[]f/u with dentist
[]held chlorthalidone and decreased lisinopril to 10mg given
BP's in the low 100's. f/u blood pressure and titrate meds as
needed
[]foley to remain in place until follow up with urology for
urodynamic study for urinary retention.
[]thyroid gland enlarged on CT scan. Consider thyroid ultrasound
Note: Patient at rehab for convalescent stay <30 days. Do not do
trial of void for patient. Patient has urology appointment
scheduled.
#Code Status: full, confirmed
#Contact: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nsaids/Anti-Inflammatory Classifier / Sulfa (Sulfonamide
Antibiotics) / Penicillins / E-Mycin / Aspirin / Azithromycin /
Flagyl
Attending: ___.
Chief Complaint:
slowed movements, unable to ambulate
Major Surgical or Invasive Procedure:
na
History of Present Illness:
Ms. ___ is an ___ F with h/o vascular parkinsonism
and multifactorial gait disorder (frontal + parkinsonian
features, on Levodopa/Carbidopa), AFib, CAD, spinal stenosis s/p
lumbar surgery who presents with 3 days of worsened gait
freezing, difficulty moving/getting out of bed and slowing of
her
speech.
For the past ___ years or so, patient has had problems with
gait, in particular increased slowness, freezing and shuffling
(especially when trying to get around a small or cluttered
area).
She uses a cane or walker at baseline. Has also had some urinary
incontinence and anxiety. She is followed by Dr. ___ as
an outpatient for this, who diagnosed her with vascular
Parkinsonism (head CT with generalized atrophy and small vessel
disease) and a multifactorial gait disorder with frontal and
parkinsonian components. She is being treated with
Levodopa-Carbidopa for the gait symptoms which has helped
slightly but not significantly. Has had a few falls over the
past
couple of years which seem to be related to attentional
difficulties, often happening in the setting of having
additional
thoughts or external cues (e.g. fell recently when fire alarm
went off in her building). Most recent clinic note from ___
documents ongoing gait freezing and slowed movements as well as
pallilalia (stuttering/halting speech).
Over the past 3 days, her slowness and gait problems acutely
worsened. She has felt unable to get out of bed or even move
much
due to marked slowness and stiffness. When she tried to walk to
the bathroom on ___ night, she noticed that she was freezing
severely, perhaps more in the left leg which felt like it was
heavy and dragging. It took her a long time to get to the
bathroom. At baseline she ambulates with a walker, but has been
unable to do so even with walker and assistance from visiting
nurse ___ ___ 7 days per week). In this setting she has had
increased incontinence due to trouble getting out of bed. Speech
has also seemed slower and softer than usual. Her ___ that she
may not have been taking all her meds, evidence of missed
medication doses in the home (a new problem for her). Pt has
also
been acutely anxious over the past 3 days, and reports getting
no
sleep in the evening before the symptoms began. Yesterday she
called PCP office reporting increased urge incontinence and was
scheduled for outpt appt. Today, her son (present at bedside)
was
called by ___ who reported acute worsening of her gait problems.
He came over and thought he also saw increased left facial droop
(a baseline problem). He called ___ because he was concerned she
had a UTI. She was brought to our ED, where labs including UA
were unremarkable. Neurology was consulted for assistance with
further workup.
Pt denies missing any doses of Sinemet recently though when
pressed she cannot remember. She denies any fluctuations in
symptoms over past 3 days. Denies dyskinetic symptoms.
On ROS, patient reports ___ pound weight loss over the past
___
months. She denies fevers, chills, cough, dysuria, nausea,
vomiting, diarrhea or constipation. Neurologic and General ROS
are otherwise negative.
Past Medical History:
- Vascular ___ Disease
- Multifactorial gait disorder w frontal and Parkinsonian
features
- Paroxysmal AFib
- CAD s/p CABG x 5 (___)
- Depression
- Diverticulosis
- GERD
- H/O L femoral hernia
- Hyperlipidemia
- Lymphocytic colitis (___)
- Spinal stenosis, s/p L1-sacral decompression + fusion (___)
- Thyroid nodule (___)
- Osteoporosis
- Sensorineural hearing loss
Social History:
___
Family History:
Her mother died in her ___ from heart failure,
father died age ___ from a pneumonia. She had a sister who died
in her ___ from a heart attack or stroke, and another sister who
died from a heart attack, also in her ___. A brother also in
her
late ___ died from a stroke. Family history, in addition to
cardiovascular disease and strokes is positive for diabetes, but
negative for dementia and ___ disease.
Physical Exam:
GENERAL EXAM:
- Vitals: 97.6 91 151/84 18 98% RA
- General: thin, frail appearing elderly woman in NAD
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. +Masked facies,
+marked hypomimia. +Grasp reflexes bilaterally. Able to relate a
fairly accurate history though requires help with details from
son. Marked inattention on ___ and ___ backward. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes.
Good knowledge of current events. 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: Decreased upgaze, otherwise EOMI without nystagmus.
+saccadic breakdown.
V: Facial sensation intact to light touch.
VII: +left NLF flattening (baseline), no facial droop with
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: Decreased bulk throughout. Marked axial and
appendicular
rigidity and paratonia (present in upper and lower extremities).
+Bradykinesia and decrement with fine finger movements
bilaterally. No tremor. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___- ___ 5 5 5 4 5 4+ 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 EXTENSOR bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: marked retropulsion when standing. Significantly slowed
movements when rising into a seated position or attempting to
stand. Can only walk a couple of steps before she retropulses,
but observed markedly decreased stride length and slowed speed.
Unable to test Romberg.
Pertinent Results:
___ 06:30AM BLOOD WBC-5.5 RBC-4.62 Hgb-13.1 Hct-41.7 MCV-90
MCH-28.3 MCHC-31.4 RDW-15.2 Plt ___
___ 05:20PM BLOOD Neuts-70.2* ___ Monos-8.1 Eos-2.0
Baso-0.4
___ 06:30AM BLOOD ___ PTT-44.7* ___
___ 06:30AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
___ 05:20PM BLOOD ALT-3 AST-14 AlkPhos-71 TotBili-0.7
___ 05:20PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.3 Mg-2.2
___ 05:51AM BLOOD TSH-6.8*
___ 07:30PM BLOOD Free T4-1.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO TID
2. Furosemide 20 mg PO DAILY:PRN swelling
3. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral 1 capsule by mouth three times daily
4. Losartan Potassium 25 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Oxybutynin 2.5 mg PO TID
7. Pravastatin 10 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Losartan Potassium 25 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN headache/fever
8. Levothyroxine Sodium 12.5 mcg PO DAILY
9. Meclizine 12.5 mg PO TID
standing through ___ - then PRN
10. Furosemide 20 mg PO DAILY:PRN swelling
11. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral 1 capsule by mouth three times daily
To be restarted after meclizine stopped. if needed
12. Oxybutynin 2.5 mg PO TID
13. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
peripheral vertigo
vascular parkinsonism
Gait instability
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 movement d/o p/w worsening of underlying neuro status.
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy wires and
mediastinal clips again noted as well as partially imaged lumbar spinal
hardware. The heart remains moderately enlarged. The lungs appear clear though
there is mild cephalization which may reflect increased pulmonary venous
pressures. No large effusion or pneumothorax is seen. Cardiomegaly is stable.
Tortuous thoracic aorta is noted with scoliotic lower T-spine.
IMPRESSION:
Cardiomegaly with mild pulmonary venous congestion.
Radiology Report
INDICATION: ___ with hx of cva with ?new L facial droop. Assess for
intracranial hemorrhage.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal, and
thin section bone algorithm reconstructed images were generated.
DOSE: DLP: 891.93 mGy-cm
COMPARISON: Noncontrast head CT ___.
FINDINGS:
No evidence of hemorrhage, edema, mass effect, or acute large territorial
infarction. Again seen is evidence of right frontotemporal chronic infarction,
unchanged in size and appearance since ___. Prominence of the
ventricles and sulci are related to age-related cortical volume loss.
Periventricular subcortical and deep white matter hypodensities are likely
sequelae of chronic small vessel ischemic disease.
The basal cisterns are patent and there is preservation of gray-white matter
differentiation.
No fracture identified. Mild mucosal thickening of the ethmoidal air cells.
The additional visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. Globes are notable for bilateral lens replacement. Dense
vascular calcifications are again noted in the cavernous portions of the
internal carotid arteries, bilateral middle cerebral arteries, basilar artery,
and vertebral arteries.
IMPRESSION:
Chronic changes as described above. No intracranial hemorrhage. Of note MR is
more sensitive to the detection of acute infarction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with OTHER MALAISE AND FATIGUE, FAILURE TO THRIVE,ADULT
temperature: 97.6
heartrate: 91.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | This is an ___ yo woman with PMH significant for multifactorial
gait disorder (frontal + parkinsonian features, on
Levodopa/Carbidopa for Parkinsonism), AFib, CAD, spinal stenosis
s/p lumbar surgery who presents with 3 days of worsened gait
freezing, difficulty moving/getting out of bed and slowing of
her speech. According to the patient's HCP and friend she had
stopped taking her medications at home in a passive suicidal
gesture. She has been very clear with her HCP and family that
her primary aim is staying in her appartment at home. She does
not wish to undergo any life extending treatments. She is
amenable to a short stay at acute rehab to maximize her mobility
followed by discharge with the plan to remain at home with the
aid of palliative services.
On presentation her exam was remarkable for Hypophonia and
hypomimia. Prominent grasp reflexes bilaterally. Decreased
upgaze. Subtle left NLF flattening (baseline). +Generalized
whole body bradykinesia. Marked paratonia and rigidity in the
trunk and extremities. Weakness L>R. She can only ambulate a
couple of steps before retropulsing onto bed, but observed
markedly shortened stride length and slowed speed.
Her clinical picture was thought likely the result of worsening
parkinsonism from medication non-compliance. Her course was
complicated by episodes of severe vertigo which is likely BPPV.
We has hoped to do an MRI to evaluate for the cause of her
vertigo and left sided weakness however the patient any family
refused this. The patient's vertigo was treated with meclazine
with improvement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysphagia, odynophagia
Major Surgical or Invasive Procedure:
Rigid bronchoscopy and tracheal stent removal ___
History of Present Illness:
As per admitting MD
___ is a ___ yo ___ man with high grade
neuroendocrine mediastinal carcinoma on paclitaxel and RT to
mediastinum, c/b malignant hemoptysis s/p tracheal stent ___,
DVT on Xarelto, who presents with 2 days of worsening
odynophagia and dysphagia.
Mr ___ was recently admitted ___ with small volume
hemoptysis. Bronchoscopy ___ showed multiple tracheal masses
and scant blood. He received 16 x 60 mm covered stent to prevent
further intrinsic and extrinsic malignant compression. CT that
admission demonstrated rapid progression of disease; so he was
urgently started on paclitaxel and RT to mediastinum ___.
Of note, day prior to discharge, Mr ___ reported dysphagia
(solids > liquids). He developed subjective fevers and
tachycardia. A CT neck/chest was done which did not demonstrate
any acute changes. His symptoms improved the next day and he was
discharged with instructions to seek medical care if recurrent.
Since discharge, Mr ___ says he has primarily had soup because
of ongoing mild dysphagia. However, 2 days prior to admission,
he noticed his dysphagia and odynophagia became worse and he was
not even able to swallow his spit. He feels his inability to
swallow was due to both pain and a sensation that the liquids
didn't seem to pass through his throat. He states he was able to
intermittently manage solids. He was able to take small pills,
although he sometimes had to chew on larger pills. He was able
to eat an apple in the ED prior to admission.
He denies any pain in the chest with swallowing; just pain in
the throat. He denies regurgitation. He does not have the
sensation of food getting stuck in his chest. No heartburn. He
denies shortness of breath, new chest pain (has ongoing L sided
cancer associated pain), lightheadedness, dizziness, fevers,
chills, hemoptysis, N/V/abdominal pain.
In ED: T 99.2 | 95 | 108/76 | 98% RA. A CT chest was done which
did not demonstrate any acute changes. IP was consulted and
noted mild migration of tracheal stent that may warrant repeat
bronchoscopy but was unlikely to be the source of his symptoms.
Prior to admission, he received:
___ 13:19 NEB Acetylcysteine 20% 3 mL
___ 13:19 IV Morphine Sulfate 2 mg
Past Medical History:
As per admitting MD
___ pancreatitis
___ gall stones s/p ERCP
Alcohol use disorder (12 beers a day; quit in ___
Tobacco use disorder ___ years; quit ___
Hyperglycemia
Hemorrhoids
S/p R knee meniscus repair
Asthma in childhood
RUE DVT (diagnosed ___, LUE DVT
High-Grade NE Tumor
ONCOLOGIC HISTORY
___ At Age ___, he presented to the ED with 3 days of
constant right sided chest pain, had a CTA that found a large
mediastinal mass with multiple pulmonary nodules compatible with
metastasis. Retrospectively, he noticed a hoarse voice and some
throat discomfort for last six months. In the previous month, he
also reported progressive dysphagia to solids initially, but
lately also to liquids and with some associated odynophagia. He
was seen by ENT and 2 laryngoscopies were negative for masses.
Patient endorses minimally nonproductive cough, chills with
night
sweats almost nightly for the last few weeks.
___ CT revealed a large superior mediastinal mass that may
represent a conglomerated lymph nodal mass measuring up to 6.1
cm
with bilateral hilar, subcarinal and paratracheal
lymphadenopathy. Left supraclavicular lymphadenopathy is also
noted. Innumerable bilateral pulmonary nodules consistent with
metastases. Diffuse sclerosis involving the right posterior
seventh and left posterior eighth ribs may reflect osseous
metastasis. No pathologic fracture. 8 mm prominent porta
hepatis
lymph node is nonspecific. MRI brain without metastasis. PET
confirmed metastatic disease at both lungs.
___ - ___: received 4 cycles of chemotherapy:
.Cisplatin 75 mg/m2 on day 1 (-20% due to neutropenia)
.Etoposide 80 mg/m2 on days 1, 2 and 3 (-20% due to neutropenia)
.Atezolizumab 1200 mg on day 1 (started from cycle 2)
___ Start Atezolizumab maintenance every 21d (IMpower133)
___ Atezolizumab 1200 mg IV
___ - ___ Admitted for small volume hemoptysis, in s/o
malignant tracheal tumors and therapeutic anticoagulation for
DVT. Underwent bronchoscopy ___ with small amounts of blood
seen coming from RUL. 16 mm x 60 mm covered stent placed for
extrinsic and intrinsic tumoral compression.
Imaging that admission also notable for rapid progression of
disease for which he was started on paclitaxel and RT
___: C1D1 paclitaxel and RT
Social History:
___
Family History:
As per admitting MD
___ + Father with HTN, 7 siblings most with HTN. Reports no
family history malignancy
Physical Exam:
Admit:
General: Well appearing pleasant man sitting up at edge of bed
Neuro: PERRL, EOMI, palate elevates symmetrically, tongue
midline
Handgrip ___
Alert, oriented, provides clear history
HEENT: Oropharynx clear, moist membranes, no lesions. Sclera
anicteric
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally. nontender to
palpation
Abdomen: Soft, nontender, nondistended. Bowel sounds present
Extr/MSK: WWP, no peripheral edema
Skin: No obvious rashes + tattoos
Access: POC
Discharge:
General: Well appearing pleasant man sitting up in bed in no
acute distress, calm
EYES: PERRLA, anicteric
HEENT: Oropharynx clear, MMM. Firm nontender left
sided cervical adenopathy
CV: RRR no murmurs, normal distal perfusion without edema
PULM: CTA b/l, no wheezes/rales/rhonchi, normal RR
ABD: Soft, nontender, nondistended, normoactive BS
LIMBS: No peripheral edema, WWP, no deformity, normal muscle
bulk
SKIN: No obvious rashes, warm/dry
NEURO: Alert, oriented, PERRL
PSYCH: Normal mood, insight, judgment, affect
ACCESS: POC, dressing c/d/i
Pertinent Results:
Admit:
___ 10:37AM BLOOD WBC-2.0* RBC-3.91* Hgb-9.9* Hct-31.8*
MCV-81* MCH-25.3* MCHC-31.1* RDW-14.1 RDWSD-41.1 Plt ___
___ 10:37AM BLOOD Glucose-117* UreaN-10 Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-26 AnGap-10
___ 05:02AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.7
Discharge:
___ 06:15AM BLOOD WBC-5.7 RBC-4.87 Hgb-12.2* Hct-38.4*
MCV-79* MCH-25.1* MCHC-31.8* RDW-14.4 RDWSD-39.3 Plt ___
___ 06:15AM BLOOD Glucose-103* UreaN-20 Creat-0.8 Na-140
K-3.9 Cl-97 HCO3-32 AnGap-11
___ 06:15AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9
IMAGING
=======
CT NECK ___
1. Large central thoracic inlet, mediastinal mass, increasing
since ___.
2. Tracheal deviation to the right, mild tracheal narrowing,
tracheal stent. Loss of fat planes between tumor and esophagus,
trachea, which may be invaded.
3. Left level ___ adenopathy, mildly increased since ___.
4. Lung nodules, right pleural effusion, refer to chest CT from
yesterday
CT CHEST ___
1. Redemonstration of a large mediastinal mass/lymph node
conglomerate within the anterior upper mediastinum, overall
similar in size and appearance compared to prior CT chest from ___, with associated mass effect deviating the trachea
and upper esophagus to the right.
2. Tracheal stent is widely patent, with trace dependent
secretions, and
slight (approximately 4 mm) inferior migration compared to the
prior study.
The inferior portion the stent protrudes into the carina.
3. Redemonstration of numerous solid and cavitating pulmonary
lesions
scattered throughout the bilateral lungs, some of which have
slightly
decreased in size.
4. Small right pleural effusion with adjacent compressive
atelectasis,
unchanged.
Bronch ___
-Moderate granulation tissue at the proximal and distal end of
stent, patent airway status post stent removal
CXR ___:
In comparison with the study of ___, there are lower lung
volumes, which may account for the increased transverse diameter
of the heart. Nevertheless, there is engorgement of indistinct
pulmonary vessels, consistent with pulmonary vascular
congestion. Blunting of the right costophrenic angle is again
seen and the Port-A-Cath extends to the right atrium. No
evidence of acute focal consolidation. Substantial displacement
of the upper thoracic trachea to the right is consistent with
thyroid mass.
Micro:
Blood Cx negative final
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine 20% ___ mL NEB BID
2. GuaiFENesin ER 1200 mg PO Q12H
3. melatonin 3 mg oral QHS:PRN
4. Acetaminophen 1000 mg PO Q8H
5. Lidocaine 5% Patch 1 PTCH TD QPM R lateral chest wall
6. Morphine SR (MS ___ 15 mg PO Q12H
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
9. Polyethylene Glycol 17 g PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
11. Rivaroxaban 20 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. sodium chloride 0.9 % inhalation TID
Discharge Medications:
1. Baclofen 5 mg PO TID:PRN hiccups
RX *baclofen 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane
TID:PRN
RX *lidocaine HCl [Lidocaine Viscous] 2 % 10mL three times a day
Refills:*2
3. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID mouth/throat
pain
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL 5 ml by mouth four times a day Refills:*1
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H
7. Lidocaine 5% Patch 1 PTCH TD QPM R lateral chest wall
8. melatonin 3 mg oral QHS:PRN
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg/5 mL 5 ml by mouth every four (4) hours
Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
14. Rivaroxaban 20 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Dysphagia (solids > liquids) ___ tumoral compression
# Odynophagia ___ mucositis
# Metastatic high-grade neuroendocrine carcinoma of the
mediastinum
# Cancer associated chest pain
# Leukopenia, neutropenia
# Acute on chronic anemia
# Malignant hemoptysis and tracheal compression s/p stenting
___ s/p stent removal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: History: ___ with mediastinal neuroendocrine carcinoma s/p
tracheal stent placement and radiation now with progressive dysphagia and
odynophagia. Evaluation for evidence of stent migration, worsening
lymphadenopathy, stricture, or other causes of dysphagia/odynophagia.
TECHNIQUE: Contiguous axial images were obtained through the chest after
administration of intravenous contrast. Coronal and sagittal reformats were
obtained.
COMPARISON: Comparison to CT chest with contrast from ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta and main pulmonary artery are normal
in caliber. Though not specifically protocoled for assessment of the
pulmonary arterial tree, there is no central pulmonary embolism through the
lobar level. There is a port in the right chest wall with catheter
terminating in the right atrium. Heart size is normal. There are moderate
coronary calcifications, most pronounced in the LAD. Trace pericardial fluid
is within physiologic limits.
AXILLA, HILA, AND MEDIASTINUM: Large mediastinal mass/lymph node conglomerate
within the anterior upper mediastinum is overall similar in size and
appearance compared to prior CT chest from ___, measuring 7.7 x 5.7
cm in greatest axial dimension (04:48), unchanged from prior study when using
similar measurement technique. The mass again deviates the trachea and upper
esophagus to the right, and splays the brachiocephalic and left common carotid
arteries. The degree of tracheal deviation is not significantly changed. The
tracheal stent is widely patent, with trace dependent secretions, and slight
(approximately 4 mm) inferior migration compared to the prior study. The
inferior portion the stent protrudes into the carina. Additional smaller
mediastinal lymph nodes are similar to the prior study. Left supraclavicular
lymphadenopathy is also unchanged.
Right hilar lymph nodes measuring up to 8 mm short axis have slightly
increased in size, previously 6 mm.
PLEURAL SPACES: No pneumothorax. Small right pleural effusion with adjacent
compressive atelectasis, unchanged.
LUNGS/AIRWAYS: Again seen are numerous solid and cavitating pulmonary lesions
scattered throughout the bilateral lungs, some which have slightly decreased
in size. The largest lesion in the right upper lobe measuring 1.1 cm (4:107),
previously measuring 1.4 cm, with decreased surrounding ground-glass change.
A 0.7 cm lesion in the left apex is now cavitary (04:42), previously solid and
measuring 8 mm. Central airways are patent. There is mild diffuse bronchial
wall thickening.
BASE OF NECK: There is compression and possible invasion of the posterior left
thyroid lobe by the mediastinal mass.
ABDOMEN: This study is not tailored for subdiaphragmatic evaluation. There is
moderate diffuse atrophy of the pancreas with scattered punctate
calcifications, likely sequela of chronic pancreatitis. A coarse
calcification is again demonstrated in the hepatic segment VIII.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Redemonstration of a large mediastinal mass/lymph node conglomerate within
the anterior upper mediastinum, overall similar in size and appearance
compared to prior CT chest from ___, with associated mass effect
deviating the trachea and upper esophagus to the right.
2. Tracheal stent is widely patent, with trace dependent secretions, and
slight (approximately 4 mm) inferior migration compared to the prior study.
The inferior portion the stent protrudes into the carina.
3. Redemonstration of numerous solid and cavitating pulmonary lesions
scattered throughout the bilateral lungs, some of which have slightly
decreased in size.
4. Small right pleural effusion with adjacent compressive atelectasis,
unchanged.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT
INDICATION: ___ year old man with high grade neuroendcrine carcinoma,
presenting with worsening dysphagia and odynophagia. CT last ___ showing edema
and compression of larynx, follow up exam// evaluate cause of odynophagia,
dysphagia-- mass, edema, other lesion?
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 11.1 mGy (Body) DLP = 292.5
mGy-cm.
Total DLP (Body) = 293 mGy-cm.
COMPARISON: CT chest ___, CT chest ___. CT neck ___.
FINDINGS:
Thoracic inlet:
Thoracic inlet mass, with supraclavicular, and upper mediastinal extension,
measures 5.1 cm x 5.8 cm in cross-section, and at least 5.5 cm superior to
inferior (inferior edge not completely seen on the CT neck. On ___,
mass measured 6.1 cm x 5.5 cm in cross-section, the and 7.2 cm superior
inferior. On ___, it measured 4.2 cm x 3.6 cm in cross-section.
On ___ it measured 5.6 cm x 5.6 cm in cross-section. Mass
effect on the trachea which is deviated to the right mildly narrowed.
Tracheal stent in place. Tumor extends to the level of the left
brachiocephalic vein, upper margin of the aortic arch, is situated between
left common carotid and right brachiocephalic artery, anterior to the
vertebral column, and to the left of the esophagus. Esophagus is deviated to
the right. Fat planes between mass, trachea, esophagus, left
tracheoesophageal groove are obliterated, there may be local invasion.
Inferior margin of the left thyroid lobe is indistinct, may be involved by
tumor. The
Aero digestive tract: There is no mucosal based mass.
Neck lymph nodes:
Right neck: There is no right level ___ adenopathy. Few subcentimeter right
level 7 lymph nodes.
Left neck:
Enlarged retro jugular level 2A, 3, 4, 5 B lymph nodes. Largest level 5B
lymph node measures 1.7 x 1.4 cm today, compared with 1.5 cm x 1.4 cm
___ level ___ lymph nodes have enlarged.
Central mediastinal mass situated at the level of the left 6 and 7 lymph
nodes, described above, may represent conglomerate adenopathy or local
extensive primary/metastatic tumor.
There is no retropharyngeal adenopathy.
Extra nodal tumor spread: Irregular contour of left level 5 B lymph node, and
central mediastinal mass, suggestive of extranodal extension.
Deep neck muscles, masticator space: There is no muscle invasion.
Bones, skull base:
There is no bone involvement.
There are no findings suggestive of perineural tumor extension. Jugular
foramen, carotid canal, pterygopalatine fossa, infraorbital foramen, other
skull base foramina are not involved.
Vessels: There is no vascular invasion.
Brachial Plexus: There is no brachial plexus contact or invasion. Left level
5B lymph node is probably just anterior to the brachial plexus.
Thyroid, salivary glands: There is no mass.
Other findings: Multiple solid and cavitated lung nodules, for thoracic
findings refer to chest CT from yesterday. Moderate free-flowing right
pleural effusion. Probable secretions in the trachea. Potential intraluminal
tumor extent is not definitely seen
IMPRESSION:
1. Large central thoracic inlet, mediastinal mass, increasing since ___.
2. Tracheal deviation to the right, mild tracheal narrowing, tracheal stent.
Loss of fat planes between tumor and esophagus, trachea, which may be invaded.
3. Left level ___ adenopathy, mildly increased since ___.
4. Lung nodules, right pleural effusion, refer to chest CT from yesterday.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with neuroendocrine mediastinal cancer, s/p
tracheal stent for tumor compression (now removed), here with
dysphagia/odynophagia, new cough e/f aspiration// cough
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___. Chest radiograph ___.
FINDINGS:
Right Port-A-Cath tip terminates in the low right atrium, similar to prior.
Lung volumes are increased. No focal consolidation. Interval decrease in
mild pulmonary edema. Minimal interval decrease in upper mediastinal mass and
and severe rightward tracheal shift. Tracheal stent has been removed, but
relatively mild tracheal narrowing is stable. The cardiomediastinal
silhouette and hilar silhouette are normal. Small right pleural effusion
persists. No significant left pleural effusion. No pneumothorax.
IMPRESSION:
Interval resolution of mild pulmonary edema with increased lung volumes.
Minimal interval decrease in upper mediastinal widening with persistent right
tracheal shift. No progression of mild tracheal narrowing following removal
of previous tracheal stent.
Small right pleural effusion persists. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p tracheal stent removal with persistent
secretions/cough, pls assess for pneumonia// ___ year old man s/p tracheal
stent removal with persistent secretions/cough, pls assess for pneumonia
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes, which
may account for the increased transverse diameter of the heart. Nevertheless,
there is engorgement of indistinct pulmonary vessels, consistent with
pulmonary vascular congestion. Blunting of the right costophrenic angle is
again seen and the Port-A-Cath extends to the right atrium.
No evidence of acute focal consolidation.
Substantial displacement of the upper thoracic trachea to the right is
consistent with thyroid mass.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Difficulty swallowing
Diagnosed with Dysphagia, unspecified, Chest pain, unspecified
temperature: 99.2
heartrate: 95.0
resprate: 18.0
o2sat: 98.0
sbp: 108.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | ___ ___ with high grade neuroendocrine mediastinal
carcinoma (on paclitaxel and RT to lung/esophagus), c/b
malignant hemoptysis and compression s/p tracheal stent ___
(now s/p removal ___, DVT (on Xarelto), who presented with
worsening
odynophagia and dysphagia x 8 days ___ mild mucositis, improved
with supportive care and short dexamethasone course, was
tolerating normal diet by discharge, has close outpatient f/u in
___ clinic
# Dysphagia (solids > liquids)
# Odynophagia
Pt presented with significant odynophagia/dysphagia. Pt received
4 days empiric fluconazole for ___ esophagitis since he
presented w/ neutropenia, though was discontinued given lack of
marked improvement and count recovery. ENT performed evaluation
and identified mild mucositis. Dr ___ that
radiation field did not extend up that high to cause findings.
CT showed left sided adenopathy, suggesting that
odynophagia/dysphagia are at least somewhat caused by tumoral
compression in the neck c/b referred pain from extrinsic
compression of the esophagus in the chest. Speech and Swallow
team followed during stay, rec'd diet modifications. Patient was
given short dexamethasone course which was tapered off by
discharge. By time of discharge he was tolerating full diet
without issue but had lingering ___ pain, managed with
combination of liquid oxycodone and magic mouthwash which he was
prescribed on discharge. Pantoprazole continued during stay and
prescribed on discharge. Patient is to followup with ENT
following completion of his ongoing radiation course.
# Metastatic high-grade neuroendocrine carcinoma of the
mediastinum
# Cancer associated chest pain
Diagnosed ___. Completed 4 cycles
cisplatin/etoposide/atezolizumab (___), followed by
2 cycles of atezolizumab (last ___. Admitted ___ for small
volume hemoptysis w/ rapid progression of disease noted on scan.
Started paclitaxel + RT to mediastinum ___. Dr ___
___ patient during stay, noted that he will receive C2D1
on ___. Pt nearing end of radiation course as discussed above
# ___, neutropenia
# Acute on chronic anemia
Counts improved during stay so was likely ___ temporary BM
suppression from recent chemotherapy. Counts to be trended in
outpatient setting with further chemotherapy.
# Malignant hemoptysis and tracheal compression s/p stenting
___
CT reviewed by IP with possible mild migration. Accordingly,
stent removed by IP ___. After removal, patient had mild cough
at night which resolved during the day, and CXR was without
infiltrate. Pt may have lingering airway irritation from stent
removal so abx held, and will need symptoms closely monitored in
outpatient setting after discharge
# HX of RUE DVT (in s/o PICC), LUE DVT
RUE DVT diagnosed ___. LUE DVT diagnosed ___ in setting
of holding rivaroxaban for 4 days while awaiting port placement.
Patient was continued on rivaroxaban during stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / acyclovir / Penicillins / aspirin / Tylenol / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
AMS, GI bleed
Major Surgical or Invasive Procedure:
esophagogastricduodenoscopy with APC
History of Present Illness:
___ w/___ vs. cryptogenic cirrhosis c/b esophageal variceal
bleed (___), recurrent
encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and
anemia who presents to ___ as a transfer from ___
with AMS and GI bleed (Hct 18). His wife called EMS when she
discovered him urinating in the wrong place and he was found to
have Hct 18 at ___. He was given 1U PRBC's and
transferred to ___, where repeat Hct was 21.8. Other labs
significant for INR 1.5, Tbili 2.5, AP 91, ALT 23, AST 35, Lip
27, and ammonia 120. At transfer, he was hemodynamically stable.
Of note, he is initiating transplant work-up but is not
currently listed. He receives most of his care at ___
___ and has had multiple recent admissions for AMS since
having TIPS in ___, averaging 2 admissions/month. Head CT in
___ was negative. His last EGD was in ___ and showed
grade I nonbleeding esophageal varices, and severe gastric
antral vascular ectasia with active bleeding throughout the
antrum, treated extensively with argon plasma coagulation with
some oozing at the end of the procedure. US in ___ showed
patent TIPS. He is now being transferred to ___ for EGD here
and consideration of TIPS reversal.
Upon arrival in the ED, vitals: 98 91 120/75 17 97%. Patient
was oriented x 1 and stool was guaiac positive. CT head was
negative. In the ED, GI evaluated the patient. RUQ US showed
patent TIPS. She was given ceftriaxone, lactulose, and plan was
initiated for EGD in the AM. There was no pocket for diagnostic
tap. Vitals prior to transfer were 97.5 86 114/59 11 98% RA.
Labs were notable for HCT of 21.8 and INR 1.5 and bili 2.5. He
was given 1U PRBCs in route.
ROS:
Otherwise negative in detail
Past Medical History:
#Cirrhosis NASH vs. cryptogenic c/b esophageal and gastric
varices
#encephalopathy s/p TIPS ___
#GI bleed (___)
#GAVE s/p APC treatments
#Anemia
#Chronic thrombocytopenia
#Chronic leukopenia
#CAD s/p CABG ___
#LVH
#Aortic stenosis s/p bovine aortic valve replacement
#Bovine aortic valve replacement ___
#Morbid obesity
#Depression
#C-spine fracture s/p fusion ___
#Peripheral neuropathy
#DM
#PVD
#Chronic ___ edema
#Arthritis
#HTN
#Migraines
#R shoulder arthroscopy x 3
Social History:
___
Family History:
Mother died in ___ after a fall, father died of heart valve
problems.
no GI malignancies or cirrhosis
Physical Exam:
ADMISSION EXAM
97 140/63 90 16 99% RA
General: NAD
HEENT: EOMI, PERRL, MMM
Neck: supple
CV: RRR, ___ SM prominent at ___
Lungs: CTAB
Abdomen: soft, nondistended, no ttp
GU: no foley
Ext: 2+ edema to sacrum
Neuro: A&Ox3, slowed speech, otherwise nonfocal, no asterixis
Skin: no rash
DISCHARGE EXAM
98.9, 114/54, 78, 18, 95% RA, Wt 119.9kg, Fasting blood sugar:
128
I/O 1260/1080, 0 BMs
General: NAD
HEENT: EOMI, PERRL, anicteric, MMM
Neck: supple, No JVD, No ___
CV: RRR, ___ SM prominent at ___
Lungs: CTAB, no w/r/r
Abdomen: NABS, soft, nondistended, no ttp
Ext: 2+ edema to sacrum
Neuro: A&Ox3, no asterixis
Skin: no rash
Pertinent Results:
ADMISSION LABS
___ 04:19PM BLOOD WBC-2.9* RBC-2.15* Hgb-6.7* Hct-21.8*
MCV-101* MCH-31.1 MCHC-30.7* RDW-20.0* Plt Ct-61*
___ 04:19PM BLOOD Neuts-63.7 ___ Monos-5.3 Eos-2.1
Baso-0.4
___ 04:19PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-1+ Ovalocy-1+
Target-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL
Stipple-OCCASIONAL Tear Dr-OCCASIONAL
___ 04:19PM BLOOD ___ PTT-33.1 ___
___ 04:19PM BLOOD Glucose-213* UreaN-25* Creat-1.2 Na-137
K-4.4 Cl-104 HCO3-26 AnGap-11
___ 04:19PM BLOOD ALT-23 AST-35 AlkPhos-91 TotBili-2.5*
___ 04:19PM BLOOD Lipase-27
___ 04:19PM BLOOD Albumin-2.4*
PERTINENT LABS
___ 05:50AM BLOOD calTIBC-247* Ferritn-56 TRF-190*
___ 05:50AM BLOOD Albumin-2.2* Calcium-7.4* Phos-3.5 Mg-1.8
Iron-40* Cholest-75
___ 05:50AM BLOOD Triglyc-63 HDL-29 CHOL/HD-2.6 LDLcalc-33
___ 05:50AM BLOOD 25VitD-58
___ 05:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 05:50AM BLOOD AMA-NEGATIVE
___ 05:50AM BLOOD ___
___ 05:50AM BLOOD CEA-<1.0 PSA-<0.1 AFP-1.1
___ 05:50AM BLOOD IgG-1203 IgA-378 IgM-56
___ 05:50AM BLOOD HIV Ab-NEGATIVE
___ 05:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:50AM BLOOD HCV Ab-NEGATIVE
Test Result Reference
Range/Units
CA ___ 15 <34 U/mL
HCT TREND
___ 12:11AM BLOOD Hgb-6.8* Hct-21.6*
___ 09:00AM BLOOD Hgb-7.9* Hct-24.8*
___ 04:10PM BLOOD Hct-22.7*
___ 01:44AM BLOOD Hct-20.7*
___ 06:45AM BLOOD Hgb-7.6* Hct-22.9*
___ 03:41PM BLOOD Hgb-8.3* Hct-26.0*
___ 05:50AM BLOOD Hgb-7.7* Hct-24.8*
___ 03:20PM BLOOD Hct-23.9*
___ 11:23PM BLOOD Hct-23.6*
___ 06:50AM BLOOD Hgb-7.8* Hct-23.5*
___ 03:00PM BLOOD Hct-26.7*
DISCHARGE LABS
___ 06:50AM BLOOD WBC-2.2* RBC-2.44* Hgb-7.8* Hct-23.5*
MCV-97 MCH-31.8 MCHC-33.0 RDW-20.2* Plt Ct-50*
___ 03:00PM BLOOD Hct-26.7*
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-27 AnGap-10
___ 06:50AM BLOOD ALT-20 AST-39 AlkPhos-72 TotBili-1.6*
___ 06:50AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
MICRO
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
CMV IgG ANTIBODY (Final ___:
EQUIVOCAL FOR CMV IgG ANTIBODY BY EIA.
4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
RUBELLA IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
URINE CULTURE (Final ___: <10,000 organisms/ml
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
CT HEAD ___: Limited examination due to patient motion and
streak artifact. No definite hemorrhage or acute large
territorial infarction.
LIVER U/S ___:
1. Patent TIPS shunt. Slightly elevated velocities as compared
to recent
prior.
2. Cirrhotic liver without definite lesion.
3. Trace perihepatic ascites and splenomegaly.
4. Gallbladder sludge.
TTE ___: The left atrial volume is moderately increased. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is higher than expected for
this type of prosthesis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Well seated aortic valve bioprosthesis, but with
increasd gradient. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the aortic valve gradient and the estimated PA systolic pressure
have increased (as has the heart rate).
If clinically indicated, a TEE would be better able to
visualize the aortic valve leaflets.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Measurements, Normal Range
Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Left Atrium - Volume: *92 ml < 40 ml
Left Atrium - LA Volume/BSA: *37 ml/m2 <= 28 ml/m2
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Lateral Peak E': 0.15 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.14 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *13 < 13
Aorta - Sinus Level: *4.3 cm <= 3.6 cm
Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *74 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 46 mm Hg
Aortic Valve - LVOT VTI: 39
Mitral Valve - E Wave: 1.9 m/sec
Mitral Valve - A Wave: 1.8 m/sec
Mitral Valve - E/A ratio: 1.06
Mitral Valve - E Wave deceleration time: 239 ms 140-250 ms
TR Gradient (+ RA = PASP): *35 mm Hg <= 25 mm Hg
EGD REPORT ___:
Three ___ of grade two varices were noted in the lower third
of the esophagus. There was no bleeding or high risk signs. 3
small venous blebs noted in the mid esophagus.
Mild congestion and erythema with a mosiac apperance consistent
with mild portal hypertensive gastropathy noted though out the
stomach. Bright red blood was oozing from the antrum consistent
with gastric antral vascular ectasia (GAVE). Hemostasis was
successfuly achieved with argon plasma coagulation (APC) which
was applied though out the antrum. No additional bleeding was
noted after APC. There were no gastric or fundic varices.
Mild amounts of patchy duodenitis was noted though segemnts one
and two of the duodenum, otherwise normal deuodenum.
Otherwise normal EGD to third part of the duodenum
Recommendations:
-Follow up with routine blood work to asses stability of
hematocrit.
- PPI 40mg PO daily
- If pt continues to have a decline in hematocrit, we suggests a
follow up EGD in ___ weeks with possible APC or RFA.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rifaximin 550 mg PO BID
2. Lactulose 45 mL PO QID
3. Citalopram 10 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. 70/30 16 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. alpha lipoic acid ___ unit oral qam
9. Multivitamins 1 TAB PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral BID
12. Magnesium Oxide 280 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. 70/30 16 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin NPH and regular human [Humulin 70/30] 100 unit/mL
(70-30) 16 Units before BKFT ; 10 Units before DINR daily Disp
#*3 Vial Refills:*1
4. Lactulose 45 mL PO QID
RX *lactulose 10 gram/15 mL (15 mL) 45 ml by mouth four times a
day Disp #*5400 Milliliter Refills:*1
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Capsule
Refills:*1
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
7. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
8. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
9. alpha lipoic acid ___ unit oral qam
10. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral BID
RX *calcium carbonate 600 mg (1,500 mg) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
12. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
13. Magnesium Oxide 280 mg PO DAILY
RX *magnesium oxide 250 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
14. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*1
15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
gastric antral vascular ectasias
decompensated cirrhosis
acute toxic/metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___)
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with history of NASH cirrhosis, now presenting
with confusion and left facial droop.
COMPARISON: Head CT from ___.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Bone and soft tissue algorithms were reviewed. Coronal and
sagittal reformations were prepared.
NON-CONTRAST HEAD CT: Examination is limited secondary to patient motion and
streak artifact from cervical spinal fusion hardware. There is no definite
hemorrhage, mass, mass effect, or acute large territorial infarction.
Gray-white matter differentiation is preserved. The ventricles and sulci are
mildly prominent compatible with age appropriate atrophy. There is no shift
of the midline structures. Suprasellar and basilar cisterns are widely
patent. No scalp abnormality is detected. The visualized paranasal sinuses
and mastoid air cells appear clear. Cervical spinal fusion hardware is only
partially imaged and incompletely evaluated.
IMPRESSION: Limited examination due to patient motion and streak artifact.
No definite hemorrhage or acute large territorial infarction.
Radiology Report
INDICATION: History of NASH cirrhosis and TIPS, now presenting with
confusion.
COMPARISON: Abdominal ultrasound from ___ and ___
FINDINGS: The coarse heterogeneous appearance of the liver is consistent with
cirrhosis. No definite hepatic lesion is identified. There is no biliary
ductal dilatation. The common bile duct measures 4 mm. There is splenomegaly
measuring up to 21 cm. The gallbladder remains filled with sludge. There is
no ascites within the lower abdomen. Trace perihepatic ascites is noted.
DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was
performed. The main portal vein is patent with hepatopetal flow with a
velocity of 36 cm/sec. The TIPS stent is patent with wall-to-wall flow and
velocities of 156, 206, 128 cm/sec in the proximal, mid and distal portions
respectively. Helical flow is again seen within the anterior right portal
vein. Flow towards the TIPS shunt is seen within the left portal vein. The
velocities are slightly increased in the shunt, findings are overall similar
compared to most recent prior examination.
IMPRESSION:
1. Patent TIPS shunt. Slightly elevated velocities as compared to recent
prior.
2. Cirrhotic liver without definite lesion.
3. Trace perihepatic ascites and splenomegaly.
4. Gallbladder sludge.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOW HCT
Diagnosed with ALTERED MENTAL STATUS , GASTROINTEST HEMORR NOS
temperature: 98.0
heartrate: 91.0
resprate: 17.0
o2sat: 97.0
sbp: 120.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ w/NASH vs. cryptogenic cirrhosis c/b esophageal variceal
bleed (___), recurrent
encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and
anemia who presents to ___ as a transfer from ___
with AMS and GI bleed (Hct 18), found to have hepatic
encephalopathy and oozing GAVE.
#) Oozing GAVE - Pt has a history of recurrent bleeding from
GAVE. An EGD on ___ confirmed the diagnosis, and APC was
repeated. The pt required a total of 4 units of pRBCs at ___
this admission, one each on ___ and 1 just prior to
d/c on ___. His hct was stable but low at 23.5 on the day of
discharge and post-transfusion hct rose to 26.7. The pt needs
repeat CBC drawn in 1 week. He was discharged with a Rx for CTX
to complete 7 days of SBP prophylaxis given the UGI bleed. If pt
continues to have a decline in hematocrit, we suggests a follow
up EGD in ___ weeks with possible APC or RFA. He should continue
taking PPI 40mg PO daily.
#) Encephalopathy - The pt has a history of recurrent
encephalopathy after undergoing TIPS. This episode of HE likely
was a result of GI bleed. Infectious work-up was negative (CXR
clean at OSH. UA neg for infection. No tappable pocket of
ascites to r/o SBP). His doctors at ___ considered TIPS
reversal given frequent HE admissions, however the hepatology
team at ___ recommend against TIPS reversal due to frequent
GAVE bleeding, which would likely worsen with TIPS reversal. In
addition, RUQ U/S this admission showed increased velocity
through TIPS shunt, so it is naturally becoming more stenosed.
The pt should continue taking lactulose TID for goal of ___ BMs
daily. Ideally he should be on rifaximin as well, but financial
restraints prohibit him from taking it. The pt was provided with
1 month of free prescriptions on discharge from ___, but the
free pharmacy would not provide rifaximin.
#) NASH cirrhosis - c/b esophageal variceal bleed ___,
___, recurrent encephalopathy s/p TIPS
(___), GAVE s/p APC treatments, and anemia. Transplant eval had
been delayed, per pt's hepatologist at ___, given social
stresses with wife currently undergoing w/u for possible breast
cancer as well as frequent hospitalizations lately resulting
difficulty making it to outpatient appointments. The pt's
transplant work-up was initiated during this hospitalization
with routine labs, social work consult, and a TTE (see "severe
AS" below). Further work-up is being delayed due to severe
aortic stenosis. He has follow-up at the transplant ___
clinic at ___. MELD labs were trended and stable this
admission. The pt should continue lasix and spironolactone at
home dose.
#) Severe AS - The pt has a history of aortic valve replacement
(bovine, per pt). A TTE was checked this admission due to
anasarca. It revealed severe aortic stenosis with a peak
gradient of 74 which has rapidly increased since last echo at
___ in the ___. A cardiology consult was obtained
and they stated pt "will likely will need aortic valve issue
resolved prior to liver transplant. Since he is a poor
candidate for redo-AVR, we could consider aortic valvuloplasty
as temporary treatment prior to liver transplant or TAVR in the
future when he is on waiting list for liver transplant or AS
worsens. He is followed by private cardiologist in ___, so he
should be followed by his cardiologist as outpatient." ___ was
recommended to further evaluate aortic valve prior to any valve
intervention. However, since pt had just had APC for GAVE, they
recommended holding off on TEE and following up with cards as
outpatient. Pt was continued on his home dose diuretics. He was
also re-started on nadolol for both cardiac protection and
prevention of variceal bleed. Cards recommended aspirin and
statin in the future, however benefit of these meds should be
weighed against bleeding/hepatic injury risk. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUE weakness
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy and arthrodesis C4-5.
2. Application of interbody cage, machined allograft C4-5.
3. Arthrodesis C4-5.
4. Anterior instrumentation C4-5 with a plate.
History of Present Illness:
Patient is a ___ w four days of RUE weakness and neck pain. She
has a 6 month history of intermittent neck pain, but it had
recently become worse and the weakness is a new finding. She is
otherwise well. She has no bowel or bladder sx, she does state
she has had clumsiness in her RUE intermittently.
Past Medical History:
HTN
Social History:
No tobacoo, etoh, ___ speaking.
Physical Exam:
Physical Exam Per Ortho Spine Admission Note dated ___-
NAD
Normal chest rise
Motor key
0 - Flaccid
1 - Voluntary twitch
2 - Voluntary mvmt cannot overcome gravity
3 - Can overcome gravity only
4 - Voluntary can overcome some resistance
5 - Normal strength
Sensation key
0 - Insensate
1 - Altered sensation
2 - Normal sensation
Upper Motor Upper Sensation
R L R L
C5 5 5 Elbow flexor ___
C6 3+ 5 Wrist extensor ___
C7 4- 5 Elbow extensor ___
C8 4+ 5 Finger flexor ___
T1 3+ 5 Finger abduction ___
Lower Motor Lower Sensation
R L R L
L2 5 5 Hip adductor L2 2 1
L3 5 5 Knee extensor L3 2 1
L4 5 5 Ankle DF L4 2 2
L5 5 5 ___ L5 2 2
S1 5 5 Ankle PF S1 2 2
Midline pain: TTP right side of cervical spine and shoulder
Rectal sensation: intact
Rectal tone: intact
Babinski:equivocal
___: negative
Clonus: none
Quality of exam: excellent
Upper extremity reflexes symmetric.
Pertinent Results:
___ 05:00AM BLOOD WBC-13.8* RBC-4.01* Hgb-11.2* Hct-35.3*
MCV-88 MCH-28.0 MCHC-31.8 RDW-12.9 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-26 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*45 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not operate heavy machinery, drink alcohol, or drive
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every four (4) hours Disp #*75 Tablet Refills:*0
4. Amlodipine 10 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cervical disk herniation C4-5.
2. Cervical right upper extremity radicular symptoms with
weakness.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Pre-operative evaluation for cervical fixation.
COMPARISON: None available.
TECHNIQUE: PA and lateral chest radiographs, two views.
FINDINGS: Heart size is mildly enlarged. 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
HISTORY: Right-sided neck pain and C4-5 disc herniation on MR. ___
evaluation of bones.
COMPARISON: Same-day cervical spine MR of ___, cervical spine
radiograph ___.
TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 720.42 mGy-cm.
CTDIvol: 36.76 mGy.
FINDINGS: There is no cervical spine fracture or malalignment.A 7 mm
sclerotic lesion in the left C1 posterior arch suggests a bone island.
Vertebral body heights are maintained. Again seen are large disc herniations
at C3-4, C4-5, and C5-6 with spinal canal narrowing and mass effect on the
spinal cord, most severe at C4-5 where severe cord compression is demonstrated
on the preceding MRI. There is also a smaller central disc herniation at C6-7.
In addition, there are posterior endplate osteophytes from C3-4 through C6-7.
There is moderate left facet arthropathy from C3-4 through C5-6, and milder
facet arthropathy at other levels on the left and on the right. Uncovertebral
osteophytes are also present bilaterally. The extent of neural foraminal
narrowing is better assessed on MRI.
The prevertebral soft tissues are unremarkable. The imaged lung apices are
clear. The visualized portion of the thyroid is unremarkable.
A 9 mm left level 5 lymph node on image 3:35 is top normal in size and unusual
for age, but appears to contain a preserved fatty hilus.
IMPRESSION:
1. No cervical spine fracture or malalignment.
2. Multilevel degenerative disease with severe cord compression at C4-5,
better assessed on the preceding MR.
Radiology Report
SIX INTRAOPERATIVE RADIOGRAPHS OF THE CERVICAL SPINE
CLINICAL INDICATION: ___ female with anterior cervical spine fusion.
TECHNIQUE: Six intraoperative radiographs of the cervical spine were
obtained.
COMPARISON: CT cervical spine dated ___.
FINDINGS:
The initial radiograph demonstrates a marker within the C5-C6 intervertebral
disc space. The final image demonstrates anterior cervical fusion from C4
through C5. No definite hardware complication is seen.
IMPRESSION:
Anterior cervical fusion at C4-C5 without definite hardware complication.
Please refer to the intraoperative report for further details.
Radiology Report
HISTORY: Right-sided neck pain, PCP once ___.
TECHNIQUE: AP, lateral, and open-mouth views of the cervical spine.
COMPARISON: None.
FINDINGS:
On the lateral view, C1-C7 are included. The C7/T1 interval is not well seen
although grossly, anatomic alignment is likely maintained. There is a small
well corticated ossific structure measuring 2-3 mm just anterior to the
inferior/anterior aspect of the C5 vertebral body, which appears old. Minimal
disc space narrowing is seen at C4/C5. Vertebral body heights are maintained
without findings to suggest acute fracture. Atlanto axial interval is
maintained. No dislocation is seen. There is no prevertebral soft tissue
swelling. The visualized lung apices are grossly clear.
IMPRESSION:
C7/T1 interval not optimally seen, although grossly, anatomic alignment is
likely maintained. If there is high clinical concern at this location,
suggest swimmer's view or CT. Otherwise, mild degenerative changes without
definite acute fracture or dislocation.
Radiology Report
CERVICAL SPINE MRI WITHOUT CONTRAST, ___
INDICATION: Right-sided neck pain, weakness of right wrist flexion. Evaluate
for cord impingement.
COMPARISON: Cervical spine radiographs performed earlier today.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical
spine, as well as sagittal diffusion-weighted images of the cervical spine,
and axial gradient echo and T2-weighted images of the cervical spine.
FINDINGS: Vertebral body heights are preserved. There is no subluxation. No
concerning bone marrow signal abnormalities are seen.
At C2-3, there is no significant spinal canal or neural foraminal narrowing.
There is mild left facet arthropathy.
At C3-4, there is a broad-based disc osteophyte complex moderately narrowing
the spinal canal and flattening the ventral spinal cord. Cord signal appears
preserved at this level. There is moderate bilateral neural foraminal
narrowing by uncovertebral and facet osteophytes.
At C4-5, there is a large central disc herniation, larger on the right than
left, which severely narrows the spinal canal and compresses the spinal cord.
There is high signal in the cord at this level on T2-weighted images,
compatible with edema or myelomalacia. There is mild right and moderate left
neural foraminal narrowing by uncovertebral osteophytes.
At C5-6, there is a central disc protrusion moderately narrowing the spinal
canal and flattening the ventral spinal cord. Cord signal appears preserved.
There is moderate right and severe left neural foraminal narrowing by
uncovertebral and facet osteophytes.
At C6-7, there is a small central disc protrusion which abuts the ventral
spinal cord without significant cord deformation. There is mild-to-moderate
spinal canal narrowing. There is mild left neural foraminal narrowing by
uncovertebral osteophytes.
C7-T1 level demonstrates mild left neural foraminal narrowing by uncovertebral
osteophytes.
Sagittal images through the T1-2 level demonstrate a possible shallow disc
herniation without significant spinal canal narrowing.
Cerebellar tonsils are normally positioned. The imaged portion of the
posterior fossa appears unremarkable. There is no diffusion abnormality in
the spinal cord.
IMPRESSION:
1. At C4-5, there is a large central disc herniation, larger on the right
than left, which compresses the spinal cord and severely narrows the spinal
canal. Abnormal cord signal at this level may indicate edema or myelomalacia.
2. At C3-4 and C5-6, there is moderate spinal canal stenosis with deformation
of the spinal cord, but no abnormal cord signal.
Cord compression and cord signal abnormality were documented in the ___
medical record and immediately transmitted to the ED dashboard by Dr. ___
on ___ at 9:11 p.m. At the time of final dictation, the patient
had already been taken to the operating room.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Weakness, Shoulder pain
Diagnosed with CERVICAL DISC DISPLACMNT
temperature: 97.4
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 57.0
level of pain: 13
level of acuity: 3.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical therapy
and Occupational Therapy was consulted for mobilization OOB to
ambulate and functional status. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vasotec / Niaspan Starter Pack / Ibuprofen
Attending: ___.
Chief Complaint:
R elbow pain and swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M w/ h/o AF on coumadin p/w right arm redness and swelling
since ___. Per wife, was watching TV, when pt noted
pain with movement of his R arm. Went to ___'s office on ___
where plain films were obtained and sent to Dr. ___
(___), who felt that there may be hemarthrosis given
elevated INR 5. Patient's wife noted redness was more extensive,
arm more warm, tender on ___ so she brought pt to ___
for further evaluation. At ___, labs notable for INR 5.2,
WBC 6.9, hct 34.9 (c/w baseline). He received ancef for possible
cellulitis, was going to be admitted for further abx and
monitoring but patient requested transfer to ___.
In the ED, initial vs were: 98.5 70 149/73 18 94% RA. Labs were
remarkable for INR 4.7, hct 36.1, creatinine 1.2 w/ BUN 27,
lactate 1.0. Patient was given 1g IV vancomycin. Was seen by
ortho who felt exam was not c/w septic arthritis and recommended
admission to medicine for antibiotics and monitoring. Vitals on
Transfer: 98.7 78 144/77 16 98%.
On the floor, vs were: T 97.8 P 93 BP 144/77 R 16 O2 99% on RA.
Patient was comfortable without any complaints except pain in
his R arm with movement. Denied fevers, chills, any recent
trauma or injury, no recent dietary changes or medication
changes/antibiotics. Per patient has not had many difficulties
keeping INR in therapeutic range and has only had one other
episode of bleeding- lower GI bleed in ___.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies myalgias. Ten point review of
systems is otherwise negative.
PAST MEDICAL HISTORY:
Past Medical History:
-Atrial fibrillation on warfarin
-Chronic constipation
-Pancolonic diverticuli
-Colon polyps
-BPH
-Partial lung resection for suspicious nodule, ___
-TKRs bilaterally at ___
-open cholecystectomy
-open appendectomy
-Squamous cell carcinoma (skin)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 144/77 P: 93 R: 16 O2: 99% RA
General: Alert, orient to person, place, and partially to time,
no acute distress, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; well healed
surgical scars
Ext: R UE with extensive hematoma on medial aspect, marked, and
tender to palpation; no other surrounding erythema; pt unable to
actively move R arm ___ pain, but ROM on passive evaluation is
intact; ___ are warm, well perfused, 2+ pulses, trace edema b/l;
no clubbing, cyanosis
Neuro: alert, oriented x3, CNII-XII grossly intact; motor and
sensation grossly intact; normal gait
Discharge Physical Exam: no significant difference from
admission exam
Pertinent Results:
=============================================================
LABS:
___ 07:40PM BLOOD WBC-7.5 RBC-3.84* Hgb-12.3* Hct-36.1*
MCV-94 MCH-31.9 MCHC-33.9 RDW-13.9 Plt ___
___ 07:43AM BLOOD WBC-7.0 RBC-3.84* Hgb-11.7* Hct-35.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.2 Plt ___
___ 07:40PM BLOOD Neuts-63.5 ___ Monos-10.4 Eos-1.7
Baso-0.9
___ 07:40PM BLOOD ___ PTT-63.2* ___
___ 07:43AM BLOOD ___ PTT-57.0* ___
___ 07:40PM BLOOD Glucose-119* UreaN-27* Creat-1.2 Na-138
K-3.7 Cl-102 HCO3-27 AnGap-13
___ 07:43AM BLOOD Glucose-113* UreaN-23* Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
___ 07:40PM BLOOD Calcium-8.9 Phos-2.1* Mg-2.0
___ 07:43AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.9
___ 07:40PM BLOOD CRP-70.0*
___ 07:40PM BLOOD Digoxin-0.4*
=============================================================
MICROBIOLOGY:
___ 7:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
Reported to and read back by ___ (___)
___ @1740.
___ 7:40 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
=============================================================
IMAGING:
Upper Extremity Ultrasound ___: FINAL READ
IMPRESSION: No evidence of pseudoaneurysm or drainable fluid
collection.
Small hematoma at the site of patient's echhymosis.
=============================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Tricor *NF* (fenofibrate nanocrystallized) 48 mg Oral daily
6. Warfarin 5 mg PO DAILY16
7. Losartan Potassium 80 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Triamterene 32.5 mg PO DAILY ___ edema
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Digoxin 0.25 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Losartan Potassium 80 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Triamterene 32.5 mg PO DAILY ___ edema
10. Tricor *NF* (fenofibrate nanocrystallized) 48 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ecchymosis
Supratherapeutic INR
Mild hemarthrosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with painful elbow and ecchymosis over right medial
arm.
COMPARISON: None.
TECHNIQUE: Limited soft tissue ultrasound of the right arm.
FINDINGS: Evaluation of the area of discoloration over the patient's right
medial forearm demonstrates no evidence of vascular compromise or
pseudoaneurysm. Soft tissue changes consistent with a small hematoma is noted
below the area of the discoloration.
IMPRESSION: No evidence of pseudoaneurysm or drainable fluid collection.
Small hematoma at the site of patient's echhymosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R ARM SWELLING
Diagnosed with JOINT EFFUSION-UP/ARM, JOINT PAIN-UP/ARM, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERCHOLESTEROLEMIA
temperature: 98.5
heartrate: 70.0
resprate: 18.0
o2sat: 94.0
sbp: 149.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | ___ year-old male with a PMH of atrial fibrillation on coumadin
who presents with right elbow pain and bruising/redness in the
setting of supratherapeutic INR, most consistent with extensive
ecchymosis.
# Ecchymosis/Right arm pain: He presented with large area of
ecchymosis covering approximately 40% of right upper extremity,
most notably at the medial aspect and antecubital fossa. Area
of ecchymosis was relatively stable during course of admission.
No drainage, pus or ulcerations consistent with cellulitis. Pt
remained afebrile without leukocytosis. Blood cultures were
drawn and he did receive Vancomycin IV x1 in the ED. Orthopedic
service felt there may be mild hemarthrosis but did not
recommend arthrocentesis given elevated INR and likelihood of
reaccumulation. Ortho recommended elevation, ice, and full
active ROM of elbow. Right upper extremity ultrasound was
performed and prelim read was without obvious pseudoanyeurysms
or blood collections. US final read pending on discharge. He
used tylenol for pain control.
*******************
PLEASE NOTE: after patient's discharge, Blood culture ___
bottles) resulted in gram positive rods consistent with bacillus
or clostridium species. Thought to be skin or lab contaminant as
patient was clinically afebrile, no leukocytosis, did not meet
sirs criteria, and there were only ___ blood cultures with this
species. Pt's PCP (Dr. ___ alerted by inpatient
attending, Dr. ___. Patient will be followed-up
day-after-discharge in clinic with Dr. ___.
********************
# Supratherapeutic INR: On coumadin for AFib with CHADS2 =2.
His INR was elevated to 5.2 at ___ which decreased to 4.7
in ED and 3.5 morning of discharge with just holding coumadin.
His Coumadin was held ___ and ___. He was given specific
instructions to follow with his PCP ___ ___ for INR check and
further instructions about restarting Coumadin.
# AFIB: CHADS2=2, rate control with digoxin. Anticoagulation
with coumadin, which was held given supratherapeutic INR. Plan
to restart Coumadin on ___ after INR check at outpatient appt.
# HTN: stable, he continued home meds
# Normocytic Anemia: at baseline, no need for transfusion.
# BPH: stable, continued finasteride
# Hypercholesterolemia: continued home atorvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness, slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a very pleasant ___ w/ thalamic glioblastoma c/b
hydrocephalus s/p VP shunt, s/p IMRT/TMZ ___, TMZ and
Bevacizumab, c/b disease recurrence s/p SRS ___, now on
TMZ/Beva q3 mo w/ recent dx of disease progression who p/w
slurred speech.
She went to have her MRI today prior to her brain tumor clinic
appointment. There she noted she had dizziness so a code was
called and she was referred to the ED. SHe states her symptoms
are largely stable since she last presented to the hospital.
Of note, I admitted her on ___ when she presented w/ sig nausea,
vertigo, difficulty projecting voice, DOE, dysphagia, found to
have disease progression, and started on dex. LP was done and
cytology negative for malignant cells but MRI was c/f
progression. She was discharged ___ on 4 mg dex BID.
Since then, she noted no change in her dizziness. Dizziness is
mainly when she moves her head or eyes, but does NOT have
dizziness at rest looking straight. Her nausea improved on dex.
She still has dysphagia and that seems to be slightly worse. Her
speech is sometimes slurred as well, not always, but "feels like
my tongue is swollen," or like "i'm speaking with a swollen
tongue." Her HA improved on dex but still has them
intermittently, not currently. She had sig relief w/ fioricet on
last admission.
In the ED, she was seen by neurology service who noted a
baseline
neurological exam w/ exception of mild dysarthria. They
recommended admission to neuro-onc for brain MRI and further
workup.
Past Medical History:
Positive PPD
Depressive disorder
Suicide threat or attempt
Burn
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS:97.8 PO 160 / 111 R Lying 78 18 98 RA
General: NAD, Resting in bed with fiance at bedside
HEENT: MMM, no OP lesions, no nystagmus at rest, tongue is
midline
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact, she has >10
sec nystagmus in both horizontal and vertical directions but
much
worse on end horizontal gaze and that reproduces her dizziness,
unable to assess for fatigability as she became sig symptomatic
holding her vision and had to abort, PEERL 3->2 mm, she has
minimal to no dysarthria, speech is clear and fluent w/o word
finding difficulty but slightly hypophonic, she has no dysmetria
or dysdiadochokinesia, negative rhomberg, she sways ambulating
in
room, + subjective orthostatic dizziness
PSYCH: Thought process logical, linear, future oriented
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
Vitals: ___ 2308 Temp: 97.8 PO BP: 150/94 R Lying HR: 78
RR:
18 O2 sat: 97% O2 delivery: RA Pain Score: Sleeping
General: NAD, Resting in bed
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: horizontal nystagmus present, tongue with left sided
deviation. Remaining CNs intact. strength b/l ___ intact,
PEERL, mild dysarthria, speech is fluent w/o word
finding difficulty but slightly hypophonic, she has no dysmetria
or dysdiadochokinesia, negative rhomberg, she sways ambulating
in
room, + subjective orthostatic dizziness
PSYCH: Thought process logical, linear, future oriented
ACCESS: PIV
Pertinent Results:
ADMISSION LABS
==============
___ 03:27PM BLOOD WBC-12.4* RBC-5.23* Hgb-16.8* Hct-47.8*
MCV-91 MCH-32.1* MCHC-35.1 RDW-12.1 RDWSD-40.3 Plt ___
___ 03:27PM BLOOD Neuts-84.0* Lymphs-8.1* Monos-5.9
Eos-0.1* Baso-0.1 Im ___ AbsNeut-10.41* AbsLymp-1.00*
AbsMono-0.73 AbsEos-0.01* AbsBaso-0.01
___ 03:52PM BLOOD ___ PTT-25.6 ___
___ 03:27PM BLOOD Glucose-148* UreaN-10 Creat-0.7 Na-133*
K-5.1 Cl-95* HCO3-21* AnGap-17
___ 03:27PM BLOOD ALT-51* AST-53* AlkPhos-65 TotBili-0.4
___ 03:27PM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.5 Mg-2.4
___ 03:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:53PM BLOOD Lactate-3.3*
DISCHARGE LABS
==============
___ 01:10PM BLOOD WBC-26.6* RBC-5.13 Hgb-16.3* Hct-46.8*
MCV-91 MCH-31.8 MCHC-34.8 RDW-12.1 RDWSD-40.3 Plt ___
___ 01:10PM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-69* UreaN-11 Creat-0.5 Na-138
K-3.6 Cl-99 HCO3-24 AnGap-15
___ 06:55AM BLOOD ALT-41* AST-22 LD(LDH)-181 AlkPhos-61
TotBili-0.5
___ 07:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3
MICRO
=====
___ 5:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
CXR ___
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are stable. No pulmonary edema is seen. Partially imaged right
sided catheter, likely VP shunt.
CT CHEST ___. Allowing for differences in modality, ill-defined hypodensity
about the
posterior midline pons, middle cerebellar peduncles, and upper
cervical spine appears grossly similar. MRI is more sensitive.
Nonspecific periventricular and subcortical white matter
hypodensities appear similar as well. No evidence of acute
large territory infarction or intracranial hemorrhage.
2. Stable appearance of ventricular system.
MR HEAD ___. Slight interval decrease in leptomeningeal enhancement along
the
anteroinferior surface of the fourth ventricle. Otherwise, no
interval change
compared with the MRI of ___.
2. Specifically, FLAIR hyperintense signal and swelling of the
brainstem
primarily involving the pons as well as with extension into the
medulla and
cervicomedullary junction is re-demonstrated, with slight
effacement of the
inferior fourth ventricle, no associated parenchymal enhancement
or restricted
diffusion.
3. Appearance is nonspecific and differential is broad,
including disease
progression, atypical/central-variant hypertensive
encephalopathy (PRES),
radiation necrosis, as well as demyelinating or other
inflammatory conditions,
viral encephalitis. Correlate with CSF analysis, if not
recently performed.
Additionally, MR perfusion and spectroscopy could be performed
for further
evaluation.
4. Unchanged faint enhancement along the floor of the fourth
ventricle.
5. No new abnormal enhancement or new acute intracranial
process. No recent
infarction or extra-axial collection.
6. Stable right thalamic post treatment changes.
7. Unchanged right frontal ventriculostomy, tip at the foramina
of ___.
Stable shunted ventricular caliber.
8. Stable nonspecific supratentorial white matter FLAIR
hyperintensities.
VIDEO SWALLOW ___
Penetration with thin liquids. No evidence of aspiration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
3. Dexamethasone 4 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache
Do not exceed 6 tablets/day
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills:*0
2. Meclizine 12.5 mg PO Q8H:PRN dizziness
RX *meclizine 12.5 mg 1 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
3. NIFEdipine (Extended Release) 60 mg PO DAILY
RX *nifedipine 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth two times per day Disp
#*60 Tablet Refills:*0
6. Dexamethasone 4 mg PO BID
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
8. Omeprazole 40 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
10.Outpatient Speech/Swallowing Therapy
Clinical swallow evaluation and therapy for dysphagia
ICD-10: R13.10
11.Outpatient Lab Work
Please draw CBC on ___
Results should be faxed to Dr. ___ at ___.
ICD-10: ___.___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Thalamic glioblastoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with rule out cardiopulmonary process// rule out
cardiopulmonary process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No
pulmonary edema is seen. Partially imaged right sided catheter, likely VP
shunt.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with left face numbe, vertticla nystagmus// left
face numbe, vertticla nystagmus
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, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head ___ and CT head ___
FINDINGS:
Right frontal approach ventriculostomy catheter tip is seen near the foramina
of ___, unchanged. Reservoir is again seen over the right frontal scalp.
Shunted ventricular caliber is stable. Allowing for differences in modality,
periventricular and subcortical white matter hypodensities, worst on the
right, appear similar to prior. Streak artifact within the posterior fossa
limits evaluation of the brainstem, although allowing for this, ill-defined
hypodensity about the posterior midline pons, middle cerebellar peduncles, and
upper cervical spine appears grossly similar to fuller hyperintensity seen on
recent prior MRI from ___. Right thalamic hypodensity is again
seen, possibly related to biopsy. There is no evidence of acute large
territory infarction or hemorrhage.
There is no evidence of acute fracture. 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. Allowing for differences in modality, ill-defined hypodensity about the
posterior midline pons, middle cerebellar peduncles, and upper cervical spine
appears grossly similar. MRI is more sensitive. Nonspecific periventricular
and subcortical white matter hypodensities appear similar as well. No
evidence of acute large territory infarction or intracranial hemorrhage.
2. Stable appearance of ventricular system.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with GBM w/ recent dx of disease progression,
started on dex, now p/w dysarthria// eval for disease progression.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON:
1. CT head ___.
2. MR head ___ and ___.
FINDINGS:
There are stable post treatment changes along the medial right thalamus.
Infiltrative FLAIR hyperintensity seen centered symmetrically about the
posterior brainstem involving primarily the pons but also extending to involve
the middle as well as the cervicomedullary junction and upper cervical cord,
as well as the very posteromedial aspects of the mid brain nearly to the level
of the sylvian aqueduct. There is involvement as well the adjacent scratch
posteromedial portions of the middle cerebellar peduncles. These signal
abnormalities are so seated with swelling and of mass-effect of the involved
areas of brainstem (03:12), with slight effacement of the inferior aspect of
the fourth ventricle, new from ___, similar to ___.
Linear enhancement along the inferior, ventral surface of the fourth ventricle
posterior to the pons and midbrain (series 10 images ___ is minimally
decreased from prior, particularly on the right, now with enhancement mostly
confined to the left of the midline.
The previously demonstrated focus of enhancement along the floor of the third
ventricle is unchanged (900:82).
Again seen is right frontal approach ventriculostomy catheter with tip
terminating near the foramen of ___, unchanged.
There is no new area of enhancement. No recent infarction, new hemorrhage,
extra-axial collection, new parenchymal edema, mass, or mass effect.
The ventricles and sulci are normal in caliber and configuration.
Linear FLAIR hyperintensity along the right frontal approach ventriculostomy
catheter is unchanged. A few scattered supratentorial deep white matter foci
of FLAIR hyperintensity are also unchanged, nonspecific.
The visualized paranasal sinuses and mastoids appear clear.
The globes and orbits are unremarkable.
Major intracranial vascular flow voids are preserved. Major dural venous
sinuses are patent.
IMPRESSION:
1. Slight interval decrease in leptomeningeal enhancement along the
anteroinferior surface of the fourth ventricle. Otherwise, no interval change
compared with the MRI of ___.
2. Specifically, FLAIR hyperintense signal and swelling of the brainstem
primarily involving the pons as well as with extension into the medulla and
cervicomedullary junction is re-demonstrated, with slight effacement of the
inferior fourth ventricle, no associated parenchymal enhancement or restricted
diffusion.
3. Appearance is nonspecific and differential is broad, including disease
progression, atypical/central-variant hypertensive encephalopathy (PRES),
radiation necrosis, as well as demyelinating or other inflammatory conditions,
viral encephalitis. Correlate with CSF analysis, if not recently performed.
Additionally, MR perfusion and spectroscopy could be performed for further
evaluation.
4. Unchanged faint enhancement along the floor of the fourth ventricle.
5. No new abnormal enhancement or new acute intracranial process. No recent
infarction or extra-axial collection.
6. Stable right thalamic post treatment changes.
7. Unchanged right frontal ventriculostomy, tip at the foramina of ___.
Stable shunted ventricular caliber.
8. Stable nonspecific supratentorial white matter FLAIR hyperintensities.
RECOMMENDATION(S): Correlation with CSF analysis, if not recently performed,
as well as consideration of MR spectroscopy and perfusion for further
evaluation of brainstem FLAIR abnormalities, as above.
Radiology Report
EXAMINATION: Video oropharyngeal swallow study.
INDICATION: ___ year old woman with GBM and progressive dysphagia// eval for
silent 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: 5 minutes 2 seconds
FINDINGS:
There was penetration with thin liquids. No evidence of aspiration.
IMPRESSION:
Penetration with thin liquids. No evidence of aspiration.
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: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Secondary malignant neoplasm of brain, Dizziness and giddiness, Dysarthria and anarthria, Anesthesia of skin
temperature: 97.1
heartrate: 100.0
resprate: 16.0
o2sat: 100.0
sbp: 170.0
dbp: 115.0
level of pain: 0
level of acuity: 2.0 | ___ w/ thalamic glioblastoma c/b hydrocephalus s/p VP shunt, s/p
IMRT/TMZ ___, TMZ and Bevacizumab, c/b disease recurrence s/p
SRS ___, now on TMZ/Beva q3 mo, started on dex for recent dx
of disease progression on ___, who p/w persistent dizziness
and now intermittent dysarthria.
ACUTE ISSUES
# GBM with progressive disease
# Dizziness
These symptoms have been attributed to disease progression as
enhancement on MRI c/w leptomeningeal disease previously.
Radiation necrosis
is unlikely as she is on Avastin. Was started on dexamethasone
recently ___ to determine if she may have any benefit and
this helped w/ nausea, but did not help w/ dysarthria nor
dizziness. Dizziness is provoked by any movement, dysarthria and
dysphagia are worsening from prior admission. MRI as an
inpatient showed stable disease. The patient was continued on
her home medications and instructed to follow-up as an
outpatient to start chemotherapy.
# Dysphagia: Symptoms appeared to be worse on this admission.
Speech and swallow were consulted and recommended a video
swallow, which showed a risk for aspiration. Swallow
recommendations are the following:
1. Diet: thin liquids and moist ground solids until chewing
improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
# HTN:
Patient significantly hypertensive. Was started on nifedipine at
last admission as was bradycardic with metoprolol. Dose was
increased to 20mg q8h with improvement in blood pressures. Goal
BP <140/90.
# Leukocytosis: Noted to be as high as 26.6 at the time of
discharge. The patient was otherwise asymptomatic. Etiology
unclear.
CHRONIC ISSUES
# Headaches: Improved w/ fioricet on last admission.
# Dyspnea on Exertion: CTA ruled out PE on recent admission and
these symptoms have resolved.
TRANSITIONAL ISSUES
[]goal BP <140/90
[]nifedipine increased from 10mg q8 to 20mg q8; converted to
total of 60mg nifedipine ER daily
[]will need continued outpatient speech and swallow evaluation;
patient sent with prescription
[]speech and swallow recommendations: 1. Diet: thin liquids and
moist ground solids until chewing improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
[]should check CBC at next neuro-oncology visit on ___ to
ensure leukocytosis is improving
#CODE STATUS: Full code, presumed
#HCP: Name of health care proxy: ___
___ number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
___
1. Redo sternotomy.
2. Coronary artery bypass grafting x2 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery.
3. Aortic valve replacement with a 29 ___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___.
4. Reconstruction of pericardium with CorMatrix
History of Present Illness:
___ year old male with past medical
history of hypertension, hyperlipidemia, and s/p ascending
aortic
aneurysm repair and single vessel bypass (SVG-PDA) in ___ at
___ who presented to OSH with shortness of breath. He was seen
by Dr. ___ in ___ after CTA chest revealed saccular
outpouching of contrast, 1.1 x 1.8 cm, at the site of his aortic
root repair, not seen on prior imaging studies and concerning
for
pseudoaneurysm, no surgery indicated at that time and plan was
to
follow up with echo. CTA at ___ showed mural thrombus.
Patient transferred to ___ on Heparin gtt for further
evaluation. Cardiac surgery consulted.
Past Medical History:
Ascending Aortic Aneurysm repair with 26 mm gelweave graft/ CABG
x1(SVG-PDA) in ___ at ___ w/ Dr. ___ c/b MRSA sternal
wound infection (6 weeks of vancomycin)
Coronary Artery Disease
Bicuspid aortic valve
Aortic stenosis
GERD
BPH
Hypertension
Hyperlipidemia
Umbilical hernia
Urosepsis
Left spontaneous PTX requiring CT placement
Bilateral Shoulder surgery x 5 -most recent ___
Umbilical Hernia repair
C5-C6 fusion
Social History:
___
Family History:
Denies significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
VS: T 98.7 HR 60 BP 150/58 RR 18 O2 Sat 98% RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CHEST: Sternal incision, well healed
CV: ___ midsystolic murmur auscultated in upper sternal area
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, mildly distended, nontender, +umbilical hernia
EXTREMITIES: no cyanosis, clubbing. Trace edema
MSK: Bilateral shoulder incisions, well healed
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Multiple tattoos covering chest and arms. Warm and well
perfused, no excoriations or lesions, no rashes
.
DISCHARGE PHYSICAL EXAM:
98.6 125 / 67 70 18 97 Ra
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [x]
Respiratory: CTA [x] No resp distress []
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [] Edema
Left Upper extremity Warm [] Edema
Right Lower extremity Warm [x] Edema 1+
Left Lower extremity Warm [x] Edema 1+
Pulses:
DP Right: Left:
___ Right: Left:
Radial Right: Left:
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena []
Lower extremity: Right [] Left [x] CDI [x]
Pertinent Results:
ADMISSION LABS
========================
___ 05:30PM BLOOD WBC-7.1 RBC-4.15* Hgb-13.1* Hct-37.6*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.7 RDWSD-48.3* Plt ___
___ 05:30PM BLOOD Neuts-88.6* Lymphs-9.5* Monos-1.3*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.24* AbsLymp-0.67*
AbsMono-0.09* AbsEos-0.01* AbsBaso-0.01
___ 05:30PM BLOOD ___ PTT-50.1* ___
___ 05:30PM BLOOD Glucose-151* Creat-1.1 Na-140 K-5.4
Cl-104 HCO3-17* AnGap-19*
___ 05:30PM BLOOD ALT-23 AST-42* AlkPhos-62 TotBili-0.6
___ 05:30PM BLOOD cTropnT-<0.01
___ 10:24PM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD Lipase-20
___ 05:30PM BLOOD Albumin-4.1
___ 07:12PM BLOOD %HbA1c-5.5 eAG-111
IMAGING
==========================
___ TTE
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is moderate symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Overall left ventricular systolic function is low normal.
Quantitative 3D volumetric left ventricular ejection fraction is
50 %. There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18mmHg). Mildly dilated
right ventricular cavity with normal free wall motion. The
aortic sinus is mildly dilated with mildly dilated ascending
aorta. The aortic arch is mildly dilated. The aortic valve is
bicuspid with moderately thickened leaflets with fusion of the
right/left raphe. There is severe aortic valve stenosis (valve
area less than 1.0 cm2). There is an eccentric, anterior mitral
leaflet directed jet of moderate [2+] aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is mild to moderate [___] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
moderate to severe pulmonary artery systolic hypertension. There
is a trivial pericardial effusion. IMPRESSION: Moderate
symmetric left ventricular hypertrophy with normal cavity size
and lownormal global systolic function. Increased PCWP. Bicuspid
aortic valve with fusion of the right and left commissures
___ 1A). Severe aortic valve stenosis. Moderate aortic
regurgitation. Mild to moderate mitral regurgitation. Mild
tricuspid regurgitation. Moderate to severe pulmonarya rtery
systolic hypertension. Mild thoracic aortic enlargement.
Compared with the prior TTE ___ , the aortic valve area
is now smaller, the degree of aortic regurgitation has
increased, and left ventricular systolic function is slightly
worse.
___ CAROTID US
No atherosclerotic plaque or hemodynamically significant
stenosis of the
bilateral carotid arteries.
___ CXR
Small bilateral pleural effusions and mild atelectasis in the
lung bases.
.
preliminary TEE report ___
PREBYPASS
1. Overall normal LVEF
2. Severe Aortic stenosis with bicuspid severely calcified Ao
valve (valve area 0.8 cm2)
3. Moderate AI with eccentric jet towards AMVL
No spontaneous echo contrast or thrombus is seen in the body of
the right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. with normal free wall contractility. The
aortic root is mildly dilated at the sinus level. There are
simple atheroma in the descending thoracic aorta. The aortic
valve is bicuspid. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. The mean LVOT gradient is 0.9 mmHg. There is
severe aortic valve stenosis (valve area <1.0cm2). The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve appears structurally normal
with trivial mitral regurgitation. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
POSTBYPASS
RHYTHM: A paced.
INFUSIONS: Epi and neo
Well seated bioprosthesis noted in the aortic position.
Biventricular LV fuction remains unchanged.
Interpretation assigned to ___, MD, Interpreting
physician
.
___ 04:14AM BLOOD WBC-6.1 RBC-2.54* Hgb-7.9* Hct-23.3*
MCV-92 MCH-31.1 MCHC-33.9 RDW-15.0 RDWSD-50.4* Plt ___
___ 04:14AM BLOOD ___
___ 04:18AM BLOOD ___ PTT-26.6 ___
___ 09:31AM BLOOD ___ PTT-28.2 ___
___ 02:10AM BLOOD ___ PTT-27.3 ___
___ 09:25PM BLOOD ___ PTT-34.7 ___
___ 04:14AM BLOOD Glucose-113* UreaN-24* Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-10
___ 04:01AM BLOOD Glucose-98 UreaN-30* Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-24 AnGap-15
___ 02:10AM BLOOD ALT-22 AST-107* LD(LDH)-509* AlkPhos-36*
Amylase-50 TotBili-0.3
___ 04:14AM BLOOD Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. NIFEdipine (Extended Release) 30 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. krill oil 1,000-170-50-80 mg oral DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Ascending aortic aneurysm pseudoaneurysm
- Severe aortic stenosis
- Moderate aortic regurgitation
SECONDARY DIAGNOSES
- Coronary artery disease
- Hyperlipidemia
- Hypertension
- GERD
- BPH
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
Followup Instructions:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old male with a history of bicuspid aortic valve with
mild-moderate AS/AR, ascending aortic aneurysm s/p graft repair (___),
CABG x 1 to RCA ((SVG to PDA) ___, HTN, and BPH who presents as a
transfer from ___ for new mural thrombosis in the setting of an ascending
aortic aneurysm// pre-op, eval for stenosis
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 64 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 90, 85, and 73 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 19 cm/sec.
The ICA/CCA ratio is 1.4.
The external carotid artery has peak systolic velocity of 73 cm/sec.
The vertebral artery is patent with antegrade flow slightly diminished
diastolic flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 70 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 45, 54, and 68 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 16 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 60 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No atherosclerotic plaque or hemodynamically significant stenosis of the
bilateral carotid arteries.
Radiology Report
INDICATION: ___ year old man with s/p Redo AVR// cardiac surgery fast track.
eval for ptx, effusions. call ___ house officer at ___ if there is any
concern with findings Contact name: ___ house officer, ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest x-ray dated ___.
FINDINGS:
Sternotomy wires are intact.
Aortic mechanical valve.
Right-sided Swan-Ganz in right pulmonary artery.
Esophageal feeding tube passes the GE junction.
ET tube is 5.4 cm above the carina.
Right chest tube lies in lung base.
Mediastinal drains.
Undefined radiopaque marker projecting over the mandible.
Mild cardiomegaly.
Mild bilateral pleural effusions.
No pneumothorax.
New left lower lobe atelectasis and milder in the right base.
IMPRESSION:
Normal postoperative appearance.
Esophageal tube ends in stomach fundus, and could be pushed further down.
Radiology Report
INDICATION: ___ year old man with s/p avr cabg redo sternotomy// post op
bleeding
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The patient is post median sternotomy, aortic valve replacement and CABG. The
supporting lines and tubes are unchanged in position. Unchanged retrocardiac
opacities likely reflect atelectasis and pleural fluid. There is no
pneumothorax identified. The right lung is clear. The size of the
cardiomediastinal silhouette is enlarged.
IMPRESSION:
Expected postoperative changes. No pneumothorax. Further advancement of the
gastric tube is recommended to ensure that it lies well beyond the GE
junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with as above// s/p CABG/AVR w/increased chest
tube output r/o effusion
IMPRESSION:
In comparison with the study of ___, there is no evidence of pneumothorax
or increased pleural effusion. Indeed, the left hemidiaphragmatic contour is
actually more sharply seen on the current study.
Endotracheal tube and nasogastric tube have been removed.
Radiology Report
INDICATION: ___ year old man with s/p CABG, RIJ MAC changed to TLC// eval new
line Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The Swan-Ganz catheter has been removed.A right IJ catheter tip projects over
the mid to distal SVC. Mediastinal drains and left chest tubes are present.
The size of the cardiac silhouette is enlarged, unchanged. There are small
bilateral pleural effusions and subjacent atelectasis, left greater than
right. Mild pulmonary edema is new since prior. No pneumothorax.
IMPRESSION:
The tip of a new right internal jugular central line projects over the mid to
distal SVC. No pneumothorax.
Small bilateral pleural effusions and subjacent atelectasis, left greater than
right. Mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p AVR/repair of pseudoan// eval hemothorax
eval hemothorax
IMPRESSION:
Comparison to ___. The left chest tubes are in stable position.
Correct alignment of the sternal wires, correct position of the right internal
jugular vein catheter. There is no pneumothorax. The right lung basis is
slightly better ventilated than on the previous image. No pulmonary edema.
Stable borderline size of the cardiac silhouette and retrocardiac atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cabg, AVR// s/p chest tube removal s/p
chest tube removal
IMPRESSION:
Comparison to ___. Status post removal of the left chest tube.
There now is a 2 cm left apical pneumothorax without evidence of tension.
Bleeding along the tract of the tube is noted. Mild retrocardiac atelectasis.
Stable normal appearance of the right lung.
Radiology Report
EXAMINATION: Chest radiograph PA and lateral
INDICATION: ___ year old man s/p CABG, AVR// eval post op changes, effusions
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest x-rays, most recently ___.
FINDINGS:
Sternotomy wires are intact.
Right IJ ends in upper SVC.
Mild to moderate cardiomegaly.
Left pneumothorax is slightly larger than in ___..
Stable appearance of mild retrocardiac atelectasis..
IMPRESSION:
Slight increase in left pneumothorax.
Overall unchanged appearance of remaining findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Dyspnea, unspecified
temperature: 98.2
heartrate: 66.0
resprate: 18.0
o2sat: 97.0
sbp: 127.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | This is a ___ male who had previously underwent an
ascending aortic hemiarch replacement back in ___ for an
aneurysm. He also had a saphenous vein graft to
the posterior descending artery. He presented with shortness of
breath and a CT scan was performed and this demonstrated
possible aortic intramural thrombus of the ascending aorta.
Further workup revealed aortic stenosis. The usual preoperative
work up included Dental clearance, carotid US, and Chest CT.
ON ___ he was taken to the operating room and underwent the
following: 1.Redo sternotomy.2.Coronary artery bypass grafting
x2 with left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery.3. Aortic valve replacement with a 29 mm
___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___. 4. Reconstruction of pericardium with CorMatrix.
Please see operative report for further surgical details.
He tolerated the procedure well and was transferred to the CVICU
for recovery and invasive monitoring. He required inotropy and
pressor support to augment his hemodynamics postop. FFP, PRBCs
and Protamine were administered for elevated chest tube
drainage. He awoke neurologically intact and weaned to extubate.
He was started on ___, Lasix. He continued to
progress and was transferred to the step down unit for further
recovery. Chest tubes remained in due to elevated drainage.
Pacing wires were discontinued per protocol without incident.
Physical Therapy was consulted for evaluation of strength and
mobility. POD# 4 Chest tubes were discontinued per protocol
without incident. His rhythm went into Atrial fibrillation and
Amiodarone was administered. Anticoagulation was initiated and
will be managed by ___ Medical in ___ as discussed
with ___.
By the time of POD 5 he was ambulating independently, wounds
healing, and pain controlled. He was cleared for discharge to
home with ___ services. All follow up appointments were advised. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
fall, intoxication, left ___ rib fractures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p fall 4 days ago. He states that he was in his home while
standing on a stool and fell to the ground. He claims he was not
intoxicated when he fell and has not had a drink since last
___, but his EtOH level on arrival was 45. He
has had multiple admission in the past for alcohol withdrawal.
After his recent fall, he states he presented to an OSH and was
discharge with pain medications. Given persistent pain, he
presented to the ___ ED for further evaluation. FAST exam was
performed which showed no evidence of intra-abdominal free
fluid.
Past Medical History:
PMH:
HTN, HLD, Eczema, GERD, alcoholic steatosis, Alcohol abuse c/b
withdrawal s/p hospitalization x2, MVA ___ c/b thoracic back
pain
PSH:
None
Social History:
___
Family History:
Father is ___ with diabetes, mother passed at ___ for unknown
cause (?stroke vs. head bleed); reports his siblings are all
healthy; reports no one in family has alcohol-related issues
Physical Exam:
Physical Exam
Vitals: 97.0 62 165/94 14 96%RA
GEN: AOx3, ill-appearing, tremulous, diaphoretic
HEENT: No scleral icterus
Back: C7 and 79 tenderness to palpation
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Imaging
___
CHEST (PA & LAT)
IMPRESSION:
No radiographic evidence of traumatic injury. Please note that
this is not a dedicated exam for evaluation of the bones.
Correlate with focal exam findings and obtain dedicated
radiographs as needed
CT TORSO W/CONTRAST
IMPRESSION:
1. Nondisplaced left ___ and 10th rib fractures with small
left chest
wall hematoma and complex effusion likely representing a
hemothorax. No
pneumothorax. No other fractures identified.
2. No other acute intrathoracic or intra-abdominal injury.
CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No acute fracture or malalignment.
2. Focal prevertebral soft tissue edema anterior to C4 which
raises the
possibility of ligamentous injury. If focally tender in this
area, MRI could
be obtained if clinically indicated.
CT HEAD W/O CONTRAST
IMPRESSION:
No acute intracranial process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrochlorothiazide 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO BID
4. Pravastatin 40 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
discontinue if more that 7 loose stools per day
7. Senna 8.6 mg PO BID:PRN constipation
discontinue use if more than 7 loose stools a day
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Hydrochlorothiazide 50 mg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Thiamine 100 mg PO DAILY
14. Acetaminophen 650 mg PO Q6H pain
do not exceed more than 4gms a day
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures secondary to Mechanical fall
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 s/p fall, etoh // eval for acute injuries
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
No significant interval change. The lungs are clear. No focal consolidation,
effusion, edema, or pneumothorax. The heart is top-normal in size, unchanged.
No acute osseous abnormality.
IMPRESSION:
No radiographic evidence of traumatic injury. Please note that this is not a
dedicated exam for evaluation of the bones. Correlate with focal exam
findings and obtain dedicated radiographs as needed.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, etoh // eval for acute injuries
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the mastoid air
cells and middle ear cavities are clear. There is trace bilateral maxillary
sinus and sphenoid sinus mucosal thickening. Incidentally noted is a left
frontal sinus osteoma. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with s/p fall, etoh // eval for acute injuries
TECHNIQUE: Non-contrast helical multidetector CT was performed through the
cervical spine. Soft tissue and bone algorithm images were generated.
Coronal and sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 673 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No acute fractures are identified.There is subtle focal
prevertebral soft tissue edema anterior to the vertebral body of C4.
Degenerative changes are present most notable at C2-C3 and C3-C4 including
osteophytosis and uncovertebral joint hypertrophy. Multilevel disc bulges
result in mild spinal canal narrowing. Incidentally noted is a calcified
right stylohyoid ligament.
IMPRESSION:
1. No acute fracture or malalignment.
2. Focal prevertebral soft tissue edema anterior to C4 which raises the
possibility of ligamentous injury. If focally tender in this area, MRI could
be obtained if clinically indicated.
NOTIFICATION: The updated findings were discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 11:17 AM, 2 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT torso.
INDICATION: ___ with s/p fall, etoh // eval for acute injuries
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 560 mGy-cm.
COMPARISON: MRI of the abdomen and pelvis from ___.
Ultrasound of the liver from ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pneumothorax. There is a small left complex pleural
effusion likely representing a hemothorax.
LUNGS/AIRWAYS: Bibasilar atelectasis is present. The airways are patent to
the level of the segmental bronchi bilaterally. Apical emphysematous changes
are present. No mass or consolidation is seen.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
CHEST WALL: A small left chest wall hematoma is present adjacent to the
nondisplaced left ___, and 10th rib fractures.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout
consistent with hepatic steatosis. There is no evidence of focal lesion or
laceration. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted. Mild eccentric noncalcified plaque
within the left common iliac artery is seen.
BONES: There are nondisplaced left ___, and 10th rib fractures. No
other fractures are identified. A sclerotic focus within the right ilium is
most consistent with a bone island.
SOFT TISSUES: Incidentally noted is a lipoma deep to the right gluteus
maximus. Otherwise the abdominal and pelvic walls are within normal limits.
IMPRESSION:
1. Nondisplaced left ___ and 10th rib fractures with small left chest
wall hematoma and complex effusion likely representing a hemothorax. No
pneumothorax. No other fractures identified.
2. No other acute intrathoracic or intra-abdominal injury.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with a history of HTN, multiple admissions for
alcohol withdrawal, now with rib fractures and acute withdrawal: // Interval
assessment Interval assessment
IMPRESSION:
Comparison to ___. New retrocardiac opacity with air bronchograms,
likely reflecting pneumonia. No pleural effusions. No pulmonary edema.
Borderline size of the cardiac silhouette.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man with s/p fall from standing with mild ?
ligamentous abnormality on CT // eval for dynamic instability
TECHNIQUE: Neutral, flexion and extension lateral projections of the cervical
spine.
COMPARISON: CT cervical spine ___.
FINDINGS:
Multilevel mild degenerative changes with disc space narrowing and endplate
spurring. Impression of mild prevertebral soft tissue swelling in the upper
cervical spine. No dynamic instability is demonstrated on flexion extension
views.
IMPRESSION:
Degenerative changes. No dynamic instability is identified. There is mild
prevertebral soft tissue swelling in the upper cervical spine.
RECOMMENDATION(S): As previously recommended, if concern for ligamentous
injury, recommend MRI.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with a history of HTN, multiple admissions for
alcohol withdrawal, now with rib fractures and acute withdrawal // Interval
assessment Interval assessment
IMPRESSION:
Comparison to ___. Minimal improvement of the pre-existing
retrocardiac atelectasis. No other relevant change. Borderline size of the
cardiac silhouette. No pulmonary edema, no pleural effusions, no pneumonia.
Known rib fractures are subtle and better appreciated on the CT examination
from ___.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: s/p Fall, Chest pain, Back pain
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Other fall from one level to another, initial encounter, Alcohol dependence with withdrawal, unspecified, Blood alcohol level of 40-59 mg/100 ml
temperature: 97.0
heartrate: 101.0
resprate: 17.0
o2sat: 96.0
sbp: 209.0
dbp: 114.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ presented to ___ emergency room on ___ after a fall that occurred four days prior to admission. He
was evaluated by trauma surgery and admitted for pain control
and further evaluation. His hospital course was complicated by
agitation secondary to likely alcohol withdrawal. Once evaluated
in the ED, he was transferred to the TSICU for observation.
Neuro: On admission, he received a rescue dose of phenobarb
2.5mg/kg for acute alcohol withdrawal. His CIWA scales was rated
from ___. After 24 hours, he was transferred to the floor for
further recovery. On ___ a coded purple was called, and patient
required IV Haldol and transfer to the TSICU for management.
Psychiatry was consulted and determined that he was acutely
delirious. After re evaluation, psychiatry noted much
improvement in patient's delirium and noted that patient can be
discharged if no further medical needs. Pain was initially
managed with a narcotic, but primarily Tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, then diet was
sequentially advanced as tolerated
MSK: Per imaging, he had a chest wall hematoma adjacent to a
nondisplaced left ___, and 10th rib fractures. Pain was
managed expectantly. A tertiary exam revealed no new injuries.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up is currently as needed, and should follow up with PCP.
Instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right-sided abdominal pain for 9 hours
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female, s/p ___ gastric bypass
surgery in ___ at ___. The patient was
in her usual state of health until approximately 11:30 am
___, today, when she began having ___ non-radiating RUQ and
middle right side abdominal pain. She went to ___ for lunch
and before she started eating the pain worsened to ___. She
has a history of kidney stones and thought this might be a
recurrence so she tried to hydrate with PO fluids. She states
that she urinated x 2, with simultaneous BM and flatus around 12
pm. She continued to hydrate with PO fluids and had more
micturition and flatus. The patient's pain continued at ___
and at around 12 pm she called her PCP who directed her to the
___. She arrived at the ___ at approximately 2:15 pm
where a CT scan wet read showed nephrolithiasis and possible
partial SBO. The patient was given morphine which relieved her
pain to a ___ level and she was sent via ambulance to the ___
___. When she arrived at ___ she had more flatus and her pain
has since been very well controlled.
Ms. ___ had a ___ bypass surgery in ___ which was
complicated on POD 1 with bleeding, possibly from a pre-existing
duodenal ulcer. She was taken back to the OR that day and a
repair was performed which remained laparoscopic, no records are
available. The patient endorses a 40-lbs total weight loss sinc
surgery and no other interval changes. On exam today, she
denies fever, chills, nausea, vomiting, dyspnea, chest pain,
dysuria, weakness or dizziness. She has had no changes in
appetite, temperature intolerance or changes in hair or skin
texture.
Past Medical History:
1. Depression.
2. Ovarian cancer, cancer free since ___.
PSH:
1. Total hysterectomy with BLSO ___ ovarian cancer (___). No
chemotherapy or radiation at that time.
2. ___ gastric bypass (___).
3. Colonoscopy (___).
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Physical Exam: VS-T: 98.4, HR: 74, BP: 150/70, RR: 15, SpO2: 96%
RA, Pain: ___.
GEN: Lying in bed, NAD, pain well controlled, pleasant
cooperative.
HEENT: EOMI, PERRLA, trachea midline, mucous membranes moist,
(-)
LAD.
CHEST: No cyanosis, no tachypnea or accessory muscle use.
Lungs-CTA bilaterally, on anterior and posterior exams.
Heart-RRR, (+) S1/S2, (-) S3/S4/m/c/r/g/h/t
ABDOMEN: Soft, non-distended, mildly TTP RUQ/right mid-abdomen,
no jaundice, not rigid, no guarding.
EXTR/MSK: Pulses full and RRR x 4 extremities, moves all
extremities against gravity.
NEURO: CN II-XII grossly intact, no focal neurological deficits.
Full and appropriate affect.
On discharge:
Tm 98.2 Tc98.2 BP 140/62 HR 72 RR 18 Sat 97% on RA
GEN: alert, pleasant, NAD, nontoxic appearing
HEENT: MMM sclera anicteric
CV: RRR no m/r/g
PULM: ctab nonlabored breathing
ABD: soft, nontender, nondistended, normotympanitic to
percussion, well healed lap scars no appreciable hernia, no
masses
EXT: no ___
Pertinent Results:
--CBC/Chem10
Hct 32.3 stable; WBC 5.3 stable; Cr 0.7
--LFTs
ALT 9 AST 16 AlkP 90 Amylase 52 TB 0.2 Lipase 32 ___ 49
Lactate 1.2
--Nutrition Labs
-Iron 29 VitB12 329 Folate out of range >20
----CT Abd/Pelvis WITH contrast ___--
The lung bases are clear. There is annular calcification of the
mitral valve. The heart size is normal. Probable small hiatal
hernia. Postsurgical changes related to gastric bypass are
noted. There is no oral contrast seen in the excluded portion
of the stomach and proximal small bowel. Oral contrast has
passed through the stomach and the distal loops of small bowel.
Contrast is also present within the ascending colon to the level
of the hepatic flexure. The small bowel loops are normal in
caliber with interval resolution of the obstruction.
The adrenal glands, pancreas, spleen, and kidneys are normal.
Of note, there is IV contrast within the bilateral collecting
systems from previously performed contrast enhanced CT. There
is no free fluid or free air. The urinary bladder is distended
with contrast material.
Osseous structures are intact with degenerative disc disease at
L5-S1.
----OSH CT abd/pelvis WITHOUT contrast ___--
Wet read: possible pSBO
Medications on Admission:
Wellbutrin
Protonix
Discharge Medications:
Protonix
Wellbutrin
Discharge Disposition:
Home
Discharge Diagnosis:
Enteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain status post gastric bypass with recent obstruction.
Evaluate for obstruction.
TECHNIQUE: Limited CT acquisition through the abdomen and pelvis was
performed after the administration of oral contrast only. Post processing
reconstruction was performed in the coronal and sagittal planes.
DLP: 880.2 mGy-cm
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
The lung bases are clear. There is annular calcification of the mitral valve.
The heart size is normal. Probable small hiatal hernia. Postsurgical changes
related to gastric bypass are noted. There is no oral contrast seen in the
excluded portion of the stomach and proximal small bowel. Oral contrast has
passed through the stomach and the distal loops of small bowel. Contrast is
also present within the ascending colon to the level of the hepatic flexure.
The small bowel loops are normal in caliber with interval resolution of the
obstruction.
The adrenal glands, pancreas, spleen, and kidneys are normal. Of note, there
is IV contrast within the bilateral collecting systems from previously
performed contrast enhanced CT. There is no free fluid or free air. The
urinary bladder is distended with contrast material.
Osseous structures are intact with degenerative disc disease at L5-S1.
IMPRESSION:
1. Interval resolution of previously seen obstruction.
2. Small hiatal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPOTHYROIDISM NOS, BARIATRIC SURGERY STATUS , HX OF OVARIAN MALIGNANCY
temperature: 98.4
heartrate: 74.0
resprate: 15.0
o2sat: 96.0
sbp: 150.0
dbp: 70.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ was admitted to the bariatric service with
abdominal pain after being transferred from an OSH with a CT
read of possible small bowel obstruction. Due to her ___ en y
gastric bypass, there was concern of an internal hernia and need
for operative intervention. On arrival, she had a nutritional
IV fluids given ("banana bag") which consisted of thiamine and
Vitamin B12. Stat CBC/chem10 and lactate revealed no etiology
of her abdominal pain. She had normal LFTs, lipase, lactate,
and white count. She was started on an IV BID PPI and IVF and
made NPO. She had a repeat CT abdomen with PO contrast to
better evaluate for a small bowel obstruction. There were no
abnormal findings on the CT scan. Her diet was advanced to
stage III which she tolerated well. Nutrition labs were drawn
which revealed iron deficiency. On questioning, she reported
not following up with a nutritionist and not being aware of
having her vitamin levels drawn by her PCP since her ___ en Y
gastric bypass. The importance of having close nutritional
follow up due to her altered anatomy was emphasized, including
following closely Vitamin B1, B12, iron, vitamin D, and folate.
Her primary care physician ___ was also telephoned and
a message was with left with his office to communicate these
recommendations. She had also been taking NSAIDs in the past
and was unaware of their danger with after a gastric bypass, and
the need to avoid NSAIDs was also reinforced.
On the day of discharge, she was tolerating a stage III
bariatric diet. Her pain was well controlled. She was voiding
freely. She was ambulating independently without assistance.
She will follow up with her PCP in one to two weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pt found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female w/ PMH HTN,
hypothyroidism, mood disorder with sleep issues, constipation,
history of breast cancer who presents after she was found down.
She was found down for an unknown time. She was found to have an
elevated CK and was started on IV hydration for rhabdomyolysis.
She had an episode of chest pain while in the ED with first
troponin negative and normal EKG. Chest pain resolved without
intervention. Second troponin was pending on transfer. She was
given full dose aspirin.
In the ED she received 1.5L IVF.
CT head, C-spine were negative for pathology of fracture.
Gleno-humeral shoulder X-ray showed no fracture of dislocation.
CXR showed no acute process, hiatal hernia.
On arrival to the floor, she is very tired and is upset that I
have woken her. She asks if "we can do this tomorrow" and says
she has bad heart burn. She told the nurse she knew she was in
the hospital but she isn't answering my question now and goes
back to sleep.
She does respond that she doesn't remember any of the events of
today's fall but does have a history of falls.
She can't confirm her medications.
Past Medical History:
HTN
Hypothyroidism
Mood disorder with sleep issues
Constipation
History of breast cancer s/p surgery and radiation
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Sleeping, doesn't want to wake up
EYES: Anicteric, pupils equally round
CV: Heart regular, ___ systolic murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: unable to assess
PSYCH: tired, not wanting to engage in interview
Pertinent Results:
Admission Data
WBC 15.3, Hgb 13, Cr 0.9, bicarb 21, AST 80, CK 4960, CK-MB 29,
trop negative x 1, lactate 2.6
EKG: sinus rhythm, normal axis, normal rate, normal QRS. T wave
flat in V2,
III, inverted T wave aVF.
Telemetry: no events
CTH
No acute intracranial process. Chronic small vessel disease.
CT C Spine
No fracture or alignment abnormality. Degenerative changes as
stated without critical stenosis.
CXR: No acute intrathoracic process, hiatal hernia.
Discharge labs:
___ 06:49AM BLOOD WBC-6.0 RBC-3.68* Hgb-11.4 Hct-35.7
MCV-97 MCH-31.0 MCHC-31.9* RDW-13.5 RDWSD-48.7* Plt ___
___ 06:49AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140
K-5.8 (hemolyzed)* Cl-101 HCO3-25 AnGap-14
___ 06:49AM BLOOD CK(CPK)-153
___ 03:35PM BLOOD Lipase-15
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:04AM BLOOD Phos-3.0 Mg-1.9
___ 07:50AM BLOOD TSH-5.5*
___ 04:37PM BLOOD Lactate-2.6* K-4.3
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 30 mg PO DAILY
2. Finasteride 2.5 mg PO DAILY
3. Vesicare (solifenacin) 10 mg oral DAILY
4. Doxepin HCl 10 mg PO HS
5. CARVedilol 3.125 mg PO BID
6. TraZODone 100 mg PO QHS:PRN insomnia
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Divalproex (EXTended Release) 250 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. meloxicam 15 mg oral DAILY
11. Escitalopram Oxalate 20 mg PO DAILY
12. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Ramelteon 8 mg PO QHS:PRN insomnia
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. meloxicam 15 mg oral DAILY
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall, altered mental status
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with altered mental status, fall, pain// Fracture, bleed
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations.
DOSE: Total DLP (Body) = 351 mGy-cm.
COMPARISON: None
FINDINGS:
There is no acute fracture or malalignment in the cervical spine. The
visualized outline of the thecal sac is unremarkable. Degenerative disease is
most pronounced at C4-5 and C5-6 with disc space narrowing and small endplate
osteophytes. Facet and uncovertebral joint hypertrophy is noted at multiple
levels with moderate neural foraminal stenosis noted on the left at C3-4
level. No critical central canal or neural foraminal stenosis. No
prevertebral edema. The aerodigestive tract appears patent. Lung apices are
clear. Thyroid gland appears normal.
IMPRESSION:
No fracture or alignment abnormality. Degenerative changes as stated without
critical stenosis.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with fall, chest pain, pneumothorax// Fracture
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Retrocardiac opacity is noted most
likely representing a hiatal hernia. The lungs are clear bilaterally.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process, hiatal hernia.
Radiology Report
INDICATION: History: ___ with left shoulder pain//Fracture
COMPARISON: Three views of the left shoulder were provided.
FINDINGS:
A rounded ossific density is seen projecting over the left humeral neck along
the medial cortex which could represent a loose body, measuring approximately
9 x 10 mm. No fracture or dislocation is seen. There is mild inferior
spurring at the left glenohumeral joint. AC joint aligns normally without
significant OA. The imaged left upper ribs appear intact.
IMPRESSION:
No fracture or dislocation. Possible loose body within the left glenohumeral
joint space. Mild left glenohumeral OA.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with altered mental status, fall, pain// Fracture, bleed
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed. Repeated imaging due to patient motion.
DOSE: Total DLP (Head) = 934 mGy-cm.
COMPARISON: prior study is dated ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Periventricular white matter hypodensities are again noted
reflecting chronic microvascular ischemic disease. A tiny right basal ganglia
lacunar infarct noted. Age related involutional changes are noted.
Ventricles appear normal in stable in size. Basal cisterns are patent. The
imaged paranasal sinuses, mastoid air cells and middle ear cavities appear
well aerated. The bony calvarium is intact. A sebaceous cyst is seen at the
right parietal scalp.
IMPRESSION:
No acute intracranial process. Chronic small vessel disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, s/p Fall
Diagnosed with Altered mental status, unspecified
temperature: 97.4
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | #Found down: Patient with history of falls and dizziness and has
been evaluated by Gerontology at ___ for this. Concern was for
POTS disease because her HR increased >30 with standing. Has not
been worked up for arrhythmia. She is on many medications that
can cause hypotension, will however she was hypertensive on
admission. She also has a murmur on exam that is known but has
not had a recent echo, so one was ordered. It was notable for
mild-mod aortic stenosis. EKG was nonischemic and telemetry not
notable for any arrhythmias. Orthostatics were normal throughout
the admission but the patient felt dizzy with sitting up.
Physical and occupational therapy were consulted and recommended
rehab. On discharge, carvedilol and aldactone were stopped and
her amlodipine and lisinopril were uptitrated, with good control
of BPs.
#Mild Rhabdomyolysis: No evidence of ___, levels elevated to ~5K
on admission.
IVF were continued until CK downtrended to normal.
#Leukocytosis: likely due to stress reaction. No evidence of
infection. Downtrended on recheck.
#Chest pain: Had chest pain episode in ED. On arrival to the
floor she complained of heart burn. Trop neg x 1. ___ trop 0.02
but could be elevated due to rhabdo. No evidence of ischemia on
EKG. Was given Tums and protonix for heartburn. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/vomiting/jaundice; mass causing duodenal and biliary
obstruction
Major Surgical or Invasive Procedure:
Percutaneous transhepatic cholangiography/biliary decompression
(___)
Exploratory laparotomy with biopsy of periduodenal nodule,
cholecystectomy, Roux-en-Y, choledochojejunostomy and
gastrojejunostomy (___)
History of Present Illness:
Chief Complaint: nausea, vomiting, jaundice
Reason for MICU transfer: hypotension after nausea
___ ___ who presented with a 2 month history of
abdominal pain, nausea and vomiting. The patient and her family
reported that she had not been able to eat well and had lost
___ lbs. Her family first noted that she became jaundiced 1
month prior. She denied fevers, chills, diarrhea and
constipation. Her last formed bowel movement had been 2 days
prior. She denied BRBPR. She denied pain radiating to her back.
The patient resides in ___, ___ and came to ___ for
medical care at the ___ "Benevolant Association"
a non-medical care facility. It was there that she fell due to
weakness and hit her head. She had no loss of consciousness and
minor facial abrasions. She decided on
___ to pursue further medical care and arranged transport to
the ___ ED.
Past Medical History:
None documented
Social History:
___
Family History:
No cancer in the family. Father died of heart disease at age of
___. Mother died of diabetes.
Physical Exam:
Admission Exam:
General: AAOx3, NAD, grossly jaundiced
HEENT: Sclera severely icteric, MM relatively dry, oropharynx
clear, EOMI, PERRL
CV: RRR, + S1/S2, ___ systolic murmur best heard at ___, no
rubs or gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. +1
edema b/l
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Exam upon discharge:
Vitals:
General: AAOx3, NAD
HEENT:
CV: RRR, +S1/S2, systolic murmur
Resp: CTAB
Abdomen: Right subcostal incision open to air with steri strips
and c/d/i.
Ext: no cyanosis/clubbing/edema, warm, well-perfused
bilaterally, 2+ distal pulses bilaterally
Pertinent Results:
Admission Labs:
___ 09:35AM BLOOD WBC-16.4* RBC-4.99 Hgb-15.2 Hct-43.9
MCV-88 MCH-30.4 MCHC-34.6 RDW-17.7* Plt ___
___ 09:35AM BLOOD Neuts-85.6* Lymphs-9.1* Monos-4.9 Eos-0.1
Baso-0.2
___ 09:35AM BLOOD ___ PTT-33.0 ___
___ 09:35AM BLOOD Glucose-126* UreaN-52* Creat-1.6* Na-126*
K-2.0* Cl-69* HCO3-39* AnGap-20
___ 09:35AM BLOOD ALT-128* AST-174* AlkPhos-530*
TotBili-42.4* DirBili-28.8* IndBili-13.6
___ 09:35AM BLOOD Lipase-48
___ 09:35AM BLOOD Albumin-3.4* Calcium-9.7 Phos-2.7 Mg-3.3*
___ 09:48AM BLOOD Lactate-2.7*
___ 02:55PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:55PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 02:55PM URINE CastHy-5*
___ 02:55PM URINE Mucous-RARE
CT Head w/o contrast ___: There is no evidence of hemorrhage,
edema, mass, mass effect, or infarction. The ventricles and
sulci are normal in size and configuration for the patient's
age. The basal cisterns are patent. There is preservation of
gray-white matter differentiation. Atherosclerotic
calcifications are noted in the internal carotid arteries. No
fracture is identified. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The soft
tissues are unremarkable. IMPRESSION: No acute intracranial
abnormality.
CT C-spine w/o contrast ___: 1. No fracture or malalignment.
2. Multilevel degenerative changes with multilevel neural
foraminal narrowing due to facet arthrosis. 3. Multiple nodules
in the thyroid gland. If clinically indicated, recommend
further evaluation with a thyroid ultrasound.
RUQ U/S ___: 1. Severely dilated intra- and extra-hepatic
biliary ducts without definite associated mass. Recommend MRCP
for further evaluation if there are no contraindications to MRI.
Alternatively, a multiphasic CT of the abdomen should be
performed.
2. Distended gallbladder with cholelithiasis and sludge, but no
other
findings to suggest evidence of acute cholecystitis.
CXR ___: no intrathoracic process.
CT Abdomen/Pelvis ___: There is a mass lesion involving the
ampullary region which results in severe dilatation of the intra
and extrahepatic biliary tree as well as mild main pancreatic
ductal dilatation. Differential considerations include a
cholangiocarcinoma versus a pancreatic neoplasm. There is no
evidence of distant metastases. Trace ascites is seen.
Incidental hepatic and renal hypodensities, likely cysts as
described above. Incidental pancreatic cystic lesions, most
compatible with IPMN.
EGD ___: The duodenal bulb was dilated. There was a complete
obstruction in the duodenal bulb preventing an ERCP from being
performed.
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY ___: 1. Marked intra
and extrahepatic biliary dilatation to the level of the distal
CBD.
2.Successful placement of an 8 ___ percutaneous transhepatic
biliary drain throught the obstruction which has been left on
free drainage.
OPERATIVE PATHOLOGY:
(Periduodenal nodule): Metastatic well differentiated
adenocarcinoma present in fibroadipose tissue.
Discharge Labs:
___ 04:15AM BLOOD WBC-10.5 RBC-3.01* Hgb-9.3* Hct-29.1*
MCV-97 MCH-31.0 MCHC-32.1 RDW-15.9* Plt ___
___ 04:15AM BLOOD Plt ___
___ 04:15AM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-137
K-3.7 Cl-106 HCO3-25 AnGap-10
___ 04:15AM BLOOD ALT-71* AST-77* AlkPhos-245* TotBili-7.0*
DirBili-4.7* IndBili-2.3
___ 04:15AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.1
___ 04:20AM BLOOD Triglyc-278*
Medications on Admission:
None
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*5
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
3. Senna 1 TAB PO BID:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Megestrol Acetate 400 mg PO DAILY
RX *megestrol 400 mg/10 mL (40 mg/mL) 1 Suspension(s) by mouth
once a day Disp #*30 Packet Refills:*0
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth QIDACHS Disp #*56 Tablet
Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Metastatic well differentiated adenocarcinoma.
2. Chronic cholecystitis and cholelithiasis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: New jaundice and poor oral intake. Evaluate for metastatic
disease.
COMPARISONS: None.
FINDINGS: The lungs are clear without consolidation or edema. No large
nodules are identified. There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal. Probable small calcified lymph nodes
are noted in the left hilum.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Fall with head strike.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin slice
bone image reformats were obtained and reviewed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration for
the patient's age. The basal cisterns are patent. There is preservation of
gray-white matter differentiation. Atherosclerotic calcifications are noted
in the internal carotid arteries. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
soft tissues are unremarkable.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
INDICATION: Fall with head strike.
COMPARISONS: None.
TECHNIQUE: Contiguous helical axial MDCT images were obtained from the base
of the skull to the apices of the lungs without the administration of IV
contrast. Sagittal and coronal reformatted images were obtained and reviewed.
FINDINGS: The patient is diffusely osteopenic. There is no prevertebral soft
tissue abnormality. No fracture is identified. There is no malalignment.
Straightening of the normal cervical lordosis is likely due to patient
positioning.
There are multilevel degenerative changes with disc space narrowing,
osteophyte formation, uncovertebral hypertrophy, and severe facet arthrosis.
There is no significant spinal canal narrowing. Multilevel neural foraminal
narrowing is present from the facet arthrosis, most severe at C3-4 on the
left.
The apices of the lungs are clear. Multiple nodules are noted in both lobes
of the thyroid gland. The largest is in the right lobe and measures 7 mm (2,
56). There is no lymphadenopathy. The visualized portions of the brain are
unremarkable.
IMPRESSION:
1. No fracture or malalignment.
2. Multilevel degenerative changes with multilevel neural foraminal narrowing
due to facet arthrosis.
3. Multiple nodules in the thyroid gland. If clinically indicated, recommend
further evaluation with a thyroid ultrasound.
Radiology Report
INDICATION: Painless jaundice for one month.
COMPARISONS: None.
FINDINGS: The liver is normal in shape and contour. There is normal
echogenicity. No focal hepatic lesions are identified. The portal vein is
patent.
There is severe intra- and extra-hepatic biliary duct dilation. The common
hepatic duct measures 2 cm at its greatest width, and the common bile duct
measures 1.8 cm at its greatest width. The common bile duct remains dilated
as it enters the pancreatic head. There is no intraluminal lesion identified
within the ducts. No definite extrinsic mass is identified. The visualized
portions of the pancreas are unremarkable. There is no pancreatic duct
dilation.
The gallbladder is mildly distended. There are stones and sludge layering
within the gallbladder. The largest stone measures 1.7 x 0.7 x 1.2 cm and is
present within the neck of the gallbladder. There is no gallbladder wall
thickening or pericholecystic fluid to suggest acute cholecystitis.
There is no ascites. Limited views of the kidneys are unremarkable without
evidence of hydronephrosis. The spleen is normal, and measures 10.2 cm.
IMPRESSION:
1. Severely dilated intra- and extra-hepatic biliary ducts without definite
associated mass. Recommend MRCP for further evaluation if there are no
contraindications to MRI. Alternatively, a multiphasic CT of the abdomen
should be performed.
2. Distended gallbladder with cholelithiasis and sludge, but no other
findings to suggest evidence of acute cholecystitis.
Radiology Report
HISTORY: PICC placement.
FINDINGS: PICC line extends into the right neck. This information has been
telephoned to the IV nurse.
The nasogastric tube extends to the uppermost portion of the stomach.
However, the side hole is only in the lower esophagus.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the earlier study of this date, the right
subclavian PICC line has been re-positioned so that the tip lies in the
mid-to-lower portion of the SVC.
Radiology Report
INDICATION: ___ woman with painless jaundice. High suspicion for
pancreas cancer.
COMPARISON: Ultrasound ___.
TECHNIQUE:
FINDINGS: There is an NG tube with its tip in the gastric body.
There is severe dilatation of the intra and extra hepatic biliary tree
extending to the level of the common bile duct. The common bile duct abruptly
terminates as it enters the pancreas, where a hypoattenuating mass is seen in
the region of the pancreatic ampulla. This region measures 1.5 x 2.9 cm. There
is dilatation of the main pancreatic duct as well as the accessory pancreatic
duct.
There is a 7mm cystic lesion seen within the pancreatic head, most compatible
with a focal intraductal papillary mucinous neoplasm. There is a fat
containing lesion in the pancreatic groove, most in keeping with a lipoma.
There is conventional hepatic arterial anatomy. The SMV, splenic vein and
portal vein are patent and demonstrate no thrombus.
There are no focal parenchymal hepatic mass lesions. There is a cystic lesion
within hepatic segment VI, most compatible with a simple cyst measuring 1.9
cm.
There is no intraperitoneal or retroperitoneal lymphadenopathy. The adrenals,
spleen, right kidney and proximal ureters are unremarkable. There is a small
hypodensity within the interpolar region of the left kidney, too small to
characterize but most in keeping with a simple cyst.
There is a small amount of free fluid within the small bowel mesentery as well
as the right paracolic gutter.
There is evidence of pancolonic diverticulosis. The small and large bowel are
unremarkable otherwise with no evidence of obstruction.
SKELETON/ LUNG BASES:
Atelectasis is seen at the lung bases. There are bilateral pleural effusions.
Discogenic degenerative changes are noted within the proximal thoracic spine.
There are no suspicious bony lesions.
IMPRESSION:
There is a mass lesion involving the ampullary region which results in severe
dilatation of the intra and extrahepatic biliary tree as well as mild main
pancreatic ductal dilatation. Differential considerations include a
cholangiocarcinoma versus a pancreatic neoplasm. There is no evidence of
distant metastases. Trace ascites is seen.
Incidental hepatic and renal hypodensities, likely cysts as described above.
Incidental pancreatic cystic lesions, most compatible with IPMN.
Radiology Report
INDICATION: Painless jaundice with concern for malignancy. Acutely altered
mental status.
TECHNIQUE: Multidetector CT scan of the head was obtained without the
administration of contrast.
COMPARISON: CT examination dated ___.
FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or
recent infarction. Prominence of the ventricles and sulci is compatible with
age-related global atrophy. No concerning osseous lesion is seen. A mucosal
retention cyst is partially imaged within the left maxillary sinus. The
mastoid air cells are clear.
IMPRESSION: No evidence of acute intracranial process.
Radiology Report
INDICATION: ___ woman with no past medical history, admitted with
painless jaundice, altered mental status, evidence of infection?
COMPARISON: ___ at 18:48.
TECHNIQUE: Portable supine chest radiograph.
FINDINGS: The right PICC line appears now to enter the right internal jugular
vein and trend up into the neck where it loops on itself and turns back
around, coming down to the level of the clavicle. This line is not properly
placed and needs to be repositioned. NG tube is again noted but tip is not
visualized. Cardiomediastinal contours are stable. Lung fields are clear.
No significant pleural effusions and no pneumothorax.
IMPRESSION:
Left PICC line enters the right internal jugular vein and loops around, coming
down to the level of the right clavicle. The line needs to be withdrawn and
repositined.
Radiology Report
HISTORY: PICC placement.
FINDINGS: The right subclavian PICC line again extends well into the neck.
Otherwise, little change.
Radiology Report
PROCEDURE: PICC LINE REPOSITIONING.
HISTORY: ___ female with painless jaundice with misplaced right PICC
line. Request is to reposition.
OPERATORS: Dr. ___ and Dr. ___ performed the procedure.
PROCEDURE NOTE IN DETAIL: Informed verbal consent was obtained from the
patient. The patient was then transferred to the ___ suite and placed supine
on the imaging table. A limited fluoroscopic spot film of the chest
demonstrates the right-sided PICC line extending into the right internal
jugular vein. The area was prepped and draped in the usual sterile fashion.
A preprocedure huddle and timeout were performed as per ___ protocol. Under
real-time fluoroscopic guidance, the catheter was withdrawn and the tip
positioned at the origin of the SVC. Using a pre-curved 018 nitinol wire, the
wire was advanced into the SVC and the catheter then tracked along the wire.
The tip was positioned at the cavoatrial junction. The wire was withdrawn.
Satisfactory blood aspiration and flushing was noted from both lumens.
Sterile dressing was applied.
The patient was then transferred to the floor in stable condition for further
post-procedure monitoring.
IMPRESSION:
Uncomplicated repositioning of a right-sided PICC line with the tip now
positioned at the cavoatrial junction.
The line may be used for infusion therapy immediately.
Radiology Report
INDICATION: ___ woman with painless jaundice, total bilirubin in the
___, cholangitis on Zosyn, needs decompression .
PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___
___ (radiology attending)and Dr ___.
MEDICATION: The procedure was performed under general anesthesia, please see
the dedicated anesthesia note for further details.
RADIATION: 21 minute 47 seconds of fluoroscopy time.
CONTRAST: 50 cc Omnipaque 320.
PROCEDURE:
1. Percutaneous transhepatic cholangiography.
2. Placement of an ___ internal-external percutaneous transhepatic 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 a preprocedure timeout was performed using three
patient identifiers. The procedure was performed under general anesthesia
which was induced in the angiographic suite, please see relevant
documentation.
The patient received 2 g of cefazolin IV prior to commencing the procedure.
The skin in the right anterior abdominal wall was prepped and draped in usual
sterile fashion. Using ultrasound guidance, a peripheral dilated right
posterior intrahepatic bile duct was targeted with a 21G Cook needle.
Positioning within the bile duct was confirmed by a small injection of
contrast to opacify the dilated intrahepatic biliary tree. A nitinol wire was
advanced via the Cook needle, the needle was removed and the central portion
of an AccuStick system was advanced over the wire to stabilize access to the
biliary tree. The nitinol wire was removed and a Glidewire was advanced via
the AccuStick into the dilated bile ducts, with some difficulty we manipulated
the Glidewire into the common bile duct. The wire would not pass further than
the mid portion of the common bile duct, therefore we removed at AccuStick
system and advanced a 5 ___ sheath advanced over the wire. We then used a
5 ___ long Kumpe catheter also over the Glidewire which advanced into the
proximal common bile duct and injected a small amount of contrast. This
opacified a very dilated common bile duct, cystic duct and gallbladder, but no
contrast was seen to pass distally through the CBD into the duodenum. We
advanced the sheath into the dilated common bile duct, and we used a
combination of the Kumpe catheter and Glidewire to locate the opening of the
markedly narrowed distal common bile duct. The Kumpe catheter was advanced
over the Glidewire and a small injection of contrast confirmed access to the
duodenum. The Glidewire was exchanged for an Amplatz wire and advanced via
the Kumpe into the duodenum and jejunum. The Kumpe catheter and sheath were
removed, the tract was dilated with an 8 ___ dilator. An 8 ___
percutaneous transhepatic biliary drain was advanced over the Amplatz wire
down to the level of the duodenum. A pigtail was formed and the catheter was
confirmed to be in adequate position by injection of small amount of contrast.
There were no immediate post-procedure complications, and the patient was
returned to the ___ ICU.
FINDINGS:
1. Marked intrahepatic biliary duct dilatation down to the level of the mid
to distal common bile duct with a tight stenosis at that level.
2. Predominant opacification of the right-sided intrahepatic ducts; however,
some contrast and at least one guidewire was seen to enter the left-sided
ducts which are presumed to be in free communication.
3. Succesful traversal of the distal CBD obstruction with placement of an ___
Internal / External biliary drain.
4. Of note NG tube noted with its distal tip in the stomach.
IMPRESSION:
1. Marked intra and extrahepatic biliary dilatation to the level of the distal
CBD.
2.Successful placement of an 8 ___ percutaneous transhepatic biliary drain
throught the obstruction which has been left on free drainage.
Radiology Report
INDICATION: Painless jaundice, confirm NG tube placement.
COMPARISON: ___.
TECHNIQUE: Single AP portable upright chest.
FINDINGS: A nasogastric tube courses below the diaphragm, with tip below the
borders of the radiograph, but likely located within the distal stomach. A
right-sided PICC has been repositioned and now terminates in lower SVC. Mild
left basilar atelectasis is persistent but slightly improved. Otherwise, no
significant interval change.
IMPRESSION: Nasogastric tube below the diaphragm, with tip likely located in
distal stomach. Right-sided PICC with tip in lower SVC after repositioning.
Left basilar atelectasis.
Radiology Report
HISTORY: Right IJ line placement.
CHEST, SINGLE PORTABLE VIEW.
Right IJ central line tip overlies the proximal/mid SVC and a right subclavian
PICC line tip overlies the SVC/RA junction. NG tube tip extends beneath the
diaphragm and overlies the stomach. No pneumothorax detected.
Upper zone re-distribution, without overt CHF. Patchy retrocardiac opacity,
similar or slightly improved compared with ___. No pneumothorax detected.
Biapical pleural thickening again noted. Calcified left hilar lymph nodes
again noted.
Radiology Report
INDICATION: ___ female status post ex lap Roux-en-Y
choledochojejunostomy and gastrojejunostomy, now with recent removal of right
IJ on the same side as the PICC line.
COMPARISON: Comparison is made with chest radiograph from ___ and
___.
FINDINGS: Two frontal images of the chest demonstrate a right PICC line
terminates in the low SVC, unchanged from previous imaging. There is no
pneumothorax or other complications. Interval removal of NG tube is also
noted. There is a left pleural effusion and opacity in the left lower lobe
associated with some volume loss. A catheter is seen overlying the liver.
Calcified left hilar lymph nodes are again noted. Otherwise, the lungs appear
clear and well expanded. Osseous structures are unremarkable.
IMPRESSION: Right PICC line in unchanged position. No pneumothorax or other
complications. Small left pleural effusion.
Radiology Report
CT CHEST WITH CONTRAST
COMPARISON: None. Correlation is made with CTA abdomen of ___.
TECHNIQUE: Multiple axial CT images were obtained through the chest following
the administration of 75 cc of Omnipaque IV contrast. Sagittal and coronal
reconstructions were obtained. No adverse reactions were reported.
INDICATION: ___ female with pancreatic cancer, status post
exploratory laparotomy with biopsy of ___ nodule, cholecystectomy,
Roux-en-Y procedure, choledochojejunostomy, and gastrojejunostomy. Exam is
done for oncology staging.
FINDINGS: Right PICC terminates at the superior atriocaval junction. No
supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy. Small
right hilar lymph node measures 8 mm on short axis and does not meet criteria
for pathologic enlargement by size. Scattered left hilar pulmonary calcified
granulomas. Heart size is within normal limits without pericardial effusion.
The thoracic aorta is normal in caliber without dissection or aneurysmal
dilatation. Branches of the aortic arch are normal. Pulmonary trunk is
within normal limits by size. No central pulmonary thromboembolic disease is
identified. Thyroid gland demonstrates homogeneous attenuation without focal
lesions.
There is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural
right lower lobe (2:36). No pulmonary mass is identified. Bilateral basilar
subsegmental atelectasis. Small bilateral pleural effusions. No
pneumothorax.
ABDOMEN: Pneumobilia is likely related to recent changes of reported
choledochojejunostomy. Hypodensity in the gallbladder fossa with intrinsic air
is compatible with Surgicel packing although an abscess would have a similar
appearance. Stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe
(segment VII). Small perihepatic and perisplenic ascites. Colonic
diverticulosis without diverticulitis involving the visible splenic flexure.
There is patchy fluid surrounding the splenic flexure, which may be due to
post-surgical change.
BONES AND SOFT TISSUES: No acute fracture or destructive osseous process.
Multilevel degenerative disc disease. Advanced degenerative changes of the
right and moderate degenerative changes of the left acromioclavicular joint.
Degenerative arthrosis of both humeral heads. There is a calcific structure
along the greater tuberosity of the left humerus which may relate to calcific
tendinosis. No acute fracture or destructive osseous process.
IMPRESSION:
1. Indeterminate right middle lobe and lower lobe pulmonary nodules. In a
patient with history of prior malignancy, unenhanced CT chest is recommended
in three months to monitor growth pattern and malignant potential.
2. No intrathoracic lymphadenopathy.
3. Pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
flexure are likely related to recent surgery. Hypoattenuation in gallbladder
fossa with intrinsic air is compatible with Surgicel packing, however an
abscess would have a similar appearance and cannot be excluded.
4. Scattered colonic diverticulosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIFFICULTY EATING
Diagnosed with JAUNDICE NOS, OBSTRUCTION OF BILE DUCT
temperature: 96.8
heartrate: 80.0
resprate: 12.0
o2sat: 100.0
sbp: 94.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | At the time of her admission on ___ the patient was
hypotensive and had an elevated WBC to 16 with a left shift.
She was therefore transferred to the ICU for further management.
She was started on zosyn and given Vitamin K and FFP to reverse
her coagulopathy. Due to her hypotension, CT scan was initially
post-poned. Upon stabilization of the patient's blood pressure,
it was decided to proceed with ERCP on ___. ERCP was
unsuccessful due to an obstructing duodenal mass. An NG tube
was placed, and three liters of gastric contents were removed
from her stomach.
At this time, the Hepatobiliary Surgical team was consulted for
evaluation. Upon review of CT Abdomen/Pelvis, it was determined
that the patient had a potentially operable lesion. The patient
was scheduled for an upcoming surgical procedure on ___. For
immediate biliary decompression and relief of the associated
symptoms and abnormal laboratory values, on ___, the patient
underwent percutaneous transhepatic cholangiography with
decompression and drain placement. In the days thereafter, the
patient was noted to have significant improvement in her TBili
laboratory values, and some improvement her jaundiced
appearance. Additionally, on ___, the patient had a PICC line
placed, and TPN was started. The patient was repleted with
intravenous fluids to replace the losses from both her abdominal
drain as well as her NG tube. The patient had notable
improvement in laboratory values and clinical appearance in this
manner, over the following days, leading up to her scheduled
operation on ___.
On ___, the patient underwent an exploratory laparotomy with
biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y,
choledochojejunostomy and gastrojejunostomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
on a single-day-course of IV zosyn, with a foley catheter, and
her PTBD in place, and an epidural for pain control. The
patient was hemodynamically stable.
On POD#1 (___), she continued to have the epidural for pain
control. She therefore continued to have a foley catheter. She
required aggressive IV fluid hydration post-operatively, which
she responded well to, as gauged by her urine output and vitals,
which remained hemodynamically stable and normal throughout. Her
TPN was held on this day, and she remained NPO with her NGT n
place.
On POD#2 (___), her pain remained well-controlled with the
epidural. Due to a hematocrit of 23, she was transfused 2 units
of Packed Red Blood Cells on this day. Through follow-up of
post-transfusion hematocrit, it was determined that she had
responded well to this step. She worked on ambulating with
Physical Therapy on this day. Her NG tube and foley catheter
were maintained, and she remained NPO. TPN was restarted on this
day.
On POD#3 (___), she continued to have good pain control with the
epidural. Her foley catheter was therefore also maintained. Her
NGT was clamped on this day, and residuals were checked every
four hours. She consequently also remained NPO. She ambulated
twice with Physical Therapy.
On POD#4 (___), she continued to have good pain control with the
epidural. Her foley catheter was also maintained. Her NGT was
removed, and she was permitted to have sips of liquids, which
she tolerated well. She ambulated with Physical Therapy.
On POD#5 (___), the patient's epidural was removed, and she was
transitioned to oral pain medications, which she tolerated well.
Diet was advanced to clears, in addition to having TPN, which
she also tolerated well. She continued to ambulate multiple
times per day. The foley catheter was removed, and she voided
successfully.
On POD#6 (___), the patient's PTBD drain was removed. She was
advanced to full liquids, which she tolerated well. She was
continued on TPN. She continued to ambulate multiple times
daily, with physical therapy.
On POD#7 (___), the patient was continued on TPN, and Enlive
supplementation was added to her full liquid diet. Her pain was
well controlled with oral medications. She continued to ambulate
frequently and regularly.
On POD#8 (___), per recommendations by Hematology/Oncology, a
CT Chest was obtained for staging purposes. She was continued on
TPN, but the volume was decreased to half. She continued to have
good pain control, tolerating full liquids, and ambulating
regularly.
On POD#9 (___), she was advanced to a regular diet with Enlive
supplementation, and continued on half-volume TPN. She continued
to ambulate regularly, and have good pain control.
On POD#10 (___), she was maintained on half-volume TPN, regular
diet with Enlive supplementation, ambulating regularly, working
with ___.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. *********Staples were removed, and steri-strips
placed.***** The patient was discharged home without/with
services.***** The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter,
currently on coumadin, who presents from his nursing home s/p
fall on his face/and right side after tripping on a table.
Patient reports that he had recent increase in dose of his
pscyhiatric medications and since then he has felt increased
dizziness and a little more trouble ambulating. He is
experiencing ___ headache located in the right temple without
radiation, associated with no vision changes, recent
nausea/vomiting, limb weakness, confusion.
He reports that he has had increased SOB this morning at rest
and with exertion over the past day. He denies any assoicated
cough, fevers/chills, orthopnea, PND, ___ pitting edema, chest
pain.
He has had nausea and abdominal pain over the past week that is
mild and diffuse in nature. He has been using Maalox for this
which improves these symtoms. He has had 3 episodes of emesis on
___, one of which had dark "red blood" in it per patient report.
He reports constipation, and his last BM was yesterday, which he
reported was hard with no hematochezia or melena. He denies any
recent fevers/chills/ malaise/motor/sensory neuro
abnormalities/vision changes/diarrhea.
In the ___ initial vitals were: 98.7 P 79 BP 108/71 RR 16 POx 94%
RA. He was given IV 40mg Pantoprazole , and 2mg IV Zofran. The
patient was noted to be less responsive this AM and repeat CT
head was carried out which revealed no frank head bleed.
Neurosurgery consult was obtained which concluded he is
neurologically intact and no further neurological intervention
needs to be done. BP holding around 90-100s SBP. DRE showed
positive occult blood and pt had 3 episodes of bloody vomitus
yesterday. IV 10mg Vitamin K. Started protonix bolus and drip.
Consulted GI who recommended repeating hematocrit. Also CXR has
some elements of CHF and he was admitted to MICU for further
management.
On arrival to the MICU, the patient looks well and his only
complaint is headache. He currently denies nausea, vomiting,
abdominal pain, chest pain, dyspnea. He denies vision changes,
numbness or problems moving his arms and legs. He is "tired" but
denies any confusion.
Review of systems:
Obtained from patient
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
___ PE, left-sided DVT (___) s/p IVC filter on Coumadin
Chronic pain ___ DJD disease, compression fractures of T11,
L2 (wheelchair use)
GERD
Hiatal hernia (associated with prior chest pain)
___ of Osteomyelitis in R ___ toe
Past Psychiatric History:
Reported multiple past hospitalizations at ___, ___
___, etc, typically for similar SI though no documented SA.
Has received OP treatment through ___ and ___ in the
past, currently without treaters. Has been on "multiple
antidepressants" per record without specific names recalled, no
overt side effects or adverse outcomes. Reportedly on lithium
___, stopped several months ago for noncompliance. No other
known med trials. No record of assault, violence.
Substance Use History:
1PPD tobacco. Denies EtOH, IVD, cocaine, THC abuse. No past
withdrawal/seizure/DTs. Per PCP, has ___ heavy ETOH.
Social History:
___
Family History:
Father died of MI at ___
Mother died of MI at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented X 3 , no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated though hard to assess given
habitus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: no wheezes, bibasilar insp. rales,no ronchi
Abdomen: soft, tendernes in the epigastric region,
non-distended, bowel sounds present, no organomegaly. No rebound
tenderness, no guarding.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Rectal: Dark brown guaiac positive stool
DISCHARGE PHYSICAL EXAM:
VS - 98.5, 126/88, 73, 18, 98% RA FSBG 121
GENERAL - awake, comfortable, in NAD
HEENT - NC/AT, sclerae anicteric
LUNGS - few crackles at the base of the lungs, bilaterally.
Moving air well and symmetrically, resp unlabored, no accessory
muscle use
HEART - RRR, S1-S2 clear and of good quality without murmurs,
rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral DP pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission Labs
___ 11:30PM BLOOD WBC-11.1*# RBC-4.14* Hgb-12.4* Hct-37.5*
MCV-91 MCH-29.9 MCHC-33.0 RDW-15.9* Plt ___
___ 11:30PM BLOOD Neuts-72.3* ___ Monos-2.9 Eos-1.7
Baso-0.2
___ 11:30PM BLOOD ___ PTT-38.9* ___
___ 11:30PM BLOOD Glucose-94 UreaN-21* Creat-0.8 Na-138
K-4.6 Cl-105 HCO3-27 AnGap-11
___ 11:30PM BLOOD ALT-19 AST-27 AlkPhos-56 TotBili-0.3
___ 11:30PM BLOOD Lipase-12
___ 11:30PM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.3 Mg-2.5
___ 11:30PM BLOOD VitB12-486
___ 11:30PM BLOOD Valproa-79
DISCHARGE LABS:
___ 03:02AM BLOOD WBC-6.5 RBC-4.05* Hgb-11.9* Hct-36.9*
MCV-91 MCH-29.5 MCHC-32.4 RDW-15.9* Plt ___
___ 03:02AM BLOOD Plt ___
___ 03:02AM BLOOD ___ PTT-34.3 ___
___ 03:02AM BLOOD Glucose-120* UreaN-26* Creat-0.8 Na-139
K-4.4 Cl-106 HCO3-25 AnGap-12
IMAGING:
- CT HEAD W/O CONTRAST ___: IMPRESSION: Mildly
artifact-limited study. Previously seen focus of left frontal
cortical hyperdensity is no longer present on the current
examination. Apparent foci of hyperdensity now project over
different portions of the frontal cortex bilaterally, almost
certainly artifactual. The artifacts are in part related to the
protective goggles over the patient's eyes. If additional
imaging is desired, the patient should be rescanned with his
neck flexed, so that the goggles would not project over the
frontal lobes.
- CXR ___: FINDINGS AND IMPRESSION: Lung volumes are low.
As compared to the prior examination, previously seen bibasilar
opacities are improved and right midlung pneumonia has cleared.
There is mild bibasilar atelectasis, but no consolidation to
suggest pneumonia. Moderate cardiomegaly, increased since ___,
generalized systemic and pulmonary overcirculation and is
incipient pulmonary edema indicate biventricular cardiac
decompensation. I discussed these findings by telephone with Dr
___ in the ___ at 8:30AM.
- CT HEAD W/O CONTRAST ___: IMPRESSION: Motion-limited
study. Apparent hyperdensity projecting over the left anterior
frontal cortex, subjacent to bone, is probably artifactual.
However, given history of fall and anticoagulation, a small
hemorrhage cannot be excluded. Close clinical follow-up and
short-interval follow-up imaging should be considered.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ home medication sheet.
1. Divalproex (DELayed Release) 500 mg PO QAM
2. Divalproex (DELayed Release) 750 mg PO HS
3. Ferrous Sulfate 325 mg PO DAILY
4. Quetiapine extended-release 500 mg PO DAILY
5. Doxepin HCl 100 mg PO HS
6. BuPROPion (Sustained Release) 450 mg PO HS
7. Warfarin Dose is Unknown PO DAYS (___)
8. Furosemide 40 mg PO DAILY
9. TraMADOL (Ultram) 25 mg PO BID
10. Clonazepam 2 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. Paroxetine 30 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 450 mg PO HS
2. Clonazepam 2 mg PO BID
3. Divalproex (DELayed Release) 500 mg PO QAM
4. Divalproex (DELayed Release) 750 mg PO HS
5. Doxepin HCl 100 mg PO HS
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Paroxetine 30 mg PO DAILY
9. Quetiapine extended-release 500 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO BID
11. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI
upset
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath or wheezing
14. Bisacodyl 10 mg PR HS:PRN constipation not responsive to
milk of magensia
15. Fleet Enema ___AILY:PRN constipation not responsive
to suppository
16. Guaifenesin 10 mL PO Q6H:PRN cough
17. Milk of Magnesia 30 mL PO QHS:PRN constipation
18. Prochlorperazine 10 mg PO Q6H:PRN nausea or vomiting
19. TraMADOL (Ultram) 25 mg PO BID
for back pain
20. Acetaminophen 650 mg PO Q6H:PRN pain or fever
21. Miconazole Powder 2% 1 Appl TP BID:PRN rash
22. Polyethylene Glycol 17 g PO EVERY OTHER DAY
hold for diarrhea
23. ___ MD to order daily dose PO DAYS
(___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Mechanical Fall
Erosive gastritis
Secondary: Bipolar disorder
Gastroesophageal reflux disorder
History of deep venous thrombosis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
INDICATION: Status post fall. On Coumadin. Initial head CT with question of
possible subarachnoid hemorrhage.
TECHNIQUE: Multidetector CT scan of the head was obtained without the
administration of contrast. Coronal and sagittal reformations were prepared.
COMPARISON: Correlation with CT dated ___ obtained approximately
5.5 hours prior. Review of CT head examination dated ___.
FINDINGS: The study is mildly limited by artifacts, less so than the prior
study performed approximately 5.5 hours earlier. The location of the
previously described hyperdensity appears normal on the current CT
examination. Apparent hyperdensity now projects over the left anteromedial
frontal cortex (___), in a different location than the questionable
finding on the prior CT. There are bilateral apparent areas of hyperdensity
along the inferomedial frontal cortex bilaterally (102A:36-37). These are
almost certainly artifactual. No subdural or epidural collection is seen.
Prominence of the ventricles and sulci is consistent with mild cerebral
atrophy, unchanged.
No concerning osseous lesion or fracture is identified. There is minimal
mucosal thickening of the left maxillary sinus and bilateral anterior ethmoid
air cells.
IMPRESSION: Mildly artifact-limited study. Previously seen focus of left
frontal cortical hyperdensity is no longer present on the current examination.
Apparent foci of hyperdensity now project over different portions of the
frontal cortex bilaterally, almost certainly artifactual.
The artifacts are in part related to the protective goggles over the patient's
eyes. If additional imaging is desired, the patient should be rescanned with
his neck flexed, so that the goggles would not project over the frontal lobes.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: UNWITNESSED FALL
Diagnosed with HEAD INJURY UNSPECIFIED, NAUSEA WITH VOMITING, UNSPECIFIED FALL
temperature: 98.7
heartrate: 79.0
resprate: 16.0
o2sat: 94.0
sbp: 108.0
dbp: 71.0
level of pain: 9
level of acuity: 3.0 | ___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter, on
coumadin, who presents from his nursing home s/p mechanical fall
on his right side of his head and hemetemesis.
# GI Bleed: He reported multiple episodes of non-bloody emesis
prior to emesis with frank blood, and the coffee-ground emesis.
Additionally, he was found to be guaiac positive on admission.
He was admitted to the MICU for close monitoring and
observation. There, he was initially started on a PPI drip, and
he was evaluated by GI, who recommended inpatient EGD. He was HD
stable, his crit was stable, and did not have any additional
episodes of vomiting. He was transitioned to IV PPI BID, which
he tolerated well. He underwent EGD which showed erosive
gastritis and duodenitis, as well as a large amount of food in
the stomach. GI recommended repeat EGD in 8 weeks, double dose
PPI PO, and an outpatient gastric emptying study.
#Reported Dyspnea- He reported dyspnea prior to admission,
although this was not an active issue during this
hospitalization. He appeared euvolemic on admission with no
evidence of wheezing or acute heart failure on exam. No
infiltrate on CXR or fevers/chills to suggest pneumonia. Mild
pulm edema on CXR better than ___, and stable on room air. He
was diuresed with lasix, and restarted on his home regimen. He
maintained excellent oxygen saturations throughout this
hospitalization.
# Lightheadedness: Complained of lightheadedness/dizziness on
muptiple days prior to admission. Exact etiology was unclear,
but most likely secondary to medication side-effects. There were
no focal signs to suggest TIA or CVA, and head CT was normal. He
was not orthostatic while on the medicine floor.
#Bipolar disease- Stable on this admission. He was maintained on
his home regmine of divalproex, doxepin, clonazepam, wellbutrin,
paxil and quetiapine.
#Hx PE/DVT- In the setting of GI bleed, his home coumadin was
held, and he was given 10 mg FFP for reversal, prior to EGD. His
INR on discharge was 1.8.
#GERD- Well controlled on omeprazole. He denied any abdominal
pain or reflux symptoms. In the setting of GIB (see above) he
was on PPI drip, and transitioned to IV PPI BID. He was
discharged on PO PPI BID, with close GI follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Percocet
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/CLL, pure red cell aplasia, dCHF and A-fib present
presents with fatigue x 2 weeks. Pt admitted from ___ to
medicine for fatigue and ___ and ___ ___ w/dyspnea, cough,
increasing pleural effusion with pneumonia. Patient was
discharged the first hosptial visit on Metalozone for increasing
edema. Patient was readmitted with Cr 3.7 (baseline ~ 1.6 -
1.9), metalozone was held and Cr improved to 3.2 and patient was
discharged. On repeat lab draw today, Cr still 3.2 so patient
was referred to ED.
Patient reports continued to feel fatigued. Reports 19lb weight
loss since ___. No night sweats. Denies chest pain, SOB,
cough, fever, chills, nausea, vomiting, diarhea. Leg swelling
improved from baseline. No blood in stool.
In the ED, initial vitals were: 97.5 75 100/48 18 100% 0
- Labs were significant for Na 127, Cr 2.7 (2.0 on ___, up to
3.7 on ___ , BUN 77, Hgb/Hct 8.___.1 (at baseline). Coags and
UA were normal, however 21 casts noted.
- Imaging revealed CXR - no fluid overload. Bilateral pleural
effusions
- The patient was not given medications, started on 75cc/hr IVF.
Vitals prior to transfer were: 78 118/78 23 Nasal Cannula
Upon arrival to the floor, patient reports fatigue no other
complaints.
Past Medical History:
PAST MEDICAL HISTORY
-CLL c/b immune thrombocytopenia, pure RBC aplasia, HSV
stomatitis
oral candidiasis therapy-related hypoplastic myelodysplastic
syndrome, parvovirus B19 infection and CMV infection
-Coronary artery disease (no h/o MI, stents, or CABG)
-atrial fibrillation, not on anticoagulation
-chronic diastolic CHF (EF 50%)
-S/p hernia repair
Social History:
___
Family History:
- Mother: ___ cancer
- Father: CAD, MI
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM:
==========================
Vitals: 98.8 106/60 104 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: irregular rate normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 1+ edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
===========================
DISCHARGE PHYSICAL EXAM:
===========================
Vitals: Tmax 99.2, Tc 98.9 BP 125/69 HR 114 RR 18 96%RA
I/O: ___ (8H) 900/850 (24H)
***Discharge Weight***: 137.8 lbs.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP
9 cm at 45 degrees
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, trace peripheral edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
=================
ADMISSION LABS:
=================
___ WBC-7.0 RBC-2.46* Hgb-8.8* Hct-26.1* MCV-106* MCH-35.8*
MCHC-33.7 RDW-13.8 RDWSD-53.9* Plt Ct-ERROR
___ Neuts-49 Bands-5 ___ Monos-2* Eos-0 Baso-0
___ Myelos-0 AbsNeut-3.78 AbsLymp-3.08 AbsMono-0.14*
AbsEos-0.00* AbsBaso-0.00*
___ Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+
Microcy-NORMAL Polychr-NORMAL
___ ___ PTT-39.6* ___
___ Glucose-137* UreaN-77* Creat-2.7* Na-127* K-4.5 Cl-90*
HCO3-24 AnGap-18
====================
PERTINENT RESULTS:
====================
___ TSH-1.6
==
CXR ___: As compared to ___ chest radiograph,
bilateral pleural effusions and adjacent basilar atelectasis
have slightly worsened. The right pleural effusion is now
moderate, in the left is small to moderate. No other relevant
changes.
==
CXR ___: The right Port-A-Cath is in stable position. There
unchanged appearance of the small right pleural effusion and
small left pleural effusion. Adjacent atelectasis is seen. The
heart size is stable. No overt pulmonary edema or pneumothorax
is seen. No new focal consolidation is seen.
==================
DISCHARGE LABS:
==================
___ WBC-5.9 RBC-2.18* Hgb-7.8* Hct-23.7* MCV-109* MCH-35.8*
MCHC-32.9 RDW-13.9 RDWSD-55.4* Plt ___
___ Glucose-128* UreaN-61* Creat-1.8* Na-130* K-4.1 Cl-94*
HCO3-27 AnGap-13
___ Calcium-8.5 Phos-2.8 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
5. Diltiazem Extended-Release 180 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO QPM
8. Metoprolol Succinate XL 200 mg PO QAM
9. PredniSONE 7.5 mg PO DAILY
10. Furosemide 80 mg PO BID
11. Potassium Chloride 10 mEq PO TID
12. Cyanocobalamin 1000 mcg PO DAILY
13. Magnesium (oxide/AA chelate) (magnesium oxide-Mg AA chelate)
133 mg oral BID
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
5. Diltiazem Extended-Release 180 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO QPM
8. Metoprolol Succinate XL 200 mg PO QAM
9. PredniSONE 7.5 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Magnesium (oxide/AA chelate) (magnesium oxide-Mg AA chelate)
133 mg oral BID
12. Potassium Chloride 10 mEq PO TID
13. Furosemide 40 mg PO EVERY OTHER DAY
14. Furosemide 80 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Acute on Chronic Kidney Injury
Secondary Diagnoses:
- Acute on Chronic Diastolic Heart Failure
- Atrial fibrillation
- Coronary artery disease
- Chronic Lymphocytic Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with congestive heart failure and presents with
fatigue and renal failure. Evaluate for CHF.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The right Port-A-Cath is in stable position. There unchanged appearance of
the small right pleural effusion and small left pleural effusion. Adjacent
atelectasis is seen. The heart size is stable. No overt pulmonary edema or
pneumothorax is seen. No new focal consolidation is seen.
IMPRESSION:
Similar appearance of the bilateral small pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CLL and new fever. // Signs of Pneumonia or
infiltrate?
IMPRESSION:
As compared to ___ chest radiograph, bilateral pleural effusions and
adjacent basilar atelectasis have slightly worsened. The right pleural
effusion is now moderate, in the left is small to moderate. No other relevant
changes. .
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, Lethargy
Diagnosed with RENAL & URETERAL DIS NOS, OTHER MALAISE AND FATIGUE
temperature: 97.5
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 100.0
dbp: 48.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ man with history of CLL,
thrombocytopenia, pure red cell aplasia, chronic kidney disease,
and diastolic congestive heart failure who was admitted for
acute on chronic kidney injury secondary to overdiuresis.
================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with history of CAD s/p
CABG, HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on
pomalidomide/daratumumab presenting with weakness.
The patient has a history of multiple myeloma s/p auto SCT
(___). He was initially on Revlimid, then Ninlaro, and now
initiated ___ on pomalidomide/daratumumab/dexamethasone. The
patient and his wife report that he has progressively become
weaker over the past several months, but it has been worse in
the
past several weeks. He also notes that he has had drenching
sweats for over a year but this has also gotten worse recently.
He reports that his blood sugars have been labile since
initiating the dexamethasone, sometimes in the 300-400s, but
also
low in the ___.
About 3 weeks ago, the patient got up in the night to urinate
and
feel extremely weak. His wife found him lying on the floor in
the
bathroom. He was taken to BID-M on ___. There, he was found to
have febrile neutropenia and acute on chronic anemia. ID was
consulted and he underwent extensive infectious evaluation
including blood and urine cultures, sputum culture, Flu/RSV
swab;
Lyme, Anaplasma, Babesia, Erlichia negative; CT abdomen/pelvis;
TTE without vegetations. The patient was given
vancomycin/cefepime empirically for 10 days and defervesced. His
hospital course was complicated by an acute gout flare for which
he received prednisone and colchicine. He was discharged on ___.
The patient saw his oncologist Dr. ___ on ___. The plan at that
time was to hold Bactrim/acyclovir prophylaxis, hold aspirin
given worsened thrombocytopenia, resume atenolol, and to hold
pomalidomide. However, the patient took a dose on ___.
At home, he continued to feel extremely weak. He denies any
fevers at home, but noted ongoing drenching sweats. His wife
reports that she went to the supermarket and returned 45 minutes
later and found her husband on the floor. The patient reports
that he was sitting in a recliner and attempted several times to
stand but felt extremely weak and repeatedly fell back into the
recline. On his final attempt to stand he rocked forward and
fell
out of the chair. He denies any loss of consciousness. He denies
any antecedent symptoms such as chest pain, palpitations,
dizziness or lightheadedness. He felt too weak to prop himself
up, and when his wife returned she called EMS. He was taken to
___, where he was febrile to 100.5. He was give IV vancomycin,
IV cefepime, oral vancomycin for potential C. diff, and 1 unit
pRBCS. He was transferred to ___ for further care.
The patient additionally notes that he developed a dry cough
while at ___ but denies any shortness of breath. No abdominal
pain, nausea, vomiting. He had a few loose stools several days
prior to admission this has been ongoing related to
chemotherapy.
He has a rash on his forehead due to his use of ___ for his
actinic keratosis but no other rashes or lesions. No dysuria. No
known sick contacts.
In the ED, vitals: Tmax 102.7 80 122/66 16 98% RA
Exam notable for: CTAB no WRR, unlabored breathing
Labs notable for: WBC 5.5, Hb 7.9, plt 94, INR 1.6; trop
0.07->0.04, MB 3->2; UA with glucosuria
Imaging: CXR
Patient given: Magnesium 2 gm IV, insulin 6 units, Tylenol 1 gm,
erythromycin eye ointment
In our ED, he was noted to have left eye lid with scant purulent
appearing discharge. No pain or redness in the eye. Started on
erythromycin ointment for presumed bacterial conjunctivitis
On arrival to the floor, the patient reports that he feels
fatigued but otherwise has no complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Multiple myeloma
Social History:
___
Family History:
Mother and father died of CAD in their ___
Physical Exam:
ADMISSION
VITALS: 99.7 125 / 80 67 18 94 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Rash on forehead
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
GENERAL: Alert and in no apparent distress
EYES: Anicteric sclera
ENT: Oropharynx without visible lesion, erythema or exudate.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen is soft, non-distended, non-tender to palpation.
MSK: Neck supple, moves all extremities
SKIN: Crusted rash on face extending across midline
NEURO: Alert, oriented, speech fluent
PSYCH: Pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 11:30PM BLOOD WBC-5.5 RBC-2.86* Hgb-7.9* Hct-25.5*
MCV-89 MCH-27.6 MCHC-31.0* RDW-16.2* RDWSD-51.4* Plt Ct-94*
___ 11:30PM BLOOD Neuts-70.7 ___ Monos-7.7 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-3.89 AbsLymp-1.08* AbsMono-0.42
AbsEos-0.01* AbsBaso-0.01
___ 11:30PM BLOOD ___ PTT-26.8 ___
___ 11:30PM BLOOD Glucose-182* UreaN-13 Creat-0.9 Na-136
K-4.3 Cl-102 HCO3-23 AnGap-11
___ 11:30PM BLOOD CK(CPK)-857*
___ 05:51AM BLOOD ALT-7 AST-19 LD(LDH)-96 CK(CPK)-109
AlkPhos-65 TotBili-0.9
___ 11:30PM BLOOD CK-MB-3 cTropnT-0.07*
___ 11:30PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.2* Iron-40*
___ 08:48AM BLOOD PEP-PND FreeKap-134.6* FreeLam-1.3* Fr
K/L-103.5*
___ 11:30PM BLOOD calTIBC-120* Ferritn-1101* TRF-92*
___ 07:30AM BLOOD Cortsol-17.7
___ 11:30PM BLOOD TSH-3.4
___ 11:38PM BLOOD Glucose-178* Lactate-1.0
IMAGING
- CT Head (___): CT head that did not show acute hemorrhage,
mass, territorial infarct.
- CT chest (___)
1. Multiple lucent lesions scattered throughout the axial
skeleton are concerning for myelomatous involvement. Several of
the lesions including dominant lesions in the T6 and T7
vertebral
bodies, which were not FDG avid on the prior PET-CT appear
grossly unchanged. A probable lesion in the medial
aspect of the right clavicle, appears new from PET-CT ___ and is concerning for new or worsening myelomatous
involvement.
2. Small pulmonary nodules measure up to 2 mm, not definitely
seen on PET-CT ___, possibly due to poor resolution.
Recommend ___ month interval follow-up to assess for stability.
3. Assessment is moderately limited by respiratory motion, but
no
definite evidence of pneumonia or bronchitis.
- CT sinus (___)
1. There is moderate mucosal thickening of the bilateral ethmoid
air cells and left maxillary sinus with partial opacification of
the left maxillary sinus which may represent sinus disease in
the
appropriate clinical setting.
2. There is opacification of the left infundibulum.
3. Polypoid soft tissue in the left maxillary sinus may
represent
sinus polyposis.
4. The bilateral orbits are unremarkable.
___ 07:05AM BLOOD WBC-3.4* RBC-2.61* Hgb-7.3* Hct-23.2*
MCV-89 MCH-28.0 MCHC-31.5* RDW-15.4 RDWSD-49.4* Plt Ct-87*
___ 07:05AM BLOOD Glucose-93 UreaN-12 Creat-1.1 Na-136
K-3.4* Cl-100 HCO3-29 AnGap-7*
___ 07:05AM BLOOD Mg-1.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
2. Nateglinide 120 mg PO TIDAC
3. pomalidomide 2 mg oral DAILY
4. Dexamethasone 20 mg PO 1X/WEEK (___)
5. fluorouracil 5 % topical DAILY
6. Omeprazole 20 mg PO DAILY
7. colestipol 5 gram oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
10. Glargine 22 Units Bedtime
11. FoLIC Acid 1 mg PO DAILY
12. magnesium chloride 64 mg oral BID
13. Lisinopril 10 mg PO DAILY
14. Atenolol 25 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Aspirin 81 mg PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
Discharge Medications:
1. Benzonatate 200 mg PO TID Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
2. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin [Mucus-ER MAX] 1,200 mg 1 tablet(s) by mouth
twice a day Disp #*28 Tablet Refills:*1
3. LevoFLOXacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO/NG Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*24 Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*3
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. colestipol 5 gram oral DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Dexamethasone 20 mg PO 1X/WEEK (___)
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Glargine 22 Units Bedtime
15. Lisinopril 10 mg PO DAILY
16. magnesium chloride 64 mg oral BID
17. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
18. Nateglinide 120 mg PO TIDAC
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
20. Omeprazole 20 mg PO DAILY
21. HELD- fluorouracil 5 % topical DAILY This medication was
held. Do not restart fluorouracil until your oncologist tells
you to
22. HELD- pomalidomide 2 mg oral DAILY This medication was
held. Do not restart pomalidomide until your oncologist tells
you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Febrile illness
Acute metabolic encephalopathy
Multiple myeloma
Anemia and thrombocytopenia
CAD s/p CABG
Demand ischemia
Diabetes mellitus
Weakness
Fall
Conjunctivitis
Essential hypertension
Hyperlipidemia
Gout
Actinic keratosis:
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 multiple myeloma, low grade fevers and cough//
pna?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and CABG.The lungs are clear without
focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac
and mediastinal silhouettes are unremarkable. Cardiac silhouette remains
mildly enlarged. Mediastinal contours unremarkable. No pulmonary edema is
seen. Osseous structures are not well assessed on this study.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with History of multiple myeloma on immunotherapy
presenting with recurrent fever of unclear etiology with cough// Possible
encephalopathy evaluate cause of alter mental status
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP 855 mGy cm
COMPARISON: None.
FINDINGS:
There is no evidence of large territory acute infarction,hemorrhage,edema, or
mass. The ventricles and sulci are age-appropriate. There is mild calcified
atherosclerosis at the bilateral carotid siphons.
There is no evidence of fracture. There is a moderate sized anterior nasal
septal defect. There is moderate mucosal thickening of the left maxillary
sinus and mild mucosal thickening of the ethmoid air cells and left sphenoid
sinus. The visualized portion of the remaining paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
No acute intracranial process. If there is high clinical concern for
encephalitis, further evaluation may be performed with MRI brain with contrast
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with myeloma and recurrent febrile illness.
Notable left eye edema and discharge with chronic rhinitis.// Evaluate for
sinus infection.
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 14.4 cm; CTDIvol = 27.9 mGy (Head) DLP = 408.8
mGy-cm.
Total DLP (Head) = 409 mGy-cm.
COMPARISON: CT head dated ___
FINDINGS:
No fractures are identified.
There is no evidence of facial swelling.
There is moderate mucosal thickening of the bilateral ethmoid air cells and
left maxillary sinus. There is aerosolized material and a polypoid soft
tissue left maxillary sinus. There is opacification of the left infundibulum.
The partially visualized bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
IMPRESSION:
1. There is moderate mucosal thickening of the bilateral ethmoid air cells and
left maxillary sinus with partial opacification of the left maxillary sinus
which may represent sinus disease in the appropriate clinical setting.
2. There is opacification of the left infundibulum.
3. Polypoid soft tissue in the left maxillary sinus may represent sinus
polyposis.
4. The bilateral orbits are unremarkable.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with multiple myeloma presenting with recurrent
febrile illness and cough// Assess for lung pathology to explain symptoms such
as pneumonia/bronchitis
TECHNIQUE: Multidetector scanning of the chest was performed and
reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal
and sagittal, and 8 x 8 mm MIPs axial images. No IV Contrast administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 33.4 cm; CTDIvol = 8.1 mGy (Body) DLP = 272.4
mGy-cm.
Total DLP (Body) = 272 mGy-cm.
COMPARISON: PET-CT ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid is unremarkable. No
axillary or supraclavicular lymphadenopathy.
UPPER ABDOMEN: Limited assessment of the upper abdomen is grossly
unremarkable.
MEDIASTINUM: No mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy within the limitations of this noncontrast
study.
HEART and PERICARDIUM: Coronary calcifications are heavy. No pericardial
effusion.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: Assessment of the lungs is moderately limited by respiratory
motion. Multiple granulomas are noted at the right lung apex. Small
pulmonary nodules measure up to 2 mm (series 5, image 71, 84, 86).
2. AIRWAYS: Airways are patent to the subsegmental level.
3. VESSELS: Vascular calcifications are moderate. Aorta and main pulmonary
artery are normal in size.
CHEST CAGE: Superficial soft tissues are grossly unremarkable. The patient is
status post median sternotomy. A large lytic lesion involving the T6 and T7
vertebral body (series 7, image 85, 81) and extending into the left seventh
rib, as well as a lytic lesion in the spinous process and extending into the
facets at T8 (series 7, image 39) allowing for technical differences are
unchanged from PET-CT ___ and concerning for myelomatous
involvement, although were not FDG avid on prior. Lucent lesion in the medial
aspect of the right clavicle (series 5, image 49) was not definitely seen on
prior PET-CT.
Numerous additional subcentimeter lucent lesions scattered throughout the
axial skeleton (Series 7, image 84, 81) are concerning for myelomatous
involvement.
DISH is noted throughout the visualized thoracic spine.
IMPRESSION:
1. Multiple lucent lesions scattered throughout the axial skeleton are
concerning for myelomatous involvement. Several of the lesions including
dominant lesions in the T6 and T7 vertebral bodies, which were not FDG avid on
the prior PET-CT appear grossly unchanged. A probable lesion in the medial
aspect of the right clavicle, appears new from PET-CT ___ and is
concerning for new or worsening myelomatous involvement.
2. Small pulmonary nodules measure up to 2 mm, not definitely seen on PET-CT
___, possibly due to poor resolution. Recommend ___ month interval
follow-up to assess for stability.
3. Assessment is moderately limited by respiratory motion, but no definite
evidence of pneumonia or bronchitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, Transfer
Diagnosed with Weakness
temperature: 98.7
heartrate: 63.0
resprate: 16.0
o2sat: 96.0
sbp: 113.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with history of CAD s/p CABG,
HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on
pomalidomide/daratumumab presenting with weakness and fever.
#Fever
#Sinusitis
Patient recently was admitted to BID-M for neutropenic fever
with extensive evaluation without source identification. Patient
was treated with 10 day course of empiric vancomycin/cefepime.
He re-presented with recurrent fever. No clear localizing signs
or symptoms of infection other than cough and possible
conjunctivitis. CXR was without focal infiltrate. CT chest
showed no pneumonia. CT sinus showed possible sinusitis. Patient
did have loose stools prior to admission, but they were
self-limiting. Infectious disease and oncology were consulted to
help advise investigation and management. Patient was treated
with empiric broad spectrum antibiotics with IV vancomycin, IV
cefepime, and IV metronidazole, then transitioned to PO
levofloxacin and flagyl on ___ once it was determined that he
likely had viral URI +/- superimposed bacterial
conjunctivitis/sinusitis. He remained stable on this regimen and
was discharged on levofloxacin and metronidazole to complete a
14-day total course on ___.
# Acute metabolic encephalopathy
Delirium, febrile effects related to immunotherapy versus
infection. Infectious workup and management as above. His
encephalopathy resolved with the aforementioned treatment.
# Multiple myeloma
# Anemia/thrombocytopenia: Currently receiving treatment with
daratumumab/pomalidomide. Intention had been to hold
pomalidomide, but patient took 2 doses since recent discharge.
Held daratumumab/pomalidomide but per Atrius onc. He will see
his oncologist Dr. ___ on ___ to discuss resuming therapy.
He received 1 U pRBC for symptomatic anemia and Hgb <7.
# CAD s/p CABG
# Demand ischemia: Patient with mild troponin elevation on
admission, likely represents mild demand in setting of acute
illness. Patient is asymptomatic and EKG was without acute
ischemic changes. His home cardiac medications were resumed.
# DMII: Labile blood sugars in setting of recent dexamethasone
use. His home medications were resumed
# Weakness
# Fall
Patient with global weakness in setting of febrile illness,
labile blood sugars, and multiple myeloma on new immunotherapy
regimen. ___ worked with the patient, and his mobility progressed
to where they felt he would be safe to return home with home ___.
# Conjunctivitis (viral versus bacterial): Patient had scant
purulent discharge in left eye in ED and started on
erythromycin. He completed 7 days of erythromycin ointment.
# Gout: No evidence of acute flare.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Omeprazole
Attending: ___.
Chief Complaint:
Pneumonia
Dyspnea/hypoxia
Atrial fibrillation - new dx
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history notable for
HTN and endometrial cancer with oligometastasis to the left lung
status post TAH-BSO in ___ and radiation in ___,
presenting with fever and dyspnea, sent in by PCP.
She developed malaise and fatigue a few days ago, and yesterday
(___) she developed a fever with Tmax of 100.8 (axillary).
This was associated with some dyspnea on mild exertion,
generalized fatigue/weakness, and decreased appetite. This
morning, she was afebrile, but had a productive cough (mostly
clear sputum; question of some sputum with a speck of blood).
Of note, she has history of endometrial adenocarcinoma s/p
TAH/BSO in ___ and was recently found to have an
oligometastasis to the left lower lobe, which was treated with
radiation completed on ___ (5 treatments over 2 weeks).
At her baseline, she ambulates with a walker or cane; a few
months ago she hurt her right knee and has been getting ___ at
home to help with her recovery from this injury. No
weight-bearing restrictions.
In the ED, initial vitals: 97.4 83 105/53 w/ neg orthostatics RR
16 95% 2L Nasal Cannula
In the ED, lung exam notable for b/l lower lobe crackles.
ED course notable for: blood/urine cx sent, u/a obtained c/f UTI
although sample likely contaminated, EKG with sinus rhythm 78
left axis, with episode of afib with RVR noted on telemetry.
Cefepime 2gm and Vanco 1gm given. IVF given.
Imaging showed CXR ___, discussed with ___, concern for
early left lobe pneumonia in the right clincial setting,
bilateral pleural effusion. Decision was made to admit for
treatment of presumed pneumonia and UTI.
Vitals prior to transfer: 98 77 112/58 24 98% Nasal Cannula
Currently, she is feeling well with some mild shortness of
breath when talking (on 4L O2). Has some left-sided chest pain
that is reproducible with palpation.
ROS:
Notable for some dizziness with standing, chronic back/leg pain,
swelling of her ankles when she stands, possible chronic mild
orthopnea, paresthesias in her legs (equal b/l, chronic), mild
constipation (last BM ___, and stress urinary incontinence.
No chills, night sweats, or weight changes. No changes in vision
or hearing. No chest pain or palpitations. No nausea or
vomiting. No diarrhea. No dysuria or hematuria. No hematochezia,
no melena. No focal deficits.
Past Medical History:
HTN
Arthritis
HLD
spinal stenosis
Uterine cancer s/p TAH/BSO with metastasis in left lung treated
with radiation completed ___.
Knee replacements (left x1, right x3, most recently in ___
cholecystectomy ___
TAH-BSO ___, ___)
hernia repair
surgery for stress incontinence (? sling)
cateract surgeries
Social History:
___
Family History:
Brother with DM, ___ on HD
Sister with breast and colon ca
Brother with CAD s/p CABG
Father with CVA
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 97.7 139/48 77 22 97% on 4L NC
GEN: Alert, lying in bed with family at bedside, no acute
distress, slightly tachypneic, O2 via NC
HEENT: MMM, anicteric sclerae
NECK: Supple without LAD, no supraclavicular LAD
PULM: Bibasilar crackles
COR: RRR, (+)S1/S2 no m/r/g
ABD: Soft, non-distended, mild diffuse tenderness to palpation,
no guarding
EXTREM: Warm, well-perfused, no pitting edema, 2+ DP pulses,
thick yellow toenails.
NEURO: A&Ox2 (oriented to person, place, "last month of ___"
but not to year). CN II-XII intact, no pronator drift, ___
strength in biceps, triceps, hip flexors, and on ankle
plantar/dorsiflexion. Sensation to light touch grossly intact.
ON DISCHARGE:
Vitals-97.6-98.5 ___ 130s-150s/50s-80s 18 93%RA
General- Alert, oriented, no acute distress, ___ speaking
HEENT- Sclera anicteric, MMM, no LAD, no elevated JVP
Lungs- breathing comfortably on RA, +bibasilar crackles
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present
MSK: tender to palpation in lower extremities, R>L
Ext- warm, well perfused, 2+ pulses, trace non-pitting edema
Pertinent Results:
ADMISSION LABS
===============
___ 12:00PM BLOOD WBC-6.9# RBC-3.80* Hgb-11.9 Hct-37.1
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.6 RDWSD-52.8* Plt ___
___ 12:00PM BLOOD Neuts-77.4* Lymphs-5.1* Monos-15.3*
Eos-1.5 Baso-0.4 Im ___ AbsNeut-5.31# AbsLymp-0.35*
AbsMono-1.05* AbsEos-0.10 AbsBaso-0.03
___ 12:00PM BLOOD Glucose-111* UreaN-25* Creat-1.1 Na-139
K-4.5 Cl-101 HCO3-25 AnGap-18
___ 12:00PM BLOOD Calcium-9.7 Phos-2.9 Mg-1.6
___ 11:54AM BLOOD Lactate-1.9
DISCHARGE LABS
===============
___ 07:00AM BLOOD WBC-5.5 RBC-3.33* Hgb-10.4* Hct-33.0*
MCV-99* MCH-31.2 MCHC-31.5* RDW-14.4 RDWSD-52.0* Plt ___
___ 07:00AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140
K-4.2 Cl-98 HCO3-34* AnGap-12
___ 04:47PM BLOOD ___ Temp-36.9 pO2-38* pCO2-49*
pH-7.43 calTCO2-34* Base XS-6 Intubat-NOT INTUBA
___ 12:09AM BLOOD Lactate-0.9
___ 12:09AM BLOOD O2 Sat-90
IMAGING AND OTHER STUDIES
==========================
CXR ___:
FINDINGS:
Left lung base mass with fiducial markers is again noted.
Elevated right hemidiaphragm is again seen. There is a small
left pleural effusion and a trace right pleural effusion. There
is no focal consolidation or pneumothorax. Left lower lobe
opacity is best seen on the lateral view. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact. No
free air below the right hemidiaphragm is seen.
IMPRESSION:
Left lower lobe opacity is most likely atelectasis. In the
appropriate clinical setting, pneumonia cannot be excluded, but
this is thought to be less likely.
CTA CHEST ___:
Findings (excerpt):There is a right lower and middle lobe
consolidation with areas of hypoenhancement in the inferior
portions worrisome for pneumonia superimposed on atelectasis.
There is obliteration of the segmental right lower lobe bronchi.
Impression:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Concern for right lower and middle lobe pneumonia
superimposed on atelectasis.
3. Mild pulmonary edema with small right and trace left pleural
effusion.
4. Few new scattered 3mm pulmonary nodules, in the setting of
edema and possible right lower lobe pneumonia/aspiration
pneumonia is of uncertain significance and etiology.
5. No significant change in a 3.4 cm left lower lobe mass with
fiducial markers.
MICROBIOLOGY
=============
___ 11:50 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
2:10PM.
GRAM POSITIVE COCCI IN CLUSTERS.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Gabapentin 600 mg PO QHS
3. Gabapentin 600 mg PO QAM
4. Gabapentin 300 mg PO NOON
5. NIFEdipine CR 30 mg PO QAM
6. Ranitidine 150 mg PO BID
7. Acetaminophen 1000 mg PO QAM
8. Acetaminophen 1000 mg PO QPM
9. Acetaminophen 500 mg PO NOON
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID:PRN constipation
14. Simethicone Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO QAM
2. Senna 8.6 mg PO BID:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO NOON
7. NIFEdipine CR 30 mg PO QAM
8. Ranitidine 150 mg PO BID
9. Acetaminophen 1000 mg PO QPM
10. Acetaminophen 500 mg PO NOON
11. Gabapentin 600 mg PO QHS
12. Gabapentin 600 mg PO QAM
13. Simethicone 40-80 mg PO PRN gas
14. Vitamin D 1000 UNIT PO DAILY
15. Diltiazem 30 mg PO Q6H
16. Warfarin 1 mg PO DAILY16
17. Enoxaparin Sodium 80 mg SC Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Atrial fibrillation - new dx
Mild diastolic dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest.
INDICATION: ___ year old woman with h/o endometrial cancer metastatic to lungs
s/p recent radiation now with acute shortness of breath/hypoxia (requiring 4L)
and fever concerning for possible PE. Assess for pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 606 mGy-cm.
COMPARISON: CT chest ___. , chest radiograph ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
top-normal in size without evidence of right heart strain. The heart is
notable for coronary artery calcifications, mitral valve and aortic valve
calcifications. The heart is notable for mild left atrial enlargement. There
is no evidence of pericardial effusion.
Multiple subcentimeter mediastinal and left hilar lymph nodes are noted,
largest measuring 0.9 x 0.8 cm (02:35) within the mediastinum and 1 x 0.7 cm
(02:34) within the left hilum which do not meet CT size criteria for
enlargement. There is no supraclavicular, or axillary lymphadenopathy. The
thyroid gland appears unremarkable.
Interval increase in small right and trace left non hemorrhagic pleural
effusion. The pulmonary parenchyma is notable for mild pulmonary edema with
septal wall thickening. There is a right lower and middle lobe consolidation
with areas of hypoenhancement in the inferior portions worrisome for pneumonia
superimposed on atelectasis. There is obliteration of the segmental right
lower lobe bronchi. Left lower lobe atelectasis is noted. The airways are
otherwise patent to the subsegmental level.
Pulmonary nodules are better characterized on prior examination. New 3 mm
right upper lobe nodule (3:44, 56), new 3 mm (03:59) left upper lobe nodule,
and new 3 mm left upper lobe pulmonary nodule are noted. Punctate nodules in
the left lower lobe are not well seen on today's study. There is a 3.4 x 2.8
cm (3:114) left lower lobe mass (previously 3.6 x 2.8 cm) with a radiopaque
fiducial similar to previous examination.
Limited images of the upper abdomen are notable for a stable dilated 18mm
common bile duct with mild central bile duct dilatation without peripheral
duct dilatation in a patient who is status post cholecystectomy.
Bilateral calcification of the rotator cuff is consistent with calcific
tendinosis. No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Concern for right lower and middle lobe pneumonia superimposed on
atelectasis.
3. Mild pulmonary edema with small right and trace left pleural effusion.
4. Few new scattered 3mm pulmonary nodules, in the setting of edema and
possible right lower lobe pneumonia/aspiration pneumonia is of uncertain
significance and etiology.
5. No significant change in a 3.4 cm left lower lobe mass with fiducial
markers.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 4:35 ___, 15 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with Pna and hypercarbic respiratory failure
// interval change
COMPARISON: Chest x-ray from ___ at 1303 targeted review of chest
CTA from ___
FINDINGS:
Compared with ___, there has been considerable interval increase in
CHF, with upper zone redistribution diffuse vascular blurring, left lower lobe
collapse and/or consolidation, and small bilateral effusions.
The rounded nodular opacity at the left lung base with 2 fiducials versus
surgical clips is again noted, similar to the prior study.
There are low inspiratory volumes, slightly worse than on the prior study.
Persistent right hemidiaphragm elevation again noted.
IMPRESSION:
1. Marked interval worsening of CHF findings. Worsening left lower lobe
collapse and/or consolidation.
2. Please note that the ___ chest CT referred to concern for right
lower and middle lobe pneumonia, which could be obscured by CHF findings on
the current study.
3. Left base mass with 2 fiducials again noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ woman with history notable for HTN and endometrial
cancer with oligometastasis to the left lung status post TAH-BSO in ___ and
radiation in ___, presenting with fever and dyspnea found to have RML
and RLL pneumonia and gram positive bacteremia being treated for CAP with
ceftriaxone and and with vancomycin currently trasferred to the ICU for
hypercarbic respiratory failure. // interval assessment
COMPARISON: Chest x-ray dated ___ at 03:23
FINDINGS:
Compared to ___ at 03:23, there may have been slight improvement in
the CHF findings. Otherwise, I doubt significant interval change.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with PICC // Pt had a right picc,43cm ___
___ Contact name: ___: ___ Pt had a right picc,43cm ___
___
IMPRESSION:
In comparison with the study of ___, there has been placement right
subclavian PICC line that extends into the jugular system. Little change in
the appearance of the heart and lungs.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with PICC // Malpositioned picc,
___ ___ Contact name: ___: ___
COMPARISON: ___, 09:30
IMPRESSION:
The right PICC line continues to be malpositioned in the right internal
jugular vein. No other changes are noted. No pneumothorax or other
complications.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with pneumonia, MICU callout, p/w R lower
extremity tenderness. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Lower extremity Doppler of ___.
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.
A 4.0 x 1.3 x 1.8 cm ___ cyst is identified in the popliteal fossa.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 4.0 cm ___ cyst in the right popliteal fossa.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with pneumonia and volume overload // e/o pulm
edema or congestion e/o pulm edema or congestion
IMPRESSION:
In comparison with the study of ___, the malpositioned PICC line is been
removed. There again are very low lung volumes with elevation of the right
hemi diaphragm and a mass with fiducial seeds at the left base. The pulmonary
vascularity may still be mildly elevated.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with s/p cyberknife fever cough with left lower lung crackles
// eval for pna
COMPARISON: Chest radiographs ___
FINDINGS:
PA and lateral views of the chest provided.
Left lung base mass with fiducial markers is again noted. Elevated right
hemidiaphragm is again seen. There is a small left pleural effusion and a
trace right pleural effusion. There is no pneumothorax. Left lower lobe
opacity is best seen on the lateral view. The cardiomediastinal silhouette is
normal. Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
Left lower lobe opacity is most likely atelectasis. In the appropriate
clinical setting, pneumonia cannot be excluded, but this is thought to be less
likely.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.4
heartrate: 83.0
resprate: 16.0
o2sat: 95.0
sbp: 105.0
dbp: 53.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with history notable for
HTN and endometrial cancer with oligometastasis to the left lung
status post TAH-BSO in ___ and radiation in ___,
presenting with fever to Tmax 100.8 (at home) and dyspnea, sent
in by PCP, found to have RML and RLL pneumonia. She was
initially treated on the general medicine floor, subsequently
transferred to the ICU for hypercarbic respiratory failure. She
was never intubated and monitored closely with improvement in
respriatory status with continued treatment of pna. She was
transferred back to the general medicine floor, where she
remained well, breathing comfortably.
# Pneumonia: Presented with SOB, hypoxia, and tachypnea. CTA
with concern for lower and middle lobe pneumonia superimposed on
atelectasis. She was initially treated broadly for HCAP, then
transitioned to ceftriaxone and azithromycin for treatment of
CAP. On ___, patient was noted to have worsening delirium
and increased somnolence, in the setting of sustained tachypnea
and hypercarbia. She was transferred to the ICU and started on
BiPAP. Hypercarbia resolved and she was considered well enough
to transfer to medicine. On the floor she remained afebrile
without leukocytosis. She was transitioned to RA and breathing
comfortably, sats in the early ___. She completed 8 days of abx
(initally vanc/cefepime, narrowed to CTX/azithro) for CAP.
Of note, vancomycin was re-started on the afternoon of ___
given blood culture showing GPCs but DC'd later as this was
ultimately felt to be a contaminant.
# Atrial fibrillation with RVR: Afib with RVR to the 130s was
noted incidentally on telemetry in the ED on ___. In the
MICU afib with RVR was observed again, and she was started on po
diltiazem. Asymptomatic during episodes. She has a CHADS2-vasc
of 4 and intermittent afib. She was started on warfarin with
lovenox bridge.
#Volume overload: Concern for mild diastolic heart dysfunction.
CT and CXR with evidence of mild pulmonary edema. Underwent IV
and PO diuresis. On discharge, on 1L supplemental O2. O2
requirement most likely thought to be from underlying lung
disease from metastatic cancer to lung and subsequent radiation,
as well as resolving pneumonia.
# Hypertension
Continued home nifedipine with holding parameters for SBP<100 or
DBP<40.
# Hyperlipidemia
Continued home lipitor.
# Chronic back pain ___ spinal stenosis
Continued home gabapentin, but held Tylenol out of concern that
tylenol would mask her fevers. Tylenol was restarted upon
discharge.
# Risk of CAD
Aspirin continued this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ nursing home dwelling male with past medical history
HTN, HLD, DM, BPH, dementia, BPH and indwelling Foley with
recent
treatment for urinary tract infection on ciprofloxacin presents
with worsening lethargy per family.
History from chart review, transferring ___, limited input from
patient.
He was noted to be more tired than usual ___ and was started on
cipro (no UA or micro records transferred.) He was noted to be
more lethargic per family, Flagyl was added on, and labs were
sent. When they revealed leukocytosis to 29 he was sent to the
hospital.
Records from ___ show he is on regular diet on thin liquids.
He was started on ground in ED. He came with MOLST filled out
this month filled out with nephew, HCP that states he would want
CPR, intubation.
In the ED, initial VS were: 97.6 81 116/64 16 100% RA
Exam notable for:
4 out of 6 murmur best heard at second right intercostal space,
Abdomen soft, nontender, nondistended, no masses
Labs showed:
Grossly hemolyzed specimen: k5.3, hco3 18, BUN/Cr 72/1.9, gluc
179, AST 60, ALT 25, bili 0.5 albumin 2.9
INR 1.2
UA with Lg leuk, pos nitrite, >182 WBC, mod bacteria +blood,
protein
lactate 2.0
Imaging showed:
CT abd/pelvis:
1. No acute abnormality in the abdomen or pelvis. Specifically,
no evidence of a fluid collection or obstruction in the abdomen
or pelvis. Appendix not visualized but no secondary sign of
acute
appendicitis.
2. Bladder wall thickening likely due to bladder outlet
obstruction from the enlarged prostate. Cystitis cannot be ruled
out
CT head:
No acute intracranial abnormality.
CXR:
___ opacity right lobe is nonspecific and could
represent
atelectasis or pneumonia, in the right clinical setting.
Received:
Vancomycin, ceftriaxone, 1L NS, asa 243mg, insulin 6 units at
16:13
No consults
Transfer VS were: 98.6 89 ___ 99% RA
On arrival to the floor, patient reports feeling tired. Nursing
states he has incontinence of soft stool.
Past Medical History:
HTN
HLD
DM
Dementia
BPH
Chronic foley
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.5 PO 123 / 72 84 18 99 RA
GENERAL: elderly male laying in bed. He is arousable to voice
but
falls asleep within ___ seconds. He is oriented to self only.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, harsh ___ murmur heard
throughout the precordium, no gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing. trace edema to B/L shins. L
foot with toe deformity. b/l heals with stage I ulcers
GU: foley draining dark yellow urine
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose. following
commands.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.7 120 / 69 83 18 99 RA
GENERAL: elderly male laying in bed. More alert this AM. NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, harsh ___ murmur heard
throughout the precordium, no gallops or rubs
LUNGS: nonlabored respirations. no appreciable adventitious
sounds.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, edema. L foot with toe
deformity. b/l heals with stage I ulcers
GU: foley in place
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose. following
commands.
Oriented to self. Mental status stable from yesterday.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 08:10AM BLOOD ___
___ Plt ___
___ 08:10AM BLOOD ___
___
___
___ 08:10AM BLOOD ___ ___
___ 08:10AM BLOOD ___
___
___ 08:10AM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:23AM BLOOD ___
PERTINENT LABS:
===============
___ 11:00AM BLOOD ___
___ 03:00PM BLOOD ___
___ 12:15AM BLOOD ___
___ 12:28AM BLOOD ___
___ Base XS--5 ___ INTUBA
___ 12:28AM BLOOD ___
DISCHARGE LABS:
===============
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___
MICROBIOLOGY:
===============
___ 7:56 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 1 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 8:10 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:42 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
IMAGING/STUDIES:
===============
CXR (___):
IMPRESSION:
___ opacity right lobe is nonspecific and could
represent atelectasis or pneumonia, in the right clinical
setting.
CT A/P (___):
IMPRESSION:
1. No acute abnormality in the abdomen or pelvis. Specifically,
no evidence of a fluid collection or obstruction in the abdomen
or pelvis. Appendix not visualized but no secondary sign of
acute appendicitis.
2. Bladder wall thickening likely due to bladder outlet
obstruction from the enlarged prostate. Cystitis cannot be
ruled out.
CT HEAD W/O CONTRAST (___):
IMPRESSION:
No acute intracranial abnormality on noncontrast head CT.
CXR (___):
IMPRESSION:
Mild left basilar opacity is likely secondary to atelectasis,
however a
superimposed infectious process can't be excluded. No evidence
of a pleural effusion or pneumothorax.
Interval improvement of the previously seen mild pulmonary edema
with mild
residual pulmonary vascular congestion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Tamsulosin 0.8 mg PO QHS
4. Lisinopril 10 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. TraZODone 12.5 mg PO Q5PM
7. Haloperidol 2 mg PO QHS
8. Haloperidol 0.5 mg PO Q4PM
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Lantus 26 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
Last day: ___. Glargine 22 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Sertraline 50 mg PO DAILY
10. Tamsulosin 0.8 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Haloperidol 2 mg PO QHS This medication was held. Do
not restart Haloperidol until you see your PCP
13. HELD- Haloperidol 0.5 mg PO Q4PM This medication was held.
Do not restart Haloperidol until you see your PCP
14. HELD- TraZODone 12.5 mg PO Q5PM This medication was held.
Do not restart TraZODone until you see your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Urinary Tract Infection
Dementia
Altered Mental Status
NSTEMI, type II
Acute kidney injury
SECONDARY DIAGNOSES:
Hypertension
Diabetes Mellitus
Hypothyroidism
Depression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with lethargy// ?pneumonia
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is an ill-defined opacity in the right lower lobe. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
Ill-defined opacity right lobe is nonspecific and could represent atelectasis
or pneumonia, in the right clinical setting.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with elevated wbc count, dementia, increased
lethargy// ?infection
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 48.6 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominent ventricles and sulci are compatible with age-related
involutional changes. Periventricular white matter hypoattenuation is
nonspecific but likely represents chronic small vessel ischemic disease.
There are moderate atherosclerotic calcifications of the carotid siphons.
There is mild mucosal thickening of bilateral ethmoid air cells. An osteoma
is noted in the anterior left ethmoid air cells. Remaining paranasal sinuses
are clear. Mastoid air cells and middle ear cavities are well aerated. The
bony calvarium is intact.
IMPRESSION:
No acute intracranial abnormality on noncontrast head CT.
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast.
INDICATION: ___ with elevated wbc count in ___, dementia, increased lethargy.
Evaluate for infection.
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: Total DLP (Body) = 578 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis in the bilateral lower lobes.
There are severe calcifications of the aortic roots and coronary arteries.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is a simple cyst at the dome measuring 5.6 x 5.5 cm (series 2:8). There
also scattered sub-centimeter hypodensities which are too small to
characterize. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. Mild perinephric stranding
bilaterally is within normal limits given the patient's age.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is not visualized but there is no secondary sign
of acute appendicitis.
PELVIS: There is a Foley catheter in the bladder. Air in the anti dependent
portions of the bladder is likely due to Foley insertion. There is bladder
wall thickening likely due to outlet obstruction from prostatomegaly.
REPRODUCTIVE ORGANS: Prostate is enlarged and protrudes into the base of the
bladder.
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.
Moderate to severe endplate degenerative changes are noted of the lower
thoracic and lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute abnormality in the abdomen or pelvis. Specifically, no evidence
of a fluid collection or obstruction in the abdomen or pelvis. Appendix not
visualized but no secondary sign of acute appendicitis.
2. Bladder wall thickening likely due to bladder outlet obstruction from the
enlarged prostate. Cystitis cannot be ruled out.
Radiology Report
INDICATION: ___ year old man with leukocytosis and AMS// atelectasis vs PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph the chest from ___.
FINDINGS:
The heart size is normal. The hilar and mediastinal contours are normal.
There has been interval improvement of the previously seen pulmonary edema
with mild residual pulmonary vascular congestion. Mild left basilar opacity
is seen. There is no evidence of a pleural effusion or pneumothorax. The
visualized osseous structures are unremarkable. Aortic knob calcifications
are seen.
IMPRESSION:
Mild left basilar opacity is likely secondary to atelectasis, however a
superimposed infectious process can't be excluded. No evidence of a pleural
effusion or pneumothorax.
Interval improvement of the previously seen mild pulmonary edema with mild
residual pulmonary vascular congestion.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Lethargy
Diagnosed with Urinary tract infection, site not specified, Sepsis, unspecified organism, Non-ST elevation (NSTEMI) myocardial infarction
temperature: 97.6
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 116.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT AND PLAN:
___ yo M with history of HTN, HLD, DM, dementia, BPH s/p
indwelling foley with recent UTI on cipro presenting with
lethargy found to have urosepsis and likely demand ischemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine
Attending: ___.
Chief Complaint:
S/P fall at home
Major Surgical or Invasive Procedure:
Palliative radiation
Cyber Knife
History of Present Illness:
Mr. ___ is a ___ year old man with a history of HBV, HCV
cirrhosis with gastric varices, portal hypertension and
splenomegaly, as well as type I DM and recurrent DLBCL s/p CHOP,
EPOCH and Rituxan who presented to the ER after sustaining a
fall and landing on his left knee. He states that he was walking
across his tile kitchen wearing his diabetic sneakers and
tripped over his feet. He landed with his left knee on the tile.
He was on the floor unable to get up for about 10 minutes. He
denies dizziness, lightheadedness, chest pain, shortness of
breath, loss of consciousness or head trauma. He remembers the
entire event. He waited until his son was able to help him and
came to the ER for pain and inability to ambulate. Of note, he
denies recent memory changes, difficulty concentrating, changes
in speaking or swallowing, focal weakness or numbness. He notes
a bizzare sound in his hear (a whoozing noise) which occurs only
in his right ear every few days and lasts for a moment. He
denies headaches or ear pain.
He was recently admitted to ___ from ___ for
hyperglycemia, hyperkalemia and hyponatremia which occurred in
the setting of forgetting to take his insulin. His laboratory
abnormalities resolved with treatment and he was discharged.
In the emergency department, initial vitals: 98.5 61 135/87 20
100% 0. A knee film showed a non-displaced patellar fracture.
Orthopedics was consulted and recommended conservative
management with a knee immobilizer. A head CT was obatined which
showed a new 1.3 cm cortical lesion in the right temporal lobe
with vasogenic edema, highly suspicious for malignancy. The
patient was given 10 mg IV decadron. Neurosurgery was consulted
and recommended not continuing steriods and obtaining an MRI of
the head to further characterize the lesion. They also
recommended blood pressure control with a goal SBP < 160. The
patient was also given 4 mg IV morphine and 10 units of regular
insulin.
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.
Past Medical History:
PAST MEDICAL HISTORY:
-chronic hepatitis B, chronic hepatitis C with resultant
cirrhosis, portal hypertension, gastric varices and splenomegaly
related to portal hypertension, thrombocytopenia and leukopenia
as a consequence of his splenomegaly, possibly also with a
contribution from lymphoma.
-Diabetes mellitus: Type 1 DM diagnosed age ___. Followed at
___.
-Diffuse large B-cell lymphoma: Dx ___ s/p CHOP with subsequent
recurrence, s/p one cycle of EPOCH in ___, s/p single agent
Rituxan ___, recent imaging with recurrence in his
iliac bone
-Hypertension
-Hypothyroidism
-Opioid dependence (on chronic methadone for pain vs. addiction)
-Peripheral neuropathy in hands and feet. Patient attributes to
chemotherapy but likely multifactorial given longstanding DM.
-Chronic neck and low back pain
-L ankle and back fractures in accidental ___, no surgery
-Total right knee replacement ___
-moderate pulm HTN, R-THR ___
PAST ONCOLOGIC HISTORY:
___ seen by heme for progressive LAD in abdomen.
___ retroperitoneal LAD bx shows morphologic and
immunophenotypic profile consistent with a diffuse large B cell
lymphoma of possible germinal center cell derivation.
___ started on CHOP (Rituxan not used because of
concern for HepB reactivation); ___ clinic visit - abd pain
sent to ED and admitted. Abd pain thought secondary to biliary
obstruction, stent was placed.
___: CHOP cycle 2 start ___ VAD port placed ___
left chest.
___ to ___ CHOP x 6 cycles, except from C5 - Oncovin held
for neuropathy
___: Had planned to start rituxan after patient off of
lamivudine. Continued thrombocytopenia and leukopenia, perhaps
associated with start of tenofovir for hepB and therefore
switched back to lamivudine.
___: Continued cytopenias. Bone marrow biopsy ___ with
hypocellular marrow without evidence of lymphoma. Cytogenics and
flow cytometry also negative. Rituxan deferred.
___: PET/CT without evidence of recurrent lymphoma
___: PET/CT without evidence of recurrent disease
___: PET/CT new low level FDG-uptake in right level II
cervical lymph node (image 21; maxSUV 2.7); could be reactive
node.
___: Persistent by stable 6mm right cervical LN and 11mm
left infraclavicular LN with decreased SUV, limited by
background noise.
___: biopsy recurrence of PET positive right iliac bone
lesion with noted right inferior axillary positive lymph node
___: C1D1 EPOCH (no vincristine)
___: noted recurrence palpated in right axilla ___:
cyclophos 600mg/m2 D1 and 8, etoposide 70mg/m2 D1-3, pred 60mg D
___: rituximab 375mg/m2
___: rituximab 375mg/m2
___: rituximab 375mg/m2
___: rituximab 375mg/m2
___: PET CT showed new FDG activity in right illiac area.
Social History:
___
Family History:
- Father died of colon cancer at ___, diagnosed age ___.
- Mother had a heart attack in ___.
- 2 brothers, both living, ___ s/p CABG.
- Son is healthy.
- No other significant family history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T97.5 BP 130/60 HR 60 RR20 97%RA
GENERAL: alert and oriented, appears chronically ill, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, L cervical node is freely mobile, non-enlarged.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Protuberant abdomen without evidence of ascites.
Soft, non-tender. Unable to appreciate liver or spleen
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
MSK: L knee with swelling and clear effusion. No warmth or
redness on exam. ROM limited by pain.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___.
DISCHARGE PHYSICAL EXAM
========================
VS: Tm 98.4 Tc 97.5 130/70 79 20 98% on RA
GENERAL: Chronically ill appearing, uncomfortable
HEENT: MMM
CARDIAC: RRR no m/r/g
LUNGS: Limited due to limited participation during exam, but
could not appreciate crackles, wheeze, rhonchi
ABDOMEN: Nontender to palpation
EXTREMITIES: Chronic venous stasis bilaterally, RLE with ulcer
1.5 inches in diameter at anterior surface, wrapped in bandage,
c/d/i.
NEURO: Sleepy but alert and oriented
Pertinent Results:
ADMISSION LABS
==============
___ 10:25AM BLOOD Lactate-1.5
___ 10:15AM BLOOD Albumin-3.2*
___ 12:20AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
___ 10:15AM BLOOD CK-MB-5 cTropnT-0.01
___ 10:15AM BLOOD ALT-59* AST-83* CK(CPK)-54 AlkPhos-136*
TotBili-1.1
___ 10:15AM BLOOD Glucose-390* UreaN-36* Creat-1.0 Na-130*
K-5.0 Cl-96 HCO3-26 AnGap-13
___ 10:15AM BLOOD ___ PTT-32.1 ___
___ 10:15AM BLOOD Plt ___
___ 10:15AM BLOOD Neuts-74.8* Lymphs-12.6* Monos-10.4
Eos-1.7 Baso-0.4
___ 10:15AM BLOOD WBC-3.4* RBC-2.96* Hgb-9.8* Hct-30.2*
MCV-102* MCH-33.3* MCHC-32.7 RDW-14.4 Plt ___
OTHER LABS
==========
___ 06:00PM BLOOD Ammonia-31
___ 10:15AM BLOOD CK-MB-5 cTropnT-0.01
___ 12:20AM BLOOD CK-MB-4 cTropnT-<0.01
___ 12:00AM BLOOD cTropnT-<0.01
___ 10:15AM BLOOD Lipase-9
RADIOLOGY
=========
LEFT KNEE XRAY (___)
Acute nondisplaced transverse fracture of the patella with large
joint effusion.
CT HEAD WITHOUT CONTRAST (___)
New 1.3 cm right temporal hyperdense lesion suspicious for
malignancy, possibly metastasis given this patient's history of
lymphoma. Further characterization with MR is recommended.
EKG (___)
Sinus rhythm. Left anterior fascicular block. Compared to the
previous
tracing the findings are similar.
FDG TUMOR IMAGING (PET-CT) (___)
1. Multiple new FDG-avid lymph nodes predominantly in the chest
as
detailed above.
2. New small volume ascites and diffuse mesenteric and
retroperitoneal fat stranding with associated FDG-uptake as
above.
3. Abnormal uptake appears to track along the right iliac
vessels into the right leg with intense patchy uptake uptake in
the proximal musculature (gluteus, abductor group, and
hamstrings).
4. New uptake in the right iliac bone.
5. Pericardial uptake may be from the pericardium or from small
pericardial lymph nodes, although these are not detected on the
CT.
6. The constellation of findings is compatible with marked
disease progression.
MR HEAD W/ AND W/O CONTRAST (___)
1.9 cm inhomogeneously enhancing mass with internal enhancement
and a small amount of peripheral hemorrhage seen in the right
temporal lobe with surrounding vasogenic edema. This mass most
likely arises from an extra-axial location. It does not have
the typical characteristics of lymphoma as lymphoma lesions tend
to be homogeneous and demonstrate slow diffusion. Abscess was
also considered, however usually abscess also demonstrates slow
diffusion. As the masses likely extra-axial, a glioma less
likely.
Thus, more likely differential for this mass include aggressive
meningioma or metastatic disease.
MR ABDOMEN (___)
1. Gallbladder sludge. No concerning gallbladder mass.
2. No intra or extrahepatic bile duct dilation. No ductal
stones.
3. Extensive soft tissue throughout the right perinephric space
and
retroperitoneum, with compression of the IVC, in keeping with
known history of lymphoma, corresponding to FDG avid soft tissue
lesion on the PET-CT from ___.
4. Stable moderate right hydronephrosis with delayed contrast
excretion from a head MRI examination on ___.
5. Mild bibasilar atelectasis.
6. Cirrhotic liver. Trace perihepatic ascites, mild
splenomegaly, diffuse
anasarca, and mild gallbladder wall edema likely secondary to
chronic liver disease.
CXR (___)
Consolidation in the right upper lobe marginated by the major
fissure is
probably pneumonia. ___ a second region of pneumonia in the
right lower lobe or fissural pleural fluid. Heart is top normal
size and pulmonary vasculature is still engorged, but as yet no
pulmonary edema. Left pleural effusion. Left subclavian
infusion port ends low in the SVC. No pneumothorax.
CXR ___
An ovalary structure now seen on the frontal radiograph reflects
an
intrafissural portion of right pleural effusion, as documented
on the lateral image. The structure is not a mass. The pleural
effusion on the right has minimally increased. Left and right
atelectasis are seen in unchanged manner. No evidence of acute
lung changes. Normal size of the cardiac silhouette. No
pneumothorax. No evidence of pneumonia.
URINALYSIS (___)
Specific Gravity 1.009 1.001 - 1.035
DIPSTICK URINALYSIS
Blood NEG
Nitrite NEG
Protein NEG mg/dL
Glucose NEG mg/dL
Ketone NEG mg/dL
Bilirubin NEG mg/dL
Urobilinogen 2* 0.2 - 1 mg/dL
pH 5.0 5 - 8 units
Leukocytes TR
MICROSCOPIC URINE EXAMINATION
RBC 1 0 - 2 #/hpf
WBC 2 0 - 5 #/hpf
Bacteria NONE
Yeast NONE
Epithelial Cells 0 #/hpf
URINE CASTS
Hyaline Casts 1* 0 - 0 #/lpf
OTHER URINE FINDINGS
Urine Mucous RARE
VANCOMYCIN TROUGH
___ 05:58AM BLOOD Vanco-25.8*
___ 06:16AM BLOOD Vanco-42.3*
___ 06:15AM BLOOD Vanco-<1.7*
DISCHARGE LABS
==============
___ 05:58AM BLOOD WBC-5.7 RBC-2.13* Hgb-7.2* Hct-22.3*
MCV-105* MCH-33.7* MCHC-32.1 RDW-18.8* Plt Ct-39*
___ 05:58AM BLOOD Neuts-82.4* Lymphs-9.9* Monos-7.1 Eos-0.3
Baso-0.3
___ 05:58AM BLOOD Plt Ct-39*
___ 05:58AM BLOOD Glucose-86 UreaN-23* Creat-1.0 Na-138
K-3.6 Cl-102 HCO3-30 AnGap-10
___ 05:58AM BLOOD ALT-18 AST-34 LD(LDH)-611* AlkPhos-83
TotBili-0.7
___ 05:58AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Furosemide ___ mg PO DAILY
3. Lantus (insulin glargine) 12 units subcutaneous daily
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Methadone 90 mg PO DAILY
6. Nadolol 10 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Glargine 16 Units Breakfast
9. LaMIVudine 100 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Glargine 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. LaMIVudine 100 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Nadolol 10 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. CefePIME 2 g IV Q12H
Please take through ___ to complete a ___. Gabapentin 100 mg PO Q8H
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
11. Lactulose 30 mL PO Q4H
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Lorazepam 0.5 mg PO Q4H:PRN pain/agitation
14. Rifaximin 550 mg PO BID
15. Methadone 30 mg PO TID
16. Furosemide 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Diffuse Large B cell lymphoma
Left patellar fracture
HCAP pneumonia
___ ulcer/cellulitis
Secondary:
Chronic pain
Diabetes Mellitus I
Hyponatremia
Thrombocytopenia
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Fall and syncope.
COMPARISON: Chest radiograph from ___.
FINDINGS: There are chronic small bilateral pleural effusions and thickening
with chronic atelectasis/scarring of the lower lobes. The hilar and
cardiomediastinal contours are normal and the lungs are otherwise clear.
There is no pneumothorax. A left chest wall port catheter terminates in the
low SVC.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Left knee pain after syncope and fall.
COMPARISON: None.
FINDINGS: Left knee, 3 views. There is a nondisplaced transverse patellar
fracture at the inferior ___ of the bone. There is a large joint effusion
without fat-fluid level on this cross-table lateral view. There are
degenerative changes as well as chondrocalcinosis. A prominent superior
patellar spur is present.
IMPRESSION: Acute nondisplaced transverse fracture of the patella with large
joint effusion.
Radiology Report
INDICATION: Fall with syncope.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, thin-section bone reconstruction algorithm
images were prepared.
COMPARISON: NECT of the head, ___.
FINDINGS: There is a new 1.3 x 1.1 cm cortical lesion with hyperdense rim
arising from the right temporal lobe (2:14). Also seen is surrounding
vasogenic edema. None of these findings were present on ___. There is
no shift of normally midline structures. The ventricles and sulci are
prominent, consistent with global atrophy. The basal cisterns are patent.
There is no hemorrhage. The calvaria are unremarkable. Bilateral lens
replacements are seen. Sclerosis of the imaged portion of the right maxillary
sinus is probably due to chronic inflammation. Mild mucosal thickening
involves the anterior ethmoid air cells. The remaining visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: New 1.3 cm right temporal hyperdense lesion suspicious for
malignancy, possibly metastasis given this patient's history of lymphoma.
Further characterization with MR is recommended.
These findings were discovered at 12:01 pm and communicated via phone call to
Dr. ___ by Dr. ___ at 12:51 pm. on ___.
Radiology Report
HISTORY: Patient with history of DLBCL and new brain mass seen on CT,
evaluate for lymphoma versus other malignancy.
COMPARISON: NECT of the head on ___.
TECHNIQUE: Multiplanar, multi sequence MRI of the head was performed before
and after administration of IV contrast.
FINDINGS:
In the right temporal lobe, there is a 1.9 x 1.1 cm inhomogeneously enhancing
lesion with internal enhancement and a small amount of hemorrhage at the
margins, compatible with mass seen on most recent CT. There is vasogenic
edema surrounding this mass. This lesion does not demonstrate slow diffusion.
The mass appears to arise from an extra-axial location as it appears to exert
mass effect on the surrounding cortex with enhancement of the adjacent dura on
the postcontrast images.
There is no acute infarct. Principal intracranial vascular flow voids are
preserved. There is no shift of normally midline structures. Again noted is
a punctate focus of low signal in the susceptibility sequence along the left
periventricular region, likely representing a small focus of old
microhemorrhage. Scattered T2/FLAIR hyperintensities throughout the
periventricular white matter likely represent chronic small vessel ischemic
disease.
The brainstem, posterior fossa and cervical medullary junction are preserved.
The orbits, periorbital and paracavernous spaces are normal. No abnormality
of the skullbase or calvaria is identified.
IMPRESSION:
1.9 cm inhomogeneously enhancing mass with internal enhancement and a small
amount of peripheral hemorrhage seen in the right temporal lobe with
surrounding vasogenic edema. This mass most likely arises from an extra-axial
location. It does not have the typical characteristics of lymphoma as
lymphoma lesions tend to be homogeneous and demonstrate slow diffusion.
Abscess was also considered, however usually abscess also demonstrates slow
diffusion. As the masses likely extra-axial, a glioma less likely.
Thus, more likely differential for this mass include aggressive meningioma or
metastatic disease.
The findings were discussed with ___ by ___ telephone at 5:45pm on
___, 20 minutes after discovery.
Radiology Report
HISTORY: Cirrhosis with gallbladder mass suspected on recent ultrasound.
History of lymphoma.
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to,
during, and following the administration of 7 cc of Gadavist intravenous
contrast. 1 cc of Gadavist mixed with 50 cc of water were administered for
oral contrast.
COMPARISON: Ultrasound from ___. PET/CTs from ___ and ___.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
There is mild bibasilar atelectasis (series 6 image 3). The heart size is
normal.
There is no pericardial or pleural effusion.
Diffuse anasarca is present. Trace perihepatic ascites is present (series 6
image 15). The liver contour is markedly nodular, in keeping with known
history of cirrhosis. No discrete intrahepatic mass is detected.
Conventional hepatic arterial anatomy is demonstrated. The portal and hepatic
veins are patent and normal in caliber.
The gallbladder contains a small amount of sludge. There is no gallbladder
mass. Mild gallbladder wall edema is likely secondary to third spacing from
chronic liver disease. There is no intra or extrahepatic bile duct dilation.
No ductal stones are detected.
The left kidney is normal. Moderate right hydronephrosis is unchanged since
the ___ PET-CT examination (series 1,203 image 91), with
precontrast T1 weighted sequences demonstrating uniformly high signal
intensity within the renal pelvis and proximal right ureter, likely reflecting
delayed excretion of gadolinium-based contrast from the head MRI examination
on ___ (series 7 image 37).
Again seen is extensive enhancing soft tissue throughout the right perinephric
space and retroperitoneum, demonstrating restricted diffusion (series 8 image
31, 32, series 1,203 images 81), corresponding to the areas of high FDG
avidity on the prior PET-CT. The IVC remains patent but compressed by the
mass (series 1,203 image 102).
The spleen is mildly enlarged (series 5 image 26). The adrenal glands,
pancreas, and intra-abdominal loops of small and large bowel are normal. The
abdominal aorta, celiac trunk, SMA, and renal arteries are patent.
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. Gallbladder sludge. No concerning gallbladder mass.
2. No intra or extrahepatic bile duct dilation. No ductal stones.
3. Extensive soft tissue throughout the right perinephric space and
retroperitoneum, with compression of the IVC, in keeping with known history of
lymphoma, corresponding to FDG avid soft tissue lesion on the PET-CT from ___.
4. Stable moderate right hydronephrosis with delayed contrast excretion from a
head MRI examination on ___.
5. Mild bibasilar atelectasis.
6. Cirrhotic liver. Trace perihepatic ascites, mild splenomegaly, diffuse
anasarca, and mild gallbladder wall edema likely secondary to chronic liver
disease.
Radiology Report
AP CHEST, 10:58 A.M., ___
HISTORY: A ___ man, now neutropenic after chemotherapy.
IMPRESSION: AP chest compared to ___:
Consolidation in the right upper lobe marginated by the major fissure is
probably pneumonia. ___ a second region of pneumonia in the right lower
lobe or fissural pleural fluid. Heart is top normal size and pulmonary
vasculature is still engorged, but as yet no pulmonary edema. Left pleural
effusion. Left subclavian infusion port ends low in the SVC. No
pneumothorax. Dr. ___ was paged at 1:15 p.m. and we discussed the findings
by telephone.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chest pain, evaluation for intrapulmonary process.
COMPARISON: ___.
FINDINGS: An ovalary structure now seen on the frontal radiograph reflects an
intrafissural portion of right pleural effusion, as documented on the lateral
image. The structure is not a mass. The pleural effusion on the right has
minimally increased. Left and right atelectasis are seen in unchanged manner.
No evidence of acute lung changes. Normal size of the cardiac silhouette. No
pneumothorax. No evidence of pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L KNEE INJURY
Diagnosed with FRACTURE PATELLA-CLOSED, UNSPECIFIED FALL, BRAIN CONDITION NOS
temperature: 98.5
heartrate: 61.0
resprate: 20.0
o2sat: 100.0
sbp: 135.0
dbp: 87.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year old man with recurrent DLBCL, DM1 and
cirrhosis who presents after a mechanical fall and is found to
have a patellar fracture of the left knee. He incidentally was
found to have a 1.6 cm mass in the right temporal area, highly
suspicious for malignancy now with evidence of extensive
lymphoma progression.
ACTIVE ISSUES
=============
# HCAP Pneumonia
CXR on ___ was suggestive of a RUL pneumonia and given that
he had been hospitalized since ___, he was treated for an
HCAP with Cefepime and Vancomycin with plan for a 14 day course
to end through ___. He did not have fevers and was
not symptomatic. His Vancomycin levels were difficult to
control, with Vanc trough of 42 on the day prior to discharge
(at which point Vancomycin was discontinued) and 25.8 on the day
of discharge with evidence ___ (resolved s/p discontinuation
of Vanc). Given that he was clinically asympomtatic from a
pulmonary status and elevated Vancomycin levels his Vancomycin
was discontinued. He will continue to take Cefipime through
___, to complete a 2 week course.
# RLE ulcer
Patient was admitted with a known RLE ulcer which was evaluated
and treated per wound care. However, on ___, given his
neutropenia, there was concern for cellulitis and he began
treatment with Vancomycin (day ___ with plan for a 14
day course through ___. His Vancomycin levels were
difficult to control. His trough was 1.7 on Vancomycin 750 BID
and subsequently 42.3 on Vancomycin 1g BID. Given elevated
trough, as well as evidence of ___, his Vancomycin was
discontinued. His RLE wound was much improved on day of
discharge without evidence of infection and his Vancomycin was
discontinued as noted without plans to restart.
# DLBCL
MRI abdomen as well as PET CT showing evidence of progression of
disease. He is now s/p palliative chemo with cytoxan/etoposide
on ___ and palliative radiation therapy on ___. S/p
rituxan on ___. Methadone was converted to TID dosing for
pain control (methadone 30mg PO TID) and dilaudid was used for
breakthrough pain. He initially required IV dilaudid for pain
control and as his pain decreased after chemo/radiation, he was
transitioned to PO dilaudid. However, he subsequently endorsed
poorly controlled pain with dilaudid ___ PO Q4H PRN and
required 0.25 mg IV for breakthrough. He was started on Ativan
0.5 mg PRN pain/agitation which proved to be effective for
symptom control. Home dose acyclovir was continued as ppx.
# Type I DM
Patient has a known history of type I diabetes. He was followed
by ___ throughout his hospitalization. He had several issues
with both hypoglycemia and hyperglycemia. Ultimately he is
discharged on the following regimen:
- Lantus 11 units QAM
- Humalog sliding scale for goal glucose <300
Breakfast Lunch Dinner Bedtime
71-150 0 0 0 0
151-200 3 3 3 0
___ 5 5 5 1
301-350 6 6 6 2
351-400 7 7 7 2
- He does have a tendency to fall asleep during his meals and it
is thus advised to give him his Humalog after he finishes his
meal to prevent hypoglycemia
# Hyperbilirubinemia: Initially presented with
hyperbilirubinemia, likely related to pRBC transfusion and
resolved.
# Hyponatremia
Patient had hyponatremia to 132 in the setting of hyperglycemia.
Most likely a pseudohyponatremia. Resolved with better control
of his blood glucose levels.
# Thrombocytopenia
Patient has baseline thrombocytopenia-acute drop likely due to
cirrhosis versus lymphoma versus chemo. There was initial
concern for HIT and heparin products were discontinued, however,
platelets dropped after stopping heparin products, making HIT
less likely. Most likely due to chemo and demonstrated slow
improvement throughout his hospitalization.
# Anemia
Patient anemic at baseline (likely multifactorial) now with
acute decrease in Hct, likely due to chemo. Patient was
transfused for Hct<21. His blood counts remained stable
throughout his hospital stay.
# Abdominal pain
Likely due to lymphoma, treated with pain regimen as noted
above.
# Brain mass
Incidentally found on Head CT after fall. Better seen with brain
MRI. Per radiology, the mass did not appear to look like
lymphoma- however it is possible given his extensive disease
progression. Unlikely to be meningioma given that it was not
seen in ___. He received cyber knife treatment once on
___.
# HBV/HCV Cirrhosis
Patient has a known history of hepatitis B and hepatitis C.
Hepatitis B viral load was negative on this admission. His home
dose lamivudine and nadolol were continued during this
admission. The patient intermittantly took lactulose but was
difficult to maintain complete compliance.
# Scrotal swelling
Ascities and scrotal swelling malignant versus due to cirrhosis.
He was treated with lasix 40mg PO daily; however, swelling with
minimal improvement during hospital stay. Will continue on
Lasix. On the day prior to discharge he had low urine output,
and was bladder scanned for >500 cc (likely largely ___ to
narcotic use). He was straight catheterized. He may require
intermittent straight catheterization during his rehabilitation
stay.
# Prolonged QTc
QTc 502 on EKG on ___. From reviewing past EKGs, looks as
though this has been ongoing. Most likely due to his methadone.
QTc was monitored weekly throughout his admission. Qtc 473 on
___.
# ___
Was likely in the setting of hyperuricemia. He was started on
Allopurinol and his renal function resolved back to baseline. He
had another episode ___ in the setting of Vanc trough of
42.3. He was given IVF, Vancomycin discontinued, and his ___
resolved.
# Hyperuricemia
After receiving chemotherapy, patient noted to have
hyperuricemia. Uric acid found to be around 11 and he received
rasburicase on ___. He was also maintained on allopurinol
___ PO daily.
# L knee patellar fracture s/p Mechanical Fall
Patient was evaluated by orthopedic surgery who recommended
conservative treatment with immobilization and pain control.
Patient worked with physical therapy while hospitalized. He will
be discharged with a knee immobilizer.
# Hx of substance abuse
Patient was admitted on maintenance methadone 90mg PO daily.
However, this home dose methadone was transitioned to 30mg PO
TID to be used as pain control instead of as maintenance
methadone.
TRANSITIONAL ISSUES
===================
- Patient to follow up with Dr. ___ on ___
- Please continue patient on Lantus and ISS as noted above
- Please change wound dressing daily
- Patient OK to weight bear as tolerated on left knee with left
knee immobilizer
- Patient to continue on Cefipime Q12 hours through ___ to complete a 2 week course |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Altered mental status and intraparenchymal hemorrhage on CTH at
___
___ Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo RHF with alcoholic cirrhosis c/b portal
vein HTN, esophageal varices s/p TIPS ___, encephalopathy on
lactulose, T2DM, and cervical stenosis who initially presented
to
___ this morning for altered mental status and
transferred to ___ after found to have right frontal IPH.
Patient is poor historian, though improving mental status and
interaction per daughter and ___ staff. Per daughter ___ at
bedside, this morning around 530 AM she found her mother
conscious but on the floor with phone in hand. Last known time
normal was 1230 AM ___. Patient could not get up on own
and
was less responsive than normal. Patient adamant about not
hitting her head during the fall but cannot actually describe
the
fall or events surround it. Due to continued weakness and change
in mental status, daughter called EMS and patient was brought to
___.
Per patient and daughter, she has been having increasing falls.
She fell in ___ and fell again 2 days ago. During her fall
in ___ she was brought ___ ___ where she had a CT cspine which
showed severe cervical canal stenosis and a CTH with no acute
intracranial process. Daughter notices pt does not pick up feet
and feels that these are mechanical falls. She describes them
that patient often "slides to the ground". Patient cannot
describe the falls. Patient has limited mobility secondary to
right knee fracture from these falls, for which she now wears a
brace. She is currently going to ___, however daughter feels
patient is moving less than usual, including issues with poor
effort/motivation. She has not noticed any focal weakness.
Patient has stopped taking lactulose on her own as she cannot
make it to bathroom in context of limited mobility. She has a
walker available however does not use it. Daughter also relates
worsening short term memory over the past few months.
Per family at ___ staff, patient's exam is improving while she
has
been in the ___. SBP primarily 140-160. Briefly required
nicardipine gtt to keep SBP<150
Past Medical History:
HTN
alcoholic cirrhosis c/b esophageal varices and hepatic
encephalopathy, s/p TIPS ___
T2DM
Osteoporosis
GERD
?Coronary Artery DIsease: cardiac catheterization in ___ after
perfusion defect seen on stress, catch revealed mild CAD (___
___ in OMR ___
Social History:
___
Family History:
Father with alcoholic liver disease
Deny family hx of strokes, bleeding disorders, or seizures
Physical Exam:
UPON ADMISSION
Vitals:
T: 98.4 BP: 163/75 HR: 80 RR: 16 SaO2:97%
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted. No abrasions or
hematomas
noted on face/neck
Neck: Supple, no nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: non-pitting edema in R calf, not erythematous
Skin: Excoriations on R anterior calf
Neurologic:
-Mental Status: Alert, oriented to ___ only and answering
___ to location, name, date. Poor historian. Attentive,
able
to name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to name both high and low frequency
objects. Slight dysarthria (though did not have dentures in).
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 sluggish (eye surgery b/l
in
past). EOMI without nystagmus. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Atrophy in L calf. paratonia in L arm, increased tone
in
L leg. Slight L arm pronator drift. No adventitious movements,
such as tremor or asterixis noted. No myoclonus.
[___]
L 4+ 5 5 4- 4+ 5 5 5 5 5 5 5
R 5 5 5 poor effrt 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS. ___ deferred given risk of falls.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L (IV) 2 2 2 1
R 2 2 2 2 1
Plantar response with upgoing toes bilaterally.
-Coordination: Slight ataxia in R and L on FTN. Normal RAM. HKS
on L unable to perform due to increased tone in L leg.
-Gait: deferred due to risk of falls.
UPON DISCHARGE:
Neurologic:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact repetition and comprehension. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally.
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: L NLFF with symmetric activation, symmetric forehead raise,
eye closure.
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 ___ 5 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 ___
R 5 5 5 ___
Reflex: toes down bilaterally
-Sensory: No deficits to light touch. No extinction to DSS.
-Coordination: No ataxia on FNF bilaterally.
-Gait: deferred
Pertinent Results:
___ 12:10PM BLOOD WBC-3.8* RBC-4.08 Hgb-12.6 Hct-38.0
MCV-93 MCH-30.9 MCHC-33.2 RDW-14.6 RDWSD-49.7* Plt Ct-60*
___ 12:10PM BLOOD Neuts-68.0 ___ Monos-7.1 Eos-2.1
Baso-0.5 Im ___ AbsNeut-2.60 AbsLymp-0.84* AbsMono-0.27
AbsEos-0.08 AbsBaso-0.02
___ 03:35PM BLOOD Poiklo-1+* Ovalocy-1+* RBC Mor-SLIDE REVI
___ 12:10PM BLOOD ___ PTT-31.6 ___
___ 09:08AM BLOOD ___ 12:10PM BLOOD Glucose-256* UreaN-25* Creat-0.9 Na-143
K-5.3 Cl-110* HCO3-23 AnGap-10
___ 12:10PM BLOOD ALT-27 AST-55* AlkPhos-166* TotBili-2.6*
___ 12:10PM BLOOD Lipase-56
___ 12:10PM BLOOD cTropnT-0.03*
___ 07:10PM BLOOD cTropnT-0.01
___ 12:10PM BLOOD Albumin-3.3* Calcium-9.2 Phos-3.0 Mg-1.5*
___ 09:23AM BLOOD %HbA1c-7.9* eAG-180*
___ 12:40PM BLOOD Ammonia-17
___ 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:10PM BLOOD LtGrnHD-HOLD
___ 12:20PM BLOOD Lactate-1.7
___ 06:30AM BLOOD WBC-4.4 RBC-3.64* Hgb-11.5 Hct-35.0
MCV-96 MCH-31.6 MCHC-32.9 RDW-14.8 RDWSD-51.5* Plt Ct-35*
___ 06:07AM BLOOD WBC-5.2 RBC-3.47* Hgb-11.0* Hct-33.0*
MCV-95 MCH-31.7 MCHC-33.3 RDW-15.4 RDWSD-52.3* Plt Ct-69*
___ 10:15AM BLOOD ___ PTT-30.8 ___
___ 06:07AM BLOOD Glucose-125* UreaN-19 Creat-1.0 Na-141
K-4.6 Cl-111* HCO3-20* AnGap-10
IMPRESSION:
1. Examination is moderately motion degraded.
2. Approximately 2.8 cm right frontal intraparenchymal hematoma
with
associated surrounding edema, grossly stable in size compared to
the prior CT
head examination.
3. No new areas of intracranial hemorrhage or evidence of acute
to subacute
infarction.
4. Within limits of study, no definite evidence of enhancing
mass. Please
note that a enhancing intracranial mass in region of right
frontal
intraparenchymal hemorrhage is not excluded on the basis of this
examination.
Recommend follow-up imaging to resolution.
5. Paranasal sinus disease, as detailed above.
RECOMMENDATION(S): Within limits of study, no definite evidence
of enhancing
mass. Please note that a enhancing intracranial mass in region
of right
frontal intraparenchymal hemorrhage is not excluded on the basis
of this
examination. Recommend follow-up imaging to resolution.
CTH ___
FINDINGS:
Redemonstration of right inferior frontal lobe intraparenchymal
hematoma, 2.9
x 2.2 cm, previously 2.7 x 2.0 cm, with surrounding edema.
There is no
significant mass-effect on the adjacent frontal horn of the
right lateral
ventricle. There is no evidence of acute infarction, new
hemorrhage, or mass
effect. There is no midline shift. There are grossly stable
bilateral
calcifications in the globus pallidus. The ventricle and sulci
are grossly
stable in size configuration.
There is no evidence of fracture. There is mild mucosal
thickening in the
bilateral maxillary sinuses. Otherwise, the visualized portion
of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The
visualized portion of the orbits demonstrate bilateral lens
replacement
postoperative changes.
IMPRESSION:
1. Grossly stable right frontal lobe intraparenchymal hematoma,
with
surrounding edema and no definite midline shift.
2. Paranasal sinus disease , as described.
CTA ___
IMPRESSION:
1. Redemonstration of the right inferior frontal lobe
intraparenchymal
hematoma, with surrounding edema. This is unchanged in
appearance. No new
intracranial hemorrhage.
2. Patent circle of ___ without definite evidence of
stenosis,occlusion,or
aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries
without definite
evidence of stenosis, occlusion, or dissection.
4. Multiple pulmonary nodules measuring up to 4 mm in the right
apex.
For incidentally detected multiple solid pulmonary nodules
smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an
optional CT
follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colestid (colestipol) 1 gram oral QID
2. Aspart Unknown Dose
Glargine 60 Units Bedtime
3. Lactulose 30 mL PO TID
4. Pantoprazole 40 mg PO Q24H
5. rifAXIMin 550 mg PO BID
6. Spironolactone 25 mg PO DAILY
7. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium-
200 unit oral DAILY
8. Magnesium Oxide 400 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Captopril 6.25 mg PO TID
2. Glargine 30 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Citracal Regular (calcium citrate-vitamin D3) 250 mg
calcium- 200 unit oral DAILY
4. Colestid (colestipol) 1 gram oral QID
5. Lactulose 30 mL PO TID
6. Magnesium Oxide 400 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. rifAXIMin 550 mg PO BID
10. Spironolactone 25 mg PO DAILY
11. HELD- Fish Oil (Omega 3) Dose is Unknown PO Frequency is
Unknown This medication was held. Do not restart Fish Oil
(Omega 3) until you return home
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
intraparenchymal hemorrhage
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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with altered mental status.// h/o cirrhosis, AMS.
Please evaluate for PVT.
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Liver ultrasound dated ___.
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified.
There is no ascites.
There is stable splenomegaly, with the spleen measuring 13.6 cm.
There is no intrahepatic biliary dilation. The CHD measures 3 mm.
Cholelithiasis without gallbladder wall thickening.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 21 cm/sec, previously 23 cm/sec
Proximal TIPS: Measurements for the proximal tips are likely artifactual due
to respiratory motion.
Mid TIPS: 176 cm/sec, previously 278 cm/sec
Distal TIPS: 124 cm/sec, previously 134 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent TIPS. Of note, the measurements for the proximal tips are
inadequately obtained as the patient was unable to hold her breath. The
velocities within the mid and the distal tips are within normal range.
2. Portal vein is patent.
3. Cirrhotic liver morphology with stable splenomegaly. No ascites.
4. Cholelithiasis without sonographic evidence of acute cholecystitis.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with altered mental status// Altered mental status,
requested by neuro
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 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 17.4 mGy (Body) DLP =
8.7 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 601.8
mGy-cm.
Total DLP (Body) = 611 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___ at 06:43, CT head from ___, CT
C-spine from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Redemonstration of right inferior frontal lobe intraparenchymal hematoma
measuring approximately 2.9 x 2.2 cm, previously 2.7 x 2.0 cm, with
surrounding edema. There is no mass-effect on the adjacent frontal horn of
the right lateral ventricle. There is no evidence of acute infarction, new
hemorrhage, or masses. There is no midline shift. The ventricle and sulci
are normal in size and configuration.
There is mild mucosal thickening of the bilateral maxillary sinuses.
Otherwise, the visualized portion of the paranasal sinuses, mastoid air
cells,and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
CTA HEAD:
There is mild atheromatous calcification in the carotid siphons bilaterally.
The vessels of the circle of ___ and their principal intracranial branches
appear otherwise normal without stenosis, occlusion, or aneurysm formation
greater than 3mm. The dural venous sinuses are patent.
CTA NECK:
There is mild atheromatous calcification of the bifurcation of both common
carotid arteries and of the aortic arch. Bilateral carotid and vertebral
artery origins are patent. There is no evidence of internal carotid stenosis
by NASCET criteria. The carotidandvertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. The right vertebral
artery is dominant.
OTHER:
There is mild emphysematous change at the right apex. There are multiple
nodules in the right lung apex measuring up to 4 mm (3:51). The visualized
portion of the thyroid gland is within normal limits. There is moderate
cervical spondylosis, most marked at C3-C4, C5-C6 and C6-C7, with reduced
intervertebral disc height and anterior osteophyte formation. There is 3 mm
of anterolisthesis of C5 on C6.
IMPRESSION:
1. Redemonstration of the right inferior frontal lobe intraparenchymal
hematoma, with surrounding edema. This is unchanged in appearance. No new
intracranial hemorrhage.
2. Patent circle of ___ without definite evidence of stenosis,occlusion,or
aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries without definite
evidence of stenosis, occlusion, or dissection.
4. Multiple pulmonary nodules measuring up to 4 mm in the right apex.
For incidentally detected multiple solid pulmonary nodules smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an optional CT
follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with RLE swelling, AMS// Please eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. 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.
There is extensive calcified atherosclerotic plaque, particularly in the
common femoral artery.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Extensive calcified atherosclerotic plaque, particularly in the common femoral
artery.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with IPH, unknown etiology. Evaluate for
structural abnormalities in setting of right frontal IPH exam around 10AM on
___ for 24 hr scan.
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 performed ___. CT head and neck performed ___.
FINDINGS:
Examination is moderately degraded by motion. Within these confines:
There is a 2.8 x 2.6 cm (03:13) area of T1 hyperintensity centered within the
right frontal lobe with associated susceptibility artifact and moderate
adjacent FLAIR/T2 hyperintense edema signal compatible with known
intraparenchymal hematoma. This appears relatively unchanged compared to ___, allowing for differences in imaging technique. Local sulcal mass
effect also appears essentially unchanged. No other areas of intraparenchymal
hemorrhage are identified.
Susceptibility artifact in the bilateral basal ganglia are compatible with
mineralization, as seen on prior CT head examinations.
There is no evidence of recent infarction or midline shift. Prominence of the
ventricles and sulci is likely related to age-related involutional change.
Periventricular and subcortical T2/FLAIR hyperintensities are nonspecific but
may reflect the sequelae of chronic microvascular ischemic disease. The major
vascular flow voids appear relatively well preserved. Postcontrast images are
moderately motion degraded. Within these confines, no definite abnormal
postcontrast enhancement is identified.
There is mild bilateral mucosal thickening of the maxillary sinuses, right
greater than left. Minimal mucosal thickening of the anterior ethmoid air
cells. Mild opacification of the left-sided mastoid air cells. Status post
bilateral lens replacements.
A 7 x 4 mm T1 and T2 isointense lesion arising from the superficial soft
tissues overlying the right zygomatic process may reflect a skin tag versus
sebaceous cyst (03:10).
IMPRESSION:
1. Examination is moderately motion degraded.
2. Approximately 2.8 cm right frontal intraparenchymal hematoma with
associated surrounding edema, grossly stable in size compared to the prior CT
head examination.
3. No new areas of intracranial hemorrhage or evidence of acute to subacute
infarction.
4. Within limits of study, no definite evidence of enhancing mass. Please
note that a enhancing intracranial mass in region of right frontal
intraparenchymal hemorrhage is not excluded on the basis of this examination.
Recommend follow-up imaging to resolution.
5. Paranasal sinus disease, as detailed above.
RECOMMENDATION(S): Within limits of study, no definite evidence of enhancing
mass. Please note that a enhancing intracranial mass in region of right
frontal intraparenchymal hemorrhage is not excluded on the basis of this
examination. Recommend follow-up imaging to resolution.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with IPH, liver disease and thrombocytopenia//
worsening edema or bleed
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 =
747.5 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: ___ 06:43 noncontrast head CT.
FINDINGS:
Redemonstration of right inferior frontal lobe intraparenchymal hematoma, 2.9
x 2.2 cm, previously 2.7 x 2.0 cm, with surrounding edema. There is no
significant mass-effect on the adjacent frontal horn of the right lateral
ventricle. There is no evidence of acute infarction, new hemorrhage, or mass
effect. There is no midline shift. There are grossly stable bilateral
calcifications in the globus pallidus. The ventricle and sulci are grossly
stable in size configuration.
There is no evidence of fracture. There is mild mucosal thickening in the
bilateral maxillary sinuses. Otherwise, the visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits demonstrate bilateral lens replacement
postoperative changes.
IMPRESSION:
1. Grossly stable right frontal lobe intraparenchymal hematoma, with
surrounding edema and no definite midline shift.
2. Paranasal sinus disease , as described.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, ICH, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 98.4
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 163.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman past medical history
of alcoholic cirrhosis c/b portal vein HTN, encephalopathy
esophageal varices, s/p TIPS ___, T2DM, cervical stenosis with
a right frontal intraparenchymal hemorrhage.
#Right frontal IPH
Mic___ initially presented to ___ ___ after being
found on the ground by her daughter confused and less responsive
and left sided weakness. She was found to have a right frontal
IPH on CTH and was subsequently transferred to ___ for further
evaluation. All antiplatelets and anticoagulants were held. In
the ___, she transiently required a nicardipine gtt to maintain
SBP <150 but this was quickly titrated off. She was given 1 ___ in the ___, and on repeat CBC platelets decreased to
35; another unit of platelets were given for goal platelet count
>50. Patient was clinically improving, and admitted to the ___
for Q2H neuro checks for close monitoring given
thrombocytopenia. Her platelets were trended Q6H for 24 hours,
and she required no further platelet transfusions. CTA H&N
negative for stenosis, occlusion, dissection. CTH was repeated
___ and was stable. MRI stable with 2.8 cm hematoma in R
frontal lobe, and otherwise negative.
Etiology of stroke thought to be secondary to coagulopathy,
could also consider hypertensive etiology. We will plan to
follow up in stroke neurology clinic for repeat MRI to evaluate
for resolution of hemorrhage.
#Thrombocytopenia
Thought to be secondary to coagulopathy. She received a total of
2U of platelets and required no further transfusions. Discussed
case with hematology, who recommended no further workup or
intervention. Also discussed with hepatology, who recommended
continuing to hold SSRI as these medications can worsen a
coagulopathy.
#Hypertension
She was on a tight BP control, with goal SBP <140. We continued
home spironolactone 25 qDaily, and captopril increased from 6.25
TID to 12.5 TID. This medication can be switched to long acting
once per day prior to discharge.
#Trop 0.03 on admisison
Trended down, thought to be secondary to demand. No complaints
of chest pain. EKG with no acute findings.
#DM
A1c 7.9. Patient was put on sliding scale insulin for tight
blood sugar control, and this should be continued at rehab. Her
home lantus dose was cut by 50%, and this should be increased as
needed.
#Pulmonary nodules
Incidental finding of pulmonary nodules on CTA H&N. "Multiple
pulmonary nodules measuring up to 4 mm in the right apex.For
incidentally detected multiple solid pulmonary nodules smaller
than 6mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT follow-up in 12 months is recommended in a
high-risk patient. See the ___ ___ Guidelines
for the Management of Pulmonary |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transient facial droop, right-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old man with no significant past
medical history who presents with transient facial droop and
right-sided weakness.
Patient was in his usual state of health this morning and
returned from work driving a bus around 7:50 AM. His wife
noticed that he had sudden onset slurred speech and a right
facial droop and looked confused. He tried to grab a door to
walk through the house and was unable to lift his right arm.
His
wife called EMS who brought him to ___ - ___. ___ stroke
scale was notable for 1 for right facial droop. CT head did not
show any bleed CTA showed a possible acute thrombus in the left
M2 segment. No TPA was given. Patient did not go for
thrombectomy given his rapidly improving symptoms. Given that
neurology is not available at ___, patient was transferred
for further management.
On arrival to ___, patient felt back to normal and had a stroke
scale of 0.
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:
Enlarged prostate
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.0 P: 61 R: 16 BP: 130/84 SaO2: 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
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 x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch. 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 dysmetria on FNF or HKS
bilaterally.
-Gait: Deferred
DISCHARGE PHYSICAL EXAMINATION:
Vitals:
Temperature: 99.5-97.9
Heart rate: ___
Blood pressure: 98/61-125/89
Respiratory rate: ___
O2 saturation: 96-98%
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental status:
Patient is pleasant and he has no problem with communication
with examiner including expressing ideas and following commands.
Fluent use of language.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor:
Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
Sensory:
No deficits to light touch, proprioception throughout.
No extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination:
No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
Gait:
Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
MRI/MRA of brain ___:
A couple of punctate foci of hyperintense DWI signal in the left
parietal cortex without definite correlate on ADC, T2 or FLAIR
imaging. These lesions most likely represent tiny hyperacute
infarcts, but in the differential consider the fact that these
lesions may be artifactual in nature
Periventricular and deep white matter T2 and FLAIR
hyperintensities are
nonspecific but most likely related to microangiopathy.
Bilateral maxillary sinus mucosal thickening.
MRV Pelvis ___:
No evidence of deep vein thrombosis in the pelvis. Enlarged
prostate
Bilateral lower extremity US ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
None
Discharge Medications:
Atorvastatin 80 mg daily
Aspirin 81 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attacks
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old man with right sided weakness// eval for stroke
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
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: None.
FINDINGS:
MR BRAIN:
A couple of punctate foci of hyperintense DWI signal in the left parietal lobe
cortex (4:20, 4:19) without definite corresponding signal on ADC/T2/FLAIR
could represent tiny hyperacute infarcts or less likely artifact. No
intracranial hemorrhage. No mass. The ventricular system is symmetrical.
Periventricular and deep white matter T2 and FLAIR hyperintensities are most
likely secondary to microangiopathy. Mucosal thickening involving bilateral
maxillary sinuses and to a lesser degree the ethmoid air cells. No CP angle
masses. The globes appear normal. The pituitary gland appears normal. The
craniocervical junction is normal.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
IMPRESSION:
1. A couple of punctate foci of hyperintense DWI signal in the left parietal
cortex without definite correlate on ADC, T2 or FLAIR imaging. These lesions
most likely represent tiny hyperacute infarcts, but in the differential
consider the fact that these lesions may be artifactual in nature.
2. Periventricular and deep white matter T2 and FLAIR hyperintensities are
nonspecific but most likely related to microangiopathy.
3. Bilateral maxillary sinus mucosal thickening.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:53 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with stroke with positive bubble study
(PFO/ASD)// 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.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old man with positive bubble study (PFO/ASD)// DVT
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 3.0 T magnet.
Intravenous contrast: None.
COMPARISON: None.
FINDINGS:
RECTUM AND INTRAPELVIC BOWEL: The rectum and visualized intrapelvic bowel
loops are unremarkable.
BLADDER AND DISTAL URETERS: Unremarkable appearance of the urinary bladder.
The distal ureters are normal in caliber.
PROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate is enlarged and indents
the inferior urinary bladder. Seminal vesicles are unremarkable.
LYMPH NODES: There are no enlarged pelvic lymph nodes.
VASCULATURE: Normal caliber of the iliac arteries and veins. Flow void of the
pelvic vessels are preserved. There is no evidence of venous thrombosis in
the pelvis.
OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue
lesion. Note is made of a small Tarlov cyst at the level of S2.
IMPRESSION:
1. No evidence of deep vein thrombosis in the pelvis.
2. Enlarged prostate
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 98.0
heartrate: 61.0
resprate: 14.0
o2sat: 99.0
sbp: 130.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | ___ without significant past medical history admitted with
transient right-sided facial droop, speech difficulty, upper
extremity weakness, and sensory disturbance, found on CTA at
___ to have left M2 occlusion prior to transfer to
___. Symptoms resolved on arrival to ___, although
examination notable for subtle right-sided weakness in the
distal upper > proximal lower extremities. MRI brain revealed
small left parietal infarcts suggestive of a cardioembolic
origin, although no paroxysmal atrial fibrillation noted on
telemetry during the admission. Due to intracranial artery
stenosis noted on vascular imaging, patient was started on
aspirin 81 mg daily and atorvastatin 80 mg daily. TTE revealed a
PFO, but there were no DVTs on MRA pelvis ___ US. Patient was
discharged with ___ and ___ follow up with Dr. ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 123) - () No
5. Intensive statin therapy administered? () 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
]
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? () 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? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Ciprofloxacin / Coumadin
Attending: ___.
Chief Complaint:
Dysuria
Shortness of Breath
Lower extremity swelling
Major Surgical or Invasive Procedure:
___ ___
History of Present Illness:
Ms. ___ is an ___ y/o woman with history of HFpEF, paroxysmal
atrial fibrillation, and HTN who presents with 2 months of
worsening shortness of breath. History was obtained in part from
records due to patient's poor memory, but key details were
confirmed with the patient.
Patient and providers report ___ gradual worsening of symptoms
over the past ~2 months. Patient reports strict adherence to her
diuretics, 1500cc fluid restriction, and low-sodium diet at
home, but she has nonetheless experienced worsening SOB as well
as ___ edema. She is now only able to walk about 4 steps before
becoming short of breath. Her dry weight is around 150 lbs but
she does not weight herself regularly. No orthopnea or PND. No
chest pain, palpitations, diaphoresis, or dizziness.
Patient was advised by her cardiologist to come into the CDAC
over the last month for IV diuresis but declined. Today she
noted new dysuria and vaginal itching and decided to come to the
ED for these reasons. Of note, patient has a h/o recurrent UTIs
and just completed a 7-day course of amox/clav today. She denies
fevers, chills, rhinorrhea, cough, chest pain, N/V/D/abdominal
pain, or rashes.
In the ED, patient was afebrile and hemodynamically stable on
room air. Exam, CXR, and BNP were consistent with heart failure
exacerbation. EKG showed afib vs. flutter in ___ with no
ischemic changes, and trop was negative. Cardiology was
consulted and recommended admission for IV diuresis.
Past Medical History:
- Heart failure with preserved ejection fraction.
- Paroxismal atrial fibrillation (s/p ___
___
- Hypertension.
- Dyslipidemia.
- Osteoarthritis s/p R knee arthroscopy
- Osteopenia
- Sciatica
- Recurrent UTIs
- ___ cataracts
- Thyroid nodule
- R auricular perichondritis
- Hx falls w/ T12 compression fracture in ___
- HTN
- essential tremor
Social History:
___
Family History:
Father with heart problems, mother with arthritis. Both were
killed in the ___.
Physical Exam:
ADMISSION EXAM
==============
VS: Reviewed, afebrile, hemodynamically stable, SpO2 94% on 2L
General: Elderly pleasant woman in NAD.
HEENT: No icterus or injection. MMM.
CV: Irregular rhythm, no murmurs. JVP modestly elevated.
Resp: Normal work of breathing. Bilateral crackles to mid-back.
Abd: Soft, NDNT.
GU: No suprapubic tenderness.
Extremities: 1+ edema bilaterally. No erythema or tenderness.
Skin: No rashes or lesions.
Neuro: Alert, oriented and interactive but poor short-term
memory and attention consistent with mild dementia. CN ___
intact. Strength symmetric. No ataxia.
DISCHARGE EXAM
==============
VS: Reviewed, afebrile, hemodynamically stable, SpO2 96% on RA
HEENT: No icterus or injection. MMM.
CV: RRR, s1/s2, no mgr
Resp: CTAB except decreased bibasilar breath sounds, no crackles
Abd: Soft, NDNT.
Extremities: 1+ ___ edema b/l after removal of
compression stockings
Neuro: Alert, oriented and interactive but poor short-term
memory
and attention consistent with mild dementia. +intention tremor
b/l
Pertinent Results:
___ 05:45PM BLOOD WBC-6.3 RBC-3.99 Hgb-12.2 Hct-35.4 MCV-89
MCH-30.6 MCHC-34.5 RDW-13.0 RDWSD-42.5 Plt ___
___ 05:45PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-134*
K-4.0 Cl-93* HCO3-27 AnGap-14
___ 05:45PM BLOOD ___ 05:45PM BLOOD TSH-3.5
___ 03:56AM BLOOD calTIBC-328 Ferritn-34 TRF-252
IMAGING
___ CXR: significant bilateral pulmonary edema with small
effusions
___ CXR: Underlying emphysematous changes noted. The
considerable improvement to the bilateral pulmonary edema
decrease to the size of the cardiac silhouette. No definite
effusions appreciated.
DISCHARGE LABS
___ 07:50AM BLOOD WBC-5.8 RBC-4.16 Hgb-12.6 Hct-38.4 MCV-92
MCH-30.3 MCHC-32.8 RDW-12.9 RDWSD-43.5 Plt ___
___ 07:50AM BLOOD Glucose-111* UreaN-33* Creat-1.2* Na-142
K-4.1 Cl-98 HCO3-26 AnGap-18
___ 07:50AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rivaroxaban 15 mg PO DAILY
2. Propranolol 10 mg PO TID
3. Amiodarone 200 mg PO DAILY
4. Ciprofloxacin 0.3% Ophth Soln 1 DROP RIGHT EYE QID
5. Furosemide 60 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H ?UTI
9. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Bumetanide 3 mg PO DAILY
2. Nystatin Ointment 1 Appl TP TID:PRN pruritis
3. Propranolol 10 mg PO BID
4. Rivaroxaban 15 mg PO DINNER
5. Amiodarone 200 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Atrial fibrillation s/p DVVC
Acute on chronic heart failure exacerbation
SECONDARY
=========
HTN
Mild Cognitive Impairment
Conjunctivitis
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 (PA AND LAT)
INDICATION: History: ___ with sob// ?pulmonary edema
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Moderate to severe cardiac enlargement is re-demonstrated. The aorta is
diffusely calcified. Enlargement of the hila bilaterally is unchanged. There
is moderate interstitial pulmonary edema which is worse compared to the
previous examination. Small bilateral pleural effusions are present. Lungs
are hyperinflated likely indicative of chronic obstructive pulmonary disease.
Patchy opacities in the lung bases may reflect atelectasis. No pneumothorax
is demonstrated. No acute osseous abnormality is visualized. Moderate
compression deformity of a vertebral body at the thoracolumbar junction is
unchanged.
IMPRESSION:
Moderate interstitial pulmonary edema with small bilateral pleural effusions
and bibasilar atelectasis.
Radiology Report
INDICATION: ___ year old woman with HFpEF s/p diuresis and DCCV w/SOB//
interval changes, pleural effusion, pulm edema**Please perform ___ on
___
TECHNIQUE: Chest portable AP
COMPARISON: ___
FINDINGS:
Underlying emphysematous changes noted. The considerable improvement to the
bilateral pulmonary edema decrease to the size of the cardiac silhouette. No
definite effusions appreciated.
IMPRESSION:
Improved pulmonary edema.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Pedal edema
Diagnosed with Dyspnea, unspecified
temperature: 98.6
heartrate: 73.0
resprate: 18.0
o2sat: 90.0
sbp: 111.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Ms ___ is an ___ with HFpEF, AF, HTN, p/w with progressive
SOB, ___ edema found to have CHF exacerbation, s/p IV Lasix
diuresis w/improvement in Sx, s/p ___ (___) of AF to sinus
rhythm
# Acute on chronic HFpEF
Pt had gradual progression of Sx over weeks-months, had declined
CDAC admission earlier for IV diuresis, found to have volume
overload, s/p IV Lasix diuresis. Repeat TTE similar to prior
(symmetric LVH, mild AS, mild pulm HTN, EF >65%). After
discussion with outpt Cardiologist Dr ___ for ___ of
AF to assist with CHF management, increased home Amio to BID but
discharging on once a day due to bradycardia in sinus rhythm.
Admission weight (69.1 kg 152.34 . D/c weight 62.69 kg (138.2
lbs). Restarted home Losartan as tolerated. DC'd on atorvastatin
10 mg daily, losartan 100mg daily , propranolol 10 mg (also has
tremors) BID, Bumetanide 3 mg daily
# Paroxysmal AFib vs Flutter
Pt has been in persistent AFib vs flutter since at least ___,
was initially c/w home Amiodarone + Propranolol. Previous ___
in ___. After discussion w/ outpatient Cardiologist Dr
___ (___) was performed but reverted to Aflutter on ___
and then s/p ___ (___) and returned to sinus rhythm before
discharge. Increased home Amiodarone from 200mg qd to 200mg BID
during most of her stay but now being discharged on amiodarone
200 mg daily, home rivaroxaban 15 mg daily, propranolol 10 mg
BID
# Urinary Retention
Had multiple PVRs >500cc but continued to urinate 100-200ccs
every ___ hours. UA wnl. CTs in two occasions in ___ and ___
showing distended bladder (763 ccs, 528.3 cc) and occupying the
space and creating a 4.5 cm hypodense structure posterior to the
bladder. A pelvic ultrasound had been recommended at that time,
which the patient declined. At this point she should have
outpatient urology follow up for consideration of any further
workup. A foley catheter was not placed at discharge as she was
asymptomatic without UTI ___ at time of discharge.
-F/u outpatient if patient wishes to work up
# Dysuria and pyuria
# Vaginal itching (resolved)
Patient completed a 7d course Augmentin for chalazion on day of
admission, s/p CTX & fluconazole in ED with c/f UTI vs
vaginitis. Started Nystatin w/improvement in Sx. UA w/pyuria,
though UCx was neg, no further Abx given
#Chest rash: related to pads from ___, improving.
CHRONIC ISSUES
==============
# Mild Cognitive Impairment: Alert and oriented but with poor
short-term memory and attention
# Tremor: Pt with baseline tremor, c/w home Propranolol
# ?Viral conjunctivitis: per pt, eye drops stopped per outpt
Optho, started frequent warm compresses w/improvement in Sx.
Gave artificial tears.
# HTN: slowly increased Losartan back to home dose, held home
amlodipine
# CONTACT: HCP: Proxy name: ___ (daughter) Phone:
___
TRANSITIONAL ISSUES
===================
[ ] Re-check EKG to determine if she is still in sinus in
cardiology f/u in 1w
[ ] Patient discharged with ___ of Hearts monitor, please
consider adjusting amiodarone dose based on her afib burden.
[ ] Stopped home amlodipine during admission due to soft BPs.
[ ] Discharge diuretic dose is 3mg Bumex daily
[ ] Monitor weights and titrate bumex (dry weight 62.69 kg
(138.2 lbs))
[ ] Patient had urine retention, which is likely chronic. She
should be seen by urology as an outpatient for further
evaluation. Please arrange this. She had a pelvic finding on
prior abdominal CT imaging where a mass could not be excluded
posterior to the bladder, but refused further follow up. This
could be addressed with pelvic ultrasound.
[ ] repeat chem 10 panel in ___ days to ensure stable. Cr at
discharge 1.2
Discharge weight: 62.69 kg (138.2 lbs)
>30 minutes spent on discharge planning/coordination of care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right pneumothorax
Major Surgical or Invasive Procedure:
___
Right pleural pigtail catheter placement
History of Present Illness:
Mr. ___ is a ___ man who is nearly 3 months
status post VATS right lower lobe lobectomy for lung cancer,
with
a complicated postoperative course including ARDS requiring
prolonged intubation ultimately tracheostomy and a right
pneumothorax requiring a chest tube, presents from rehab with
concern for worsening pneumothorax. When the patient left the
hospital from his last admission, he had a moderate right-sided
pneumothorax with a pleural effusion at the lung base. This is
been followed at rehab with serial chest x-rays. On today's
chest x-ray, the pleural effusion had resolved however the
pneumothorax remained and was questionably enlarged. Therefore
the patient was sent to the ___
emergency department for further evaluation.
Patient is on full vent support, and thus detailed history is
hard to obtain. However, he does report that his breathing has
not changed recently. He has an intermittent cough, and
intermittent dyspnea. His son does report that he thinks there
has been a small increase in the amount of secretions recently.
He denies fevers and chills.
Past Medical History:
PAST MEDICAL HISTORY:
Hypercholesterolemia
Anemia, iron deficiency
Cancer of ascending colon
Colonic adenoma
History of herpes zoster
Degenerative disc disease, lumbar
Post-traumatic stress disorder, chronic
Depressive disorder
History of alcohol abuse
Peripheral neuropathy due to chemotherapy
Diverticulosis of large intestine without hemorrhage
COPD mixed type
PAST SURGICAL HISTORY:
___
VATS right lower lobe wedge resection followed by VATS right
lower lobectomy, mediastinal lymph node dissection and
bronchoscopy with lavage
___
Bronchoscopy
___
Bronchoscopy
___
Bronchoscopy
___
Bronchoscopy
___
Right pleural pigtail catheter placement
___ Portex Per-Fit tracheostomy tube placed percutaneously and a
PEG tube placement.
___
Right PICC placement
___
Right common femoral Vein approach IVC filter placement.
Right common femoral artery approach right subclavian
arteriogram with gel foam embolization of lateral thoracic,
pectoral, and humeral branch
Social History:
___
Family History:
Mother
Father: throat cancer
Siblings: brother : ___
Other
Physical Exam:
Temp 97.8 HR 86 BP 160/90 RR 22 O2 sat 96%
General: frail appearing, alert and oriented in no distress
however difficult to communicate secondary to tract
HEENT: NC/AT, EOMI, trach in place
Resp: on vent support via trach, lungs clear bilaterally,
however
decreased breathsounds on the right
CV: mildly tachycardic, regular
Abd: soft, mildly distended, mildly tender to palpation
throughout
Ext: well-perfused, no edema
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 01:25 22.0* 4.11* 11.5* 37.5* 91 28.0 30.7* 16.0*
53.5* 356
___ 01:05 16.7* 4.15* 11.5* 38.2* 92 27.7 30.1* 16.2*
54.2* 371
___ 01:45 18.6* 4.17* 11.7* 38.1* 91 28.1 30.7* 15.9*
53.6* 394
___ 01:35 22.7* 4.15* 11.5* 37.8* 91 27.7 30.4* 16.1*
53.9* 448*
___ 14:55 22.7* 4.58* 12.8* 41.4 90 27.9 30.9* 16.3*
53.3* 486*
___ 22:10 19.9* 4.12* 11.5* 37.6* 91 27.9 30.6* 16.0*
52.8* 451*
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 01:25 ___ 135 4.9 93* 32 10
___ 01:05 ___ 134* 5.0 96 30 8*
___ 01:45 ___ 136 4.8 94* 31 11
___ 01:35 ___ 135 4.9 94* 30 11
___ 14:55 ___ 135 5.3 96 26 13
___ 22:10 ___ 134* 5.1 96 27 11
___ CXR :
Moderate right pneumothorax, with intervally resolved right
pleural effusion. No signs of tension. Chronic lung disease
re-demonstrated. PICC line appears well positioned.
Tracheostomy in place.
___ Chest CT :
1. Small to moderate hydropneumothorax with some possibly
loculated
components. There is no obvious bronchopleural fistula.
2. Post right lower lobectomy. Consolidations in the left lower
lobe and
lingula are concerning for pneumonia, significantly progressed
since ___.
3. The previously seen large right chest wall hematoma appears
significantly decreased in size, now measuring 6.5 x 1.9 cm.
4. Post tracheostomy. Secretions are seen in the right main
bronchus extending into the subsegmental bronchi of the right
lower lobe
5. There is diffuse lower lobe predominance of interstitial
reticulation and honeycombing, compatible with biopsy proven
UIP.
___ CXR :
In comparison with the study of ___, the monitoring and
support devices are stable, as is the cardiomediastinal
silhouette. The patient has taken a better inspiration with
continued extensive reticular changes and right
pleural effusion. Specifically, there is hazy opacification in
the right
apical region consistent with pleural fluid replacing the prior
pneumothorax.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Diltiazem 60 mg PO Q6H
4. Gabapentin 600 mg PO TID
5. LORazepam 0.5 mg PO BID
6. Metoprolol Tartrate 25 mg PO Q6H
7. QUEtiapine Fumarate 25 mg PO QHS
8. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea
9. Atorvastatin 10 mg PO QPM
10. Heparin 5000 UNIT SC BID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY
13. Ramelteon 8 mg PO QPM
14. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
16. Bisacodyl ___AILY:PRN Constipation - Second Line
17. Docusate Sodium 100 mg PO BID
18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze and w/
acetylcsyeine treatments
19. Ciprofloxacin 400 mg IV Q12H
20. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate
Discharge Medications:
1. Famotidine 20 mg PO DAILY
2. GuaiFENesin ___ mL PO TID
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Heparin 5000 UNIT SC TID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. LORazepam 0.5 mg NG Q8H:PRN anxiety
Cruch and give via PEG tube, flush w/ 10 mls water
7. Metoprolol Tartrate 37.5 mg NG Q6H
Use suspension and give via PEG tube, flush w/ 10 mls water
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
11. Atorvastatin 10 mg PO QPM
crush and give via PEG tube, flush w/ 10 mls water
12. Bisacodyl ___AILY:PRN Constipation - Second Line
13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
14. Diltiazem 60 mg NG Q6H
Cruch and give via PEG tube, flush w/ 10 mls water
15. Gabapentin 600 mg NG TID
crush and give via PEg tube. flush w/ 10 mls water
16. Multivitamins W/minerals 1 TAB PO DAILY
use elixir and give via PEG tube, flush with 10 mls water
17. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate
Give via PEG tube and flush with 10 mls water
18. QUEtiapine Fumarate 25 mg NG QHS
Crush and give via PEG tube, flush w/ 10 mls water
19. Ramelteon 8 mg NG QPM
Cruch and give via PEG tube, flush w/ 10 mls water
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Respiratory failure
Trapped right lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with right pigtail placed.// eval pigtail position
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from 2 hours prior
FINDINGS:
Following insertion of the right basal pigtail pleural drain moderate to large
right hydropneumothorax is not appreciably smaller.
Severe chronic infiltrative abnormality persists in the left lung, with no
evidence of an acute abnormality. Heart size is normal. Left pleural
effusions small if any.
Tracheostomy tube is midline. Caliber of the tube is less than half the
diameter of the trachea and may be smaller than optimal. Clinical assessment
advised.
IMPRESSION:
Status post right pigtail catheter placement without significant interval
change in moderate right hydro pneumothorax.
Chronic severe infiltrative lung disease.
Size of tracheostomy tube should be re-evaluated clinically.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax// eval
for interval change eval for interval change
IMPRESSION:
Tracheostomy is in place. Right PICC line tip is at the level of lower SVC.
Right pigtail catheter is in place. Pneumothorax is moderate to large,
unchanged. Interstitial opacities have substantially progressed in the
interim concerning for progression of interstitial edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with afib with RVR// interval change. chest tube
to H20 seal since last xr
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiograph ___ from 7 hours prior
FINDINGS:
Again seen is a right-sided PICC at the cavoatrial junction and a tracheostomy
tube, unchanged in position from prior. Redemonstration of a right pigtail
pleural catheter seen along the inferior right hemithorax.
Redemonstration of a large right sided pneumothorax without evidence of
tension, unchanged in size from prior. Again, there are diffuse airspace and
interstitial opacities, similar appearance to prior. No large pleural
effusion. Cardiomediastinal contours are unchanged.
IMPRESSION:
Unchanged size of a large right pneumothorax. No evidence of tension.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax//
Interval change
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Moderate right-sided pneumothorax with apical and basilar components is
unchanged. Right-sided pigtail catheter is in place. Right PICC line
projects to the cavoatrial junction and is also unchanged. Tracheostomy tube
is also unchanged. Interstitial abnormality bilaterally left greater than
right could represent a combination of pneumonia and edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax//
Pigtail clamped. Please obtain at 12pm ___
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiograph ___ 6 hours prior
FINDINGS:
Unchanged positioning of a right-sided PICC, tracheostomy, and right-sided
pigtail catheter.
The large right pneumothorax is unchanged in size. No pleural effusions.
There has been mild interval increase of the diffuse airspace opacities at the
left lung base, concerning for worsening of the underlying parenchyma process.
Cardiomediastinal silhouette is unchanged.
IMPRESSION:
Unchanged size of large right pneumothorax. Mild interval worsening of
underlying parenchymal process at the left lung base.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with fibrotic disease, persistent PTX with
pigtail // Disease progression
TECHNIQUE: Axial 1.25 mm slice thickness images were obtained through the
chest without the administration of intravenous contrast. Coronal, sagittal,
and axial MIPS reconstructions were then obtained
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 10.1 mGy (Body) DLP = 360.0
mGy-cm.
Total DLP (Body) = 360 mGy-cm.
COMPARISON: CT chest without contrast from ___.
CTA chest from ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Patient is status post
tracheostomy. Aerated secretions are seen proximal to the tracheostomy tube.
The thyroid gland is unremarkable. The previously seen large right chest wall
hematoma appears significantly decreased in size, now measuring 6.5 x 1.9 cm
(302:84).
UPPER ABDOMEN: Limited views of the abdomen appear grossly unremarkable.
MEDIASTINUM: There are multiple persistently enlarged mediastinal lymph nodes.
For example, there is a right paratracheal lymph node which measures 1.3 cm
(302:82), previously 1.6 cm in ___. A representative prevascular lymph
node measures 1.3 cm (302:87), unchanged. A left pericardial lymph node
measures 1.1 cm, unchanged (302:153). There is interval increase in
pneumomediastinum since ___.
HILA: Within limitations of a noncontrast enhanced exam, no obvious
lymphadenopathy is identified.
HEART and PERICARDIUM: The cardiac size is mildly prominent, but unchanged.
Dense calcifications are seen in the aortic valve, mitral valve, and coronary
arteries. Moderate amount of pneumomediastinum appears mildly progressed
since ___.
PLEURA: There is a small to moderate right hydropneumothorax. Some of the
pleural fluid in the medial posterior right lower lung may be loculated. A
right lateral approach percutaneous pigtail drainage catheter is seen
terminating in the right lower lung.
LUNG:
1. PARENCHYMA: Patient is status post right lower lobectomy. There is
diffuse lower lobe predominance of interstitial reticulation and honeycombing,
compatible with previously characterized interstitial lung disease. Diffuse
consolidations in the left lower lobe and lingula are concerning for pneumonia
and significantly progressed since ___. There are additional areas of
ground-glass opacity in the upper lobes, which are nonspecific, possibly
pulmonary edema versus developing infection. No definite bronchopleural
fistula is seen.
2. AIRWAYS: Secretions are seen in the right main bronchus extending into the
subsegmental bronchi of the right lower lobe (302:105-116).
3. VESSELS: Evaluation of the vasculature is limited on this noncontrast
enhanced exam. Within these limitations, the thoracic aorta is not
aneurysmally dilated. The main pulmonary artery is nonenlarged.
CHEST CAGE: Degenerative changes are mild-to-moderate in the visualized spine.
There is no concerning focal lesion identified.
IMPRESSION:
1. Small to moderate hydropneumothorax with some possibly loculated
components. There is no obvious bronchopleural fistula.
2. Post right lower lobectomy. Consolidations in the left lower lobe and
lingula are concerning for pneumonia, significantly progressed since ___.
3. The previously seen large right chest wall hematoma appears significantly
decreased in size, now measuring 6.5 x 1.9 cm.
4. Post tracheostomy. Secretions are seen in the right main bronchus extending
into the subsegmental bronchi of the right lower lobe
5. There is diffuse lower lobe predominance of interstitial reticulation and
honeycombing, compatible with biopsy proven UIP.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with right PTX, ILD// Interval CXR
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with mild improvement in the interstitial abnormality
which most likely represents improving edema. The residual opacity
bilaterally is consistent with known interstitial lung disease. The moderate
right pleural effusion is unchanged. Right-sided pigtail catheter and
right-sided PICC line are unchanged. Tracheostomy tube remains in place.
Cardiomediastinal silhouette is stable. There is a stable small right pleural
effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with RLL lobectomy w/ not-fully reflated right
lung s/p pig tail pulled today// interval change since removing pig tailplease
obtain at 1600 ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the right PICC projects over the right atrium, unchanged. A
tracheostomy tube is present.
Interval increase in bilateral reticular opacities. No pleural effusion or.
A small right pneumothorax is unchanged. The size the cardiac silhouette is
unchanged.
IMPRESSION:
Unchanged small right apical and basal pneumothorax.
Interval increase in reticular opacities possibly reflecting pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R pneumothorax and intermittent
desaturtations// interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices are
stable, as is the cardiomediastinal silhouette. The patient has taken a
better inspiration with continued extensive reticular changes and right
pleural effusion. Specifically, there is hazy opacification in the right
apical region consistent with pleural fluid replacing the prior pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumonia, Transfer
Diagnosed with Pneumothorax, unspecified
temperature: 97.8
heartrate: 86.0
resprate: 22.0
o2sat: 96.0
sbp: 160.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and a right pleural pigtail catheter was
placed to evacuate his right pneumothorax. He was then admitted
to the ___ for vent management as well as management of his
pigtail catheter. Most recently at rehab he had been able to
tolerate a trach collar during the day and PSV overnight. He
felt that his dyspnea improved following placement of the
pigtail catheter but on xray, the pneumothorax was the same.
There was no air leak from his pigtail catheter.
The Pulmonary service was consulted to comment on his fibrotic
lung disease which was confirmed on pathology (UIP). After the
patient's initial roughly
1-month Prednisone taper, he was not on prolonged steroids. They
felt that he didn't have clinical evidence of an ILD flare, and
CT imaging did not demonstrate progressive fibrosis or ground
glass in a pattern consistent with flaring. However, he did have
significant LLL consolidation and mucus plugging; pulmonary
hygiene and mucus clearance is key to help with vent weaning.
They also felt that his remaining R lung has less parenchymal
abnormality than his L lung and his oxygenation would
significantly be affected by any pleural process that impairs R
lung ventilation. They recommended starting albuterol nebs q6hr
with dedicated coughing and airway
clearance after, starting start Mucinex ___ mg BID. They will
also arrange outpatient pulmonary follow-up for consideration of
pirfenidone.
Mr. ___ was able to be weaned off the ventilator and has
been on a 60% trach collar for the last 72 hours. His pigtail
catheter was removed on ___ and he denies any change on his
baseline dyspnea. He was evaluated by the Speech and Swallow
therapist and cleared for use of a passey muir valve for ___
minute spurts with supervision.
His tube feedings were changed to Osmolite 1.5 from Jevity 1.2
due to loose bowel movements. All stool studies have been
negative including C diff, banana flakes have been added and the
beneprotein has been stopped.
Cardiology was also consulted to comment on his PAF with RVR and
they recommended titrating up his Metoprolol to 37.5 q 6 hrs,
continuing his diltiazem at 60 mg q 6 hrs and if needed for rate
control, possibly adding digoxin. Currently with his Metoprolol
at 37.5 mg q 6 hrs his rate is better controlled.
Anticoagulation was also discussed and deferred given his ___
sore is 1 and prior chest wall hematoma.
Mr. ___ is gradually getting stronger and now off the
ventilator but still needs more physical therapy as well as SLP
before returning home. He was discharged back to rehab on
___ and will follow up with Dr. ___ in 4 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right tibial plateau open reduction and internal fixation
History of Present Illness:
___ otherwise healthy who was playing football today and
suffered
a hyperextension injury to the R knee. Immediate onset of pain,
swelling, and inability to bear weight. No injuries elsewhere.
Denies numbness or tingling distally.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
AVSS
A&O x 3
Calm and comfortable
RLE:
Moderate effusion in the knee
No evidence of open fracture
Knee unstable to valgus stress
Knee stable to varus stress
___
SILT DP/SP/S/S/T distribution
DP and ___ pulse 2+
toes wwp
Exam on discharge:
AFVSS
A+Ox3, NAD
RLE:
Dressings c/d/i
Compartments soft and compressible
No pain with passive ankle or toe motion
___
SILT DP/SP/S/S/T distribution
DP and ___ pulse 2+
toes wwp
Pertinent Results:
___ 04:15PM BLOOD WBC-12.2* RBC-4.51* Hgb-14.4 Hct-42.0
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.1 Plt ___
___ 08:00PM BLOOD Neuts-84.6* Lymphs-9.9* Monos-4.5 Eos-0.6
Baso-0.3
___ 04:15PM BLOOD Plt ___
___ 08:00PM BLOOD ___ PTT-22.7* ___
___ 08:00PM BLOOD Glucose-96 UreaN-23* Creat-0.8 Na-138
K-3.8 Cl-___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right tibial plateau 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 WITHOUT CONTRAST
INDICATION: ___ year old man with comminuted fracture of the right tibial
plateau // Please obtain CT of the right knee for pre-op planning
TECHNIQUE: MDCT images were obtained through the right knee without
intravenous contrast. Coronal and sagittal reformations were prepared. DLP:
1140.69 mGy-cm.
COMPARISON: Right knee radiographs, ___.
FINDINGS:
Comminuted, depressed fracture involving the lateral tibial plateau extends to
the lateral metaphyseal cortex as well as the median eminence. There is
approximately 1.3 cm of depression spanning approximately 3.7 x 3.9 cm of the
articular surface. There is lateral displacement of the dominant fracture
fragment. The medial tibial plateau is spared.
Lipohemarthrosis is noted along with a locule of air (5:26). There is
surrounding soft tissue swelling as well as medial subcutaneous varices.
There is bilateral patellar tilt.
This examination is not dedicated to evaluation of the intra-articular
structures.
IMPRESSION:
1. Comminuted, depressed lateral tibial plateau fracture as described above
with approximatly 1.3 cm of depression.
2. Secondary lipohemarthrosis and intraarticular air locule, most likely
traumatic.
Radiology Report
INDICATION: ORIF of tibial plateau fracture.
TECHNIQUE: Multiple intraoperative fluoroscopic spot images were acquired,
without a radiologist present.
COMPARISON: Outside hospital knee radiographs ___. Right lower
extremity CT from ___.
FINDINGS:
The provided fluoroscopic spot images demonstrate open reduction and internal
fixation of a lateral tibial plateau fracture, utilizing a side plate and
several screws. There is no hardware complication. For additional details,
please see the operative report in the ___ medical record.
The total fluoroscopic time was 52.7 seconds.
IMPRESSION:
As above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg pain
Diagnosed with FX UPPER END TIBIA-CLOSE, OTHER OVEREXERTION AND STRENUOUS AND REPETIVE MOVEMENTS OR LOADS, ACTIVITIES INVOLVING AMERICAN TACKLE FOOTBALL
temperature: 98.0
heartrate: 73.0
resprate: 18.0
o2sat: 96.0
sbp: 132.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
History of Present Illness:
Mr. ___ is a ___ male with a history of CAD s/p
CABG in ___, PCI in ___ and ___, AS s/p AVR in ___, atrial
fibrillation, permanent pacemaker, chronic angina, hypertension,
and hyperlipidemia who presented with worsening SOB and an
episode of anginal symptoms, nausea, and pallor. Patient reports
he first began feeling unwell a month ago after undergoing ___
surgery complicated by bleeding. He states neither his coumadin
nor aspirin were stopped due to this event. Since then he began
to notice his functional capacity was becoming reduced,
especially one week PTA when he began noticing increased
fatigue, SOB and chest pain with less exertion. He contacted his
cardiologist, Dr. ___ suggested that he start Lasix 20
mg daily on ___ which he did not start because he
was concerned about the side effects. He reports he is usually
able to walk ~ ___ mile before having to stop because of chest
pain and SOB. He takes nitroglycerin daily for anginal symptoms.
Of note, a recent cardiology note from ___ states he reports not
exerting himself or doing much activity because he is afraid
something might happen. Five days PTA he experienced an episode
of SOB after walking ___ feet, and had to rest for ___
minutes. On the day of admission he reports starting to have
breakfast with a friend when he suddenly felt nauseous x4 but
never vomited. He also reports anginal symptoms during this
episode, but no worse than baseline, moderate SOB, pallor, and a
general sense of feeling unwell. He denies diaphoresis, or
radiating pain. He denied PND, and orthopnea. His wife reports
noting worsened peripheral edema over the past days PTA.
At ___, initial labs revealed Trop of 0.221 (previous one
was normal in ___. TTE was completed which showed EF of
___ (prior ___ TTE from ___ with EF of >55%) with ?
thrombus vs. vegetation on aortic valve. Patient was given lasix
20mg IV and levaquin 750mg IV for ?PNA. He was then transferred
to ___ for further management.
In the ___ ED, initial vitals were T 96.9 BP 127/79 HR 53 RR
15 O2sat 97%RA. Labs and imaging significant for troponins 0.18,
Na 119, INR 4.7. He was given vancomycin, gentamicin, and
rifampin. Vitals on transfer were to the floor where T 97.7 BP
122/63 HR 69 RR 20 O2sat 99%RA.
On arrival to the floor, he reports feeling well and without
symptoms or complaints. He denies chest pressure since yesterday
and SOB currently.
REVIEW OF SYSTEMS:
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denied recent fevers, chills or rigors.
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: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: ___ at ___ (LIMA to LAD, SVG to RCA, SVG to OM)
-Atrial Fibrillation
-Symptomatic Bradycardia
-PERCUTANEOUS CORONARY INTERVENTIONS:
- Last Cath in ___ at ___: BMS to OM2 (of note had a patent
LM stent, 60% proximal, mid occluded LAD, 95% proximal LCx, 95%
proximal OM3, patent LIMA to the LAD and occluded VG to RCA,
occluded VG to OM)
-PACING/ICD: single chamber pacemaker implant, VVI, ___
3. OTHER PAST MEDICAL HISTORY:
-Benign Prostatic Hyperplasia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Father had emphysema and angina pectoris, died aged ___ of
unspecified cause. Brother had emphysema and anginal pectories,
died aged ___ of unspecified cardiovascular problems. Brother and
sister both with CAD in ___. Mother died aged ___ of "old age."
Daughter with history of ovarian cancer. A number of other
children and grandchildren, all healthy.
Physical Exam:
Admission:
Tmax 98.0 Tc 98.0 BP 125/75 (102-131/57-84) HR 65 (60-68) RR 18
(___) O2sat 95%RA (95-97%RA) Weight: 76.6kg
I/O (as recorded): NPO, 200 IV, 525 (700) GU, no BM
General:Alert, oriented x3, cooperative, in no acute distress
HEENT: NCAT, PERRLA, EOMI, anicteric sclerae, oropharynx clear.
No pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, JVP of ~8cm, no palpable lymphadenopathy, masses
or thyromegaly
Cor: irreg irreg, mechanical heart sounds, no MRG. No thrills,
lifts. No S3 or S4.
Pulm: Dimished breath sounds on the right compared to left with
crackles, as well as bilateral crackles at the bases. No wheezes
or ronchi.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding, no palpable masses or hepatosplenomagly, normoactive
bowel sounds
GU: No costovertebral angle tenderness, foley in place
Extremities: WWP, no clubbing or cyanosis. 1+ pitting edema to
midcalves. 2+ palpable carotid, radial, dorsalis pedis, and
posterior tibial pulses bilaterally. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge:
VS: 97.8,96/54-122/70, 59-66, 18, 100% RA
Tele: NSR, rate ___. Occasionally Vpaced. rare PVCs
General: A&O x3, NAD
Neck: Supple, JVP of ~8cm, no palpable masses
CV: irreg irreg, mechanical heart sounds with loud S2, no MRG
Pulm: Rales R > L. No wheezes or ronchi.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding, no palpable masses or hepatosplenomagly, normoactive
bowel sounds
Extremities: WWP, no clubbing or cyanosis. 1+ pitting edema b/l.
R femoral cath site CDI, no hematoma or bruit, 1+ ___ pulses
b/l
Pertinent Results:
Admission:
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30PM ___ PTT-49.7* ___
___ 08:30PM PLT COUNT-223
___ 08:30PM NEUTS-76.1* LYMPHS-13.8* MONOS-9.5 EOS-0.5
BASOS-0.1
___ 08:30PM WBC-4.9 RBC-3.37* HGB-12.0* HCT-34.5*
MCV-102* MCH-35.7* MCHC-34.9 RDW-12.9
___ 08:30PM OSMOLAL-255*
___ 08:30PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.9
___ 08:30PM CK-MB-4
___ 08:30PM cTropnT-0.18*
___ 08:30PM CK(CPK)-66
___ 08:30PM estGFR-Using this
___ 08:30PM GLUCOSE-101* UREA N-25* CREAT-1.4*
SODIUM-119* POTASSIUM-4.3 CHLORIDE-86* TOTAL CO2-24 ANION GAP-13
___ 08:39PM LACTATE-1.4
Troponins:
___ 08:30PM BLOOD cTropnT-0.18*
___ 12:38AM BLOOD CK-MB-4 cTropnT-0.17*
___ 06:20AM BLOOD CK-MB-4 cTropnT-0.20*
___ 01:41AM BLOOD cTropnT-0.26*
___ 06:51AM BLOOD cTropnT-0.30*
Discharge:
___ 06:32AM BLOOD Hct-32.4*
___ 01:00PM BLOOD ___
___ 06:34AM BLOOD Glucose-83 UreaN-23* Creat-1.4* Na-132*
K-4.7 Cl-94* HCO3-29 AnGap-14
___ 06:34AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
___ 08:30PM BLOOD Osmolal-255*
___ 06:20AM BLOOD TSH-1.9
Imaging:
___ ECG: There is marked baseline artifact. The rhythm is
probably atrial fibrillation. Left bundle-branch block. No
previous tracing available for comparison. TRACING #1
___ ECG:Again marked baseline artifact is noted in this
tracing. The rhythm is probably atrial fibrillation with
controlled ventricular response. There also appear to be
occasional paced beats. Compared to tracing #1 there is no
diagnostic interval change. TRACING #2
___ ECG: Atrial fibrillation. There is loss of R wave
forces throughout the precordium. There are occasional wide
complex beats which may represent aberrant conduction, although
intermittent pacing may also be present. Compared to tracing #2
the loss of R waves in leads V4-V6 is new. TRACING #3
___ CHEST (PORTABLE AP): FINDINGS: As compared to the
previous radiograph, the extent of the partly loculated pleural
effusions has increased. This is visible both in the fissural
aspect of the pre-existing effusion as well as on the apical
lateral compartment along the right chest wall. Unchanged
evidence of moderate pulmonary edema with associated moderate
cardiomegaly. No new parenchymal opacities. Unchanged position
of the left pectoral pacemaker, unchanged course of the leads.
TEE ___:
There are simple atheroma in the descending thoracic aorta. A
single tilting disk type aortic valve prosthesis is present. It
is well seated and not rocking. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. Mild
(1+) aortic regurgitation is seen, with a trivial amount of
perivalvular leak. The mitral valve leaflets are mildly
thickened. Centrally directed Moderate (2+) mitral regurgitation
is seen. There is no abscess of the tricuspid valve. There is no
pericardial effusion.
CLINICAL IMPLICATIONS: Single tilting disk aortic valve with no
evidence of vegetation or thrombus. Moderate mitral valve
regurgitation.
Cath ___:
COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated native three-vessel coronary artery disease. The
LMCA had no apparent disease. The LAD was proximally occluded,
with the distal vessel territory filling via the patent LIMA.
The LCx had a subtotal occlusion at the ostium of the
previously-placed bare-metal stent. The RCA was totally occluded
in the mid-portion of the vessel, with the distal vessel
territory filling via collaterals from the patent LIMA.
2) Arterial conduit angiography demonstrated a LIMA-LAD that was
free of angiographically-apparent flow-limiting stenoses.
3) Fluoroscopy of the prosthetic aortic valve showed disk motion
that was probably normal; however, it is unclear which type of
prosthesis this is.
4) Limited resting hemodynamics revealed moderately-severe
left-sided filling pressures, with a mean wedge pressure of 22
mmHg. There was moderately severe pulmonary arterial pressures,
with a PA pressure of 66/21 mmHg. The cardiac index was slightly
low at 1.84 l/min/m2.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease.
2. Patent LIMA-LAD.
3. Successful angioplasty of the proximal LCx stent.
4. Moderately severe elevation of left-sided and pulmonary
pressures, with reduced cardiac output.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Warfarin 5 mg PO Frequency is Unknown
3. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp < 100
4. Ranexa *NF* (ranolazine) 1,000 mg Oral BID
5. Simvastatin 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ranexa *NF* (ranolazine) 1,000 mg Oral BID
3. Vitamin D 1000 UNIT PO DAILY
4. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Simvastatin 5 mg PO DAILY
7. Outpatient Lab Work
Please draw a ___ on ___ and fax results to
Name: ___.
Location: ___ MEDICINE
Fax: ___
8. Warfarin 5 mg PO 1X/WEEK (SA)
9. Warfarin 2.5 mg PO 6X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: acute systolic heart failure, coronary artery disease
Secondary: aortic valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Questionable loculated pleural effusion, evaluation for interval
change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the extent of the partly
loculated pleural effusions has increased. This is visible both in the
fissural aspect of the pre-existing effusion as well as on the apical lateral
compartment along the right chest wall.
Unchanged evidence of moderate pulmonary edema with associated moderate
cardiomegaly. No new parenchymal opacities. Unchanged position of the left
pectoral pacemaker, unchanged course of the leads.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA
temperature: 96.9
heartrate: 53.0
resprate: 15.0
o2sat: 97.0
sbp: 127.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ year-old-male with a history of CAD s/p CABG in ___, PCI in
___ and ___, AS s/p AVR in ___, atrial fibrillation on
coumadin, permanent pacemaker, chronic angina, hypertension, and
hyperlipidemia presenting with dyspnea found to have new
systolic CHF (EF ___ and aortic valve lesion and new
hyponatremia, now s/p POBA to ___.
# New-Onset Systolic CHF EF ___: Patient presented with
symptoms of new onset heart failure. TTE showed severe regional
LV systolic dysfunction (EF ___ with akinesis of the
inferior wall, hypokinesis of the lateral and anterior walls
with preservation of the septum which appeared to be new.
Cardiac cath performed on ___ with successful angioplasty of
subtotal occulusion of the left circumflex at the site of the
bare metal stent. Otherwise the LIMA to LAD was patient, mid
RCA occluded with collateral flow. Patient was diuresed with
lasix, discharge weight 76.6kg. He was also started on
lisinopril and metoprolol.
# Aortic Valve s/p AVR: ___ at OSH showing possibly thrombus or
endocarditis of mechanical prosthetic aortic valve. TEE
performed on ___ showed no evidence of vegetation or thombus.
Further no evidence of endocarditis on exam and blood cultures
negative. Patient initially received Vitamin K. He was started
on a heparin drip that was continued until INR was therapeutic
(>2.5).
# Coronary artery disease: Patient has known CAD s/p CABG in
___ ___ to LAD, SVG to RCA (known to be occluded) and SVG to
OM (known to be occluded), also BMS to Left circumflex/OM.
Patient presented with new wall motion abnormalities on ECHO as
described above, EKG without evidence of ischemia, Troponins
elevated with flat CK-MB. Cardiac cath performed ___ as above
with successful angioplasty of LCx stent. Patient continued on
aspirin, ranexa and statin.
# Hyponatremia: Patient presented with hypervolemic
hyponatremia, sodium of 119 and was asymptomatic. Sodium
improved with diuresis to 132.
# HLD: Patient continued on simvastatin. Consider rechecking as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Bactrim
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of COPD, tobacco abuse, atrial fibrillation on
coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm over the past 2 days. He denies any fever or chills. No
chest pain or pressure. No abdominal pain. No recent
hospitalizations. Is not on home oxygen and his normal oxygen
saturation is around 93-95%? but once recently it has been as
low as 88%at his cardiologist's office. + sick contacts in his
dtr and grand dtr who both had URI sx. He has had diarrhea 2x in
the course of hte past month. Prior to the development of this
cough he felt well. He has chronic incontinence since his TURP
and does not report dysuria. He does not have a pulmonologist.
+ rhinorrhea and sratchy throat. He has noticed that he does
wake up sob and has to sleep on 3 pillows for the past year. He
has noticed that he does need to take naps after dinner and he
also takes a nap in the daytime.
.
He has had recent life stressors as he in the process of selling
his 3 family home and moving into an ALF at ___. He is
happy because he is getting a higher ___ for his home than he
asked for. Wife of ___ years has been declining per PCP's recent
note however.
.
In ER: (Triage Vitals:0 98.4 60 164/108 26 99% 6L neb)
Meds Given:
methylprednisone 125 mg IV, kayexelate 30 gm, levofloxacin 750
mg IV
Fluids given: none
Radiology Studies: CXR
consults called. none
Admission VS: 98.8, 60, 157/59, 20, 93% 3LNC
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [+ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
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:rhinorhrea
RESPIRATORY: [] All Normal
[ x] Shortness of breath at rest [+ ] Dyspnea on exertion [
] Can't walk 2 flights [ +] Cough [ ] Wheeze [ +] Purulent
sputum [ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ?] PND [ ] Orthopnea [- ]
Chest Pain [ X] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[- ] Nausea [-] Vomiting [] Abd pain [] Abdominal swelling
[ X] Diarrhea x2 [ +] Constipation - otherwise usually
constipated and has to take colace daily [ ] 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
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
smoker
prostate ca
S/P prostatectomy: in ___
Dr. ___ urinary retention ___ - evaluated by Dr.
___ - no PVR
Anxiety disorder w/ o/c characteristics
Copd - ct in ___ revealed 'severe emphysema'
Htn
hycholesterolemia - CKD Stg IV: Seen by Dr. ___ ___ BID
Renal: q6m renal ___ advised
diastolic dysfunction - echo ___ - impaired relaxation LV
EF > 65 % mild + 1 MR, ___
nuclear stress test NL done due to CP once in ___ while on
distress
anemia - ___ H/H 12.___, MCV 102.8
Irritable bowel
diverticulosis - colonoscopy ___, Dr. ___ 4 hemangioma - MRI ___
restless leg syndrome - on ropenerol: in ___ Dr ___ rhinitis
colonoscopy ___ showing diverticulosis of distal sigmoid
colon, a polyp removed,adenoma, recomended repeat ___ years , or
even ealrier if pt agrees
atrial flutter
sick sinus syndrome
s/p pacemaker ___ f/up by cardiolgy Dr ___ (___) on Warfarin: Mx'd there (not BID System)
Mild unsteady on his feet
___: hyperlipid
___: elev TSH
___: right breast lump, poster to nipple, ref'd Surg
___: FE defic anemia:ef'd gi ___
spinal stenosis
multilevel spondylosis with degenerative disc disease
prominent at L3-4, L4-5, foraminal stenosis at L4-5 and L5-S1
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS: I< ___
Lives with wife and he has 4 children . No ETOH-quit ___ years
ago. 3 beers/night- never drank more than that.
Cigarettes: [ ] never [ ] ex-smoker [x] current Pack-yrs: 10
quit: ______
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: none
Occupation: ___
Marital Status: [ ] Married [] Single
Lives: [ ] Alone [] w/ family [ ] Other:
___ dept of a ___
Received influenza vaccination in the past 12 months [ +]Y [ ]N
Received pneumococcal vaccinationin the past 12 months [ ]Y [ ]N
>65
ADLS:
Independent of ADLS: [ ]dressing [ ]ambulating [ ]hygiene [
]eating [ ]toileting
Requires assitance with: [ [ ]dressing [ ]ambulating [
]hygiene [ ]eating [ ]toileting
IADLS:
Independent of IADLS: [ ]shopping [ ] accounting [ ]telephone
use [ ]food preparation
Requires assitance with IADLS: [ ]shopping [ ] accounting [
]telephone use [ ]food preparation
[ ]has pre-existent home care services
At baseline walks: [ ]independently [ ] with a cane [ ]walker [
]wheelchair at ___
H/o fall within past year: []Y []N
Visual aides [ ]Y [ ]N
Dentures [ ]Y [ ]N
Hearing Aides [ ]Y [ ] N
Family History:
Brother with DM. He is ___ and is "doing well."
Motther died of lung ca and smoker
Father died of asthma and heart disease
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
VS Tm T 98.5 P 60 BP 138/58 RR 18 O2Sat on __92% on 3L __
liters O2
GENERAL: elderly male who looks his stated age. He is in NAD.
Nourishment: at risk
Grooming: good
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [+] Poor dentition - 2 teeth but they do not seem
infected [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
JVP flat
[] Regular [] Tachy [X] S1 [] S2 [X] Systolic Murmur ___,
Location: LUSB
[X] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [] Peripheral [] Central site:
5. Respiratory [ ]
[] CTA bilaterally [ +] Rales- RLL [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [X] WNL
[] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender []
Tender [] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ ]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [] 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 [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [X] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ X]WNL
[X] No cervical ___
TRACH: []present [X]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
Admission Labs: ___
URINE COLOR-Yellow APPEAR-Clear SP ___
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
LACTATE-1.0
GLC-98 BUN-26* CR-1.9* SODIUM-137 POTASSIUM-5.7* CHLORIDE-103
CO2-26
WBC-9.2 RBC-3.82* HGB-13.0* HCT-37.4* MCV-98 MCH-34.0* MCHC-34.7
RDW-12.5
NEUTS-82.2* LYMPHS-9.0* MONOS-5.4 EOS-2.5 BASOS-0.9
PLT COUNT-170
___ PTT-32.6 ___
ECG: atrial paced at 60 bpm with no acute changes.
CXR (___): Frontal and lateral views of the chest
demonstrate irregular opacity punctuated with small lucencies
possibly representing dilated bronchi. This could represent
asymmetric edema versus infection, and could potentially
represent entities such as bronchioloalveolar carcinoma. There
may also be additional opacities in the right middle and left
infrahilar lungs. There is no pneumothorax or pleural effusion.
There is appearance of severe emphysema. Mild cardiomegaly is
unchanged. Mediastinal and hilar contours are within normal
limits. A left pectoral dual-channel pacer/AICD appears stable
in location with leads terminating in the right atrium and right
ventricle. Upper thoracic lordosis is unchanged.
CXR (___) Comparison suggests mild regression of heart size
and thymus, simultaneously lesser marked perivascular haze in
the pulmonary circulation compatible with dehydration in patient
previously suffering from fluid overload. The previously
identified local suspicious hazy densities in the right mid lung
field and lower lobe area as well as left upper lobe area have
all regressed and suggest improvement of the previously
identified multifocal densities suspicious to constitute
exacerbation of the patient's chronic COPD status. No new
parenchymal abnormalities are seen.
Microbiology:
Blood Cultures negative x2
Medications on Admission:
albuterol sulfate [Ventolin HFA] 90 mcg HFA Aerosol Inhaler ___
puffs(s) inhaled every four (4) hours as needed for
cough/wheeze/chest congestion/short of breath mdi with dose
counter ___
carvedilol 25 mg Tablet 1 Tablet(s) by mouth twice a day
(Prescribed by Other diazepam 5 mg Tablet 1 (One) Tablet(s) by
mouth daily
fluticasone [Flovent HFA] 220 mcg Aerosol 2 puffs(s) inhaled
twice a day gabapentin 100 mg Capsule tid
levothyroxine 50 mcg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by
lisinopril 10 mg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by Other mometasone [Nasonex] 50 mcg Spray,
Non-Aerosol 2 sparys in each nostril at ropinirole 2 mg Tablet 1
Tablet(s) by mouth twice a day (Prescribed by Other
rosuvastatin [Crestor] 5 mg Tablet
warfarin 5 mg Tablet 5 days a week and then 2.5 mg for two days
a week
* OTCs *
cholecalciferol (vitamin D3) 1,000 unit Capsule
docusate sodium 100 mg Capsule 1 Capsule(s) by mouth at bedtime
(Prescribed by
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS PRN () as
needed for insomnia.
3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
Disp:*180 neb* Refills:*0*
11. fluticasone 220 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
12. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 ___.
13. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal HS (at bedtime).
14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
16. Supplemental Oxygen Sig: Two (2) liters per minute
continuous: via nasal cannula.
Disp:*1 1* Refills:*0*
17. nebulizer accessories Misc Sig: One (1) nebulizer
machine Miscellaneous use as directed.
Disp:*1 unit* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with shortness of breath and cough. Question
pneumonia.
___.
FINDINGS: Frontal and lateral views of the chest demonstrate irregular
opacity punctuated with small lucencies possibly representing dilated bronchi.
This could represent asymmetric edema versus infection, and could potentially
represent entities such as bronchioloalveolar carcinoma. There may also be
additional opacities in the right middle and left infrahilar lungs. There is
no pneumothorax or pleural effusion. There is appearance of severe emphysema.
Mild cardiomegaly is unchanged. Mediastinal and hilar contours are within
normal limits. A left pectoral dual-channel pacer/AICD appears stable in
location with leads terminating in the right atrium and right ventricle.
Upper thoracic lordosis is unchanged.
IMPRESSION: Findings concerning for multifocal pneumonia. Recommend
treatment and followup to resolution.
emphysema
chk after edma rx
mild cardiomegaly
Radiology Report
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: ___ male patient admitted with COPD exacerbation and
volume overload.
FINDINGS: PA and lateral chest views were obtained with patient in upright
position. Analysis is performed in direct comparison with the next preceding
similar study of ___. Comparison suggests mild regression of
heart size and thymus, simultaneously lesser marked perivascular haze in the
pulmonary circulation compatible with dehydration in patient previously
suffering from fluid overload. The previously identified local suspicious
hazy densities in the right mid lung field and lower lobe area as well as left
upper lobe area have all regressed and suggest improvement of the previously
identified multifocal densities suspicious to constitute exacerbation of the
patient's chronic COPD status. No new parenchymal abnormalities are seen.
The lateral and posterior pleural sinuses remain free as they were before.
IMPRESSION: Improvement of previously diagnosed exacerbation of COPD, patient
with multiple focal parenchymal infiltrates.
The present chest findings are similar to what was noted on a more remote
examination of ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS
temperature: 98.4
heartrate: 60.0
resprate: 26.0
o2sat: 99.0
sbp: 164.0
dbp: 108.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of COPD, tobacco use (ongoing), atrial fibrillation
on coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm found to have multifocal infiltrates consistent with PNA
and COPD exacerbation.
.
## Community-acquired pneumonia: Admission CXR showed multifocal
infiltrates supportive of pneumonia. He completed 7 days of
Levofloxacin symptomatic improvement. Repeat CXR prior to
discharge showed significant regression of the infiltrates noted
on initial CXR.
.
## COPD exacerbation: Symptoms improved with antibiotics as
above as well as 5-day course of Prednisone 40mg daily and
nebulizers. He was discharged home with rx for a nebulizer
machine and Albuterol nebs. He still had mild wheezing on
discharge but overall improved.
.
## Hypoxemia: Patient is not usually on home oxygen and his
normal oxygen saturation is around 93-95% on room air with one
recent finding as low as 88% at his cardiologist's office. Here,
he initially required 3L NC to maintain sats in the low ___.
Despite multiple attempts, he could not be weaned off oxygen
completely. He had consistent desaturation to 85-88% on room air
with ambulation. Therefore, he was discharged on continuous ___
O2 and set up with ___. Repeat CXR prior to discharge showed
improvement of pneumonia and also was not remarkable for volume
overload to account for the persistent hypoxemia.
.
## Tobacco dependence: He was maintained on a Nicotine patch
with good effect. He was told that he cannot smoke now that he
is on supplemental oxygen.
.
The remainder of his medical issues were stable during this
admission.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
Pulmonary embolism
Shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
___ with recent dx of adenocarcinoma of the lung who presents as
transfer from ___ with SOB found to have PE.
The patient was recently admitted to ___ where he underwent a
supraclavicular node bx which was positive for adeno carcinoma
(seep path report below). He was also being treated for a RUL
PNA with amoxicillin and axithromycin. He represented to ___
today for worsening SOB and CTA showed PE. He was transferred to
___ for evaluation for lysis.
In the ED, initial vitals pain ___, T 99.1, HR 90, BP 149/70,
RR 18, 92%RA. No exam documented on ED dash. Labs notable for
unremarkable CBC, Chemistry with Bicarb 19, BUN/Cr ___.
Troponin and BNP negative. Blood cx obtained. Imaging notable
for subsegmental PE, large R effusion and a possible RUL
post-obstructive PNA. Patient was continued on a heparin gtt,
given 1L NS and 2gm Cefpepime. He was ordered for vancomycin but
did not receive it.
Cardiology was consulted for consideration of MASCOT
activation. Given his clinical and hemodynamic stability,
negative troponin and BNP MASCOT was not activated and he was
maintained on a heparin gtt.
On arrival to the floor, pt confirms the above history. In
brief, he reports that he was discharged from ___ on ___ and
worked ___ of this week. ___ he developed
worsening cough and SOB and took ___. His sputum is
occasionally blood tinged. He also found out about the results
of his biopsy this week and was scheduled for a PET-CT on
___ with a plan to f/u with oncology for treatment options
after. He also reports drenching night sweats and chills at
home. He has never been lightheaded. He has some chest
discomfort that has been present for several weeks.
REVIEW OF SYSTEMS: No changes in vision or hearing, no changes
in balance. No palpitations. No nausea or vomiting. No diarrhea
or constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Poorly differentiated Adenocarcinoma of Lung
Social History:
___
Family History:
He had two sisters deceased from cancer, though he is very vague
on details. One is believed to be deceased from breast cancer at
roughly age ___, the other is unclear. Father deceased from heart
disease and alcohol. Mother is still alive. He has 3 other
surviving siblings, reportedly well. His 2 biological sons are
reportedly well, living locally.
Physical Exam:
Admission exam:
Vitals: 98; 143/82; 92; 18; 95%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated
Lungs: Decreased BS at R base, RU exam with faint decrease
relative to L, however no egophany. No wheezes, rales, ronchi. L
lung CTA.
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, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Discharge exam:
Vitals: T:98.5 BP:131/69 P:82 RR:18 O2:94%RA
General- Fatigued; tearful; alert, oriented
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, + lymphadenopathy
Lungs- Normal work of breathing, +coarse rhonchi RML/RLL
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission labs:
___ 11:35PM BLOOD WBC-9.6 RBC-4.56* Hgb-13.8 Hct-39.9*
MCV-88 MCH-30.3 MCHC-34.6 RDW-12.3 RDWSD-39.4 Plt ___
___ 11:35PM BLOOD Neuts-72.3* Lymphs-11.5* Monos-9.0
Eos-5.6 Baso-0.6 Im ___ AbsNeut-6.94* AbsLymp-1.10*
AbsMono-0.86* AbsEos-0.54 AbsBaso-0.06
___ 11:35PM BLOOD Glucose-87 UreaN-21* Creat-1.1 Na-135
K-4.2 Cl-99 HCO3-19* AnGap-21*
___ 11:35PM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1
Discharge labs:
___ 04:50AM BLOOD WBC-8.4 RBC-4.15* Hgb-12.6* Hct-36.8*
MCV-89 MCH-30.4 MCHC-34.2 RDW-12.3 RDWSD-40.2 Plt ___
___ 04:50AM BLOOD ___ PTT-32.1 ___
___ 04:50AM BLOOD Glucose-116* UreaN-16 Creat-1.0 Na-139
K-4.3 Cl-102 HCO3-25 AnGap-16
___ 04:50AM BLOOD Calcium-8.3* Phos-3.5 ___
MRSA swab negative
Pleural fluid studies:
___ 08:36AM PLEURAL WBC-___* ___ Polys-11*
Lymphs-53* Monos-14* Eos-12* Atyps-1* ___ Macro-1* Other-8*
___ 08:36AM PLEURAL TotProt-3.8 Glucose-93 LD(LDH)-552
Albumin-2.4 Cholest-LESS THAN Triglyc-LESS THAN Misc-BODY
FLUID
Pleural fluid culture:
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..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Pleural Fluid Cytology:
POSITIVE FOR MALIGNANT CELLS.
- Metastatic lung adenocarcinoma.
- Immunohistochemical stains show the following pro
file in lesional cells:
Positive: TTF-1
Negative: Napsin A
- Hematology slide reviewed.
Note: The prepared cell block has high tumor cellul
arity.
Imaging:
CXR (___):
Comparison to ___. Minimal improvement of the large
consolidation
in the right lung apex. The paramediastinal consolidations as
well as the
enlargement of the right hilus and of the left hilus are stable.
No new
parenchymal opacities. Stable borderline size of the cardiac
silhouette.
Minimal right pleural effusion.
Bone scan (___):
1. Slightly more intense focus of radiotracer uptake in the
right
inferior sacroiliac joint. Although this likely represents
degenerative change,
dedicated CT pelvis for further evaluation can be obtained if
clinically
indicated.
2. Diffuse right hemithoracic radiotracer uptake corresponds to
a right pleural
effusion.
CT Chest w/ contrast (___):
Massive perihilar lung mass, with bronchial, vascular, and
mediastinal
invasion, severe ipsilateral and contralateral lymphadenopathy,
obstructive
pneumonia, pleural implants, pleural effusion, postobstructive
pneumonia, and
propagation of the process along the bronchi. Known pulmonary
embolism.
Suspicious 1 cm right adrenal mass. No evidence of metastatic
bone disease.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff q4h prn Disp
#*1 Inhaler Refills:*3
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*19 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
4. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 90 mg SC every twelve (12) hours Disp
#*60 Syringe Refills:*0
5. GuaiFENesin ER 600 mg PO Q12H Duration: 3 Days
RX *guaifenesin 600 mg 1 tablet(s) by mouth q12h prn Disp #*20
Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8h prn Disp #*60
Tablet Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
RX *oxycodone 5 mg 1 tablet(s) by mouth q3h prn Disp #*56 Tablet
Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID prn Disp
#*60 Tablet Refills:*0
9. Space Chamber Plus (inhalational spacing device) 1 oral
Q6H:PRN wheezing
Use with albuterol inhaler
RX *inhalational spacing device [ProChamber] as dir Disp #*1
Package Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Malignant pleural effusion
HCAP
Adenocarcinoma of the lung
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Rt effusion s/p thoracentesis // Residual
fluid
IMPRESSION:
In comparison to outside chest x-ray of ___, a right pleural
effusion has decreased in size, with no visible pneumothorax following recent
thoracentesis. Extensive consolidation and atelectasis predominantly
involving the right upper and middle lobes is likely post obstructive from a
right juxta hilar mass more fully evaluated by outside CT of ___.
Bulky intrathoracic lymphadenopathy is also more fully characterized on that
study.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ with recent dx of adenocarcinoma of the lung who presents as
transfer from ___ with SOB found to have PE, pneumonia, and right pleural
effusion, now s/p thoracentesis // eval for metastatic lung cancer,
diaphgragm invasion, bilateral nodules
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: 811 mGy-cm
COMPARISON: No comparison.
FINDINGS:
Small right thyroid nodule. No supraclavicular, infraclavicular or axillary
lymphadenopathy. Several normal sized lymph nodes are seen in the axillary
region. Several markedly enlarged anterior mediastinal lymph nodes (2, 20) as
well as massively enlarged lymph nodes in the aortopulmonary window and in the
pretracheal and paratracheal region (2, 24). Other pathologic lymph nodes are
located at the level of the right and left hilus (2, 30) and in subcarinal
location. As noted in the referring document, there is evidence of pulmonary
embolism (2, 31). There also is a moderate right pleural effusion. In the
upper abdomen, splenic calcifications are noted. A 1 cm right adrenal mass is
visualized (2, 59). There also is a punctate renal calcification on the left
(2, 65). No osteolytic lesions at the level of the ribs, thus sternum, or the
vertebral bodies. Moderate degenerative vertebral disease. No vertebral
compression fractures.
Moderate pulmonary emphysema. Extensive right lymphangitis carcinomatosis a.
extensive right upper lobe predominant consolidation, resulting from partial
obstruction and narrowing of the upper lobe bronchi and tapering of the
supplying arteries (603 a, 58). The consolidation has a more central and a
more peripheral subpleural component (4, 125). On the pleural surfaces (4,
131) multiple nodular implants are noted. The bronchial walls are
substantially thickened and show evidence of mucous impaction. Areas of
pleural thickening are also seen at the basis of the right lower lobe (4,
192).
IMPRESSION:
Massive perihilar lung mass, with bronchial, vascular, and mediastinal
invasion, severe ipsilateral and contralateral lymphadenopathy, obstructive
pneumonia, pleural implants, pleural effusion, postobstructive pneumonia, and
propagation of the process along the bronchi. Known pulmonary embolism.
Suspicious 1 cm right adrenal mass. No evidence of metastatic bone disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with recent dx of adenocarcinoma of the lung who presents as
transfer from AJH with SOB found to have PE, pneumonia, and right pleural
effusion, now s/p thoracentesis // eval for reaccumulation of pleural
effusion eval for reaccumulation of pleural effusion
IMPRESSION:
Comparison to ___. Minimal improvement of the large consolidation
in the right lung apex. The paramediastinal consolidations as well as the
enlargement of the right hilus and of the left hilus are stable. No new
parenchymal opacities. Stable borderline size of the cardiac silhouette.
Minimal right pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 99.1
heartrate: 90.0
resprate: 18.0
o2sat: 92.0
sbp: 149.0
dbp: 70.0
level of pain: 2
level of acuity: 2.0 | ___ y/o M with recent diagnosis of lung adenocarcinoma who
presented as a transfer from ___ with SOB,
found to have bilateral PE's, recurrent malignant right sided
pleural effusion, and post-obstructive pneumonia.
#Acute pulmonary embolism without cor pulmonale: Patient
presented to ___ on ___ with SOB and chest pressure and found
to have bilateral subsegmental PE's on imaging. Hypercoaguable
state secondary to malignancy. Was transferred to ___ for
management and further work-up. On admission to ___, he denied
chest pain or dyspnea and his vitals were stable. His cardiac
workup was negative with unremarkable EKG and negative
troponins. He received heparin on admission and was transitioned
to lovenox. Discharged on lovenox 90mg SC q12h to continue
indefinitely.
#Malignant pleural effusion: On presentation to ___, patient was
found to have a right-sided pleural effusion on imaging. Prior
to this, he had recently undergone a US-guided thoracentesis on
___ at ___ with 60cc fluid drained. Pleural fluid cytology
results were positive for malignant cells. Based on history, was
likely a re-accumulated malignant effusion but there was also
concern for a parapneumonic effusion given the patient's recent
h/o of pneumonia. IP performed a thoracentesis on ___ and 2L
were drained from right pleural effusion. Cultures negative at
both outside hospital and during this hospitalization. Fluid
results were consistent with exudative effusion, cytology
confirmed the presence of malignant cells. Patient was weaned
from 2L oxygen to RA without issues. A repeat CXR on ___ showed
mild right sided pleural effusion, but much improved from
admission. Patient was discharged on oxycodone 5mg and an
outpatient ___ with IP scheduled for ___. He was
counseled on the warning signs which should prompt emergent
re-evaluation such as dyspnea, fever, worsening chest pain,
hemoptysis.
#HCAP: Prior to admission on ___, patient had been treated for
CAP at ___ and completed a ___ day course of Augmentin and
Azithromycin on ___. He represented to ___ on ___ with
productive cough, SOB and fevers/chills. Had CXR and CT torso.
CXR showed evidence of postobstructive pneumonitis in the right
upper lobe with partial
collapse of the right upper lobe. Upon admission to ___, he
was started on vancomycin/cefepime given concern for HCAP(start
date ___. MRSA, legionella, sputum and blood cultures sent.
Sputum culture was not valid and remaining cultures were
negative. Legionella was negative. Patient was switched to
Augmentin PO on ___ to complete a 2 week course to end ___.
He received ipatroprium and albuterol nebs PRN, guaifenesin
600mg BID for management of respiratory sxs, and given a flutter
valve.
#Pain control: Had significant pain secondary to cancer, pleural
effusion, recent procedure. While inpatient his pain management
was oxycodone 5 mg mild pain, oxycodone 10 mg moderate pain,
dilaudid 0.5 mg IV severe pain. He was discharged on
oxycodone 5 mg q3h pain x1 week and bowel regimen with ___
with PCP.
#Stage IV lung adenocarcinoma: Recently diagnosed with
adenocarcinoma with positive lymph node, invasion of mediastinum
and malignant pleural effusion. Cytology was positive for
malignancy at ___ and again on this hospitalization. A recent CT
chest with contrast demonstrated invasion into mediastinum,
vasculature and bronchial tree. CT also showed evidence of
adrenal mass with concern for a possible met. Given malignant
effusion, patient has stage 4. A bone scan on ___ was negative
for bone metastases. The patient has decided to establish care
at ___ and has scheduled an outpatient appt on ___. Summary of
hospital course will be faxed to ___. Imaging results given to
patient in a CD |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Acute ischemic right occipital lobe stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ M with a h/o hypertension,
hyperlipidemia and cerebral palsy (has baseline tone increase on
left with some fine motor difficulties on that side) who has
been
seen in the Cognitive Neurology Clinic by Dr. ___ a ___
year history of progressive irritability and memory issues. As
part of his work up he had a MRI of the brain that showed an
acute left occipital stroke in addition to older
encephalomalacia. He is therefore sent into the ED for admission
for stroke work up.
In regards to the symptoms he was being evaluated for, Mr.
___
has become more irritable and short tempered for the past year.
Around this time, he had some incidents where he couldn't find
his coat despite it being in very obvious places. He started to
take longer to
perform tasks than he had previously and was mis-interpreting
emails and conversations. He has had difficulty remembering to
lock up at the Archive that he works at as well as deactiviating
alerms.
He denies any visual symptoms or acute worsening of his baseline
symptoms.
Past Medical History:
- cerebral palsy resulting in stiffness and weakness of his left
arm and leg. He was born very prematurely at 3lb, 4oz
- hypertension
- hyperlipidemia.
Social History:
___
Family History:
Mother was diagnosed with Alzheimer's Disease
around age ___, and died at age ___ from either a reaction to
Abilify or "old age". His father had "heart problems" and died
in his ___. His brother is healthy at age ___. As far as he
knows no one else in his family has had dementia.
Physical Exam:
ON ADMISSION:
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.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. 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, slight asymmetry in terms of left side
being a little smaller
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, increased tone on left with cupping of left
hand at baseline.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 3 3 1
R 2 2 2 2 1
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. left leg stiffening on walking
ON DISCHARGE: unchanged
Pertinent Results:
Laboratory Data:
___ 09:40AM BLOOD WBC-9.4 RBC-5.29 Hgb-17.4 Hct-48.0 MCV-91
MCH-32.8* MCHC-36.2* RDW-13.3 Plt ___
___ 09:40AM BLOOD Neuts-70.3* ___ Monos-5.8 Eos-2.4
Baso-0.5
___ 09:40AM BLOOD ___ PTT-29.1 ___
___ 09:40AM BLOOD Glucose-111* UreaN-23* Creat-1.3* Na-136
K-4.0 Cl-99 HCO3-24 AnGap-17
___ 06:10AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2
___ 04:20PM BLOOD Cholest-184
___ 04:20PM BLOOD %HbA1c-5.6 eAG-114
___ 04:20PM BLOOD Triglyc-193* HDL-38 CHOL/HD-4.8
LDLcalc-107
Radiologic Data:
CTA ___:
1. No evidence of acute infarction. Chronic infarction in the
right frontal
and parietal lobe.
2. Periventricular white matter low attenuation which is
nonspecific but
likely on the basis of chronic small vessel ischemic disease.
3. Unremarkable MRA of the head without evidence of stenosis,
occlusion, or
vascular malformation.
4. Stenosis at the origin of the left vertebral artery.
Echo ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are moderately thickened. The
aortic valve VTI = 58.4 cm. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: No intracardiac source of thromboembolism
identified. Moderate aortic stenosis. Preserved biventricular
size and systolic function. Normal pulmonary artery systolic
pressure.
ECG ___:
Sinus rhythm with atrial premature depolarizations. Borderline
left atrial abnormality. Minor non-specific repolarization
abnormalities. No previous tracing available for comparison.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QID
2. Lisinopril 20 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin ___ mcg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Chlorthalidone 25 mg PO DAILY
4. Cyanocobalamin ___ mcg PO DAILY
5. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute ischemic right occipital stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: History: ___ with chronic stroke on MRI // evaluate for vascluar
lesions
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered, curved
reformatted and segmented images were generated. This report is based on
interpretation of all of these images.
DOSE: DLP: 2396 mGy-cm; CTDI: 150 mGy
COMPARISON: No prior CTA available for comparison. Prior MRI dated ___.
FINDINGS:
Head CT: There is encephalomalacia in the right frontal and parietal lobe with
ex vacuo dilatation of the right lateral ventricle consistent with prior
infarction in unchanged from prior MRI. There is no evidence of acute
hemorrhage, edema, shift of midline, or extra-axial fluid collection. There is
low attenuation in periventricular white matter which is nonspecific but in
patient of this age likely reflecting chronic small vessel ischemic disease.
There is mucosal thickening within the ethmoids. The remaining paranasal
sinuses and mastoid air cells are clear. The calvarium and skullbase are
intact appear
Head CTA: There are no intracranial vascular abnormalities. There is no
evidence of aneurysm, stenosis or occlusion.
Neck CTA: There is stenosis at the origin of the left vertebral artery. The
carotid and vertebral arteries and their major branches are otherwise patent
with no evidence of stenoses. There is no evidence of internal carotid
stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of acute infarction. Chronic infarction in the right frontal
and parietal lobe.
2. Periventricular white matter low attenuation which is nonspecific but
likely on the basis of chronic small vessel ischemic disease.
3. Unremarkable MRA of the head without evidence of stenosis, occlusion, or
vascular malformation.
4. Stenosis at the origin of the left vertebral artery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABN MRI
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS
temperature: 97.6
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 95.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man man with a history of cerebral
palsy and recent cognitive decline who was found to have an
incidental acute right occipital stroke on his MRI obtained for
cognitive workup. He has no new deficits and is asymptomatic.
Etiology is unclear.
# Acute Stroke: CTA of the head and neck showed patent vessels
and small outpouching of basilar which is likely incidental. He
was switched from Plavix 75mg daily from aspirin for secondary
prevention. He was monitored on tele for afib. His atorvastatin
dose increased from 40mg to 80mg daily. Echo did not reveal
cardiac source. A1c was 5.6% and LDL was 107. No etiology of his
stroke was found and he was discharged with plan for ___
___ to monitor for afib.
# Hypertension: Lisinopril and chlorthalidone were held to allow
for permissive hypertension but were restarted prior to
discharge.
# Cognitive Decline: continued his B-12 for replacement. He will
follow up in neurology clinic for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension
light-headedness
___ swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx DM2 on insulin, CAD, OSA who presents for evaluation of
fatigue and lightheadedness for the last couple weeks.
Pt states that over the last couple weeks he has been more
fatigued with exercise intolerance. He normally walks ~1 mile to
___ but recently has been slower and unable to complete the
walk. He also endorses intermittent episodes of lightheadedness
usually with exertion, not orthostatic. He also endorses b/l
thigh pain and L>R shoulder pain. Denies f/c, CP, palpitations,
orthopnea, PND, DOE. No focal neuro symptoms or vision changes.
BP at ___ ___ and noted to be ___. He went to
PCP
___ ___ and was found to have BP in ___ and was referred to
___
ED. There he had normal labs and a negative ___. The plan was
for observation overnight but pt left AMA given it was the
Sabbath. He continued to experience symptoms and again went to
___ ___ ___ and was referred to the ED.
Past Medical History:
DM
ED
Obesity
angina, stable
CAD
dyslipidemia
s/p angioplasty/stent ___, LAD
Lyme dz
OSA (intolerant of CPAP)
s/p appy
Social History:
___
Family History:
Patient's past medical history is not pertinent to reason for
admission.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
VS: ___ ___ Temp: 97.6 PO BP: 144/70 HR: 67 RR: 18 O2 sat:
96% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: RRR, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 2+ pitting edema b/l to thighs R>L
SKIN: WWP, no obvious rashes
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
==============================
___ 1144 Temp: 98.0 PO BP: 130/71 HR: 68 RR: 18 O2 sat: 91%
O2 delivery: Ra FSBG: 275
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
CARDIAC: RRR, ___ systolic murmur best heard at RUSB; no
rubs/gallops
LUNGS: Crackles in lower lung fields bilaterally, up to middle
lung fields
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 2+ pitting edema b/l to thighs R>L
SKIN: WWP, no obvious rashes
Pertinent Results:
ADMISSION LABS:
===================
___ 05:52PM BLOOD WBC-9.0 RBC-3.70* Hgb-11.4* Hct-36.0*
MCV-97 MCH-30.8 MCHC-31.7* RDW-12.5 RDWSD-44.4 Plt ___
___ 05:52PM BLOOD Neuts-65.9 Lymphs-17.1* Monos-12.1
Eos-3.7 Baso-0.6 Im ___ AbsNeut-5.92 AbsLymp-1.54
AbsMono-1.09* AbsEos-0.33 AbsBaso-0.05
___ 05:52PM BLOOD Glucose-78 UreaN-34* Creat-1.2 Na-142
K-4.7 Cl-103 HCO3-25 AnGap-14
___ 05:52PM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9
___ 05:52PM BLOOD CRP-8.6*
___ 07:11AM BLOOD Cortsol-12.7
___ 05:57PM BLOOD Lactate-0.9
DISCHARGE LABS:
===================
___ 06:58AM BLOOD WBC-7.0 RBC-3.52* Hgb-10.9* Hct-34.1*
MCV-97 MCH-31.0 MCHC-32.0 RDW-12.7 RDWSD-44.4 Plt ___
___ 06:58AM BLOOD Plt ___
___ 06:58AM BLOOD Glucose-142* UreaN-19 Creat-1.0 Na-142
K-4.5 Cl-103 HCO3-26 AnGap-13
IMAGING
CTA CHEST AND CT ABDOMEN ___:
===========================================
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Interval increase in retroperitoneal and mediastinal
lymphadenopathy,
compared to ___, raising the possibility of chronic lymphocytic
leukemia.
Interval stability to minimal increase in pelvic
lymphadenopathy. If biopsy is to be considered, an enlarged
right external iliac node (304:73) may be amenable to sampling.
3. Moderate bilateral pleural effusions with associated
atelectasis.
4. Diffuse, moderate bronchial wall thickening, most prominent
within the
bilateral lower lobes, suggestive of inflammation.
5. Cholelithiasis, without evidence of acute cholecystitis.
TTE ECHOCARDIOGRAM:
=======================
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Mildly dilated LA.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Mildly dilated RA. Dilated
IVC with normal inspiratory collapse==>RA pressure ___ mmHg.
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity
size. Normal regional/global systolic
function. The visually estimated left ventricular ejection
fraction is 55-60%. No resting outflow tract gradient.
Tissue Doppler suggests elevated PCWP.
RIGHT VENTRICLE (RV): Mild cavity enlargement. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter.
AORTIC VALVE (AV): Mildly thickend (3) leaflets. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Normal leaflets. No systolic prolapse.
Trivial regurgitation.
PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Moderate [2+]
regurgitation. Moderate pulmonary artery systolic
hypertension.
PERICARDIUM: No effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Senna 17.2 mg PO HS
3. Docusate Sodium 100 mg PO BID
4. ___ 0.4 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Levemir 32 Units Breakfast
Levemir 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. dulaglutide 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Medications:
1. Levemir 32 Units Breakfast
Levemir 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. dulaglutide 0.75 mg/0.5 mL subcutaneous 1X/WEEK
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Senna 17.2 mg PO HS
9. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication
was held. Do not restart Metoprolol Succinate XL until okay with
PCP or cardiologist
10. HELD- ___ 0.4 mg PO DAILY Duration: 1 Dose This
medication was held. Do not restart ___ until you speak
to your PCP as it may be making you dizzy.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
--------------
Pulmonary Hypertension
lower extremity edema, bilateral
weakness
lymphadenopathy
bilateral pleural effusions
thickened bronchial walls
Secondary:
--------------
insulin dependent diabetes mellitus
coronary artery disease with stent placed in past
obesity
sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest and CT abdomen and pelvis.
INDICATION: ___ year old man with new pulmonary hypertension. Evaluate for
pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 36.2 cm; CTDIvol = 23.6 mGy (Body) DLP = 852.8
mGy-cm.
2) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 24.1 mGy (Body) DLP =
1,231.7 mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 5.4 mGy (Body) DLP = 2.7
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 24.2 mGy (Body) DLP =
12.1 mGy-cm.
Total DLP (Body) = 2,101 mGy-cm.
COMPARISON: CT torso ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: 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. Moderate coronary artery calcifications. Mild aortic
valvular calcifications. The heart is mildly enlarged. Otherwise, the heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen. The main pulmonary artery is top-normal in size. Mild
atherosclerotic calcifications of the thoracic aorta.
AXILLA, HILA, AND MEDIASTINUM: Multiple mediastinal nodes are prominent to
enlarged. For example, several enlarged right paratracheal nodes measure up
to 1.7 cm (302:67), previously 1.2 cm compared to the study from ___.
Multiple, bilateral prepectoral and axillary nodes are prominent, but not
pathologically enlarged by CT size criteria. No hilar lymphadenopathy. No
mediastinal mass.
PLEURAL SPACES: Moderate bilateral pleural effusions with associated
atelectasis. No pneumothorax.
LUNGS/AIRWAYS: The study is not optimized for evaluation of the lung
parenchyma. Within these confines, aside from the aforementioned findings,
the lungs are clear without masses or areas of parenchymal opacification.
Diffuse, moderate bronchial wall thickening is most prominent within the
bilateral lower lobes. The airways are patent to the level of the segmental
bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Tiny hyperdense stones layer within the
gallbladder. No evidence of wall thickening or pericholecystic stranding.
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.
A right renal subcentimeter hypodensity in the upper pole is too small to
characterize. 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. There is no free
intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Coarse calcification within the prostate. A penile
prosthesis is in place, partially imaged.
LYMPH NODES: Multiple retroperitoneal nodes are enlarged, increased in size
from ___. For example, a retroaortic node measures 1.4 cm, previously 1.3 cm
(304:38). A retrocaval lymph node now measures 1.4 cm (304:40), previously
1.1 cm. Prominent bilateral iliac chain and right pelvic sidewall nodes
appear stable to minimally increased in size (for example, 304:70, 304:65).
Enlarged bilateral external iliac nodes measuring up to 1.9 cm (304:73, 75)
are stable from prior.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: Moderate, fat containing paraumbilical hernia.
Otherwise, the abdominal and pelvic wall is within normal limits. There is no
evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Interval increase in retroperitoneal and mediastinal lymphadenopathy,
compared to ___, raising the possibility of chronic lymphocytic leukemia.
Interval stability to minimal increase in pelvic lymphadenopathy. If biopsy
is to be considered, an enlarged right external iliac node (304:73) may be
amenable to sampling.
3. Moderate bilateral pleural effusions with associated atelectasis.
4. Diffuse, moderate bronchial wall thickening, most prominent within the
bilateral lower lobes, suggestive of inflammation.
5. Cholelithiasis, without evidence of acute cholecystitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:01 pm, 1 minutes after discovery of
the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypotension
Diagnosed with Acute kidney failure, unspecified
temperature: 96.7
heartrate: 57.0
resprate: 16.0
o2sat: 95.0
sbp: 137.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
==================
___ hx DM2 on insulin, CAD, OSA who was referred to the ED by
his primary care physician after outpatient BP readings showed
borderline hypotension to 90 systolic, also reporting
fatigue and lightheadedness for the last 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with remote history of small bowel resection and ?right
colectomy with ileocolic anastomosis recently admitted to ___ colorectal surgery service ___ to ___ with a
complete obstruction at the site of his prior anastomosis for
which he underwent an exploratory laparotomy, extensive LOA,
ileocolectomy with new ileocolic anastomosis formation, and
incicisional hernia repair with Dr. ___ on ___. He now
re-presents to ___ in transfer from ___ with
bilious emesis similar to his prior obstruction and a CT scan
showing SBO with tapering/transition at a loop that runs near
his
RLQ anastomosis where he has significant ___
inflammation, also with enteritis of the small bowel distal to
the transition point. Patient states he hasn't passed gas in a
couple days, has been having waves of abdominal pain since
yesterday that are relieved when he vomits brown/green
non-bloody
fluid, and that his last BM was last night and was black and
liquidy (says he has been having black liquidy stools for most
of
his time at the rehab since being discharged from ___. Last
meal was ___ from the best he can remember.
ROS:
(+) per HPI, also says he has had some chills.
(-) Denies fevers, chest pain, SOB, cough,
dizziness/lightheadedness, syncope, difficulty urinating, or
pain
or swelling in his legs.
Past Medical History:
Type 2 diabetes mellitus
Diabetic neuropathy with recurrent diabetic foot ulcers
Admission to ___ for multilobar pneumonia,
infected left great toe neuropathic ulcer, wound culture growing
MSSA ___
COPD
Lung nodules
Coronary artery disease, stable angina pectoris
Hypertension
Hyperlipidemia
Right patellar chondromalacia, degenerative joint disease
Colon adenomas
Cerebral cysts
BPH, urinary retention
Constipation
Hypothyroidism
B-12 deficiency anemia
Incisional hernia
History of heavy alcohol abuse
Frontal temporal dementia without behavioral disturbance
Severe insomnia
Depression
Orthostatic hypotension
Past Surgical History:
Left great toe amputation for osteomyelitis
Left second toe amputation
History of small bowel obstruction ×3 since ___, status post
Small bowel resection with ileocolonic anastomosis, no details
available
Right knee arthroscopy
Appendectomy
Hernia repair
Tonsillectomy
Social History:
___
Family History:
Mother with diabetes, ___ dementia in her ___,
father had coronary artery disease, MI in late ___, some heart
problems and died in his mid ___
Physical Exam:
Physical Exam on Admission:
Vitals: T 98.3, HR 76, BP 166/82, RR 18, SPO2 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
ABD: Soft, obese, not appreciably distended, diffusely TTP but
no
R/G, midline incision with staples appears to be healing well
with no surrounding erythema, breakdown, or drainage to
correlate
with the fluid collection seen in his incision on imaging, left
abdominal port site also well healing with no evidence of
infection or breakdown
DRE: normal tone, no masses appreciated, no stool obtained to
test FOB, no gross blood
Ext: No ___ edema, ___ warm and well perfused
Physical Exam on Discharge
General: doing well, tolerating a regular diet, pain controlled,
ambulating, mental status at baseline pleasant and oriented to
himself however is poor historian.
VSS
Neuro: baseline, oriented to self
Cardio/Pulm: no chest pain or shortness of breath
Abd: midline incision staples removed, 5 cm area of proximal
incision opened and packed with wick draining small amounts of
serosang drainage, rest of incision with steristrips and is well
approximated without signs of infection, abdomen is soft and
nondistended.
___: no pedal edema, gait strong
Pertinent Results:
___ 07:42AM BLOOD WBC-2.8* RBC-3.10* Hgb-9.6* Hct-29.8*
MCV-96 MCH-31.0 MCHC-32.2 RDW-12.8 RDWSD-44.4 Plt ___
___ 07:35AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.2* Hct-28.4*
MCV-95 MCH-30.9 MCHC-32.4 RDW-12.7 RDWSD-44.6 Plt ___
___ 11:20AM BLOOD WBC-5.6 RBC-3.12* Hgb-9.6* Hct-29.7*
MCV-95 MCH-30.8 MCHC-32.3 RDW-12.9 RDWSD-45.1 Plt ___
___ 06:40AM BLOOD WBC-9.2 RBC-3.25* Hgb-10.0* Hct-31.0*
MCV-95 MCH-30.8 MCHC-32.3 RDW-13.1 RDWSD-46.4* Plt ___
___ 03:41PM BLOOD WBC-12.1* RBC-3.60* Hgb-11.2* Hct-34.0*
MCV-94 MCH-31.1 MCHC-32.9 RDW-13.0 RDWSD-45.4 Plt ___
___ 06:55AM BLOOD WBC-11.5* RBC-3.73* Hgb-11.6* Hct-35.4*
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.1 RDWSD-45.2 Plt ___
___ 06:55AM BLOOD Neuts-85.0* Lymphs-7.7* Monos-6.1
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.77* AbsLymp-0.88*
AbsMono-0.70 AbsEos-0.03* AbsBaso-0.03
___ 07:42AM BLOOD Plt ___
___ 07:35AM BLOOD Plt ___
___ 11:20AM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 03:41PM BLOOD Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD ___ PTT-27.4 ___
___ 07:42AM BLOOD Glucose-92 UreaN-3* Creat-0.9 Na-142
K-3.6 Cl-106 HCO3-25 AnGap-11
___ 07:35AM BLOOD Glucose-103* UreaN-6 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-10
___ 11:20AM BLOOD Glucose-142* UreaN-8 Creat-1.0 Na-137
K-3.6 Cl-100 HCO3-27 AnGap-10
___ 06:40AM BLOOD Glucose-129* UreaN-11 Creat-1.1 Na-140
K-4.0 Cl-100 HCO3-29 AnGap-11
___ 06:55AM BLOOD Glucose-126* UreaN-9 Creat-0.9 Na-141
K-4.3 Cl-100 HCO3-27 AnGap-14
___ 07:42AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2
___ 07:35AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.4
___ 11:20AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7
___ 06:40AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.6
___ 06:55AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
___ 06:40AM BLOOD Vit___-___
___ 06:40AM BLOOD TSH-2.3
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 50 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. QUEtiapine Fumarate 150 mg PO QHS
6. Simvastatin 10 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. TraZODone 50 mg PO QHS
9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
11. Melatin (melatonin) 3 mg oral QHS
12. Enoxaparin Sodium 40 mg SC Q24H
mucinex ___ bid
Discharge Medications:
1. GuaiFENesin ER 600 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO TID
please take for 14 days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*42 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
5. Citalopram 40 mg PO DAILY
6. Enoxaparin Sodium 40 mg SC Q24H Duration: 9 Days
please take until ___, 9 more days, prevents blood clots
after surgery
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp
#*9 Syringe Refills:*0
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Melatin (melatonin) 3 mg oral QHS
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
11. QUEtiapine Fumarate 150 mg PO QHS
12. Simvastatin 10 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SBO, NG tube, dyspnea// assess for NG tube
placement
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___
FINDINGS:
The enteric tube is seen extending to the left upper quadrant with tip beyond
view. The level of the side port of the enteric tube is not well assessed.The
lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. Moderate to large amount of gas is seen within the stomach.
IMPRESSION:
1. Enteric tube is seen extending to the left upper quadrant with tip out of
view of the image. Moderate to large amount of gas is seen within the stomach.
2. No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, SBO, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 98.3
heartrate: 80.0
resprate: 15.0
o2sat: 98.0
sbp: 161.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ presented to the ED of ___ on ___ for
management of small bowel obstruction. He was admitted to the
colorectal surgery unit for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending: ___.
Chief Complaint:
tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o DMII, CAD, and sCHF (LVEF <25% in ___ s/p
recent L salpingoopherectomy (discharged ___ for an enlarged
adnexal mass admitted with tachycardia and abdominal pain.
On ___, pt underwent LSO for L adnexal mass (found to be serous
cystadenoma, peritoneal cytology negative). Surgery was c/b
extensive adnesions and omental bleeding and pt required
laparotomy, L salpingo-ooperectomy and intubation over night.
She was admitted to the ICU with post-op course complicated by
respiratory failure, HCAP and e. coli/enterococcus UTI, as well
as L shoulder pain. She was treated with clindamycin -->
levofloxacin ___ - ___ 10d course intended).Discharged
home, but developed nausea, vomiting, diarrhea and readmitted
with symptoms felt secondary to viral gastroenteritis. She
returns today with palpitations, nausea, vomiting x 3 days with
worsening pain, most tender in her midepigastrium to LUQ. Pain
is non pleuritic, no associated dyspnea. + Sick contacts. Also
with chronic R shoulder pain s/p surgery.
.
On arrival to the ED, initial vitals were T: 98.7 HR: 70 bp:
148/100 02 SAT 100% RA. CT abdomen and pelvis was none
revealing. She was found to have increased creatine from 1.0 to
2.1 and was having mid epigastic pain thus she was admitted to
medicne.
Currently, she has diffuse abdominal TTP, worse at site of
recent surgery (steri strips in place). Denies chest pain.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Type 2 diabetes mellitus (A1C 6.4% in ___
- Coronary artery disease (s/p cath ___, no stents)
- Left bundle branch block
- Congestive heart failure due to cardiomyopathy ___ EF 20%)
- Asthma (FEV1 79%)
- Hypertension
- Obesity
- GERD
- Diverticulitis
- Lung adenocarcinoma s/p resection in ___ (PET neg)
- Breast cancer s/p mastectomy remotely
- Former tobacco use
- Mastectomy
- VATS wedge resection
Social History:
___
Family History:
Mother died of diabetic complications at age ___, she didn't know
her father.
Physical Exam:
ADMISSION EXAM:
VS - Temp 98.6 BP: 123/82 HR: 108 rr:22 98% RA
R , R , O2-sat % RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/diffusely TTP, worst at surgicalsite,
steris in place, no drainage, erythema,swelling. no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred
DISCHARGE EXAM:
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/none tender to palpation, steris in
place, no drainage, erythema,swelling. no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred
Pertinent Results:
ADMISSION LABS:
___ 11:58PM ALT(SGPT)-14 AST(SGOT)-15 LD(LDH)-168
CK(CPK)-51 ALK PHOS-62 TOT BILI-0.4
___ 11:58PM LIPASE-54
___ 11:58PM CK-MB-2 cTropnT-0.02*
___ 12:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG
___ 12:35PM URINE RBC-2 WBC-48* BACTERIA-FEW YEAST-NONE
EPI-2 TRANS EPI-<1
___ 12:35PM URINE HYALINE-18*
___ 12:35PM URINE MUCOUS-FEW
___ 10:51AM LACTATE-1.5
___ 10:45AM GLUCOSE-228* UREA N-24* CREAT-2.1*#
SODIUM-136 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-19* ANION GAP-20
___ 10:45AM CK(CPK)-43
___ 10:45AM cTropnT-0.03*
___ 10:45AM CK-MB-2
___ 10:45AM WBC-12.0* RBC-3.99* HGB-12.0 HCT-38.0 MCV-95
MCH-30.0 MCHC-31.6 RDW-15.1
___ 10:45AM NEUTS-71.0* ___ MONOS-4.6 EOS-1.6
BASOS-0.2
___ 10:45AM PLT COUNT-432
___ 10:45AM ___ PTT-25.2 ___
.
DISCHARGE LABS:
___ 09:45AM BLOOD WBC-9.2 RBC-3.44* Hgb-10.0* Hct-31.8*
MCV-93 MCH-29.0 MCHC-31.4 RDW-14.8 Plt ___
___ 10:30AM BLOOD WBC-8.8 RBC-3.23* Hgb-9.3* Hct-30.2*
MCV-94 MCH-28.9 MCHC-30.9* RDW-14.8 Plt ___
___ 09:45AM BLOOD Plt ___
.
___ 12:35 pm URINE
MICRO:
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT) ___
IMPRESSION: Moderate degenerative change of the left
acromioclavicular joint.
.
CXR ___
The cardiac silhouette remains enlarged. The mediastinum is
stable. Slight
tortuosity of a calcified aorta. No definite focal
consolidation is seen on
the current examination. No large pleural effusion or evidence
of
pneumothorax. Chain sutures are again seen overlying the left
upper
hemithorax. No overt pulmonary edema. No evidence of free air
is seen
beneath the diaphragms.
IMPRESSION:
Persistent cardiomegaly without other acute process seen.
.
CT ABDOMEN/PELVIS ___
FINDINGS:
LUNG BASES: Partially imaged is a right lower lobe 5 mm
pulmonary nodule (2,
image 1), stable since at least ___. There is no pleural
or pericardial
effusion.
ABDOMEN: Non-contrast-enhanced liver, gallbladder, spleen,
pancreas, and
adrenal glands are unremarkable. There are bilateral
extrarenal pelves and
minimal fullness of the renal collecting systems bilaterally.
There is a
small hiatal hernia. The stomach is relatively collapsed. No
evidence of
bowel obstruction is seen in the upper abdomen. There is no
upper abdominal
free fluid or free air. Underlying the patient's surgical wound
in the
anterior upper abdomen, an area of fat stranding is seen, deep
to the incision
site without drainable fluid collection, similar in extent as
compared to the
prior study. Evidence of vertical incision along the midline of
the abdomen
and pelvis is seen in the subcutaneous soft tissues.
PELVIS: The appendix is normal in caliber and contains
high-density material.
Trace amount of mesenteric fluid/hemorrhage is stable. Patient
is status post
recent oophorectomy. Small amount of intermediate density fluid
in the pelvis
appears slightly decreased and may be post-surgical and
hemorrhagic.
Calcified uterine fibroids are again seen. The bladder is
unremarkable and
thin-walled. No free air is seen.
OSSEOUS STRUCTURES: No acute fracture or dislocation. Vacuum
phenomenon is
again seen at L3/L4. Osseous structures are unchanged.
IMPRESSION: No significant interval change in postoperative
changes along the
anterior abdomen as well as in the pelvis. Stable small amount
of mesenteric
fluid. Mild fullness of the renal collecting systems, but
stable.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3000mg/day
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
3. Aspirin 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Isosorbide Mononitrate 30 mg PO DAILY
hold for BP<100
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold for sedation, RR<12
7. Bisacodyl 10 mg PO DAILY:PRN CONSTIPATION
8. Docusate Sodium 100 mg PO BID
HOLD FOR DIARRHEA
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Valsartan 80 mg PO DAILY
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
12. Senna 1 TAB PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3000mg/day
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN CONSTIPATION
5. Docusate Sodium 100 mg PO BID
HOLD FOR DIARRHEA
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate 30 mg PO DAILY
hold for BP<100
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold for sedation, RR<12
10. Senna 1 TAB PO BID
11. Valsartan 80 mg PO DAILY
12. Metoprolol Succinate XL 200 mg PO DAILY
13. Nitrofurantoin (Macrodantin) 100 mg PO BID
RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1
capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Pyelonephritis
Secondary
? Gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Pain, non-small cell lung cancer, four views left shoulder.
COMPARISON: None.
FOUR TOTAL VIEWS LEFT SHOULDER: The glenohumeral joint is preserved. There
is no acute fracture or dislocation. There are no amorphous soft tissue
calcifications. The acromioclavicular joint demonstrates moderate
degenerative changes. There are chain sutures within the left lung apex from
prior surgery. The heart is enlarged.
IMPRESSION: Moderate degenerative change of the left acromioclavicular joint.
Radiology Report
HISTORY: Left shoulder pain
TECHNIQUE: Single AP upright portable view of the chest.
COMPARISON: ___.
FINDINGS:
The cardiac silhouette remains enlarged. The mediastinum is stable. Slight
tortuosity of a calcified aorta. No definite focal consolidation is seen on
the current examination. No large pleural effusion or evidence of
pneumothorax. Chain sutures are again seen overlying the left upper
hemithorax. No overt pulmonary edema. No evidence of free air is seen
beneath the diaphragms.
IMPRESSION:
Persistent cardiomegaly without other acute process seen.
Radiology Report
EXAM: Non-contrast-enhanced CT of the abdomen and pelvis.
CLINICAL INFORMATION: History of oophorectomy 20 days ago with abdominal pain
and nausea.
___.
TECHNIQUE: Non-contrast-enhanced CT images of the abdomen were obtained.
Reformatted coronal and sagittal images were also obtained.
FINDINGS:
LUNG BASES: Partially imaged is a right lower lobe 5 mm pulmonary nodule (2,
image 1), stable since at least ___. There is no pleural or pericardial
effusion.
ABDOMEN: Non-contrast-enhanced liver, gallbladder, spleen, pancreas, and
adrenal glands are unremarkable. There are bilateral extrarenal pelves and
minimal fullness of the renal collecting systems bilaterally. There is a
small hiatal hernia. The stomach is relatively collapsed. No evidence of
bowel obstruction is seen in the upper abdomen. There is no upper abdominal
free fluid or free air. Underlying the patient's surgical wound in the
anterior upper abdomen, an area of fat stranding is seen, deep to the incision
site without drainable fluid collection, similar in extent as compared to the
prior study. Evidence of vertical incision along the midline of the abdomen
and pelvis is seen in the subcutaneous soft tissues.
PELVIS: The appendix is normal in caliber and contains high-density material.
Trace amount of mesenteric fluid/hemorrhage is stable. Patient is status post
recent oophorectomy. Small amount of intermediate density fluid in the pelvis
appears slightly decreased and may be post-surgical and hemorrhagic.
Calcified uterine fibroids are again seen. The bladder is unremarkable and
thin-walled. No free air is seen.
OSSEOUS STRUCTURES: No acute fracture or dislocation. Vacuum phenomenon is
again seen at L3/L4. Osseous structures are unchanged.
IMPRESSION: No significant interval change in postoperative changes along the
anterior abdomen as well as in the pelvis. Stable small amount of mesenteric
fluid. Mild fullness of the renal collecting systems, but stable.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: TACHYCARDIA
Diagnosed with TACHYCARDIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, ABN SERUM ENZY LEVEL NEC
temperature: 97.6
heartrate: 121.0
resprate: 20.0
o2sat: 100.0
sbp: 114.0
dbp: 59.0
level of pain: nan
level of acuity: 1.0 | BRIEF HOSPITAL COURSE:
Tachycardia: Ms ___ presented to the ED with tachycardia.
Serial cardiac enzymes were performed, trending down from 0.03
to 0.02. There
# Tachycardia: Ms ___ presented with palpitations found to be
dehydrated and tachycardic in ED following poor p.o intake with
likely demand ischemia with associated mild troponin leak that
trended down (0.03 to 0.02) and EKG not suggestive of myocardial
infarction. Much improved after IVF. HR wnl, patient remained
chest pain free. Her PCP should arrange for an outpatient stress
test. She will continue home services, ___ to review that she is
taking adequate p.o intake.
.
Abdominal pain: pt with diffuse abdominal pain initially, with
pain resolved on discharge. She had also endorsed associated n/v
and found to have UTI. Pain did not appear related to recent
surgery and CT abdomen and pelvis did not reveal any acute bowel
pathology. She was started empirically on IV ciprofloxacin,
switched to nitrofurantoin based on sensitivities from prior
urine cultures. A urine culture performed this hospitalization
was contaminated and she was treated empirically for UTI with
nitrofurantoin for planned 7 day total antibiotic course.
.
# CKI: pt with Cr from 2.1 from 1.0 in setting of n/v and poor
p.o intake leading to dehydration, with ___ likely prerenal in
etiology.Cr improved to 1.2 from 2.1 after receiving intravenous
fluids.
.
# s/p L salpingoopherectomy; pathology shows large cyst. Steri
strips remained in place per ob/gyn. She will f/u with her
gynecologist at ___.
.
# Recent shoulder surgery: continue home physical therapy.
.
# Anemia: pt had 8 point HCT drop from 38 to 30.2 in the setting
of receiving intravenous fluids. This HCT was believed to be
dilutional with subsequent HCT trend showing increase in HCT to
31.8 consistent with this. She should have repeat HCT check on
follow up with her PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Celebrex
Attending: ___.
Chief Complaint:
dypsnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ gentleman with high risk MDS
currently on cycle 14 of decitabine, CKD III, chronic pleural
effusions, diastolic heart failure, hypertension, and atrial
tachycardia (previously on amiodarone, not on any
anti-arrhythmics currently) who was recently admitted to ___ for
HCAP and is now readmitted for shortness of breath with sputum
culture from ___ is growing ___ transferred to the ICU for
Afib with RVR on ___ for management, controlled with Dilt drip,
transitioned to metoprolol, and now asymptomatic with normal
hemodynamics, currently followed by ID for positive AFB sputum
however most recent cultures negative and noted for +klebsiella
PNA.
Past Medical History:
In ___, he was found upon routine lab testing with his
PCP he was found to be anemic with a hemoglobin down to 8.2. He
had normal WBC and platelets were slightly decreased at 132k. He
was referred to hematology and bone marrow biopsy was performed
on ___ which revealed the following: Hypercellular marrow
with trilineage hematopoiesis,left shifted myeloid hyperplasia
and multilineage dysplasia. Peripheral blood smear with absolute
monocytosis and circulating blasts, consistent with myeloid
neoplasm, best classified as CMML-1. CD34+, CD117+ myeloid
blasts comprising ___ of the marrow cellularity. Aspirate
smear with 500 cell count reveals 7% blasts. Cytogenetics
reveal: 46,XY,inv(3)(q21q26,2)[22]. FISH panel for MDS is
normal. CBC done on ___ revealed WBC: 12.4 with ANC of 8.1
Hgb/Hct: 7.4/25.2 Plts: 268k
IPSS-R
Cytogenetics: Poor Inv (3), Score: 3
Marrow Blasts: ___, Score: 2
Hemoglobin: 7.4, Score: 1.5
ANC:8.1, Score: 0
Platelet Count: 268k, Score: 0
____________________________________________
Total Score: 6.5 Very High
PAST MEDICAL/SURGICAL HISTORY:
- MDS
- Chronic diastolic CHF
- Hypertension
- Stage IV CKD
- Hypercholesterolemia
- Gout
- Hypothyroidism
- Anxiety
- Lap chole ___
Social History:
___
Family History:
Father: deceased at age ___- CAD
Mother: deceased at age ___- ?MDS/leukemia.
Had six siblings, 3 siblings (sisters) are alive between the
ages
of ___ all in relatively good health.
Physical Exam:
Admission Physical Exam:
Vitals: 98.3 PO 131 / 37 R Sitting 66 20 95 RA
Gen: comfortable, laying in bed
HEENT: MMM, JVP slightly up, oropharynx clear
CV: RRR
Abd: Soft, NT/ND
Lungs: Crackles at bases.
Ext: No edema
Chest: Port accessed, site clean
Discharge Physical Exam:
VS: TC 97.8 133/31 63 18 96%RA
I/O: 1100/1000 BM x 1
Gen: comfortable, sitting in chair
HEENT: MMM, JVP slightly up, oropharynx clear
CV: s1/s2. RRR
Abd: Moderately protuberant w/ well healed midline abdominal
scar. Multiple ecchymosis from heparin injections. + hernia
lateral to midline scar. Soft/Rounded, NT/ND, + BS
Lungs: Mild cough on exam; Crackles at b/l bases > R, no
wheezing
or rhonchi
Ext: Trace BLE edema; no tremors
Chest: Port accessed, site w/o erythema, tenderness or discharge
Skin: No rashes, eruptions or skin breakdown
Neuro: No focal deficits, alert and oriented x 3
Pertinent Results:
___ 06:37AM BLOOD WBC-3.6* RBC-2.98* Hgb-7.8* Hct-24.7*
MCV-83 MCH-26.2 MCHC-31.6* RDW-15.9* RDWSD-47.2* Plt ___
___ 10:30AM BLOOD WBC-11.2* RBC-2.84* Hgb-6.9* Hct-23.0*
MCV-81* MCH-24.3* MCHC-30.0* RDW-16.7* RDWSD-48.5* Plt ___
___ 06:37AM BLOOD Neuts-39 Bands-0 ___ Monos-17*
Eos-0 Baso-15* ___ Myelos-0 Blasts-3* AbsNeut-1.40*
AbsLymp-0.94* AbsMono-0.61 AbsEos-0.00* AbsBaso-0.54*
___ 10:30AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-7
Eos-0 Baso-2* ___ Myelos-0 NRBC-2* AbsNeut-8.74*
AbsLymp-1.46 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.22*
___ 06:37AM BLOOD Glucose-105* UreaN-27* Creat-1.0 Na-137
K-4.4 Cl-101 HCO3-25 AnGap-15
___ 10:30AM BLOOD UreaN-62* Creat-1.8* Na-136 K-4.2 Cl-102
HCO3-21* AnGap-17
___ 06:37AM BLOOD ALT-22 AST-26 LD(___)-235 AlkPhos-120
TotBili-0.4
___ 10:30AM BLOOD ALT-19 AST-21 LD(LDH)-279* AlkPhos-90
TotBili-0.6
___ 06:37AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.8 Mg-2.2
___ 10:30AM BLOOD TotProt-6.0* Albumin-3.8 Globuln-2.2
Calcium-8.8 Phos-3.4 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Benzonatate 200 mg PO TID:PRN cough
4. Exjade (deferasirox) 500 mg oral BID
5. Furosemide 40 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. PARoxetine 20 mg PO DAILY
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Simvastatin 10 mg PO QPM
13. Aspirin 81 mg PO DAILY
14. ValACYclovir 1000 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gm IV q24 hrs
Disp #*7 Intravenous Bag Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Benzonatate 200 mg PO TID:PRN cough
6. Furosemide 40 mg PO BID
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Simvastatin 10 mg PO QPM
14. ValACYclovir 1000 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MDS
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ man with myelodysplastic syndrome, hemoptysis,
fever/chills, evaluate for pneumonia versus tuberculosis
TECHNIQUE: MDCT axial images were obtained through the chest. Coronal and
sagittal reformatted images were acquired. Axial MIP images were also
obtained.
DOSE: Total DLP (Body) = 567 mGy-cm.
COMPARISON: Chest CT ___ and ___
FINDINGS:
The thyroid is unremarkable. Scattered axillary lymph nodes are not
pathologically enlarged. Prominent supraclavicular lymph nodes measure up to
9 mm on the left, unchanged from ___. Mildly enlarged mediastinal lymph
nodes are also unchanged from ___ measuring up to 16 mm in the right lower
pretracheal station.
The thoracic aorta is normal in caliber with moderate atherosclerotic
calcification. Main pulmonary trunk is not enlarged. Heart size is mildly
enlarged. Coronary artery calcifications are moderate, as are aortic annular
calcifications. Relative low density of the blood pool is likely related to
underlying anemia.
The airways are patent to the segmental level. Motion at the lung bases
limits evaluation of subsegmental airways. There has been interval
progression of multifocal consolidative and ground-glass opacities, compared
to prior, with multiple new bilateral upper lobe and right middle lobe
opacities. Consolidative opacities at the right and left lung base have also
increased. There are new small bilateral pleural effusions left greater than
right with lower lobe septal thickening. Diffuse reticulation and upper lobe
predominant septal thickening has not significantly changed. There is no
pneumothorax.
Views of the upper abdomen demonstrate unchanged pneumobilia. There is a
small hiatal hernia.
There are no suspicious bony lesions.
IMPRESSION:
1. Progression of multifocal consolidative and ground-glass opacities, since
___ now involving all lobes, differential is broad but includes
multifocal infection, vasculitis. Given the rapid interval progression
cryptogenic organizing pneumonia, is felt to be less likely.
2. Unchanged mediastinal lymphadenopathy.
3. New small bilateral pleural effusions and lower lobe septal thickening,
consistent with background pulmonary edema.
Radiology Report
INDICATION: ___ w/worsening sob and new tachycardia // interval changes,
pulm edema, consolidations
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiographs from ___. .
CT of the chest from ___.
FINDINGS:
Multifocal opacities are unchanged from CT on ___. There is mild
engorgement of the mediastinal vascular pedicle and mild pulmonary vascular
pulmonary edema, unchanged from ___. Small bilateral pleural effusions
are stable from ___. No pneumothorax.
IMPRESSION:
Multifocal opacities, mild pulmonary edema, and small bilateral pleural
effusions are stable from ___. No significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with high risk MDS // worsening sob/cough, eval
for interval changes, pulm edema, consolidations worsening sob/cough,
eval for interval changes, pulm edema, consolidations
IMPRESSION:
In comparison with study of ___, there is increasing diffuse bilateral
pulmonary opacifications, most likely reflecting worsening pulmonary edema
with bilateral effusions and compressive basilar atelectasis. In the
appropriate clinical setting, several areas of more coalescent appearance
bilaterally could possibly represent superimposed pneumonia.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Dyspnea, Fever, Hemoptysis
Diagnosed with Pneumonia, unspecified organism
temperature: 98.1
heartrate: 62.0
resprate: 22.0
o2sat: 98.0
sbp: 115.0
dbp: 34.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ ___ man with high risk
MDS and chronic diastolic heart failure recently admitted for
several days of hemoptysis and CT showing ? PNA vs. other
process
found to have a positive AFB smear from ___, who presented to
clinic ___ with fever and SOB, s/p ICU transfer for Afib with
RVR improved with Dilt/metoprolol, now hemodynamically stable in
NSR sputum +klebsiella.
#Afib with RVR: Transferred to ICU on ___ for this, now
converted to sinus and hemodynamically stable since then.
Cardiology following. TTE with no evidence of pericardial
effusion. Resumed home metoprolol with holding parameters.
#Fever/SOB: Recent admission with chest CT ___ showing LL
predominant multifocal consolidations c/f multifocal infection
v.
vasculitis v. COPD v. pulmonary infarcts. He was treated for
HCAP. Sputum sample ___ grew AFB, repeat samples neg now off TB
precautions. Beta glucan level also highly elevated on ___.
However, most recent B-glucan is negative without a clear
therapy. Has had ongoing intermittent productive cough. CT chest
___ shows rapid progression of pulmonary infection. He is
growing klebsiella on his sputum cultures which could certainly
account for his interval change on imaging and it appears to
have
been somewhat high grade as is on three different cultures
despite therapy. Per pulmonary recs, should obtain chest CT 2
weeks after treatment for klebsiella to evaluate for possible
secondary infectious process. If no improvement or significant
residual disease per imaging, bronchoscopy would then be
indicated. Pulmonary also recommended evaluation for aspiration
risk given distribution of disease but this may be difficult to
obtain due to TB precautions.
-crypto antigen in blood and urine histo negative
-ceftazidime (___) then changed to ceftriaxone to
complete 14d course ___, off ___ and vanco since ___
-appreciate ID recs-see note AFB unlikely at this point,
negative
sputums x3
-repeat CT chest 2 weeks after most recent
-weekly fungal markers
-IgG level 796 on ___
#Acute on chronic diastolic heart failure: BNP on admission was
elevated at 4800 and patient was mildly volume overloaded on
exam the afternoon of ___, resumed home lasix. CXR ___
shows
mild pulmonary edema; however, repeat ___ in the setting of
worsening SOB showed progressive pulmonary edema w/ bilateral
effusions. Continues on home regimen of lasix 40mg BID and
baseline crackles at b/l bases.
-Lasix IV x 1 on ___, consider repeat dose if no improvement
-telemetry for continuous 02 monitoring
-monitoring strict I/Os
#Coagulopathy: Likely vit K deficient, received PO vitamin K.
Low suspicion for inhibitor but we checked a mixing study since
if he did have an inhibitor with worsened hemoptysis treatment
would be different.
-vitamin K 5mg x 1 on ___ and ___
-f/u mixing study
-restarted prophylactic heparin daily dosing and when
checking PTT, this should be done peripherally (not from his
port)
#HR MDS: He has been maintained on dacogen for about a year now,
currently on C14 so holding now in the setting of active
infection. Exjade on hold while inpatient.
-transfuse to maintain hgb > 7,
-will need Lasix prn with transfusions
#Acute on chronic kidney disease: CKD stage III attributed to
HTN
and vascular disease. Cr slightly above baseline of 1.4-1.6
though downtrending since admission. Possibly in the setting of
volume overload.
-Lasix as above
-Trend Cr
-Avoid nephrotoxins
-Hold lisinopril
#Hernia: Etiology likely due to previous abdominal surgery in
___ ? incisional-related. No abdominal discomfort or
tenderness.
We will continue to monitor closely
#HTN:
-Continue metoprolol with holding parameters
-Hold lisinopril given acute on chronic renal failure
#CAD: Continue ASA 81
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: SQ heparin daily
# Access: Port
# Communication: ___ (___)
# Code: Full (confirmed)
# Disposition: home, to complete 1wk course of ceftriaxone
outpatient, f/u next week ___ or sooner if issues arise |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hematuria, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria.
Today she had gone to a clinic appointment for transplant.
Afterward in garage around 2pm she tripped and fell on her knees
and left hip, landed on her hands. Subsequently she scraped her
right knee. She iced her right knee but then at 4pm she went to
urinate and saw that toilet bowl was full of red urine. Did not
seem to decrease even at the end of her stream. Denies having
any
recent fevers, chills, N/V, chest pain, shortness of breath,
dysuria. Has had no BM since having the fall.
She is currently in ___ pain in her LLQ. She thinks it is like
a rib pain. She does not have any blood in her underwear.
No dizziness, lightheadedness, chest pain. No hx of anemia.
Her baseline Cr is around 2.9.
In the ED, initial vitals: 98.1 79 158/83 20 100% RA
- Exam notable for:
BACK: No CVA tenderness.
MSK: No spinal tenderness
Abd: Pain in LLQ / pelvic region. Also with some suprapubic
pain.
- Labs notable for: Cr 3.3. UA w/ lg blood, >182 RBC
- Imaging notable for:
1. Multicystic enlarged kidneys and multiple hepatic cysts are
in
keeping with polycystic kidney disease. There are new areas of
increased density in the left upper renal pole which may
indicate
cyst rupture with hemorrhagic contents. There is mild left
perinephric stranding.
2. Colonic diverticulosis is seen without evidence of acute
diverticulitis.
3. No acute fractures are seen
XR Knee:
.9 x 0.3 cm ovoid ossific structure along the superior patella
may represent
a fracture of indeterminate age. No acute fracture seen
elsewhere. No
suprapatellar joint effusion is seen.
Consults:
Orthopedics team reviewed imaging. Patient has intact quads
muscle and able to extend knee. Cancelled orthopedics consult.
Will refer patient to clinic, number provided.
- Pt given: Tylenol, oxycodone 5mg x2, 1L NS
Upon arrival to the floor, the patient reports history as above.
She is interested in being discharged in the morning/afternoon,
as she has a trip planned. Reports pain worse in her L knee, L
flank able to ambulate. She takes tramadol at home about ___
times a week for pain related to her PCKD.
Past Medical History:
Abnormal ETT with typical angina
HTN
CKD IV
Adult onset polycystic kidney disease
PSH
C-section x3
Diverticulitis x 2
Social History:
___
Family History:
Sickle cell trait
Physical Exam:
===========================
ADMISSION PHYSICAL EXAM
===========================
VITALS: 65 135/81 16 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, pain in LUQ/LLQ, flank. Also with some suprapubic
pain.
Back: No CVA, spinal tenderness.
GU: No foley
Ext: Warm, well perfused. No ___ edema. Tenderness to palpation
along anterior R knee.
Skin: no bruising. Scrapes on right knee do not appear infected,
some swelling and pain around right knee
Neuro: CNII-XII intact. No focal deficits. Fluent speech
===========================
DISCHARGE PHYSCIAL EXAM
===========================
General: Alert, oriented, no acute distress
CV: regular rate and rhythm, no murmurs
Lungs: vesicular breath sounds bilaterally
Abdomen: Left CVA tenderness; LLQ tenderness to deep palpation,
no suprapubic pain
GU: No foley
Ext: Warm, well perfused. No ___ edema. Tenderness to palpation
along anterior R knee. Right knee slightly more swollen than
left but does not appear infected.
Neuro: CNII-XII intact. No focal deficits. Fluent speech
Pertinent Results:
======================
ADMISSION LAB RESULTS
======================
___ 07:39PM BLOOD WBC-8.3 RBC-4.84 Hgb-13.2 Hct-43.1 MCV-89
MCH-27.3 MCHC-30.6* RDW-13.6 RDWSD-44.2 Plt ___
___ 07:39PM BLOOD Neuts-73.1* Lymphs-17.7* Monos-6.9
Eos-1.6 Baso-0.2 Im ___ AbsNeut-6.07 AbsLymp-1.47
AbsMono-0.57 AbsEos-0.13 AbsBaso-0.02
___ 07:39PM BLOOD ___ PTT-35.2 ___
___ 07:39PM BLOOD Glucose-92 UreaN-38* Creat-3.3* Na-137
K-4.8 Cl-105 HCO3-18* AnGap-14
======================
DISCHARGE LAB RESULTS
======================
___ 05:25AM BLOOD WBC-7.9 RBC-4.41 Hgb-12.0 Hct-39.6 MCV-90
MCH-27.2 MCHC-30.3* RDW-13.5 RDWSD-44.6 Plt ___
___ 05:25AM BLOOD Glucose-84 UreaN-36* Creat-3.4* Na-140
K-4.8 Cl-108 HCO3-17* AnGap-15
===================
IMAGING/REPORTS
===================
CT ABDOMEN/PELVIS ___
IMPRESSION:
1. Multicystic enlarged kidneys and multiple hepatic cysts are
in keeping with known polycystic kidney disease. There are new
rounded areas of
hyperattenuation in the left upper renal pole which may indicate
cyst rupture with hemorrhagic contents. At least 1 of the
previously seen simple appearing cyst now appears hyperdense.
No free fluid.
2. Colonic diverticulosis without acute diverticulitis.
3. No acute fractures are seen
KNEE X-RAY ___
IMPRESSION:
0.9 x 0.3 cm ovoid ossific structure along the superior patella
may represent
a fracture of indeterminate age. No acute fracture seen
elsewhere. No
suprapatellar joint effusion is seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Calcitriol 0.25 mcg PO EVERY OTHER DAY
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
4. Losartan Potassium 100 mg PO 4X/WK
5. Selsun Blue (pyrithione zinc) (pyrithione zinc) 1 % Other
DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Every six hours as
needed Disp #*20 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Losartan Potassium 100 mg PO 4X/WK
5. Multivitamins 1 TAB PO DAILY
6. Selsun Blue (pyrithione zinc) (pyrithione zinc) 1 % Other
DAILY
7. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until cleared by
your primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Ruptured renal cyst
SECONDARY:
-CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with recent fall, scratch on R knee, some swelling
and pain on palpation// ? eval for fracture
TECHNIQUE: Three views of the right knee
COMPARISON: None.
FINDINGS:
0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent
a fracture of indeterminate age. No acute fracture seen elsewhere. No
suprapatellar joint effusion is seen. There is no dislocation.
IMPRESSION:
0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent
a fracture of indeterminate age. No acute fracture seen elsewhere. No
suprapatellar joint effusion is seen.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with hx of Polycystic kidney disease not on HD,
on renal transplant, stage IV ckd, presenting after a fall, with hematuria and
LLQ/pelvic/rib pain. No hematoma on exam.// Please eval for trauma to
bladder, kidneys, and any evidence of fracture.
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 6.7 s, 52.8 cm; CTDIvol = 19.1 mGy (Body) DLP =
1,006.6 mGy-cm.
Total DLP (Body) = 1,007 mGy-cm.
COMPARISON: CT abdomen and pelvis without contrast from ___
FINDINGS:
LOWER CHEST: Atelectasis is seen in the dependent lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There are multiple hypodense lesions scattered throughout the
liver, compatible with biliary hamartomas or hepatic cysts, with the largest
measuring up to 1.9 cm in the right hepatic lobe. Otherwise, the liver
demonstrates homogeneous attenuation throughout within the limitations of an
unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is enlarged multi cystic appearance of bilateral kidneys,
compatible with polycystic kidney disease. Previously seen hypodense cyst in
the upper pole the left kidney is now hyperdense and there are additional
smaller hyperdensities in the left kidney. These new rounded areas of
hyper-attenuation in the left upper renal pole which may indicate cyst rupture
with hemorrhagic contents (60___:62). Some of the cysts demonstrate peripheral
calcification, but are unchanged. There is no hydronephrosis. There is no
nephrolithiasis. There is small amount of left perinephric stranding tracking
medially and inferiorly along the left kidney.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Colonic diverticulosis is seen
without evidence of acute diverticulitis. Colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The urinary bladder is minimally distended. There is no distal
hydroureter. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multicystic enlarged kidneys and multiple hepatic cysts are in keeping with
known polycystic kidney disease. There are new rounded areas of
hyperattenuation in the left upper renal pole which may indicate cyst rupture
with hemorrhagic contents. At least 1 of the previously seen simple appearing
cyst now appears hyperdense. No free fluid.
2. Colonic diverticulosis without acute diverticulitis.
3. No acute fractures are seen
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hematuria, R Flank pain
Diagnosed with Acute kidney failure, unspecified
temperature: 98.1
heartrate: 79.0
resprate: 20.0
o2sat: 100.0
sbp: 158.0
dbp: 83.0
level of pain: 8
level of acuity: 3.0 | ___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate / Levofloxacin
Attending: ___.
Chief Complaint:
Elevated temperature
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with complicated PMH here from dialysis with shaking
chills. She has a long history of recurrent fevers, most
recently with hospitalization ___ for Klebsiella
bacteremia of unknown source. She reports she has not felt right
since she completed her course of cefazolin, which she received
at dialysis on ___, 10 days ago. She reports that she has been
very tired, achy, complains of SOB with DOE, and has had several
fevers to 100. She reported back pain radiating to lower
extremities, associated with lower extremity weakness. Today at
dialysis she became very cold and began having chills/rigors.
Temp 100.0. She completed dialysis, and was given acetaminophen
and either cefazolin or cefepime, then sent to the ED. Patient
denies headache, chest pain, abdominal pain, nausea, vomiting,
diarrhea, urinary symptoms. She has chronic cough which is at
baseline. Denies n/v, states she is tolerating PO. She does
report dental work 4 days prior, a ___ year old crown fell out
and she had it replaced. She reports taking unknown prophylactic
antibiotic. No longer makes urine.
In the ED intial vitals were: 4 98.6 94 146/72 18 98%
- Labs were significant for WBC 6.5, Hct 28.0, K of 4.1, Cre
3.7, Calcium 11.0, phos 3.5. INR 1.3. Lactate 1.9.
- CXR showed small bilateral pleural effusion, no focal
consolidation, pulmonary vasculature pronminant, unchanged from
prior. RUQ large rim calcified structure (c/w known liver cyst)
- Patient was given vancomycin
Vitals prior to transfer were: 98.5 91 125/66 18 98% RA
On the floor, patient is tired and feels chilly. Complains of
itchiness from eczema.
Review of Systems:
(+) as above
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia.
Past Medical History:
* Recurrent fevers
- E. coli bacteremia, ___
- s/p WBC scan ___ revealed chronic cholecystitis, s/p CCY
- Klebsiella bacteremia ___
- h/o C. diff colitis
* ESRD s/p failed ECD renal transplant in ___ on HD MWF
- c/b urinary obstruction, multiple UTIs, nephrostomy tube
- s/p coil embolization of graft artery on ___
- h/o multiple episodes of CMV viremia
- h/o BK viremia
* Chronic atrial fibrillation s/p modified AV ablation ___
- dCHF, last EF > 55% in ___
- Tachycardic cardiomyopathy
- MR/TR
* Aortic stenosis
* PCKD s/p bilateral nephrectomies in ___
* HTN
* Endometrial cancer
* Primary Hyperparathyroidism
* Hypothyroidism
* Knee Osteoarthritis
SURGICAL HISTORY
-___ - cholecystectomy
-___ - coil embolization tpx renal artery
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
-___ - hemorrhoidectomy and drainage of perirectal hematoma
-s/p tonsillectomy
Social History:
___
Family History:
Father & daughter w/ PKD. No history of CAD.
Physical Exam:
ON ADMISSION:
=============
Vitals - T: 99.6 BP: 136/75 HR: 81 RR: 20 02 sat: 99%RA
Gen: female, tired but non-toxic appearing
HEENT: MMM
CV: Irregulary irregular, ___ SEM at ___
Pulm: CTAB, no w/r/r
Abd: Soft, NTND, normoactive bowel sounds, well healed surgical
scar with palpable transplanted kidney at RLQ.
Ext: Warm, well-perfused, no edema, ? ___ cyst on Right.
Neuro: AAOx3, CN II-XII grossly intact
Skin: No concerning lesions, fistula is stable with good thrill,
not hot.
ON DISCHARGE:
==============
Vitals 99.0(tmax), 83, 132/73, 17
Gen: female, tired but non-toxic appearing, laying in bed at HD
HEENT: MMM, anicteric sclera, EOMI
Neck: supple, no LAD
CV: Irregulary irregular, ___ SEM at ___
Pulm: CTAB, no w/r/r
Abd: Soft, NTND, normoactive bowel sounds, well healed surgical
scar
MSK: no vertebral process tenderness, no CVAT
Ext: Warm, well-perfused, no edema, ? ___ cyst on Right.
Skin: No concerning lesions, fistula is stable with good thrill,
no warmth or erythma
Pertinent Results:
ON ADMISSON:
=============
___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0*
MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___
___ 05:50PM BLOOD Neuts-85.7* Lymphs-8.3* Monos-4.3 Eos-1.5
Baso-0.3
___ 05:50PM BLOOD ___ PTT-30.5 ___
___ 05:50PM BLOOD Glucose-115* UreaN-18 Creat-3.7* Na-140
K-4.1 Cl-98 HCO3-28 AnGap-18
___ 05:50PM BLOOD ALT-6 AST-21 AlkPhos-85 TotBili-0.4
___ 05:50PM BLOOD Calcium-11.0* Phos-3.5 Mg-2.2
___ 05:57PM BLOOD ___ FiO2-20 pO2-25* pCO2-48* pH-7.45
calTCO2-34* Base XS-6 Intubat-NOT INTUBA
___ 05:57PM BLOOD Lactate-1.9
MICRO:
======
___: BLOOD CX-PND
___: OSH BLOOD CX FROM ___ DIALYSIS IN ___
___: CMV VIRAL LOAD-PND
PERTINENT LABS:
================
___: SPEP-PND
RADIOLOGY:
===========
CXR ___:
FINDINGS: The inspiratory lung volumes are appropriate. There
is bilateral blunting of the costophrenic angles compatible with
small bilateral pleural effusions. There is improved aeration
of the right lung base in comparison to ___. No
focal consolidation concerning for pneumonia is seen. There is
no pneumothorax. The pulmonary vasculature is slightly
prominent, unchanged from the prior exam. No overt pulmonary
edema is present. The cardiomediastinal silhouette is within
normal limits and unchanged. In the right upper quadrant, there
is a large rim calcified rounded structure measuring 7.4 x 7.3
cm within the liver.
IMPRESSION:
1. Small bilateral pleural effusions and mild pulmonary
vascular congestion.
2. Improved aeration of the right lung base from ___.
DISCHARGE LABS:
===============
___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0*
MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___
___ 07:10AM BLOOD ___ PTT-30.9 ___
___ 07:10AM BLOOD Glucose-120* UreaN-37* Creat-6.5*# Na-138
K-4.8 Cl-97 HCO3-25 AnGap-21*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cinacalcet 60 mg PO DAILY
2. Digoxin 0.0625 mg PO 3X/WEEK (___)
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 300 mg PO 3X/WEEK (___)
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lorazepam 1 mg PO BID:PRN anxiety
9. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___)
10. Midodrine 10 mg PO MWF
11. Montelukast Sodium 10 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. sevelamer HYDROCHLORIDE 2400 mg OTHER TID
14. Warfarin 1 mg PO DAILY16
15. Cetirizine 10 mg oral daily prn allergy symptoms
16. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
17. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
18. Omeprazole 20 mg PO BID
Discharge Medications:
1. Cinacalcet 60 mg PO DAILY
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Digoxin 0.0625 mg PO 3X/WEEK (___)
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 300 mg PO 3X/WEEK (___)
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lorazepam 1 mg PO BID:PRN anxiety
11. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___)
12. Midodrine 10 mg PO MWF
13. Montelukast Sodium 10 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Omeprazole 20 mg PO BID
16. sevelamer HYDROCHLORIDE 2400 mg OTHER TID
17. Warfarin 1 mg PO DAILY16
18. Cetirizine 10 mg oral daily prn allergy symptoms
Discharge Disposition:
Home
Discharge Diagnosis:
Elevated temperatures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fever, here to evaluate for pneumonia.
COMPARISON: Chest radiograph dated ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: The inspiratory lung volumes are appropriate. There is bilateral
blunting of the costophrenic angles compatible with small bilateral pleural
effusions. There is improved aeration of the right lung base in comparison to
___. No focal consolidation concerning for pneumonia is seen.
There is no pneumothorax. The pulmonary vasculature is slightly prominent,
unchanged from the prior exam. No overt pulmonary edema is present. The
cardiomediastinal silhouette is within normal limits and unchanged. In the
right upper quadrant, there is a large rim calcified rounded structure
measuring 7.4 x 7.3 cm within the liver.
IMPRESSION:
1. Small bilateral pleural effusions and mild pulmonary vascular congestion.
2. Improved aeration of the right lung base from ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.6
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 72.0
level of pain: 4
level of acuity: 3.0 | ___ year old female with PCKD s/p failed transplant on HD MWF,
recurrent fevers due to gram negative bacteremia of unknown
source, who presents from dialysis with rigors and temperature
to 100.0, without localizing infection.
ACTIVE MEDICAL ISSUES:
# Elevated temperature: On admission, pt did not meet SIRS
criteria and was afebrile however she had report temperature to
100.0 ___s rigors at dialysis. In the past, pt has had two
episodes of E. coli bacteremia, and most recently completed a
course on ___ of cefazolin for Klebsiella bacteremia. On
admission, she had few localizing symptoms other than a cough
which is chronic as well as back pain with standing which she
reports is also chronic. She denied abdominal pain, n/v/d. No
headaches or neck pain to suggest CNS infection. CXR did not
show evidence of pneumonia. Blood cultures from ___ at both
dialysis and BI were pending, no growth at discharge. CMV viral
load was also pending. She was empirically treated with
vancomycin (HD protocol) and cefepime. Her antibiotics were
stopped as she had no symptoms, remained afebrile with no
leukocytosis. Her elevated temperature and malaise may represent
viral process rather than overt bacterial infection. Her
antibiotics were stopped on the day prior to discharge, and she
remained stable. She had an appointment to follow up with her
PCP the day after discharge.
# HYPERCALCEMIA: Pt noted to have hypercalcemia due to
hyperparathyroidism in the past. Her calcium on admission was
11.0. An SPEP was checked (given her back pain and malaise)
which is pending at discharge. Her dialysis was also modified as
below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Tylenol / ibuprofen
Attending: ___
Chief Complaint:
Confusion/weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with history of cardiomyopathy, A-fib, DM and severe
mid LAD stenosis s/p cath with one DES with presents from PCP
with weakness. Pt states his symptoms started 3 weeks ago and
relates it to his cardiac cath in ___. Described as
progressive weakness with some dizziness associated with
decreased PO intake. He fell last week on the curb last week and
has had persistent pain in his left upper back. He denies recent
fevers/chills, headaches, chest pain, SOB, abdominal pain. He
has had no change in bowel or bladder habits, denies
hematochezia, melena, dysuria or hematuria.
Of note, the patient had an admission in ___ for sepsis
related to infected nephrolithiasis.
In the ED, initial vitals were: 97.7 92 115/73 20 100% RA with
positive orthostatics
Labs notable for: WBC 10.1, AP 133, creatinine 1.3 (baseline
1.2), INR 5.2 with PTT 56.5, ___ 58.7, troponin negative x1,
lactate 2.3. He was bladder scanned and a urine sample was sent
from straight cath, with clean UA.
Imaging notable for: normal CT/CTA head, normal CXR
Patient was given: 3 L NS
Neuro was consulted and recommended: unlikely stroke but neuro
will follow as inpatient.
Vitals prior to transfer: 98.0 84 ___ 98% RA
Decision was made to admit for weakness to Medicine with Dr.
___ as attending.
On the floor initially, the patient was completely oriented and
pleasant, overall comfortable and only complaining of weakness
described before and R thigh pain. otherwise denying chest pain,
shortenss of breath, fevers/chills
##At 03:20, a trigger was called for altered mental status and
Afib with RVR into 150's. Pt had not yet received his home
evening dose of Metoprolol tartrate 50 mg. At that time he was
AOx1, more agitated. He had not received any meds by that time.
Bladder scan at that time was 780 cc despite straight cath in
ED. All AM labs were drawn early with BCx., A Foley was placed
and UA/UCx were sent. Dr. ___ was made aware and will see pt at
8 AM.
Past Medical History:
Cardiac cath s/p DES x1 LAD ___
Hospitalization ___ for sepsis d/t obstructive
nephrolithiasis, sCHF,afib RVR, hematuria
Lumbar spinal operation scheduled at ___ ___
Hx of atrial fibrillation s/p cardioversion x2 - now in A.Fib.
Hypertension
Gout
DM
Osteoarthritis
Hx of gastric ulcer in ___ /GI bleed
s/p tonsillectomy and adenoidectomy
s/p multiple prostate biopsies for elevated PSA - benign
hx of fatty liver disease/hepatitis of unclear etiology
Kyphoscoliosis DISH severe
high Cholesterol refuses statin drugs.
groin cyst removed
upper endoscopy ___ mild esophagitis
Colonoscopy ___nd back surgery ___ complicated by pneumonia and
recurrent A fib
Social History:
___
Family History:
"All kinds". Denies heart attacks. Father with AAA. Strokes.
Physical Exam:
=============
ADMISSION EXAM
================
Vital Signs: 138 / 71 126 22 100 ra
General: Initially AOx3 but by 3 AM was AOx1, speaking in a
confused manner about nonsense.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: Irregularly irregular, 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 in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
but symmetric, grossly normal sensation, gait deferred.
==============
DISCHARGE EXAM
===============
Vitals T97.7 HR86 BP 107/60 RR 18 O2 98/RA
General: NAD
HEENT: no scleral icterus, MMM, clear oropharynx
Neck: soft, supple
CV: Irregularly irregular and tachycardic, no murmur
Pulm: CTAB
Abdomen: soft, nt/nd, no rebound or guarding
Back: No focal pain, no CVA tenderness
Ext: wwp, no edema
Neuro: No focal weakness. A&Ox3 and able to name president.
Full neuro exam deferred
Pertinent Results:
========================
ADMISSION LABS
========================
___ 01:28PM BLOOD WBC-10.1* RBC-4.49* Hgb-13.6* Hct-40.5
MCV-90 MCH-30.3 MCHC-33.6 RDW-13.3 RDWSD-43.8 Plt ___
___ 01:28PM BLOOD Plt ___
___ 02:44PM BLOOD ___ PTT-56.5* ___
___ 01:28PM BLOOD Glucose-299* UreaN-28* Creat-1.3* Na-138
K-4.5 Cl-102 HCO3-24 AnGap-17
___ 01:28PM BLOOD ALT-27 AST-25 CK(CPK)-61 AlkPhos-133*
TotBili-0.8
___ 01:28PM BLOOD proBNP-683
___ 01:28PM BLOOD cTropnT-<0.01
___ 03:42AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:28PM BLOOD Albumin-3.6
___ 01:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:35PM BLOOD Lactate-2.3*
========================
DISCHARGE LABS
========================
___ 05:00AM BLOOD
___ 05:00AM BLOOD Calcium-9.6 Phos-2.2* Mg-1.9
___ 05:00AM BLOOD ALT-25 AST-25 AlkPhos-147* TotBili-1.3
___ 05:00AM BLOOD Glucose-137* UreaN-18 Creat-1.1 Na-140
K-4.4 Cl-104 HCO3-26 AnGap-14
___ 05:00AM BLOOD ___ PTT-43.6* ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD WBC-8.7 RBC-4.47* Hgb-13.7 Hct-40.3
MCV-90 MCH-30.6 MCHC-34.0 RDW-13.2 RDWSD-43.4 Plt ___
===================
MICROBIOLOGY
===================
___ Blood cx x2 - NGTD
___ Urine Cx - No growth
===================
IMAGING
===================
MRI HEAD ___ -
1. No evidence of acute or chronic large vascular territorial
infarction.
2. Mild chronic small vessel ischemic disease.
RENAL U/S ___ -
1. Bilateral non-obstructing renal stones..
2. Massively enlarged prostate.
CTA H/N ___. No CT evidence of acute intracranial abnormality. Please
note that MRI
provides greater sensitivity in evaluation of acute infarction.
2. Patent intracranial and neck vasculature without carotid
stenosis by NASCET
criteria.
3. Postsurgical changes of the cervical spine, as described,
with small fluid
collection at the posterior C1 arch decompression site of
uncertain
significance. Recommend clinical correlation.
4. Contiguous ossification of anterior longitudinal ligament
consistent with
diffuse idiopathic skeletal hyperostosis.
5. Ossification of the posterior longitudinal ligament causing
multilevel
spinal canal stenosis most advanced at C6-C7 where there is
severe spinal
canal stenosis.
6. 1 cm right thyroid lobe nodule.
RECOMMENDATION(S): Per the ___ College of Radiology
guidelines, thyroid
nodules measuring less than 1.5 cm in patient's greater than ___
years of age
do not necessitate imaging follow-up, in the absence of clinical
risk factors.
Recommend clinical correlation for 1 cm right thyroid lobe
nodule.
CXR ___ - No acute cardiopulmonary process
Radiology Report
INDICATION: ___ with back pain s/p fall // left posterior rib pain after
fall and crackles in lower lobes
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. There is no focal consolidation, effusion, or edema. No
obvious pneumothorax. The cardiomediastinal silhouette is within normal
limits. No visualized displaced fractures on this nondedicated exam.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with slurred speech // New onset slurred speech
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 4.8 s, 12.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
672.8 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 22.6 mGy (Body) DLP =
362.1 mGy-cm.
3) Stationary Acquisition 9.5 s, 0.5 cm; CTDIvol = 45.7 mGy (Body) DLP =
22.9 mGy-cm.
4) Spiral Acquisition 5.0 s, 39.3 cm; CTDIvol = 14.1 mGy (Body) DLP = 555.6
mGy-cm.
Total DLP (Body) = 941 mGy-cm.
Total DLP (Head) = 673 mGy-cm.
COMPARISON: None.
FINDINGS:
CT head: The gray-white matter differentiation is intact without CT evidence
of acute territorial infarct, hemorrhage, or mass effect. There is mild
prominence of ventricles and cortical sulci. There is hyperostosis frontalis
and calcification of the cerebral falx.
The bilateral native lenses are absent. The soft tissues are unremarkable.
Is a small mucous retention cyst within the left sphenoid sinus. The mastoid
air cells and middle ears are clear.
CTA head: There is calcification of the intracranial internal carotid
arteries, which are patent. The anterior communicating artery is visualized.
The bilateral posterior communicating arteries are not definitively seen.
There are codominant vertebral arteries. The arterial circulation is patent
without occlusion, dissection, stenosis, or aneurysm. There is normal dural
venous sinus enhancement.
CTA neck: There is a 3 vessel aortic arch with patent subclavian arteries.
There is calcification of the right carotid bulb without stenosis by NASCET
criteria. There is calcification of the left carotid bifurcation bulb,
without stenosis by NASCET criteria. The vertebral arteries are patent and
demonstrate codominant.
The lung apices are clear. There multilevel degenerative changes of the
cervical spine. There is posterior decompression of the C1 arch with a 1.6 cm
fluid collection at the decompression bed (8:181). There is posterior there
is left C3 through C6 hemilaminectomy with fixation hardware in place and a
posterior midline scar. There is ossification of the posterior longitudinal
ligament causing multilevel spinal canal stenosis, most advanced at C6-C7
where there is severe spinal canal stenosis (605b:30). There is ossification
of the anterior longitudinal ligament, with bulky osteophytes causing mild
mass effect on the pharynx. There is a 1 cm right thyroid lobe nodule (8:63).
The salivary glands are unremarkable. There streak artifact secondary to
dental hardware which obscures adjacent structures. The masticator and
parapharyngeal spaces are unremarkable. There are no suspicious lymph nodes
by size or morphology.
IMPRESSION:
1. No CT evidence of acute intracranial abnormality. Please note that MRI
provides greater sensitivity in evaluation of acute infarction.
2. Patent intracranial and neck vasculature without carotid stenosis by NASCET
criteria.
3. Postsurgical changes of the cervical spine, as described, with small fluid
collection at the posterior C1 arch decompression site of uncertain
significance. Recommend clinical correlation.
4. Contiguous ossification of anterior longitudinal ligament consistent with
diffuse idiopathic skeletal hyperostosis.
5. Ossification of the posterior longitudinal ligament causing multilevel
spinal canal stenosis most advanced at C6-C7 where there is severe spinal
canal stenosis.
6. 1 cm right thyroid lobe nodule.
RECOMMENDATION(S): Per the ___ College of Radiology guidelines, thyroid
nodules measuring less than 1.5 cm in patient's greater than ___ years of age
do not necessitate imaging follow-up, in the absence of clinical risk factors.
Recommend clinical correlation for 1 cm right thyroid lobe nodule.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with history of obstructing ureteral stones, p/w
weakness, leukocytosis, evaluate for obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CTU ___
FINDINGS:
The right kidney measures 12.8 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis or suspicious masses bilaterally. There is a 3.1 x 2.4 x
2.6 cm simple cyst in the upper pole of the right kidney and a 1.8 x 1.6 x 1.7
cm simple cyst in the upper pole of the left kidney. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally,
although views of the left kidney are limited secondary to patient
positioning. There are bilateral non-obstructing renal stones including a a 8
mm right mid pole and a 10 mm left lower pole stone.
The bladder is moderately well distended and normal in appearance. The
prostate is massively enlarged with a volume of 139 cc. This corresponds to a
predicted PSA of 16.7.
IMPRESSION:
1. Bilateral non-obstructing renal stones..
2. Massively enlarged prostate.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old man with dysarthria, word finding difficulty, and
unsteady gait. Please evaluate for acute/subacute/chronic ischemic event.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 10 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There is mild prominence of the ventricles and sulci
suggestive of age-related involutional changes. Scattered T2/FLAIR
hyperintensities are nonspecific but likely reflect sequelae of chronic small
vessel ischemic disease. There is no abnormal enhancement after contrast
administration.
The orbits are unremarkable. There is minimal mucosal thickening of the left
maxillary sinus with a mucous retention cyst within the right maxillary sinus.
Major intracranial flow voids are preserved.
IMPRESSION:
1. No evidence of acute or chronic large vascular territorial infarction.
2. Mild chronic small vessel ischemic disease.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 97.7
heartrate: 92.0
resprate: 20.0
o2sat: 100.0
sbp: 115.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | ___ h/o cardiomyopathy, A-fib, DM and severe mid LAD stenosis
s/p cath with DES who presents from PCP with weakness found to
have Afib with RVR, AMS during admission.
# AMS: On admission patient was A&Ox3 but later became A&Ox1 and
agitated. Possible triggers for delirium included urinary
retention (patient could not void spontaneously and was
discharged with foley), constipation. Workup for CVA including
MRI and CT was negative. Workup for infection including renal
u/s, cultures, and UA was negative. Renal u/s showed
non-obstructing stones. On discharge patient was A&Ox3 but very
combative. Questionable component of dementia given history from
wife. He may benefit from cognitive testing by Neurology as an
outpatient for evaluation of dementia.
# BPH with active urinary retention: Bladder scanned on ___ ___
and again had 700+cc urine in bladder. Patient was straight
cath'd multiple times for failure to void. A foley was placed
and he was discharged with a foley with plan to follow up with
urology.
# ___: Most likely post-renal in setting of urinary retention,
but may have component of prerenal due to poor po intake at
home. Creatinine decreased to 1.1 after placement of foley.
# Afib on warfarin: Developed rapid rates to 150's in setting of
missing evening dose of Metoprolol tartrate. Improved to
100's-110's after receiving PO dose of Metoprolol tartrate 50
mg. INR supratherapeutic at 5.2 (pt had been taking ___
daily). NO evidence of bleeding. Warfarin held again on ___ for
INR of 3.6. Per his PCP ___ for patient to re-start
warfarin 5 mg daily on ___.
# Leukocytosis: Mild elevation of WBC to 11.5. UA negative,
renal u/s showed non-obstructing stones. Down-trended to normal
without antibiotics.
CHRONIC ISSUES:
# CAD s/p DES in ___: Continued Aspirin and Plavix,
atorvastatin, losartan.
# dCHF: Euvolemic, home torsemide held due to ___ but then
restarted on d/c.
# DM: Metformin held in setting of elevated lactate, restarted
on d/c.
# H/o gout: Continued home colchicine + probenecid.
Transitional Issues
===================
-Patient discharged on foley due to failure to void. Needs to
followup with urology to discontinue foley.
-INR 3.6 on discharge. Warfarin was held on ___ and
___. Patient should restart Warfarin on ___ at 5mg and
check his INR at home per recommendation of Dr. ___.
-Please follow up 9mm thyroid nodule with thyroid ultrasound.
-History obtained from patient's wife and patient's
combativeness in hospital concerning for early dementia. Please
evaluate with cognitive testing as outpatient with possible
referral to cognitive neurology.
-Please consider downtitrating tramadol and lorazepam given
concern for altered mental status.
-Code Status: Full Code (confirmed)
-Contact: Name of health care proxy: ___
Relationship: wife
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of right
inguinal hernia repair with mesh in ___ who presents with 3
days of right groin pain and a bulge. Patient underwent an
uncomplicated elective open right inguinal hernia repair
(direct) with mesh in ___ ___. Patient reports she
has not had any had any problems since her repair until of
approximately 3 days ago she started to feel a growing bulge on
her right groin with an associated sharp pain. Her pain was the
worst 3 days ago which was constant and worse with movement
especially when walking. She denies any abdominal pain,
distention, nausea or vomiting or change in bowel habits. She
has been eating well with normal bowel movements and has been
passing flatus. She wanted to come to the emergency room then
however she had guests over so that she decided to come into the
emergency room today although the pain had somewhat subsided.
Upon presentation to the emergency room patient was in no acute
distress, had normal vitals, and normal laboratory work-up. Her
inguinal hernia was attempted to be reduced at the bedside by
the emergency room staff however unsuccessful. Patient reports
that her pain is currently approximately 7 out of 10. As
previously mentioned, she does not have any other associated
symptoms.
Past Medical History:
PMH:
-GERD
-IBS
-Diverticulosis
-IPMN Pancreas
-Thyroid cancer (s/p total thyroidectomy)
PSH:
-R inguinal hernia repair w/mesh ___ (Dr. ___
-R knee arthroscopy ___
-Tonsillectomy
-Total thyroidectomy
Social History:
___
Family History:
Family History:
-Father HTN, CAD, HLC, deceased at ___ years from an accident.
-Mother deceased at ___ years HTN, AF, Lupus, CAD, CHF in her
early ___.
Physical Exam:
Physical Exam on Admission:
97.6 77 128/72 16 97% 2L NC
General: No acute distress
Cardiovascular: Regular rate
Pulmonary: Nonlabored breathing on room air
Abdomen: Soft, nondistended, nontender, no abdominal incisional
scars.
Right groin: Well-healed incisional scar over the right groin. A
small bulge at the level of the inguinal ligament that is soft
but tender on palpation. No overlying skin changes. Bedside
reduction was attempted after administering 1 mg of IV Dilaudid
and 1 mg of IV Ativan however unsuccessful.
Physical Exam on Discharge:
97.7, 109/74, 75, 17, 94% RA
Gen: NAD, AAOx3
CV: RRR
Resp: breaths unlabored, CTAB
Abdomen: soft
Right groin: small bulge that is soft but tender on palpation.
No overlying skin changes.
Ext: warm
Pertinent Results:
CHEST (PA & LAT): ___
1 cm nodular opacity projects over the left lung base may
represent
atelectasis, pulmonary nodule is not excluded. Recommend
outpatient chest CT for further assessment.
CT ABD & PELVIS WITH CONTRAST: ___
1. Fat containing right inguinal hernia. Mild stranding of the
herniated fat.
2. Pancreatic cystic likely reflecting side-branch IPMN, better
evaluated on recent MRCP at which time repeat MRCP in ___ years
was recommended.
LAB DATA:
___ 02:52PM BLOOD WBC-7.6 RBC-4.18 Hgb-13.0 Hct-39.7 MCV-95
MCH-31.1 MCHC-32.7 RDW-11.9 RDWSD-41.7 Plt ___
___ 02:52PM BLOOD Neuts-61.8 ___ Monos-7.0 Eos-3.6
Baso-0.7 Im ___ AbsNeut-4.70 AbsLymp-2.02 AbsMono-0.53
AbsEos-0.27 AbsBaso-0.05
___ 02:52PM BLOOD ___ PTT-29.3 ___
___ 02:52PM BLOOD Glucose-80 UreaN-21* Creat-0.7 Na-144
K-4.4 Cl-104 HCO3-24 AnGap-16
___ 02:52PM BLOOD ALT-21 AST-23 AlkPhos-58 TotBili-0.3
___ 02:52PM BLOOD Lipase-55
___ 02:52PM BLOOD Albumin-4.3
___ 04:40PM BLOOD Lactate-0.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Vitamin D ___ UNIT PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
please limit to 4000mg in 24 hour period.
2. Hyoscyamine SO4 (Time Release) 0.375 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Vitamin D ___ UNIT PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated right inguinal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with abdominal pain // pna? pnx?CT: hernia eval
COMPARISON: Chest radiograph ___
Chest CT ___
FINDINGS:
PA and lateral views of the chest provided.
Mild left base atelectasis is seen. 1 cm nodular opacity projecting over the
left lung base may represent atelectasis, but pulmonary nodule is not excluded
in the appropriate clinical setting. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
1 cm nodular opacity projects over the left lung base may represent
atelectasis, pulmonary nodule is not excluded. Recommend outpatient chest CT
for further assessment.
RECOMMENDATION(S): Outpatient chest CT to assess left lung base nodular
opacity.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abdominal pain // pna? pnx?CT: hernia eval
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: Total DLP (Body) = 670 mGy-cm.
COMPARISON: MRCP ___
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. Lungs otherwise clear. No pleural
or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 2.1
cm cyst in segment 2 is noted. Numerous additional subcentimeter hypodense
lesions for better characterized as cysts or biliary hamartomas on recent
MRCP. 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
pancreatic ductal dilatation. 7 mm hypodense lesion in the pancreatic body
corresponds to side-branch IPMN seen on recent MRCP. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Left-sided
parapelvic cysts are noted. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. Cecum lies in the right upper quadrant
anterior to the liver, consistent with cecal bascule.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal abnormalities.
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: There is a fat containing right inguinal hernia with mild
stranding of the contained fat and trace fluid within. Hernia repair material
is noted along the right lower rectus musculature.
IMPRESSION:
1. Fat containing right inguinal hernia. Mild stranding of the herniated fat.
2. Pancreatic cystic likely reflecting side-branch IPMN, better evaluated on
recent MRCP at which time repeat MRCP in ___ years was recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Inguinal pain
Diagnosed with Right lower quadrant pain
temperature: 99.0
heartrate: 89.0
resprate: 16.0
o2sat: 96.0
sbp: 145.0
dbp: 89.0
level of pain: 1
level of acuity: 2.0 | Patient is a ___ year old female with past medical history
significant for thyroid cancer s/p thyroidectomy, IBS,
diverticulosis, and prior repair of a right inguinal hernia in
___ ___. Patient presented to the emergency
department with complaints of abdominal pain and was found to
have right incarcerated inguinal hernia on imaging. Therefore
acute care surgery was consulted for evaluation and management.
The hernia was partially manually reduced at the bedside and she
was admitted to the inpatient unit for operative planning.
Surgical repair of her incarcerated inguinal hernia with acute
care surgery was then offered however the patient declined
surgery during current admission. She reported she wishes to
have surgery completed by Dr. ___ as an outpatient. Risks of
delaying surgery were discussed at length. This included risk of
worsening pain and/or bowel incarceration, and need for emergent
operation that could require bowel resection. She reported she
was accepting of these risks. She was then given the contact
information for Dr. ___ clinic to schedule her
follow up care.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. At the time of
discharge, the patient was doing well. She was afebrile and her
vital signs were stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and her pain was
well controlled. The patient was discharged home without
services. Discharge teaching was completed, and follow up was
reviewed with reported understanding and agreement. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ female with minimal PMH who presents with
watery diarrhea, BRBPR, and abdominal cramping after running a
5K race.
She is a runner and was participating in a 5K race this morning.
Towards the end of the race, she felt like she needed to have a
bowel movement, but did not think much of it. About two hours
later, she had watery diarrhea, which was soon followed by
BRBPR. She felt dehydrated and tried to drink some water and
gatorade, but vomited all of her PO intake, with no visible
blood in her emesis. Since her symptoms started, she has had
constant lower abdominal cramping. She denies any fevers,
chills, headaches, chest pain, SOB, or cough. She has not had
any vaginal bleeding or discharge.
She runs regularly, and this amount of activity is not unusual
for her. She was feeling fine before the run. She denies any
sick contacts. She has never had similar bleeding before. She
does not have easy bruising or problems with excessive bleeding.
She did have one beer after the race, but no alcohol last night.
She takes Ibuprofen almost daily for shin pain, including 400 mg
before the race, and averaging 400-600 mg daily.
Initial vitals in ED triage were T 96.8, HR 64, BP 122/73, and
SpO2 100% on RA. Exam was notable for guaiac positive brown
stool. Her CBC showed WBC 14.7 with 88.3% neutrophils and Hct
40.3 with MCV 85. Her chemistry panel was notable for bicarb 21,
anion gap 14, and lactate 2.6. Her urinalysis and UCG were
negative.
She was given a total of normal saline 3000 ml and Ondansetron 4
mg IV. She continued to have episodes of diarrhea and feel
unwell. She was admitted to Medicine for further management of
BRBPR and diarrhea. Vitals prior to floor transfer were T 97.9,
HR 68, BP 128/76, RR 16, and SpO2 100% on RA.
On reaching the floor, she reported continued lower abdominal
pain, but no other current symptoms. She had a normal formed BM
the day before the race.
REVIEW OF SYSTEMS:
(+) Per HPI. Poor appetite currently, but normal before race.
She was feeling lightheaded before receiving IV fluids. Did have
one episode of chills before presenting to ED.
(-) No fevers, weight loss or gain, fatigue, or other
constitutional symptoms. No headache, sinus tenderness,
rhinorrhea, or congestion. No vertigo, syncope, vision changes,
hearing changes, focal weakness, or paresthesias. No chest pain,
pressure, palpitations, SOB, DOE, or cough. No dysphagia or
odynophagia. No hematuria, dysuria, frequency, urgency,
incontinence, or discharge. No back, neck, joint, or muscle
pain. No rashes or concerning skin lesions. No easy bleeding or
bruising. No recent depression or anxiety. Review of systems was
otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
# Depression / Anxiety -- well controlled
# Bulimia -- ___ years ago
Social History:
___
Family History:
No family history of GI malignancy, IBD, or abnormal bleeding.
# Mother: ___ ulcers
# Father: ___
# ___: Only child
Physical Exam:
ADMISSION:
VS: T 99.0, BP 132/87, HR 72, RR 18, SpO2 100% on RA, Wt 75.9 kg
Gen: Young athletic female in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, ND. No organomegaly or masses.
Tender to palpation in lower abdomen, particulary suprapubic
area, without rebound or guarding.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No concerning rashes or lesions.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. Normal speech.
DISCHARGE:
98.5 118/76 69 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: NABS, NT/ND
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes
Neuro: Alert and oriented, CN II-XII grossly intact, non-focal
motor/sensory exam
Pertinent Results:
ADMISSION:
___ 05:05PM PLT COUNT-272
___ 05:05PM NEUTS-88.3* LYMPHS-7.9* MONOS-3.2 EOS-0.3
BASOS-0.3
___ 05:05PM WBC-14.7*# RBC-4.76 HGB-13.3 HCT-40.3 MCV-85
MCH-28.0 MCHC-33.1 RDW-12.7
___ 05:05PM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-2.0
___ 05:05PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-226 ALK
PHOS-55 TOT BILI-0.3
___ 05:05PM estGFR-Using this
___ 05:05PM GLUCOSE-138* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18
___ 05:12PM LACTATE-2.6*
___ 05:21PM URINE MUCOUS-FEW
___ 05:21PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:21PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:21PM URINE UCG-NEG
___ 05:21PM URINE HOURS-RANDOM
CT ABDOMEN ___: LUNG BASES: The bases of the lungs are
clear without nodules, consolidations, or pleural effusions.
The base of the heart is normal. There is no pericardial
effusion. ABDOMEN: The liver is normal in shape and contour.
There are no focal hepatic lesions. There is no intra- or
extra-hepatic biliary duct dilation. Minimal periportal edema
is likely due to recent hydration. The gallbladder, spleen,
pancreas, adrenal glands, and kidneys are normal. There are no
renal lesions. There is no pyelonephritis or hydronephrosis.
The kidneys enhance and excrete contrast symmetrically. The
stomach and small bowel are normal in course and caliber. There
are no focal inflammatory changes. There is no free air or free
fluid. There is no mesenteric, abdominal, or retroperitoneal
lymphadenopathy. The abdominal vasculature is normal in course
and caliber. PELVIS: The sigmoid colon is air filled. The
remainder of the descending and transverse colon are mostly
collapsed, which limits its evaluation, but there is no definite
wall thickening or abnormal enhancement. There is no
significant surrounding stranding. The ascending colon is
somewhat collapsed, though there is a suggestion that the wall
is thickened with very minimal surrounding stranding. This
could be consistent with a very mild colitis. The appendix is
visualized and normal. The bladder and uterus are normal. There
are no adnexal abnormalities. There is a small amount of free
fluid in the pelvis, which is nonspecific. OSSEOUS STRUCTURES:
There are no concerning lytic or sclerotic osseous lesions. No
fracture is identified.
IMPRESSION:
1. Mild wall thickening of the ascending colon, which could be
due to
underdistention, however in conjunction with subtle adjacent
stranding, a very mild colitis is a consideration.
2. Small amount of free fluid in the pelvis, which is
nonspecific, and maybe physiologic.
MICRO:
___ C. difficile DNA amplification assay (Final ___:
Negative
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7(Final ___: NO E.COLI
0157:H7.
DISCHARGE:
___ 06:45AM BLOOD WBC-12.8* RBC-4.58 Hgb-13.0 Hct-38.8
MCV-85 MCH-28.4 MCHC-33.5 RDW-13.0 Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-141
K-4.2 Cl-106 HCO3-28 AnGap-11
___ 06:45AM BLOOD CK(CPK)-89
___ 06:45AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 200 mg PO DAILY
2. Loestrin ___ Fe *NF* (norethindrone-e.estradiol-iron) ___
(24)-75(4) mg-mcg-mg Oral DAILY
3. Ibuprofen 400-600 mg PO Q8H:PRN pain
Discharge Medications:
1. Loestrin ___ Fe *NF* (norethindrone-e.estradiol-iron) ___
(24)-75(4) mg-mcg-mg Oral DAILY
2. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Hematochezia
Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Bright red blood per rectum after running a 5k. Has abdominal
pain, nausea, and persistent bloody diarrhea. Evaluate for exercise-induced
ischemic colitis.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis without the administration of IV contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
FINDINGS:
LUNG BASES: The bases of the lungs are clear without nodules, consolidations,
or pleural effusions. The base of the heart is normal. There is no
pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There are no focal
hepatic lesions. There is no intra- or extra-hepatic biliary duct dilation.
Minimal periportal edema is likely due to recent hydration. The gallbladder,
spleen, pancreas, adrenal glands, and kidneys are normal. There are no renal
lesions. There is no pyelonephritis or hydronephrosis. The kidneys enhance
and excrete contrast symmetrically.
The stomach and small bowel are normal in course and caliber. There are no
focal inflammatory changes. There is no free air or free fluid. There is no
mesenteric, abdominal, or retroperitoneal lymphadenopathy. The abdominal
vasculature is normal in course and caliber.
PELVIS: The sigmoid colon is air filled. The remainder of the descending and
transverse colon are mostly collapsed, which limits its evaluation, but there
is no definite wall thickening or abnormal enhancement. There is no
significant surrounding stranding. The ascending colon is somewhat collapsed,
though there is a suggestion that the wall is thickened with very minimal
surrounding stranding. This could be consistent with a very mild colitis.
The appendix is visualized and normal.
The bladder and uterus are normal. There are no adnexal abnormalities. There
is a small amount of free fluid in the pelvis, which is nonspecific.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. No fracture is identified.
IMPRESSION:
1. Mild wall thickening of the ascending colon, which could be due to
underdistention, however in conjunction with subtle adjacent stranding, a very
mild colitis is a consideration.
2. Small amount of free fluid in the pelvis, which is nonspecific, and maybe
physiologic.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with DIARRHEA, NONINF GASTROENTERIT NEC, DEHYDRATION
temperature: 96.8
heartrate: 64.0
resprate: nan
o2sat: 100.0
sbp: 122.0
dbp: 73.0
level of pain: 8
level of acuity: 2.0 | This is a ___ female with minimal PMH who presents with one day
of watery diarrhea, BRBPR, and abdominal cramping after running
a 5K race, of unclear etiology.
# Diarrhea / BRBPR: Pt's symptoms decreased significantly at
discharge, with little to no blood in the stool (which remained
watery). Very likely lower GI in origin (vomitus was
non-bloody). She was hemodynamically stable throughout her
admission, and HCT was stable at 37-40. No clear cause at this
point, though given absence of prior GI disease, epidemiology,
CT scan, conincident nausea/vomiting, and elevated white count,
an infectious colitis seems most likely. EHEC and C.Diff neg.
Potential culprits could be shigella, salmonella, or
campylobacter (cultures pending), though she denies any obvious
exposures and absence of fever would be somewhat atypical. Other
less likely possibilities include IBD (though she is appropriate
age range) or ischemic colitis (she is young, no risk factors -
exercise-associated ischemic colitis has been described but is
rare and the inflammation in her colon is not at a watershed
area). She was given IVF while not taking POs, her nausea was
controlled with Zofran, and her diet was advanced to regular.
She was told to avoid ibuprofen for the time being given risk of
re-bleeding.
# Depression / Anxiety: Currently stable. Her home Sertraline
was continued.
# OCPs: Her home OCP was continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / aspirin / NSAIDS / Antihistamines - Alkylamine
Attending: ___
Chief Complaint:
Left subcapital femur fracture
Major Surgical or Invasive Procedure:
___: Closed reduction with percutaneous pinning of Left
subcapital femur fracture
History of Present Illness:
___ with h/o bipolar disorder on lithium, nephrogenic DI,
breast CA sp mastectomy in ___ who initially presented s/p
mechanical fall on ___ and found to have L subcapital femur
fx. She was admitted to ___ service for ORIF, now POD#1. Her
course has been complicated by AMS with slurred speech,
initially concerning for acute CVA but ruled out by head CT.
Lab work has been notable for leukocytosis (WBC 14),
hypernatremia (Na 148, increased from baseline of 145) and
hypercalcemia (Ca ranging ___.
.
Currently, she is somnolent and unable to provide a history.
Past Medical History:
- Nephrogenic DI
- breast cancer, ER+/PR+, HER2/neu-, grade II, invasive lobular
carcinoma and lobular carcinoma in situ, s/p modified radical
mastectomy with senitnel LN bx ___
- bipolar, dx ___, stable on lithium therapy
- IBS
- hyperparathyroidism (details not known)
- hypothyroidism
- CKD stage ___
- s/p bilateral salingo-oophorectomy, total abdominal
hysterectomy ___ complicated appencitis s/p appendectomy in ___
Social History:
___
Family History:
Mother had breast cancer, possibly in her ___. A maternal aunt
may also have had cancer.
Physical Exam:
Examination on Tranfer:
VS - Tm 100.5/Tc 100.4, BP 130/52, HR 90, 93% 2L
GENERAL - Somnolent elderly female in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), L hip incision c/d/i
SKIN - no rashes or lesions
NEURO - Exam limited due to pt not following commands. AAOx3,
CNs II-XII grossly intact, DTRs 2+ and symmetric
.
Discharge Exam:
A&O x 3, awake and alert, interactive
Calm and comfortable
LLE skin clean and intact
Tender lateral hip
LLE shortened and externally rotated
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
Admission Labs:
___ 06:00PM GLUCOSE-129* UREA N-32* CREAT-1.7* SODIUM-144
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-22 ANION GAP-14
___ 06:00PM CALCIUM-11.4* PHOSPHATE-3.4 MAGNESIUM-2.5
___ 06:00PM LITHIUM-1.0
___ 08:43PM ___ PTT-25.7 ___
.
Sodium Trend:
.
___ 07:05PM BLOOD Na-149*
___ 05:30PM BLOOD Na-147*
___ 09:10PM BLOOD Na-147*
___ 05:03AM BLOOD Na-142 (IV D5W stopped)
___ 05:12AM BLOOD Na-144
.
Calcium Labs:
___ 06:00PM BLOOD Calcium-11.4* Phos-3.4 Mg-2.5
___ 05:35AM BLOOD Calcium-10.7* Phos-1.9* Mg-2.2
Cholest-194
___ 11:40AM BLOOD TotProt-5.7* Albumin-3.5 Globuln-2.2
___ 05:35AM BLOOD PTH-121*
.
Discharge Labs:
___ 05:12AM BLOOD WBC-7.3 RBC-3.29* Hgb-9.5* Hct-30.2*
MCV-92 MCH-28.9 MCHC-31.5 RDW-13.9 Plt ___
___ 05:12AM BLOOD Glucose-129* UreaN-34* Creat-1.3* Na-144
K-4.3 Cl-114* HCO3-22 AnGap-12
___ 05:12AM BLOOD Calcium-10.9* Phos-2.7 Mg-2.4
.
Micro:
___ 10:09 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
IMAGING:
Bilateral Hip Xrays ___:
There is a subcapital fracture through the proximal left femur
without substantial displacement, probably complete.
IMPRESSION: Left subcapital femur fracture.
.
CT HEAD W/O CONTRAST ___:
The majority of the images are degraded due to extensive motion
artifact.
Within this limitation, no large intracranial hemorrhage is
identified. Focal hypodensities most pronounced in the right
basal ganglia likely represents a remote infarct, unchanged.
Apparent asymmetry of lateral ventricles is again noted. There
is no shift of normal midline structures. No hydrocephalus is
seen. Basal cisterns are patent. There is no large vascular
territorial infarction. Sulci and ventricles are prominent,
likely age-related involutional changes.
.
Imaged paranasal sinuses appear well aerated. The posterior
mastoid air cells are opacified, more conspicuous from prior
exam. No acute fracture is seen.
.
IMPRESSION:
.
1. No evidence of large vascular territorial infarction. Study
is suboptimal due to extensive motion artifact.
2. Prominent sulci and ventricles, likely age-related
involutional changes.
.
CXR AP ___:
Large hiatal hernia is projecting over the left lower lung
behind the cardiac silhouette. There are bibasal opacities
concerning for interval increase of areas of atelectasis.
Infectious process is less likely but cannot be excluded. Small
bilateral pleural effusions are present. Mild vascular
engorgement is seen, might be consistent with interval fluid
load on the patient.
.
MRI Head W/O CONTRAST ___:
FINDINGS: The examination is limited due to patient motion;
grossly there is no evidence of acute intraparenchymal
hemorrhage, on the diffusion axial images, there is no evidence
of intraparenchymal restricted diffusion or areas to indicate
acute/subacute ischemic changes. Please consider obtaining a
followup examination under conscious sedation if clinically
warranted.
IMPRESSION: Limited study due to patient motion, the patient
refused to
continue with the examination. Grossly, there is no evidence of
acute
hemorrhagic changes or areas with acute ischemia. Followup
examination is
recommended if clinically warranted under conscious sedation.
Medications on Admission:
Anastrozole 1 mg daily
Levothyroxine 88 mcg daily
Lithium carbonate 300 mg BID
loperamide 2 mg PRN diarrhea.
Vit D
Discharge Medications:
1. senna 8.6 mg Tablet Sig: ___ Tablets PO DAILY (Daily): while
taking oxycodone to prevent constipation, do not take if having
loose stools.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking oxycodone to prevent constipation, do
not take if having loose stools.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: while taking oxycodone, do not take if having
loose stools.
4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Injection
Subcutaneous Q24H (every 24 hours).
6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day as
needed for loose stool.
9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every six (6)
hours as needed for pain for 2 weeks: ___ cause drowsiness, do
not drive while taking medication.
Disp:*56 Tablet(s)* Refills:*0*
10. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO
twice a day.
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
12. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subcapital 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
BILATERAL HIP RADIOGRAPHS
HISTORY: Trauma. Question fracture involving the left hip status post fall
on the left hip.
COMPARISONS: None, aside from CT torso dated ___.
TECHNIQUE: Pelvis and bilateral hips, total of five views.
FINDINGS: There is a subcapital fracture through the proximal left femur
without substantial displacement, probably complete.
IMPRESSION: Left subcapital femur fracture.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Preoperative radiograph.
COMPARISONS: Scout view from a CT torso dated ___ and more recent
chest radiograph from ___.
TECHNIQUE: Chest, semi-upright AP.
FINDINGS: There is a large hiatal hernia containing stomach and also
apparently part of the colon, as seen previously. The heart is normal in
size. The mediastinal and hilar contours appear unchanged. There is no
pleural effusion or pneumothorax. The lungs appear clear.
IMPRESSION: No evidence of acute disease. Large hiatal hernia, as seen
previously.
Radiology Report
REASON FOR EXAMINATION: Pinning of the left hip.
Note is made that the radiologist was not attending the procedure.
Three fluoroscopic views obtained during fluoroscopy were brought to our
review. Note is made that the fluoroscopy time of 82.4 seconds was provided.
Internal pinning of the left hip is noted with no immediate complications.
For precise details, please review procedure report.
Radiology Report
INDICATION: Patient with aphasia. Assess for stroke.
COMPARISONS: CT head of ___.
TECHNIQUE: MDCT-acquired contiguous images through the brain were obtained
without intravenous contrast at 5 mm slice thickness. Coronally and
sagittally reformatted images were displayed. Multiple attempts were made to
obtain the images due to patient's agitation.
FINDINGS:
The majority of the images are degraded due to extensive motion artifact.
Within this limitation, no large intracranial hemorrhage is identified. Focal
hypodensities most pronounced in the right basal ganglia likely represents a
remote infarct, unchanged. Apparent asymmetry of lateral ventricles is again
noted. There is no shift of normal midline structures. No hydrocephalus is
seen. Basal cisterns are patent. There is no large vascular territorial
infarction. Sulci and ventricles are prominent, likely age-related
involutional changes.
Imaged paranasal sinuses appear well aerated. The posterior mastoid air cells
are opacified, more conspicuous from prior exam. No acute fracture is seen.
IMPRESSION:
1. No evidence of large vascular territorial infarction. Study is suboptimal
due to extensive motion artifact.
2. Prominent sulci and ventricles, likely age-related involutional changes.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with mental status changes.
COMPARISON: ___ radiograph.
Large hiatal hernia is projecting over the left lower lung behind the cardiac
silhouette. There are bibasal opacities concerning for interval increase of
areas of atelectasis. Infectious process is less likely but cannot be
excluded. Small bilateral pleural effusions are present. Mild vascular
engorgement is seen, might be consistent with interval fluid load on the
patient.
Radiology Report
STUDY: MRI of the head.
CLINICAL INDICATION: Recurrent episodes of delirium and slurred speech,
evaluate for stroke.
COMPARISON: Prior head CT dated ___ and ___.
TECHNIQUE: Limited examination, the patient refused to continue with the
study after the diffusion-weighted sequence, only sagittal T1 and axial DWI
sequences were provided.
FINDINGS: The examination is limited due to patient motion; grossly there is
no evidence of acute intraparenchymal hemorrhage, on the diffusion axial
images, there is no evidence of intraparenchymal restricted diffusion or areas
to indicate acute/subacute ischemic changes. Please consider obtaining a
followup examination under conscious sedation if clinically warranted.
IMPRESSION: Limited study due to patient motion, the patient refused to
continue with the examination. Grossly, there is no evidence of acute
hemorrhagic changes or areas with acute ischemia. Followup examination is
recommended if clinically warranted under conscious sedation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT HIP
Diagnosed with FX FEMUR INTRCAPS NEC-CL, FALL FROM BED
temperature: 98.5
heartrate: 70.0
resprate: 12.0
o2sat: 95.0
sbp: 104.0
dbp: 70.0
level of pain: 13
level of acuity: 3.0 | Primary Reason for Hospitalization:
___ yo F with nephrogenic DI, breast CA sp mastectomy in ___,
admitted with hip fracture sp ORIF on ___. Post-op course
complicated with AMS and slurred speech, hypernatremia,
hypecalcemia, and pt was transferred to medicine.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene-SD / valproic acid / Levaquin
Attending: ___.
Major Surgical or Invasive Procedure:
EGD ___
attach
Pertinent Results:
ADMISSION LABS:
================
___ 10:00AM BLOOD WBC-14.6* RBC-2.37* Hgb-5.9* Hct-20.4*
MCV-86 MCH-24.9* MCHC-28.9* RDW-18.3* RDWSD-58.1* Plt ___
___ 10:00AM BLOOD Neuts-83.6* Lymphs-6.2* Monos-9.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.18* AbsLymp-0.90*
AbsMono-1.39* AbsEos-0.02* AbsBaso-0.04
___ 10:00AM BLOOD Glucose-99 UreaN-36* Creat-0.7 Na-139
K-4.4 Cl-106 HCO3-22 AnGap-11
___ 10:00AM BLOOD ALT-9 AlkPhos-114 TotBili-<0.2
___ 10:00AM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.3*
Mg-2.0
PERTINENT LABS/MICRO:
=====================
___ 10:00AM BLOOD WBC-14.6* RBC-2.37* Hgb-5.9* Hct-20.4*
MCV-86 MCH-24.9* MCHC-28.9* RDW-18.3* RDWSD-58.1* Plt ___
___ 04:40PM BLOOD WBC-12.6* RBC-2.80* Hgb-7.4* Hct-26.1*
MCV-93 MCH-26.4 MCHC-28.4* RDW-16.9* RDWSD-57.7* Plt ___
___ 08:55PM BLOOD WBC-8.0 RBC-2.19* Hgb-5.9* Hct-19.1*
MCV-87 MCH-26.9 MCHC-30.9* RDW-16.8* RDWSD-52.6* Plt ___
___ 10:50PM BLOOD WBC-6.4 RBC-2.06* Hgb-5.5* Hct-17.9*
MCV-87 MCH-26.7 MCHC-30.7* RDW-16.5* RDWSD-51.8* Plt ___
___ 03:57AM BLOOD WBC-7.1 RBC-2.79* Hgb-7.6* Hct-24.8*
MCV-89 MCH-27.2 MCHC-30.6* RDW-16.0* RDWSD-51.8* Plt ___
___ 10:00AM BLOOD Lipase-31
___ 10:00AM BLOOD cTropnT-<0.01
___ 09:36AM BLOOD Hapto-152
___ 02:09PM URINE Color-Straw Appear-HAZY* Sp ___
___ 02:09PM URINE Blood-TR* Nitrite-NEG Protein-50*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0
Leuks-LG*
___ 02:09PM URINE RBC-15* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-2
___ BCx x2: NGTD
___ UCx: No growth
DISCHARGE LABS:
================
___ 09:36AM BLOOD WBC-4.6 RBC-3.12* Hgb-8.4* Hct-27.8*
MCV-89 MCH-26.9 MCHC-30.2* RDW-17.0* RDWSD-54.3* Plt ___
___ 09:36AM BLOOD ___ PTT-27.9 ___
___ 09:36AM BLOOD Glucose-106* UreaN-11 Creat-0.6 Na-139
K-4.4 Cl-106 HCO3-23 AnGap-10
___ 09:36AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
PERTINENT IMAGING:
==================
___ CXR:
No acute cardiopulmonary process.
___ KUB:
There is a large amount of colonic stool. Non-specific,
nonobstructive gas pattern. No pneumoperitoneum.
___: EGD:
"Normal mucosa in the whole stomach"
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
2. Phenytoin (Suspension) 150 mg PO BID
3. Rivaroxaban 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Bisacodyl 10 mg PO Frequency is Unknown
6. Cyanocobalamin 1000 mcg PO DAILY
7. Felbamate 1400 mg PO BID
8. LevETIRAcetam 750 mg PO BID
9. Magnesium Citrate 300 mL PO Frequency is Unknown
10. Psyllium Powder 1 PKT PO DAILY
11. Selsun Blue (selenium sulfide) 1 % topical 3x/week prn
12. Senna 8.6 mg PO BID
13. Sucralfate 1 gm PO QID
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
16. starch (thickening) ___ spoonfuls oral TID W/MEALS
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
3. Magnesium Citrate 300 mL PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Cyanocobalamin 1000 mcg PO DAILY
6. Felbamate 1400 mg PO BID
7. LevETIRAcetam 750 mg PO BID
8. Phenytoin (Suspension) 150 mg PO BID
9. Psyllium Powder 1 PKT PO DAILY
10. Rivaroxaban 20 mg PO DAILY
11. Selsun Blue (selenium sulfide) 1 % topical 3x/week prn
12. Senna 8.6 mg PO BID
13. starch (thickening) ___ spoonfuls oral TID W/MEALS
14. Sucralfate 1 gm PO QID
15. Tamsulosin 0.4 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
======================
- Upper GI bleed
SECONDARY DIAGNOSIS
======================
- ___ syndrome
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
INDICATION: ___ with poor IV access // Poor IV access
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lung volumes are slightly low with left basilar atelectasis. There is no
consolidation, effusion, or edema. Cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities. Old healed left lateral rib
fractures are noted. Multilevel midthoracic vertebral body height loss as
seen on prior.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with n/v and coffee ground emesis // R/o SBO or
volvulus
TECHNIQUE: Supine and decubitus abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
large amount of colonic stool.
There is no free intraperitoneal air.
The imaged bones are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
There is a large amount of colonic stool. Non-specific, nonobstructive gas
pattern. No pneumoperitoneum.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man S/P Midline placement. Line found to not be IV
after receiving 300 mL LR and 40 mg propofol // R/O pleural collection of
fluid from midline Contact name: ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
No vascular access catheter is identified. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. There are no acute osseous abnormalities. Healed left rib
fractures are noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Coffee ground emesis
Diagnosed with Anemia, unspecified
temperature: 98.1
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 100.0
dbp: 58.0
level of pain: uta
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
=====================
___ Hx ___, severe intellectual disability, recurrent
GIBs, unprovoked DVT on rivaroxaban, p/w acute on chronic anemia
I/s/o likely UGIB. Patient underwent unrevealing EGD (___)
with self-resolution of ongoing bleeding, with course
complicated by propofol infiltrate requiring MICU transfer for
observation and generalized seizure in setting of acute illness
and not receiving home medications
TRANSITIONAL ISSUES
===================
[] HEART MURMUR: Holosystolic murmur best heard at apex noted on
exam, please monitor and consider TTE on outpatient basis.
[] ASPIRATION RISK: Patient continues to demonstrate chronic
risk of aspiration. Recommend ongoing precautions as well as
ongoing discussions with guardian regarding the risks of
complications with aspiration
[] PPI: Patient should complete a 12 week twice a day PPI course
for likely UGIB
ACTIVE ISSUES
=============
# UGIB
He presented with coffee-ground emesis with Hgb 5.5 (baseline
___. EGD ___ was unrevealing. Of note, patient has had
extensive GI work up in the past with negative colonoscopy and
capsule studies in past. His bleeding self resolved and he was
started on lansoprazole 30 BID, and he was discharged with GI
follow-up.
# Seizure
# ___ syndrome
Known history ___ Gastaut syndrome. He was continued on
felbamate 1400 big + phenytoin 150 bid + levetiracetam 750 bid
throughout this admission. He had two breakthrough, generalized
seizures during this admission which were treated with IV
lorazepam. Neurology was consulted and this was believed to be
due to difficulty with medication administration in the ED as
well as in the setting of acute illness and no changes were made
to his medication regimen.
#Aspiration Risk: Patient was evaluated by speech and swallow
service and felt to be at baseline swallowing capacity.
# Propofol IV infiltration
# Arm swelling
Midline infiltrated during propofol bolus prior to EGD. He was
transferred in the MICU and toxicology was consulted. There were
no complications.
CHRONIC ISSUES
==============
# Hx unprovoked DVT - his home anticoagulation was resumed by
the time of discharge after short bridge with heparin gtt to
ensure stability after bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Cholangiogram and plasty of biliary tree (___)
History of Present Illness:
___ year old woman with history of NASH cirrhosis s/p DDLT
(___) on cyclosporine and mycophenolate sodium w/ aortic
conduit complicated by biliary stricture s/p stent placement &
multiple PTBD exchanges, who has had multiple hospitalizations
for recurrent cholangitis who presents with fevers
She was recently admitted from ___ for cholangitis,
found
to have perihepatic abscess s/p ___ drainage. Prior bile cultures
growing VRE, pseudomonas resistant to ___. Initially was on
linezolid/meropenem and narrowed back to suppressive
ciprofloxacin per ID.
She presents with 1 day of fever without any additional
symptoms.
In the ED, initial VS were: 99.2 87 140/65 18 100% RA
Exam notable for:
JP drain/PTBD site c/d/i, no signs of septic joint on knee exam,
full ROM, no rashes, lungs CTA, abd unremarkable, systolic
murmur
Labs showed:
___ 30 AGap=15
-------------
4.9 24 1.0
Cyclosporine: 104
Lactate: 2
ALT: 91 AP: 1025 Tbili: 0.7 Alb: 3.8
AST: 65 LDH:
Imaging showed:
RUQUS:
1. Patent hepatic vasculature.
2. No significant change in fluid collection adjacent to the
falciform
ligament when accounting for differences in technique.
3. Stable mild splenomegaly.
4. Right pleural effusion.
CXR:
No acute intrathoracic process. Unchanged small right pleural
effusion.
Patient received: linezolid/cipro
Hepatology was consulted: Concern for recurrent cholangitis. OK
to admit to ___. Please obtain RUQUS, blood cultures.
Transfer VS were: 100.1 82 136/60 18 98% RA
On arrival to the floor, patient reports she feels better.
States
she only had fever today. Denies any abdominal pain, changed
output from her ___ drain, N/V, diarrhea, constipation, chest
pain, SOB. She has been taking good PO. She has been compliant
with all her medications including ciprofloxacin.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-Idiopathic cirrhosis s/p DDLT with aortic conduit (___) with
post-operative course complicated by biliary stricture and poor
drainage of the left biliary system s/p PTBD
-Psychosis
-Malnutrition- moderate
-Hypertension
-Diabetes mellitus- on insulin
-HLD
-Asthma
Social History:
___
Family History:
HTN - mother and father
CAD - father
No significant family history of liver cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.9 167/71 87 16 98% RA
GENERAL: laying comfortably in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender, nondistedned. medial ___ drain & PTBD
c/d/I without surrounding erythema. PTBD is capped. ___ drain w/
scant fluid in JP
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
GENERAL: pleasant, elderly woman, appears comfortable and in
NAD,
sitting up in bed
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender, nondistended. medial ___ drain & PTBD
c/d/i without surrounding erythema. PTBD capped. ___ drain w/
scant fluid in JP
EXTREMITIES: warm and well perfused, no cyanosis, clubbing, or
lower extremity edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS
___ 08:40AM BLOOD WBC-5.0 RBC-3.18* Hgb-8.3* Hct-26.4*
MCV-83 MCH-26.1 MCHC-31.4* RDW-17.2* RDWSD-51.5* Plt ___
___ 08:40AM BLOOD Neuts-76.5* Lymphs-13.1* Monos-5.8
Eos-3.8 Baso-0.2 Im ___ AbsNeut-3.79 AbsLymp-0.65*
AbsMono-0.29 AbsEos-0.19 AbsBaso-0.01
___ 08:40AM BLOOD ___
___ 08:40AM BLOOD UreaN-30* Creat-1.0 Na-142 K-4.9 Cl-103
HCO3-24 AnGap-15
___ 08:40AM BLOOD Glucose-173*
___ 08:40AM BLOOD ALT-91* AST-65* AlkPhos-1025* TotBili-0.7
___ 08:40AM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.3 Mg-1.5*
___ 08:40AM BLOOD Cyclspr-104
___ 08:04PM BLOOD Lactate-2.0
PERTINENT LABS
___ 04:33AM BLOOD WBC-4.9 RBC-2.62* Hgb-6.9* Hct-21.7*
MCV-83 MCH-26.3 MCHC-31.8* RDW-17.3* RDWSD-51.8* Plt ___
___ 07:05AM BLOOD WBC-5.4 RBC-3.28* Hgb-8.6* Hct-27.4*
MCV-84 MCH-26.2 MCHC-31.4* RDW-17.0* RDWSD-51.8* Plt ___
___ 07:06AM BLOOD ALT-55* AST-25 LD(LDH)-151 AlkPhos-826*
TotBili-0.8
___ 04:22AM BLOOD ALT-32 AST-17 AlkPhos-838* TotBili-1.1
___ 07:06AM BLOOD calTIBC-237* Ferritn-281* TRF-182*
DISCHARGE LABS
___ 04:22AM BLOOD WBC-3.6* RBC-2.97* Hgb-7.7* Hct-24.6*
MCV-83 MCH-25.9* MCHC-31.3* RDW-17.0* RDWSD-50.9* Plt ___
___ 04:22AM BLOOD ___ PTT-31.5 ___
___ 04:22AM BLOOD Glucose-120* UreaN-19 Creat-1.0 Na-139
K-5.1 Cl-102 HCO3-24 AnGap-13
___ 04:22AM BLOOD ALT-40 AST-31 AlkPhos-916* TotBili-1.1
___ 04:22AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.8 Mg-1.7
___ 04:22AM BLOOD Cyclspr-190
IMAGING/STUDIES
CXR (___)- No acute intrathoracic process. Unchanged small
right pleural effusion.
RUQ U/S (___)- 1. Patent hepatic vasculature.
2. No significant change in fluid collection adjacent to the
falciform ligament when accounting for differences in technique.
3. Stable mild splenomegaly.
4. Right pleural effusion.
Cholangiogram (___)- 1. Right 12 ___ percutaneous
transhepatic biliary drainage catheters.
2. Cholangiogram showing distal occlusion of indwelling right
internal
external biliary drainage with absence of flow into the
duodenum. Antegrade
cholangiogram demonstrates common bile duct stricture with
sluggish flow of
contrast into the duodenum. Post cholangio plasty and ___
sweep
cholangiogram demonstrates improved antegrade flow of bile into
the duodenum.
3. Successful exchange of right 12 ___ percutaneous
transhepatic biliary
drainage catheter with new right 12 ___ internal external
biliary catheter.
4. Successful exchange of subhepatic 8 ___ abscess drain.
Radiology Report
EXAMINATION: Chest Radiograph
INDICATION: ___ with liver tx, p/w fevers// r/o PNA
COMPARISON: Radiograph dated ___.
FINDINGS:
PA and lateral views of the chest provided.Low lung volumes. No focal
consolidations. Cardiomediastinal and hilar silhouettes are unchanged. No
pulmonary edema. Small right pleural effusion is again noted. No left
pleural effusion. No pneumothorax. A percutaneous biliary drainage catheter
is partially visualized in the right upper abdomen.
IMPRESSION:
No acute intrathoracic process. Unchanged small right pleural effusion.
Radiology Report
EXAMINATION: DUPLEX DOP ABD/PEL LIMITED
INDICATION: r/o any abnl
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound dated ___. CT dated ___.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. A biliary
drainage catheter is noted. The common hepatic duct measures 6 mm. A fluid
collection adjacent to the falciform ligament is again noted, measuring 5.0 x
1.6 cm.
Pancreas: The pancreas is largely obscured by overlying bowel gas, with
imaged portions of the pancreas appearing within normal limits.
Spleen: The spleen demonstrates normal echotexture, and measures 13.3 cm.
Kidneys: The right kidney measures 10.4 cm. The left kidney measures 9.6 cm.
No stones, masses, or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 36.3 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Incidental note is made of a right pleural effusion.
IMPRESSION:
1. Patent hepatic vasculature.
2. No significant change in fluid collection adjacent to the falciform
ligament when accounting for differences in technique.
3. Stable mild splenomegaly.
4. Right pleural effusion.
Radiology Report
INDICATION: ___ aortic conduit complicated by biliary strictures and stent
and multiple percutaneous transhepatic biliary drain exchanges with recurrent
cholangitis, pseudomonas bacteremia, on suppressive Cipro, VRE infections, and
left hepatic abscess who presented with fevers, and elevated ALP consistent
with cholangitis// please evaluate PTBD and JP drain/fluid collection.
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 55 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site
MEDICATIONS: None
CONTRAST: 50 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 17.4 min, 85 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing right 12 ___ percutaneous
internal external transhepatic biliary drainage access.
2. Exchange of the existing percutaneous trans-hepatic biliary drainage
catheter with a new 12 ___ internal-external PTBD catheter.
3. Cholangio plasty and ___ sweep of common bile duct.
4. Abscessogram
5. 8 ___ abscess drain exchange.
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/mid abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
right tube was injected with dilute contrast. The images were stored on PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right catheter was cut and ___
wire was advanced through the catheter into the duodenum. The catheter was
removed over the wire and a 8 ___ 25 cm sheath was advanced. Next a 5
___ Kumpe catheter was advanced into the duodenum which was confirmed with
contrast injection and exchange was made for an Amplatz wire. Antegrade
cholangiogram was then performed. Based on the findings of the cholangiogram,
cholangio plasty was performed in the common bile duct and at the level of the
ampulla with a 10 mm Conquest balloon. Exchange was then made for a 5.5
___ ___ balloon and multiple sweeps were performed within the common
bile duct into the duodenum. Completion cholangiogram was then performed.
The sheath was removed and a 12 ___ percutaneous trans hepatic internal
external biliary drainage catheter was advanced into the duodenum. Side holes
were positioned above and below the level of obstruction to facilitate
internal drainage. The wire and inner stiffener were removed, the catheter was
flushed, the loop was formed, the catheter was attached to a bag and sterile
dressings were applied.
Attention was then turned to the indwelling subhepatic abscess drain. The
indwelling 8 ___ drain was injected with contrast which demonstrated
persistent collection. No evidence of pericatheter leakage or fistulous
communication. However there is difficulty with aspirating through the
catheter. The catheter was cut and ___ wire was advanced into the
collection. The catheter was removed over the wire and a new 8 ___ APDL
drain was advanced into the collection. The wire and inner stiffener were
removed, the catheter was flushed, the loop was formed. The catheter
successfully flushed and aspirated. The catheter was attached to a JP bulb
placed to suction and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right 12 ___ percutaneous transhepatic biliary drainage catheters.
2. Cholangiogram showing distal occlusion of indwelling right internal
external biliary drainage with absence of flow into the duodenum. Antegrade
cholangiogram demonstrates common bile duct stricture with sluggish flow of
contrast into the duodenum. Post cholangio plasty and ___ sweep
cholangiogram demonstrates improved antegrade flow of bile into the duodenum.
3. Successful exchange of right 12 ___ percutaneous transhepatic biliary
drainage catheter with new right 12 ___ internal external biliary catheter.
4. Successful exchange of subhepatic 8 ___ abscess drain.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new 12 ___ internal external biliary catheter.
Successful exchange of subhepatic 8 ___ abscess drain.
RECOMMENDATION(S): 1. The biliary drainage catheter can be capped when the
output is bilious and nonbloody.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Cholangitis
temperature: 99.2
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 140.0
dbp: 65.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ year-old woman with history of CAD,
hypertension, diabetes mellitus, NASH cirrhosis with DDLT
(___) (on cyclosporine and mycophenolate) with aortic conduit
complicated by biliary strictures s/p stenting and multiple
percutaneous transhepatic biliary drain exchanges with recurrent
cholangitis, pseudomonas bacteremia, on suppressive cipro, VRE
infections, and left hepatic abscess, who presented with fevers,
and elevated ALP concerning for recurrent cholangitis.
ACUTE ISSUES
#Cholangitis: The patient presented with 1 day of fever &
elevated LFTs concerning for recurrent cholangitis. She did not
have abdominal pain, however she denies ever abdominal pain with
her recurrent cholangitis. Fever occurred while on suppressive
cipro. Previous bile cultures grew MDR pseudomonas sensitive
only to cipro & aminoglycosides as well as VRE. RUQ U/S revealed
persistent perihepatic collection, so likely continued source of
infection. The patient's PTBD was uncapped with significant
drainage to bag concerning for PTBD dysfunction. She was started
on high dose ciprofloxacin and linezolid and ultimately
underwent cholangiogram with dilation of biliary stricture and
subsequent improved flow. The patient remained afebrile
throughout her hospitalization. Her PTBD was capped on ___.
Patient did not spike fever overnight, after capping. ID
consulted and recommended to complete a 2 week course of cipro
750mg BID and linezolid ___ BID (last day ___, followed
by return to ___ 500mg daily for suppression.
CHRONIC ISSUES
#Idiopathic cirrhosis s/p DDLT: With aortic conduit (___) and
stenosis of arterial graft of liver. Patient with multiple
complications. Now more stable, though with continued biliary
strictures.
# Anemia: Patient anemic to 6.9 on ___. Given 1U pRBCs. Likely
related to chronic disease/bone marrow suppression given low
retic index. Anemia improved appropriately. Now stable in 8s.
Iron studies consistent with inflammatory picture (high
ferritin, low iron).
TRANSITIONAL ISSUES
[] Labs on ___: CBC, Chemistries, cyclosporine level.
Should be faxed to Dr. ___ ___, Dr. ___
___.
[] discharge antibiotic regimen: ciprofloxacin 750mg q12h,
linezolid ___ q12h (last day ___
[] once initial antibiotic regimen is complete, should stay on
suppressive ciprofloxacin 500mg daily indefinitely
[] follow-up to be scheduled with ___ for PTBD and JP drain
management
[] discharge hemoglobin: 7.7
[] discharge immunosuppression: Mycophenolate Sodium ___ 360 mg
PO BID, CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
# CODE: FULL CODE (presumed)
# CONTACT: ___ (sister and HCP), ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
productive cough, hemoptysis, abdominal pain, nausea, and fever
Major Surgical or Invasive Procedure:
___ Transcutaneous liver biopsy
___ Transcutaneous liver biopsy
History of Present Illness:
___ with history of cirrhosis (HCV and EtOH, s/p orthotopic
liver transplant ___ with subsequent recurrence of cirrhosis
(s/p treatment with simeprevir/sofosbuvir ___, presents with
___ days of productive cough, hemoptysis, abdominal pain,
nausea, and fever to 103.
His symptoms began ___ with cough productive of white
bloody sputum (not massive hemoptysis), head congestion, and
diarrhea. On ___, he woke up feeling clammy alternating with
feeling hot, and measured a temperature of 103. He also had
dizziness and continued cough with blood-streaked sputum. His
diarrhea improved after taking Immodium. On ___, he developed
vomiting with all POs as well as pain in his "stomach,"
especially his RUQ and RLQ, which was severe and exacerbated by
movement and coughing. He has never had pain of this type
before. He also reported throbbing pain in his chest, which he
thought was due to vomiting. He was reluctant to present to his
PCP or the hospital due to frequent hospitalizations since liver
transplant, but on ___ his symptoms persisted and he presented
to his PCP. He then presented to the ___ ED.
In the ED, initial vitals were: 8 98.8 82 124/78 20 98% RA
Labs were significant for H/H 11.8/34.0 (below baseline of
hemoglobin ___. He had no leukocytosis, with WBC 4.2, 63%
neutrophils. Lactate 1.4. U/A clear.
Imaging included negative CXR and CT abdomen and pelvis which
was felt to be negative by the surgical team. He was given
morphine 5mg IV x3, 2L NS and admitted to Medicine for workup of
his nausea/abdominal pain/fever.
Vitals prior to transfer were: 98.1 61 138/72 16 98% RA
This morning, he reports continued abdominal pain with movement
and coughing. He reports no vomiting today even after breakfast
(he had vomited all POs prior).
On ROS, he noted some hematuria one week prior to admission
which had cleared. He has had ~35lbs weight loss over the past
few months, partially intended, partially unintentional as he
"wasn't eating well;" he is taking Ensures at home. He has
chronic LBP after an accident. Remainder of ROS negative.
Past Medical History:
- S/p OLT liver transplant in ___ ago for HCV cirrhosis with
recurrent HCV after transplant (stage 3 fibrosis per biopsy
___. Endoscopy ___ revealed two cords of grade 1
varices and esophagitis.
- relapsed ETOH abuse
- remote hx of sbp
- chronic back pain on opiates, s/p bilateral RFA
- T2DM complicated by nephropathy A1c 11%
- depression
- BPH
- chronic back pain
- hypertension
- tobacco use
- history or prior IVDU
Social History:
___
Family History:
Mother healthy, father passed away in the ___ due to prostate
cancer. No known history of colon cancer. No history of MI.
Physical Exam:
EXAM AT ADMISSION:
VS: T 97.7, Tm 98.2, HR 61, BP 132/93 (132-143/83-93), RR 20,
O2S 97 RA, Wt 81kg.
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
RESP: Coarse breath sounds at bases bilaterally, improves
somewhat after cough.
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, ND, bowel sounds present, TTP diffusely with pain
referred to RLQ, especially TTP at RLQ with +rebound tenderness.
Liver edge smooth and palpable >4cm below costal margin. No
guarding
GU: No foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
EXAM AT DISCHARGE:
VS: T:98.3 HR:77 BP:121/94 RR:18 O2:95RA
FSG: 132-282
GENERAL: Well appearing, in bed
HEENT: Sclerae anicteric, MMM
NECK: Triple lumen IJ on R
RESP: CTAB
CV: RRR, Nl S1, S2, No MRG
ABD: Abdomen soft, non-tender.
EXT: Pitting edema to mid calf L>R
NEURO: AAOx3, motor and sensory exam grossly intact
Pertinent Results:
LABS ON ADMISSION:
___ 02:06PM GLUCOSE-234* UREA N-18 CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
___ 02:06PM ALBUMIN-3.4* CALCIUM-8.4 PHOSPHATE-2.8
MAGNESIUM-1.7
___ 02:06PM LIPASE-22
___ 02:06PM ALT(SGPT)-53* AST(SGOT)-63* ALK PHOS-207* TOT
BILI-0.6
___ 02:06PM WBC-4.2# RBC-3.83* HGB-11.8* HCT-34.0* MCV-89
MCH-30.8 MCHC-34.7 RDW-13.9 RDWSD-44.7
___ 02:06PM NEUTS-63.6 ___ MONOS-9.5 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-2.69# AbsLymp-1.00* AbsMono-0.40
AbsEos-0.11 AbsBaso-0.02
___ 02:06PM PLT COUNT-103*
___ 02:06PM ___ PTT-28.1 ___
___ 04:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 04:26PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:26PM URINE MUCOUS-RARE
DISCHARGE LABS:
___ 06:28AM BLOOD WBC-4.4 RBC-3.65* Hgb-11.1* Hct-33.9*
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.9* RDWSD-54.1* Plt Ct-89*
___ 06:28AM BLOOD Plt Ct-89*
___ 01:07PM BLOOD Glucose-123* UreaN-36* Creat-1.3* Na-138
K-5.1 Cl-103 HCO3-26 AnGap-14
___ 06:28AM BLOOD ALT-82* AST-52* AlkPhos-270* TotBili-0.8
MICRO:
CMV Viral Load (Final ___: CMV DNA not detected.
URINE CULTURE (Final ___: NO GROWTH.
___ 2:06 pm BLOOD CULTURE Blood Culture, Routine
...........
IMAGING:
___ Chest X-ray
COMPARISON: ___
IMPRESSION: Bilateral lower lobe atelectasis and/or scarring.
No radiographic evidence for pneumonia.
___ Chest X-ray
COMPARISON: ___ at 13:22
FINDINGS: There has been interval placement of a right internal
jugular central venous catheter which courses to the midline and
appears to follow the expected location of the mid SVC. No
pneumothorax is seen. Mild basilar atelectasis is seen without
definite focal consolidation. No pleural effusion. Stable
cardiac and mediastinal silhouettes.
___ CT abdomen and pelvis +IV contrast +PO contrast
COMPARISON: CT abdomen and pelvis dated ___.
+FINDINGS:
LOWER CHEST: Visualized lower lung fields demonstrate mild
bibasilar
atelectasis. A 6 mm right lower lobe solid pulmonary nodule
(02:14) and a 4 mm right lower lobe subpleural nodule (2:7) are
unchanged from ___.
HEPATOBILIARY: The patient is status post liver transplant, and
the background liver attenuation appears heterogeneous, similar
to the prior examination. Linear heterogeneity is seen involving
segments 8 and 4. The gallbladder is surgically absent.
PANCREAS: There is mild prominence the main pancreatic duct,
which is unchanged from prior examination. A hypodensity within
the pancreatic uncinate process measures 8 mm (02:34), unchanged
from the prior examination.
URINARY: Bilateral subcentimeter renal hypodensities are too
small to characterize but unchanged from prior examination and
likely cysts.
LYMPH NODES: Multiple prominent retroperitoneal lymph nodes are
again
identified, none of which are pathologically enlarged by CT size
criteria, and all of which appear grossly unchanged from the
prior examination.
VASCULAR: Moderate atherosclerotic disease is noted.
IMPRESSION:
1. No evidence for acute intra-abdominal process.
2. Status post hepatic transplant with heterogeneous appearance
of the
hepatic parenchyma. Linear heterogeneity is seen involving
segments 8 and 4. Focal ductal dilatation or underlying lesion
not excluded. Findings could be further assessed on MRI.
Patent portal vein.
PATHOLOGY:
___ Pathology Tissue: LIVER, TRANSPLANT BIOPSY
Compared to patient's prior biopsy (___) portal/septal
inflammatory infiltrate appears unchanged. No definitive
endothelialitis identified in this sample
___ Pathology Tissue: LIVER, TRANSPLANT BIOPSY
The biopsy is limited by the high percentage of septal fibrous
tissue. Within these septal/portal areas, mild to focally
moderate, predominantly mononuclear inflammation is identified,
comprised of lymphocytes and focally prominent plasma cells,
with scattered neutrophils and rare eosinophils. Foci of mild
venous endothelialitis and rare lymphocytic cholangitis are
present. Minimal periportal and lobular inflammatory extension
is seen; only a rare apoptotic is identified.
In the clinical context of negative HCV viral load and initially
undetectable serum immunosuppression level, these features are
consistent with mild acute cellular rejection. In addition to
these findings, the current biopsy shows progression of fibrosis
and decreased steatosis as
compared to the prior biopsy (___).
Radiology Report
INDICATION: ___ year old man with liver transplant and worsening LFTs //
percutaneous liver biopsy
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist.
Dr. ___ the procedure.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. No other abnormalities were identified on the limited
imaging.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with approximately 7 mL 1% lidocaine. Under
real-time ultrasound guidance, an 18 gauge core biopsy needle was then
advanced into the liver and a single core biopsy sample was obtained and
placed in formalin. The sample was submitted for rush pathologic processing
and hand delivered to the pathology pickup site in OR with telephone call to
pathology. The skin was then cleaned and a dry sterile dressing was applied.
There was no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 4
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated rush non-targeted liver biopsy.
Radiology Report
INDICATION: ___ year old man with orthotopic liver transplant now with acute
transplant rejection on immunosuppression // Assess for ongoing signs of
rejection. Please expedite pathology.
COMPARISON: Ultrasound-guided liver biopsy ___.
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. No other abnormalities were identified on the limited
imaging.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound
guidance, a 18 gauge core biopsy needle was then advanced into the
transplanted liver and a single core biopsy sample was obtained and placed in
formalin. The skin was then cleaned and a dry sterile dressing was applied.
There was no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
0.5 mg Versed and 25 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:
Uncomplicated non-targeted liver biopsy.
Radiology Report
INDICATION: ___ year old man with acute rejection of orthotopic liver
transplant on immunosuppressives, with persistent small amount hemoptysis c/f
infection. // Assess for infection, masses
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 351 mGy-cm
COMPARISON: ___
FINDINGS:
MEDIASTINUM: The imaged thyroid is normal. No pathologically enlarged
supraclavicular, axillary, hilar or mediastinal lymph nodes.
HEART AND GREAT VESSELS: The aorta and pulmonary arteries are normal in size.
No large central filling defects in the pulmonary arteries. The right chambers
are enlarged with relative straightening of the intraventricular septum and
there is no pericardial effusion. Mild atherosclerotic calcifications of the
thoracic aorta and moderate of the coronary arteries.
PLEURA: There is no pneumothorax. There is new small to moderate right-sided
pleural effusion.
LUNGS AND TRACHEOBRONCHIAL TREE: The airways are patent. Mild paraseptal and
centrilobular emphysema. Numerous sub 5 mm peribronchial nodules are stable
dating back to ___ (5: 40, 54, 69, 95, 97). Peribronchial spiculated
nodule in the right upper lobe measuring up to 7 mm is also stable dating back
to ___ (5:75). There is a new peribronchial sub solid nodule in the left
upper lobe (5:84) measuring 6 x 6 mm.
Mild linear scarring and atelectasis in the right middle lobe, lingula and
lower lobes bilaterally. There is also compressive atelectasis adjacent to
the small right-sided pleural effusion. Mild interlobular septal thickening
in keeping with mild interstitial edema. No bronchiectasis.
BONES AND CHEST WALL: There are no destructive focal osseous or chest wall
lesions concerning for malignancy within the imaged thoracic skeleton.
Bilateral symmetric gynecomastia.
UPPER ABDOMEN:
Although this study is not designed for the evaluation of subdiaphragmatic
structures, the patient has had prior orthotopic transplant surgical clips.
The liver appears homogeneous on this late arterial phase and the portal veins
are patent. Trace perihepatic stranding and small volume ascites. There is a
wedge-shaped hypodensity at the hilum of the spleen likely a perfusional
defect due to timing of contrast.
IMPRESSION:
1. New 6 mmn nodule in the left upper lobe, potentially infectious or
inflammatory in etiology. Numerous additional pulmonary nodules are stable
dating back to ___ and are consistent with a benign etiology given
long-term stability.
2. Mild interstitial edema and small to moderate right pleural effusion.
Enlargement of the right atrium and ventricle with straightening of the
interventricular septum, suggestive of right heart disease.
3. Trace perihepatic stranding and small volume ascites, incompletely
assessed.
4. Wedge-shaped hypodensity at the splenic hilum, likely perfusional defect
related to timing of contrast.
RECOMMENDATION(S): Follow-up CT thorax in 3 months to reassess the left upper
lobe nodule.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Dizziness
Diagnosed with ABDOMINAL PAIN UNSPEC SITE
temperature: 98.8
heartrate: 82.0
resprate: 20.0
o2sat: 98.0
sbp: 124.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ with a history of cirrhosis (HCV and
EtOH, s/p orthotopic liver transplant ___ with subsequent
recurrence of cirrhosis (s/p treatment with
simeprevir/sofosbuvir ___, who presented to ___ on ___
with ___ days of cough, hemoptysis, abdominal pain, nausea and
fever, found to have subsequent acute liver rejection.
# Acute liver transplant rejection: Patient was admitted to
___ on ___ with fevers to 103, ___ days of productive
cough, hemoptysis, abdominal pain, nausea, and vomiting of all
POs including his immunosuppressive medications. His LFTs were
elevated on admission and continued to increase during his
hospitalization with peak AST of 144 and peak ALT of 148. His
elevated LFTs were concerning for transplant rejection in the
setting of decreased tacrolimus level. CT abdomen was concerning
for an intraparenchymal process. He then underwent liver biopsy
on ___ with confirmed acute liver rejection. Patient was
started on high dose steroids for 5 days along with tacrolimus
and cellcept, but continued to have elevated LFTs. He underwent
repeat liver biopsy on ___ which showed ongoing rejection. He
then received 7 days of anti-thymocyte globulin (ATG) for
steroid resistant rejection. His LFTs improved with ATG
administration to ALT 82 AST 52, and patient was discharged with
planned repeat liver biopsy and hepatology follow up.
___: Patient had mild ___ during his admission. His creatinine
was elevated to creatinine 1.4 above baseline 1.1-1.2. This
stabilized to 1.3 at discharge after fluid administration. His
___ was thought to be secondary to tacrolimus vs hypovolemia.
# Diabetes: Patient had difficult hospital course with regard to
his glycemic control likely due to steroid administration. He
was at times hypoglycemic and hyperglycemic but was not
symptomatic. He was managed with his home 70/30 and an insulin
sliding scale. His insulin was adjusted per ___ consult
recommendations.
# Viral syndrome: Presented with ___ days of productive cough,
hemoptysis, abdominal pain, nausea, and fever to 103. Likely
viral given improvement off antibiotics. Pt had fever of 103
days prior to seeking care and may benefit from prompt
evaluation next time he is febrile, given his immunosuppression.
Team has counseled patient to seek care immediately with future
fevers. He received guaifenisin/dextromethorphan and benzonatate
for symptomatic relief of cough. He receieved a CT scan for
ongoing mild hemoptysis that showed a small nodule that will
need subsequent follow up with pulmonology.
# Hyponatremia: Patient had Na+ that was initially downtrending,
but resolved with IVF. Patient did not have any associated
symptoms.
# Medications: You have the following new or adjusted
medications:
Tacrolimus 3 mg po twice a day
Mycophenolate Mofetil 1000mg twice a day
Prednisone 20 mg po daily
Valganciclovir 450 mg po daily
Fluconazole 400 mg po daily
Insulin dosing now 24 Units in AM and 26 units in ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) /
Gadolinium-Containing Contrast Media / glyburide
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a hx of pancreatitis and membranous glomerulonephritis
with nephrotic syndrome and recent admission for hyponatremia
who was at clinic appointment, and had an unresponsive episode.
___ was at ___ with his nephrologist and they were
discussing treatment options when he suddenly began to feel
dizzy, nauseous and have slight headache. The next thing he
knew, he was slumped over and there were a lot of people around.
Per ED records, he "syncopized at some point and for an unknown
period of time was pulseless, a CODE BLUE was called, and he
regained pulses after no compressions." Timeframe of all of this
is unclear. No shaking or urinary incontinence. No palpitations
before or after. Subsequently he has felt an intermittent
headache, dizziness and chest pain. The chest pain is on the
left side of his chest, is described as "hollow pressure" and
does not radiate. It does not change with position or breathing
and is not reproducible. He endorses chills that he has
especially noticed since the ED, but otherwise no fevers,
nausea, vomiting, diarrhea, cp, sob, leg swelling, abd pain,
flank pain.
In the ED, initial vital signs were: 98.8 85 125/84 11 99% RA
Labs were notable for WBC 8.6, H/H 13.1/36.7, Na 131, lactate
1.5. CXR showed no acute intrathoracic process. CT head with no
acute intracranial process and age advanced involutional change.
Patient was given 1L IVF. Vitals on transfer 98.8 88 122/81 14
99% RA
Upon arrival to the floor, Mr. ___ endorses the above story.
Of note, patient was recently discharged on ___ for
hyponatremia, initially 126 that was improved with IVF.
Patient's glipizide was stopped given concern for potential
SIADH upon discharge. Patient also completed a 24-hour protein
urine collection with ___ with his nephrologist, Dr. ___,
___ was significant for >6 g proteinuria over 24 hrs.
Past Medical History:
PANCREATITIS
HYPERLIPIDEMIA
NON-INSULIN DEPENDENT DIABETES MELLITUS
MEMBRANOUS GLOMERULONEPHRITIS
NEPHROTIC SYNDROME
Social History:
___
Family History:
Mother Living ___
Father Living ___
Brother Living ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals- 99 133/87 93 20 100% RA 62.8 kg
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD, no carotid bruits
bilaterally
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, no murmur rub or gallop appreciated
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no unilateral swelling
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
==================
Vitals- 97.8 129/82 80 16 100% RA
orthostatics (___)
131/79 90 -> 128/81 90 -> 115/80 108
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, no murmur rub or gallop appreciated
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no unilateral swelling
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABORATORY:
============
___ 10:34AM BLOOD WBC-8.6 RBC-4.30* Hgb-13.1* Hct-36.7*
MCV-85 MCH-30.6 MCHC-35.8* RDW-13.1 Plt ___
___ 06:20AM BLOOD WBC-9.2 RBC-3.77* Hgb-11.6* Hct-32.8*
MCV-87 MCH-30.8 MCHC-35.4* RDW-13.1 Plt ___
___ 03:05PM BLOOD WBC-10.0 RBC-3.90* Hgb-12.3* Hct-34.1*
MCV-88 MCH-31.7 MCHC-36.2* RDW-13.7 Plt ___
___ 10:34AM BLOOD ___ PTT-24.5* ___
___ 10:34AM BLOOD Glucose-190* UreaN-12 Creat-0.9 Na-131*
K-4.1 Cl-98 HCO3-25 AnGap-12
___ 06:20AM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-134
K-4.1 Cl-103 HCO3-24 AnGap-11
___ 10:34AM BLOOD ALT-14 AST-17 CK(CPK)-46* AlkPhos-51
TotBili-0.5
___ 10:34AM BLOOD Lipase-21
___ 07:20PM BLOOD cTropnT-<0.01
___ 10:34AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:20AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.8
___ 10:34AM BLOOD Albumin-2.5* Calcium-8.8 Phos-4.7* Mg-1.8
___ 10:45AM BLOOD Lactate-1.5
IMAGING:
============
ECG:
Normal sinus rhythm. Normal ECG. Compared to the previous
tracing of ___
sinus tachycardia is no longer present.
IntervalsAxes
___
___
CT head without contrast
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally
midline structures, or evidence of acute major vascular
territorial
infarction. Ventricles are normal. Sulci are prominent for a
patient of this
age. Mild to moderate ethmoidal opacity is noted. Otherwise the
paranasal
sinuses are clear. Mastoid air cells and middle ear cavities are
well aerated.
The bony calvarium is intact.
IMPRESSION:
1. No acute intracranial process.
2. Age advanced involutional change.
___ CXR
IMPRESSION: No acute intrathoracic process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Atovaquone Suspension 1500 mg PO DAILY
3. CycloSPORINE (Sandimmune) 100 mg PO Q12H
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lisinopril 15 mg PO DAILY
6. PredniSONE 10 mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Atovaquone Suspension 1500 mg PO DAILY
3. CycloSPORINE (Sandimmune) 100 mg PO Q12H
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lisinopril 15 mg PO DAILY
6. PredniSONE 10 mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
vasovagal and orthostatic syncope
hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with syncope, unresponsive episode
COMPARISON: Prior exam from ___.
FINDINGS:
AP upright and lateral views of the chest provided. Overlying EKG leads
noted. There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with syncope, unresponsive episode, headache
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891.93 mGy-cm
COMPARISON: None available for comparison.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles are normal. Sulci are prominent for a patient of this
age. Mild to moderate ethmoidal opacity is noted. Otherwise the paranasal
sinuses are clear. Mastoid air cells and middle ear cavities are well aerated.
The bony calvarium is intact.
IMPRESSION:
1. No acute intracranial process.
2. Age advanced involutional change.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: Unresponsive
Diagnosed with SYNCOPE AND COLLAPSE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ with membranous nephropathy and nephrotic syndrome with
progressive proteinuria who presents after syncopal episode with
concern for pulselessness.
# Syncope: By symptoms consistent with vasovagal syncope,
borderline orthostatic by vital signs. Received IVF and was
monitored on telemetry. Though unlikely, was ruled out for ACS.
No tachycardia, pleuritic chest pain, leg swelling or hypoxia to
suggest DVT/PE. Felt better day after. Was persistently
borderline orthostatic per BP and HR but w/o symptoms, likely
due to hypoalbuminemic state resulting in relative intravascular
volume depletion. PO intake encouraged upon discharge
# Chest pain: Noted upon admission, not pleuritic, unchanged.
Acute coronary syndrome ruled out. Resolved by HD 1. Etiology
may be muscle soreness/MSK.
# Hyponatremia: Improved with more IVF to 134.
# Membranous nephropathy/nephrotic syndrome: On prednisone and
cyclosporine, recent 24 hr urine with > 6g protein. No
significant edema on exam, BPs ok and renal function stable.
Continued these medications and associated prophylaxis with
atovaquone.
# T2DM: Recent HbA1c 7.2%. Glipizide held at last admission, and
continued to be held during this admission. Trended FSBG while
inpatient as on prednisone, reasonable control achieved on
sliding scale alone. Will continue to hold glipizide upon
discharge as may potentially be contributing to
SIADH/hyponatremia.
# Anemia: Mild and stable. Trended while inpatient with no other
intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin / Prozac
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an ___ with a hx of NSCLC (diagnosed ___, recurrent L
pleural effusion, COPD, hyponatremia who presents to the ED
following outpatient CT imaging showing a complex L pleural
effusion. Pt was in her usual state of healthy until two months
ago. She developed dyspnea and presented to ___, where she
was noted to have a LLL mass, L pleural effusion and
hyponatremia. Biopsy and PET scan revealed Stage IV NSCLC. She
was discharged home and underwent thoracentesis as an
outpatient.
She represented to ___ ___ with dyspnea and recurrent L
pleural effusion. She was admitted to the ___ ICU where she
underwent a thoracentesis and was treated with cefepime.
Following discharge on ___, she presented to interventional
pulmonology clinic on ___ (Dr. ___ where ultrasound revealed
a
loculated pocket. A thoracoscopy and possible placement of an
indwelling catheter was planned for ___. A follow up
Chest CT for interventional planning was performed yesterday
(___). This CT revealed a "moderate-size complex left pleural
effusion with suggestion of nodular peripheral enhancement the
lung base", concerning for infection and malignancy. CBC on ___
was notable for WBC of 32. She was instructed by her outpatient
IP to present to ___ ED by IP to receive antibiotics for
further management.
- In the ED, initial vitals were: T 97.6 HR 119 BP 156/59 RR 17
SpO2 95% RA
- Exam was notable for: resting comfortably on room air
- Labs were notable for: WBC 36.6 Na 130
- Studies were notable for: CXR: "Opacity in the left mid and
lower lung better assessed on CT performed 1 day prior with
malignancy suspected and probable adjacent pneumonia, with small
left pleural effusion."
- The patient was given: Vancomycin, zosyn and 1L LR. Chest tube
was attempted to be placed, however, the pleural fluid was too
dense to be evacuated.
On arrival to the floor, pt reported feeling short of breath
while exerting herself. She was placed on 2L NC and began to sit
forward, which resolved her dyspnea. On interview, patient was
leaning forward to allow herself to breathe comfortably. She
reported ongoing dyspnea but denied chest pain, chest pressure,
abdominal pain, fever, chills. She notes feeling weaker over the
past three weeks and losing her appetite. She reports that she
does not want any surgical intervention at this time but is
amenable to interventional procedures.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Hyponatremia
COPD
Seasonal allergies
Pelvic adhesions with a history of bowel obstruction
Hysterectomy
Hypertension
History of anxiety
Social History:
___
Family History:
Breast cancer in sister
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 1736 Temp: 97.7 PO BP: 183/105 HR: 120 RR: 20
O2
sat: 94% O2 delivery: 2L
GENERAL: Thin elderly woman, leaning forward, on NC. Can
converse
comfortably.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Tachycardic. Regular rhythm, normal rate. Audible S1
and
S2. No murmurs/rubs/gallops.
LUNGS: R side clear to ausculation. No sounds in L base. Rhonchi
in middle of L lung.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 24 HR Data (last updated ___ @ 819)
Temp: 97.8 (Tm 97.9), BP: 138/78 (138-183/76-105), HR: 109
(104-120), RR: 18 (___), O2 sat: 96% (94-96), O2 delivery: 2L
(2L-4L)
GENERAL: Thin elderly woman, leaning forward, on NC. Can
converse
comfortably.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Tachycardic. Regular rhythm, normal rate. Audible S1
and
S2. No murmurs/rubs/gallops.
LUNGS: R side clear to ausculation. No sounds in L base. Rhonchi
in middle of L lung.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
Admission Labs
===============
___ 04:30PM BLOOD WBC-33.2* RBC-3.54* Hgb-11.5 Hct-33.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-14.3 RDWSD-49.1* Plt ___
___ 04:30PM BLOOD Neuts-84* Bands-2 Lymphs-4* Monos-6 Eos-2
___ Metas-2* AbsNeut-28.55* AbsLymp-1.33 AbsMono-1.99*
AbsEos-0.66* AbsBaso-0.00*
___ 04:30PM BLOOD Plt Smr-HIGH* Plt ___
___ 12:30PM BLOOD ___ PTT-25.8 ___
___ 04:30PM BLOOD Glucose-107* UreaN-5* Creat-0.4 Na-130*
K-4.1 Cl-91* HCO3-26 AnGap-13
___ 04:30PM BLOOD ALT-14 AST-20 AlkPhos-82 TotBili-0.4
___ 04:30PM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.2*
Mg-2.0
___ 04:30PM BLOOD Osmolal-265*
Important Imaging
==================
CXR ___
IMPRESSION:
Opacity in the left mid and lower lung better assessed on CT
performed 1 day
prior with malignancy suspected and probable adjacent pneumonia,
with small
left pleural effusion.
Discharge Labs
===============
___ 08:02AM BLOOD WBC-30.8* RBC-3.22* Hgb-10.1* Hct-31.5*
MCV-98 MCH-31.4 MCHC-32.1 RDW-14.7 RDWSD-52.8* Plt ___
___ 08:02AM BLOOD Plt ___
___ 08:02AM BLOOD ___ PTT-28.0 ___
___ 08:02AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-136 K-3.9
Cl-91* HCO3-31 AnGap-14
___ 08:02AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GuaiFENesin-CODEINE Phosphate ___ mL PO HS:PRN Sleeping
2. ibandronate 150 mg oral EVERY 4 WEEKS
3. LevoFLOXacin 750 mg PO Q48H
4. Mirtazapine 15 mg PO QHS
5. Calcium Carbonate 600 mg PO Q24H
6. Vitamin D 1000 UNIT PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Lisinopril 2.5 mg PO DAILY
9. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*100 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H complicated
pleural effusion
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
every twelve (12) hours Disp #*60 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
RX *bisacodyl 10 mg ___aily PRN Disp #*30 Suppository
Refills:*0
4. LORazepam 0.5 mg PO Q4H:PRN anxiety, insomnia
RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 4 hours as
needed Disp #*42 Tablet Refills:*0
5. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
6. Morphine Sulfate (Oral Solution) 2 mg/mL 4 mg PO Q2H:PRN
Dyspnea
RX *morphine 20 mg/5 mL (4 mg/mL) 4 mg by mouth every 2 hours as
needed Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a
day Disp #*30 Packet Refills:*0
9. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth QHS PRN
Disp #*30 Tablet Refills:*0
11. GuaiFENesin-CODEINE Phosphate ___ mL PO Q2H:PRN cough
12. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
1 puff IH twice a day Disp #*1 Inhaler Refills:*0
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone propionate 50 mcg/actuation 1 spray NU once a
day Disp #*30 Spray Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Loculated pleural effusion
Stage IV non-small cell lung cancer
Secondary Diagnosis
====================
Hyponatremia
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 pleural effusion// Pleural effusion characterization
COMPARISON: CT of the chest from ___
FINDINGS:
PA and lateral views of the chest provided. Opacity in the left lung base is
better assessed on CT from 1 day prior representing a large mass, with
adjacent small pleural effusion and consolidation which may represent
atelectasis versus pneumonia. Please refer to CT report for further details.
Right lung remains clear. Cardiomediastinal silhouette appears grossly
unchanged. Imaged bony structures are intact.
IMPRESSION:
Opacity in the left mid and lower lung better assessed on CT performed 1 day
prior with malignancy suspected and probable adjacent pneumonia, with small
left pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Pneumonia, unspecified organism
temperature: 97.6
heartrate: 119.0
resprate: 17.0
o2sat: 95.0
sbp: 156.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Transitional Issues
====================
[]titrate morphine to quell patient's air hunger
[]titrate Ativan to quell patient's anxiety
[]titate bowel regimen
Summary Statement
==================
This is an ___ with h/o Stage IV NSCLC (recently diagnosed),
COPD and hyponatremia, admitted for recurrent complex pleural
effusion on CT and leukocytosis concerning
for pleural infection. The patient's effusion was too viscous to
be drained by IP. After the unsuccessful drainage, the patient
requested no more interventions or escalations in care. Her
symptoms were treated with morphine and Ativan as well as
amox/clav to prevent worsening of her likely pleural infection.
She was discharged to ___ with hospice and comfort focused care.
Active Issues
==============
#Left loculated pleural effusion
#Leukocytosis
The patient presented with a loculated appearing pleural
effusion on the left side, leukocytosis to 36,000, and mild
hypoxemia requiring 2L O2. She was seen in the emergency
department by Interventional Pulmonology who attempted bedside
thoracentesis but was unable to extract any fluid due to its
viscosity. Given the patient's malignancy as well as
significant leukocytosis and fevers, her effusion is likely
malignant in nature with possible super-infection. Patient was
initially started on empiric vancomycin and cefepime. Treatment
options were discussed with the patient and her family, and she
decided that she did not want surgical drainage or any further
escalations in her care. Palliative Care was consulted.
Outpatient hospice services were arranged, and she was switched
to p.o. amoxicillin-clavulanate, given p.o. morphine and
lorazepam for air hunger and anxiety, and discharged to ___
___ for ongoing hospice care.
#Goals of care
During the ___ hospital stay, we had an extensive
conversation regarding her goals of care. She noted that she
would not want to be intubated or have chest
compressions done. She initially thought she would want to be
transferred to the ICU for BiPAP but reconsidered and decided
that it would not be within her
goals of care. We discussed the potential of a VATS surgery
which the patient noted she would not be interested in. The
patient was seen by the thoracic surgeons and declined any
further interventions including thoracentesis. The patient would
like her infection treated if possible with po antibiotics. She
was treated with po morhine for air hunger and po Ativan for
anxiety.
#Hyponatremia
Patient has a history of chronic hyponatremia with sodium around
130. Serum sodium here on presentation was 130 with serum
positives of 265 consistent with hypotonic hyponatremia. Urine
electrolytes were not consistent with SIADH. Likely some
component of hypovolemia as the patient received IV fluids as
well as p.o. intake and sodium stabilized. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
neutropenic fever
Reason for MICU transfer: severe anemia and neutropenic fever
Major Surgical or Invasive Procedure:
___ Bone Marrow Biopsy
___ Bone Marrow Biopsy
History of Present Illness:
___ woman who is otherwise healthy presented with
malaise x 1 month and worsening DOE x 1 week to her PCP and was
found to have pancytopenia after basic workup. She was referred
urgently to ___ where labwork showed WBC 0.4 hbg 4.8
and plt 38. She was started on zosyn and then transferred ___
for further evaluation.
On presentation to ___, her inital vitals were: ___
20 100%. Her Tmax in the ED was 102.9. In regards to her fever,
she has no localizing infectious symptoms cough, SOB, N/V/D, abd
pain, rash or any focal pain. A CXR could not r/o pna. Chem 10
was unremarkable. AST was elevated to 50 and AP was 112. LDH
was 224 and uric acid was 2.7. She was given vanco and
cefepime. Hem-Onc was consulted and attempted for a BM bx x 6
attemps without success despite multiple medication for pain and
anxiety control. She was also given ibuprofen for pain
control. She was given 1 unit of p RBCs
On arrival to the MICU, patient had no new complaints. She was
given a second 2 unit of pRBC (ordered in the ED). 20 mins
into the transfusion she develop severe arm pain at the PIV
where the blood was being transfused. She became hypotensive
and dizzy with MAP's in 40's (70-80/30's). The transfusion was
immediately stopped. She was given hydrocort 50mgx2, benadryl
25mg x 2, and famotidine 20mg x 1 over the next hour. She was
also bolused 4L of NS and eventually returned to being
normotensive after approximately 1 hour. She denied CP, SOB,
wheezing during this hour long episode. Blood bank was
contacted.
Past Medical History:
1. APML: diagnosed ___ treatment with ATRA/Arsenic
2. Perirectal fistula
Social History:
___
Family History:
No known family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.8, 118, 90/32, 20, 97%
General: Pale
HEENT: No scleral icterus or conjunctival erythema. Pupils
equal, round, and reactive to light. Extraocular movements
intact. Moist mucous membranes with no oral ulcers, plaques, or
thrush.
Neck/Lymph: Supple. No cervical, supraclavicular, axillary or
inguinal lymphadenopathy.
Chest: Clear to auscultation throughout. No wheezes, rales, or
rhonchi.
Cardiovascular: Regular rate and rhythm, normal S1 and S2. No
murmurs, rubs or gallops.
Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly
or palpable masses.
Back: No spinal/paraspinal tenderness to percussion.
Extremities: Warm and well perfused, no peripheral edema
Skin: No rashes or jaundice.
Neurologic: Alert and oriented, appropriate mood and affect,
normal gait, fluent speech. Face symmetric.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-0.4* RBC-1.37* Hgb-4.7* Hct-13.8*
MCV-101* MCH-34.3* MCHC-33.9 RDW-18.1* Plt Ct-33*
___ 02:10PM BLOOD Neuts-50 Bands-2 ___ Monos-8 Eos-0
Baso-0 Atyps-2* ___ Myelos-0 NRBC-4*
___ 02:10PM BLOOD ___ PTT-25.7 ___
___ 02:10PM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-136
K-3.4 Cl-105 HCO3-22 AnGap-12
___ 02:10PM BLOOD ALT-34 AST-50* LD(LDH)-224 AlkPhos-112*
TotBili-0.6
___ 02:10PM BLOOD Albumin-3.8 UricAcd-2.7
___ 04:09AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.9
___ 02:37PM BLOOD Lactate-0.9
___ 02:10PM BLOOD ___ 02:10PM BLOOD Ret Aut-3.7*
___ 10:30PM BLOOD VitB12-717 Folate-7.9
___ 04:09AM BLOOD Ferritn-1187*
___ 04:56PM BLOOD Hapto-300*
___ 04:09AM BLOOD Triglyc-95
SEROLOGY & INTERVAL LABS:
___ 10:30PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
___ 10:30PM BLOOD HIV Ab-NEGATIVE
___ 10:30PM BLOOD HCV Ab-NEGATIVE
___ PARVOVIRUS B19 ANTIBODY IGG 6.04 High
___ PARVOVIRUS B19 ANTIBODY IGM <0.9 negative
___ ___ VIRUS VCA-IgG AB POSITIVE BY EIA.
___ ___ VIRUS EBNA IgG AB POSITIVE BY EIA.
___ ___ VIRUS VCA-IgM NEGATIVE <1:10 BY IFA.
___ CMV IgG and IgM: negative
DISCHARGE LABS:
=
=
================================================================
MICROBIOLOGY:
___ C. difficile DNA amplification assay: negative
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ MRSA SCREEN negative
___ Legionella Urinary Antigen -negative
___ URINE CULTURE no growth
___ BLOOD CULTURE no growth
___ BLOOD CULTURE no growth
=
=
================================================================
IMAGING:
___ CXR portable:
Vague left lower lobe heterogeneous density, which may represent
infection in the setting of neutropenia vs overlap of
structures.
___ CT torso with contrast:
1.No lymphadenopathy in the chest, abdomen, or pelvis.
2.Severl small solid and ground-glass pulmonary nodules, some of
which may be infectious or inflammatory in etiology. Comparison
to prior exams may be helpful, otherwise, these could be
followed.
3.Findings suggestive of anemia.
4.Tiny left renal hypodensity, too small to characterize, but
could represent a small cyst or AML.
5.Gallbladder wall edema, a nonspecific finding - while
inflammatory change (cholecystitis) can cause this appearance,
as an incidental finding this could be related to other systemic
processes such as underlying hypoalbuminemia, IV hydration or
drug related effects.
___ CXR soon after CT reaction:
Moderate generalized interstitial abnormality with mild
bibasilar confluence has progressed substantially over the
course of less than an hour, strong indication that the
explanation is pulmonary edema. There is no appreciable pleural
effusion and no pneumothorax.
___ CXR after central line placement:
Right internal jugular central venous catheter tip in right
atrium for which withdrawal of 4 cm is recommended. Interval
improvement of pulmonary edema.
___ ECHO TTE:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is borderline/mild posterior leaflet
mitral valve prolapse. A late systolic jet of Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
___ ECG:
Sinus rhythm.
___
___ CXR after central line pulled back:
compared to the previous image, the right internal jugular vein
catheter has been pulled back. The catheter now projects over
the inflow
tract of the right atrium and is in correct position. No
complications,
notably no pneumothorax. Otherwise, unchanged radiographic
appearance.
___ MRI PELVIS: ****
___ CXR: *****
=
=
================================================================
___: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS: HYPERCELLULAR BONE MARROW WITH EXTENSIVE
INVOLVEMENT BY ACUTE MYELOID LEUKEMIA WITH MORPHOLOGICAL
FEATURES CONSISTENT WITH ACUTE PROMYELOCYTIC LEUKEMIA. The
morphologic features favor a diagnosis of acute promyelocytic
leukemia. Cytogenetics demonstrated a t(15:17) translocation,
confirming this diagnosis. Concurrent flow cytometry showed
that the neoplastic cells were positive for CD34, CD13, CD33,
CD117, CD56 (dim), CD64 (dim), CD71 and CD2. By flow cytometry,
blast cells comprised 53% of total gated events.
Peripheral blood smear.
The smear is adequate for evaluation. Erythrocytes are
normochromic, and normocytic with marked anisopoikilocytosis
including micro and macrocytes, many ovalocytes, occasional
dacrocytes, scattered echinocytes, mild polychromasia with rare
fine basophilic stippling. The white blood cell count is
markedly decreased. The platelet count appears markedly
decreased. Occasional large and giant platelets are seen. A
200 cell differential shows 45% neutrophils, 0% bands, 48%
lymphocytes, 5% monocytes, 0% eosinophils, 1% basophils.
Aspirate smear.
The aspirate material is inadequate for evaluation due to lack
of spicules and hemodilution. Scattered hemophagocytic
macrophages are seen. A 200 cell differential shows 21% blasts,
24% promyelocytes, 9% myelocytes, 4% metamyelocytes, 8%
bands/neutrophils, 1% eosinophils, 16% erythroids, 17%
lymphocytes, 0% plasma cells.
Clot section and biopsy slides.
The core biopsy material is adequate for evaluation. It
consists of a 2.0 cm core biopsy of trabecular marrow with a
cellularity of nearly 100%. The M:E ratio estimate is
increased. There is an interstitial infiltrate of immature
mononuclear cells, consistent with blasts and promyelocytes
occupying greater than 90% of overall cellularity. These cells
have high N:E ratio, prominent nucleoli, irregular to cleaved
nuclei and granular cytoplasm. Mitoses and apoptotic cells are
common. In the remaining cellularity, erythroid precursors are
relatively proportionately decreased in number, and have overall
normoblastic maturation. Myeloid precursors are relatively
proportionately increased in number, with left-shifted
maturation. Megakaryocytes are normal in number, and include
occasional hyperlobulated forms. Clot sections show blood and
clusters of hematopoietic precursors, with findings similar to
the above
=
=
================================================================
___: BONE MARROW ASPIRATE AND CORE BIOPSY.
HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE
PROMYELOCYTIC LEUKEMIA, SEE NOTE. The morphologic features
favor a diagnosis of acute promyelocytic leukemia, given the
increased blasts, neoplastic promyelocytes (enumerated at 55% of
cellularity) and severely left-shifted maturation. FISH study
showed the presence of the characteristic t(15:17)(q22;q12)
translocation, confirming this diagnosis. Flow cytometry showed
that the abnormal cells (53% of total events) were positive for
CD34, CD13, CD33, CD117, CD56 (dim), CD64 (dim), CD71 and CD2.
Peripheral blood smear.
The smear is adequate for evaluation. Erythrocytes are
normochromic and normocytic with anisopoikilocytosis including
micro and macrocytes, many ovalocytes, occasional dacrocytes,
scattered schistocytes, mild polychromasia and fine basophilic
stippling. The white blood cell count is markedly decreased.
Occasional neutrophils are hypolobated and hypogranular. The
platelet count appears markedly decreased. Occasional large and
giant platelets are seen. A 100 cell differential shows 52%
neutrophils, 2% bands, 33% lymphocytes, 4% monocytes, 0%
eosinophils, 0% basophils, 2% atypical lymphocytes.
Aspirate smear.
The aspirate material is inadequate for evaluation due to lack
of spicules and hemodilution. Instead, a second core biopsy
sent in saline was used to create a touch prep for evaluation.
The M:E ratio is 10:1. Erythroid precursors are decreased in
number and exhibit megaloblastic maturation, including cells
with irregular nuclear contour. Myeloid precursors are
increased in number and show left-shifted/dyspoietic maturation,
including large aggregates of neoplastic promyelocytes with
irregular to cleaved nuclear outlines, prominent nucleoli, and
coarse azurophilic cytoplasmic granules, very few maturing cells
are seen. Rare cells with Aur rods are seen. Megakaryocytes
are not seen. Hemaphagocytic macrophages are seen. A 500 cell
differential shows 13% blasts, 55% promyelocytes, 5% myelocytes,
1% metamyelocytes, 1% bands/neutrophils, 1% eosinophils, 7%
erythroids, 13% lymphocytes, 2% plasma cells, 1% macrophages.
Clot section and biopsy slides.
The core biopsy material is adequate for evaluation. It
consists of a 1.2 cm core biopsy of trabecular marrow with a
cellularity of 100%. The M:E ratio estimate is increased.
There is an interstitial infiltrate of immature mononuclear
cells, consistent with blasts and promyelocytes with a high N:C
ratio, prominent nucleoli, irregular to cleaved nuclei, and
granular cytoplasm, occupying > 90% of overall cellularity.
Erythroid precursors are decreased in number and have overall
normoblastic maturation. Myeloid precursors are increased in
number with left-shifted maturation. Mitoses and apoptotic
cells are seen, as well as hemophagocytic cells. Megakaryocytes
are decreased in number. There is one small interstitial
lymphoid infiltrate composed of small mature lymphocytes. Clot
section contains blood and marrow elements and similar findings
as above.
=
=
================================================================
BM biopsy ___
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
CELLULAR BONE MARROW WITH MYELOID DOMINANT MATURATION. NO
MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY PROMYELOCYTIC LEUKEMIA.
SEE NOTE.
Note: The marrow shows myeloid dominant maturation with
terminal differentiation. No abnormal promyelocytes are
identified. However, in a patient with a history of
promyelocytic leukemia and differentiation therapy, correlation
with cytogenetic and molecular studies is recommended to assess
minimal residual disease. Mild dyspoiesis is noted within the
erythroids, possibly due to recent therapy. Clinical
correlation is recommended.
MICROSCOPIC DESCRIPTION:
Peripheral blood smear: The smear is adequate for evaluation.
Erythrocytes are decreased, normochromic and normocytic with
slight anisopoikilocytosis including elliptocytes,
polychromatophils, and occasional dacrocytes and schistocytes.
The white blood cell count is markedly decreased. A subset of
neutrophils (5%) show abnormal maturation with
nuclear-cytoplasmic dyssynchrony. Nucleated RBCs are seen with
rare asymptomatic nuclear budding. No increase in promyelocytes
is seen. The platelet count appears markedly decreased.
Occasional large and giant platelets are seen. A 200 cell
differential shows 49% neutrophils, 3% bands, 39% lymphocytes,
5% monocytes, 0% eosinophils, 0% basophils, 1% metas, 2% myelo,
2% atyps. 4% nrbcs per 100 WBCs.
Aspirate smear: The aspirate material is inadequate for
evaluation due to lack of spicules and hemodilution. Erythroid
precursors exhibit dyspoietic maturation, including cells with
irregular nuclear contours and asymmetric nuclear budding.
Myeloid precursors show dyspoietic maturation with nuclear
cytoplasmic dyssynchrony. Terminal granulocytic differentiation
is seen. Rare megakaryocytes are present. Abnormal forms are
not seen. A 500 cell differential shows less than 1% blasts,
less than 1%% promyelocytes, 5%% myelocytes, 3% metamyelocytes,
71% bands/neutrophils, 1% eosinophils, 13% erythroids, 6%
lymphocytes, less than 1% plasma cells.
Clot section and biopsy slides: The core biopsy material is
adequate for evaluation though aspiration artifact is present.
It consists of a 0.9 cm core biopsy of trabecular marrow with a
cellularity of 50-70%. The M:E ratio estimate is increased.
Erythroid precursors are relatively decreased in number and have
overall normoblastic maturation. Myeloid precursors are
increased in number with full spectrum maturation.
Megakaryocytes are normal in number with focal loose clustering.
Additional Studies:
Flow cytometry: Not performed.
Cytogenetics: See separate report.
Molecular studies: See separate report.
Medications on Admission:
nitroglycerin topical
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN consitpation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Lorazepam 0.5-1 mg IV Q4H:PRN nausea
RX *lorazepam [Ativan] 1 mg ___ tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*90 Tablet Refills:*0
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
(may subsitute with non-dissolving tablets instead)
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
7. Outpatient Lab Work
please check blood work on ___
CEM10
CBC with diff
fax to:Dr ___ ___
Office ___
dx: AML
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: APML, perianal phlegmon
secondary: neutropenia, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Neutropenic fever. Evaluate for pneumonia.
COMPARISON: None.
FINDINGS:
Frontal views of the chest were obtained. Vague heterogeneous density in the
left lower lobe is nonspecific but in the setting of neutropenia may represent
infection. No substantial pleural effusion or pneumothorax. Heart size is
top normal and cardiomediastinal contours are otherwise unremarkable. No
radiopaque foreign body.
IMPRESSION:
Vague left lower lobe heterogeneous density, which may represent infection in
the setting of neutropenia vs overlap of structures. If the patient is able,
dedicated PA and lateral views would be helpful for further evaluation.
Radiology Report
INDICATION: ___ female presents with neutropenic fever and concerning
bone marrow biopsy. Question lymphadenopathy or mass.
COMPARISON: None available.
TECHNIQUE: MDCT images were acquired from the thoracic inlet through the
pubic symphysis prior to and following the administration of intravenous
contrast with multiphasic imaging performed through the abdomen, and
multiplanar reformations provided.
CT CHEST: There is no mediastinal, hilar, or axillary lymphadenopathy. The
heart is normal in size without pericardial effusion. There is relative
myocardial ___ to the blood pool, suggestive of anemia. Although
not tailored for assessment of pulmonary embolism, no large central thrombus
is present. In the right upper lobe, there are two sub-4-mm pulmonary nodules
(3, 23), and a tubular 5-mm opacity in the right middle lobe (3, 27) could
represent an additional nodule. A 6-mm ground-glass pulmonary nodule is seen
in the anterior basal segment of the left lower lobe (3, 41). A 6-mm
triangular nodule is seen in the left upper lobe (3, 22). These could be
either compared to prior imaging when available or followed. There is no
confluent consolidation or pleural effusion. Central airways are patent.
There is posterior fissural thickening on the right (3, 27).
CT ABDOMEN: There is no focal lesion in the liver. There is no biliary
dilatation. The hepatic and portal veins are patent. The gallbladder
demonstrates mild diffuse mural edema, without pericholecystic fluid or
stranding, which is a nonspecific finding. The spleen, a tiny splenule,
pancreas, and adrenal glands are unremarkable. The kidneys enhance
symmetrically without hydronephrosis or hydroureter. A subcentimeter
hypodensity in the lower pole of the left kidney may represent a tiny cyst or
AML, but is too small to definitively assess (5, 44). Small and large bowel
loops are normal in caliber. There is no mesenteric or retroperitoneal
lymphadenopathy. The appendix is normal. Great vessels are patent.
CT PELVIS: The bladder is collapsed, containing a Foley catheter. The uterus
contains a small fibroid. The ovaries are normal. A small enhancing corpus
luteal cyst is seen in the left ovary. Moderate amount of likely physiologic
fluid is seen in the cul-de-sac. There is no inguinal or pelvic sidewall
lymphadenopathy. No free fluid in the pelvis.
BONE WINDOWS: A circumscribed focus of sclerosis in the left iliac wing
likely represents a small bone island. There is no concerning osseous lesion.
Minimal endplate sclerosis and spondylosis is seen at T11 anterosuperiorly.
IMPRESSION:
1. No lymphadenopathy in the chest, abdomen, or pelvis.
2. Several small solid and ground-glass pulmonary nodules, some of which may
be infectious or inflammatory in etiology. Comparison to prior exams may be
helpful, otherwise, these could be followed.
3. Findings suggestive of anemia.
4. Tiny left renal hypodensity, too small to characterize, but could
represent a small cyst or AML.
5. Gallbladder wall edema, a nonspecific finding - while inflammatory change
(cholecystitis) can cause this appearance, as an incidental finding this could
be related to other systemic processes such as underlying hypoalbuminemia, IV
hydration or drug related effects.
Radiology Report
AP CHEST, 3:05 P.M., ___
HISTORY: A ___ woman with new pancytopenia and acute respiratory
distress. Is there pneumonia or pleural effusion.
IMPRESSION: AP chest compared to ___, read in conjunction with a torso
CT, ___ at 2:30 p.m.:
Moderate generalized interstitial abnormality with mild bibasilar confluence
has progressed substantially over the course of less than an hour, strong
indication that the explanation is pulmonary edema. There is no appreciable
pleural effusion and no pneumothorax. Findings were discussed by telephone
with Dr. ___ at 4:20 p.m., 1 minute after the findings were recognized.
Radiology Report
INDICATION: ___ female patient with AML and new right IJ placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable chest AP radiograph.
FINDINGS: As compared to prior chest radiograph from ___, there has
been interval placement of a right IJ central venous catheter with its tip
projecting within the right atrium. There is no pneumothorax. There are low
lung volumes. However, pulmonary edema has markedly improved. No pleural
effusions are identified. The heart is top normal in size.
IMPRESSION: Right internal jugular central venous catheter tip in right
atrium for which withdrawal of 4 cm is recommended. Interval improvement of
pulmonary edema.
A wet read of this report was provided to Dr. ___ telephone on ___ at 20:30.
Radiology Report
CHEST RADIOGRAPH
INDICATION: AML, line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous image, the right internal jugular vein
catheter has been pulled back. The catheter now projects over the inflow
tract of the right atrium and is in correct position. No complications,
notably no pneumothorax. Otherwise, unchanged radiographic appearance.
Radiology Report
MR PELVIS WITH AND WITHOUT CONTRAST
COMPARISON: CT torso from ___.
INDICATION: ___ woman with APML and worsening anal fissure for two
weeks, evaluate for perirectal abscess or possible fistula.
TECHNIQUE: Multiplanar, multisequence MR imaging was obtained before and
after administration of 10 cc of Gadovist IV contrast.
FINDINGS:
MR PELVIS:
Visualized bowel is normal. There is a mild-to-moderate amount of pelvic free
fluid noted within the cul-de-sac. The uterus demonstrates a small 1.9 x
1.6-cm fibroid within the anterior uterine wall. Additionally, there are
cysts within the bilateral ovaries, the largest measuring up to 2 cm within
the left ovary (9:7).
Small vessels with bulbous components, left greater than right are noted
within the intersphincteric space, likely representing small hemorrhoids. A
vascular blush is noted along the posterior wall of the vagina at the level of
the introitus. However, there is no underlying discrete fistula seen. This
is best appreciated on series 1101 without significant T2 signal edema.
Additionally, there is a 2.3 x 1.1 x 3.7 cm area of infrasphincteric
phlegmonous inflammation in the left medial ischio-anal fossa without evidence
of intrinsic fluid to suggest abscess formation. No discrete fistulous tract
is identified originating from this. No evidence of sphincteric involvement.
BONES AND SOFT TISSUES:
No signal abnormalities are noted within the osseous structures. Incidental
note of a left-sided Tarlov cyst. Nonspecific edema is noted within the
anterior thigh subcutaneous soft tissues and muscles.
IMPRESSION:
1. Infrasphincteric phlegmon without sphinteric involvement and without
origin from the anal canal. No discrete fistulous tract or drainable fluid
collection is noted.
2. Nonspecific vascular blush is noted about the posterior wall of the vagina
at the level of the introitus. No discrete fistula is seen. Recommend clinical
correlation of this region. Inflammation can have a similar appearance.
3. Small anterior uterine fibroid is noted.
4. Nonspecific mild-to-moderate amount of pelvic free fluid within the
cul-de-sac.
5. Left-sided Tarlov's cyst is seen.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation for pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Low lung volumes, moderate cardiomegaly, no evidence of pulmonary
edema. No pleural effusions. No focal parenchymal opacities. Unchanged
position of the right internal jugular vein catheter.
Radiology Report
PROCEDURE:
1. Placement of tunneled right-sided triple-lumen central venous catheter.
2. Removal of right-sided temporary triple-lumen venous line.
HISTORY: ___ female with advanced promyelocytic leukemia requiring:
central venous access.
OPERATOR: Dr. ___, attending, performed the procedure.
ANESTHESIA: Conscious sedation was provided by administering divided doses of
Versed (3 mg) and fentanyl (200 mcg) throughout the total intraservice time of
30 minutes during which the patient's hemodynamic parameters were continuously
monitored. In addition, the patient received 1% lidocaine and 1% lidocaine
with epinephrine over the right internal jugular vein access site and along
the right anterior chest wall subcutaneous tunnel.
PROCEDURE NOTE IN DETAIL: Informed consent was obtained outlining the risks
and benefits of the proposed procedure. The patient was then brought to the
angio department and placed supine on the imaging table. The skin overlying
the right internal jugular vein, existing catheter and right chest were
prepped and draped in the usual sterile fashion. A preprocedure huddle and
timeout were performed as per ___ protocol.
Under real-time ultrasound guidance, following administration of 1% buffered
lidocaine, a micropuncture needle was advanced into the patent and
compressible right internal jugular vein. Following return of blood, an 0.018
nitinol wire was easily advanced into the SVC. The needle was removed and
exchanged for a 4.5 ___ micropuncture sheath. Via the sheath, an 035 ___
wire was advanced to the level of the right atrium and appropriate
measurements for catheter length were calculated. This wire was then advanced
into the ___ for stability.
Attention was then turned to creation of an anterior chest wall tunnel.
Following administration of 1% lidocaine and 1% lidocaine with epinephrine, a
2 mm incision was made using an 11 blade. A 13 ___ triple-lumen catheter
was then advanced with the aid of a tunneling device to exit at the venotomy
site. The catheter was cut to the appropriate length (21 cm) and the cuff was
positioned approximately 2 cm from the skin incision. The venotomy tract was
dilated using sequential 8-, 10- and ___ dilators. This was followed by
placement of a 13 ___ peel-away sheath. Via the sheath the port tubing was
incrementally advanced and the peel-away sheath was removed. A scout
fluoroscopic image demonstrated satisfactory catheter tip positioned in the
mid right atrium with no evidence of kinking of the catheter tubing. The
catheter was secured to the skin using 0 silk anchor sutures. The catheter
was aspirated and flushed normally and sterile caps applied.
The venotomy incision was closed using a ___ Vicryl subcuticular suture and
Steri-Strips and sterile dressings were again applied. The existing temporary
triple-lumen catheter was removed from the right internal jugular vein and
manual pressure held for 15 minutes. Good hemostasis was achieved. Patient
was transferred in stable condition to the floor for further post-procedure
monitoring. The catheter may be used immediately for infusion therapy.
IMPRESSION: Uncomplicated placement of a 13 ___ Hickman catheter
(triple-lumen) via the right internal jugular vein.
The catheter may be used for infusion therapy immediately.
The tip lies in the right atrium.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER/NEUTROPENIC
Diagnosed with OTHER PANCYTOPENIA
temperature: 102.0
heartrate: 120.0
resprate: 20.0
o2sat: 100.0
sbp: 134.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | ___ otherwise healthy admitted to the MICU for pancytopenia of
unclear etiology and neutropenic fever, found on bone marrow
biopsy to have new diagnosis of acute promyelocytic leukemia.
# Acute Promyelocytic Leukemia: She presented with pancytopenia
and bone marrow biopsy showed hypercellular marrow with 55%
neoplastic promyelocytes. FISH study confirmed the diagnosis
with the characteristic t(15:17)(q22;q12) translocation. Given
leukopenia on presentation, she is classified as low-risk APML
and treatment consisted of ATRA with arsenic (added on day 10 of
tx). Her WBC went as high as 60 but she never required
dexamethasone (she had no symotoms of differentiation
syndrome)and never required hydrea. Her counts eventually went
down and she became pancytopenic from the chemo. She was
discharged still neutropenic but no signs of active infection no
fevers (Still on cipro and flagyl) and was advised to all if any
fevers
# Neutropenic Fever: Fever on presentation, likely secondary to
tumor fever or perirectal fistula (described below).
Antibiotics initially started were cefepime/Vancomycin. Flagyl
and fluconazole were added on ___ given perirectal fistula and
antibiotic course was eventually switched to cipro and flagyl
while neutropenic.
# Perirectal Enterocutaneous Fistula/Diarrhea: One week of anal
fissure prior to presentation for which she was using
nitroglycerin topical. Onset of diarrhea (cdif negative) as
inpatient resulted in pain and development of perirectal
fisutula. MRI pelvis showed no abscess. Colorectal did not feel
surgery was necessary. Flagyl was added to vanc/cefepime on
___. Her fistula improved with ___ baths and dilaudid for
pain control and antibiotcs were switched to cipro and flagyl.
# Reaction to Transfusion and IV Contrast:
On ___ she developed hypotension and complaints of pain/burning
at the IV site, lightheadedness and chills/rigors, during the
transfusion of the second of two units of PRBCs. This resolved
with steroids, H1/H2 blockers, and fluids. Blood bank did not
believe that this is a typical transfusion reaction,
specifically no evidence of hemolysis. On ___, she developed
respiratory distress and fever to 103 after IV contrast for CT
that resolved with steroids, H1/H2 blockers, and fluids. Future
transfusions and IV gadolinium contrast infusions went smoothly
with premedication (hydrocortisone, tylenol, benadryl). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aminophylline / Bactrim / Erythromycin Base /
Benadryl Decongestant / Scopolamine / Codeine / Keflex / Tagamet
/ Cytotec / Azmacort / Cipro / Zantac / Pepcid / Celebrex /
Hydrocodone / yellow dye / red dye / Lasix / metformin /
triamcinolone / Quinolones / Cephalosporins / metoprolol /
aspirin / latex / ___ / oxycodone / Milk Containing
Products / Milk Containing Products
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 06:40PM BLOOD WBC-7.7 RBC-4.03 Hgb-10.4* Hct-34.7
MCV-86 MCH-25.8* MCHC-30.0* RDW-18.1* RDWSD-56.1* Plt ___
___ 06:40PM BLOOD Neuts-63.1 ___ Monos-8.1 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-4.88 AbsLymp-2.17 AbsMono-0.63
AbsEos-0.00* AbsBaso-0.02
___ 06:40PM BLOOD ___ PTT-26.9 ___
___ 06:40PM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-137
K-6.5* Cl-106 HCO3-20* AnGap-11
___ 05:39AM BLOOD ALT-19 AST-19 AlkPhos-96 TotBili-0.3
___ 06:40PM BLOOD cTropnT-<0.01
___ 10:59PM BLOOD cTropnT-<0.01
___ 06:40PM BLOOD proBNP-59
OTHER PERTINENT LABS
====================
___ 01:16AM BLOOD %HbA1c-7.0* eAG-154*
___ 06:40PM BLOOD Triglyc-195* HDL-45 CHOL/HD-3.7
LDLcalc-81
___ 06:40PM BLOOD Cholest-165
DISCHARGE LABS
==============
___ 05:39AM BLOOD WBC-10.1* RBC-3.65* Hgb-9.4* Hct-32.3*
MCV-89 MCH-25.8* MCHC-29.1* RDW-17.8* RDWSD-57.4* Plt ___
___ 05:39AM BLOOD ___ PTT-37.5* ___
___ 05:39AM BLOOD Glucose-159* UreaN-12 Creat-1.0 Na-139
K-4.5 Cl-103 HCO3-24 AnGap-12
___ 05:39AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.3
MICRO
=====
___ 06:40PM URINE Color-Straw Appear-Clear Sp ___
___ 06:40PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-SM*
___ 06:40PM URINE RBC-0 WBC-4 Bacteri-NONE Yeast-NONE Epi-1
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
IMAGING
=======
CXR ___
PA and lateral views of the chest provided. Lungs are clear.
No large
effusion or pneumothorax. Previously noted NG tube has been
removed.
Cardiomediastinal silhouette appears mildly prominent though
unchanged. No
definite signs of congestion or edema. Bony structures are
intact. Partially
visualized spinal hardware is noted in the upper abdomen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
3. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose
inhalation DAILY
4. azelastine 137 mcg (0.1 %) nasal DAILY
5. Montelukast 10 mg PO QPM
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Propafenone HCl 225 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. TraZODone 200 mg PO QHS
11. DULoxetine ___ 60 mg PO BID
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Gabapentin 300 mg PO BID
14. TraMADol 50 mg PO BID
15. Potassium Chloride 10 mEq PO BID
16. Vitamin D ___ UNIT PO 1X/WEEK (SA)
17. Invokana (canagliflozin) 100 mg oral DAILY
18. Fexofenadine 180 mg PO DAILY
19. Docusate Sodium 100 mg PO BID
20. Polyethylene Glycol 17 g PO DAILY
21. Magnesium Oxide 500 mg PO DAILY
22. FoLIC Acid ___ mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
24. Pyridoxine 100 mg PO DAILY
25. Cyanocobalamin 2500 mcg PO DAILY
26. Acetaminophen 1000 mg PO BID
27. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness
28. azithromycin 500 mg oral 1X:ASDIR
29. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks
This is dose # of tapered doses
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID
3. azelastine 137 mcg (0.1 %) nasal DAILY
4. Azithromycin 500 mg oral 1X:ASDIR
5. Breo Ellipta (fluticasone furoate-vilanterol) 200-25
mcg/dose inhalation DAILY
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 2500 mcg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. DULoxetine ___ 60 mg PO BID
11. Fexofenadine 180 mg PO DAILY
12. FoLIC Acid ___ mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Invokana (canagliflozin) 100 mg oral DAILY
15. Levothyroxine Sodium 200 mcg PO DAILY
16. Magnesium Oxide 500 mg PO DAILY
17. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks
This is dose # of tapered doses
18. Montelukast 10 mg PO QPM
19. Pantoprazole 40 mg PO Q24H
20. Polyethylene Glycol 17 g PO DAILY
21. Potassium Chloride 10 mEq PO BID
22. Propafenone HCl 225 mg PO BID
23. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
24. Pyridoxine 100 mg PO DAILY
25. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraMADol 50 mg PO BID
28. TraZODone 200 mg PO QHS
29. Vitamin D 1000 UNIT PO DAILY
30. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
GERD
Chest Pain
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 history of A. fib, chief complaint of left-sided chest
pain and shortness of breath // Pneumonia? Chest pathology?
COMPARISON: Prior study from ___
FINDINGS:
PA and lateral views of the chest provided. Lungs are clear. No large
effusion or pneumothorax. Previously noted NG tube has been removed.
Cardiomediastinal silhouette appears mildly prominent though unchanged. No
definite signs of congestion or edema. Bony structures are intact. Partially
visualized spinal hardware is noted in the upper abdomen.
IMPRESSION:
No acute findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 98.5
heartrate: 67.0
resprate: 22.0
o2sat: 97.0
sbp: 126.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] A1C 7.0. Patient on Invokana only. Patient would benefit
from additional oral hypoglycemic to lower A1C further as an
outpatient.
[ ] Patient started on atorvastatin 40mg daily for ASCVD score
>10% (12%). Please monitor for tolerance.
[ ] Patient with close cardiology follow-up with Dr ___.
Recommend dobutamine stress test to further evaluate cardiac
function.
BRIEF HOSPITAL COURSE
======================
Ms. ___ is a ___ year old woman with history of AFib,
severe asthma, DM, HLD, and iron deficiency anemia who presented
with chest pain during IV iron infusion found to have possible
ST depressions on EKG, without elevated troponins initially
started on heparin gtt. However, patient then described more GI
symptoms with indigestion, belching, N/V, and acid reflux
relieved with Tums and Zofran. Heparin was discontinued and
patient continued to be chest pain free even with
ambulation/exertion, making GERD more likely and cardiac
pathology less of an acute concern. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___
Chief Complaint:
Aphasia, R sided plegia
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 4 minutes
Time (and date) the patient was last known well: 22:00 on
___
___ Stroke Scale Score: 24
t-PA given:
No Reason t-PA was not given or considered: The patinet was out
side of the window for IV t-PA. she also had a supratherapeutic
INR.
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
HPI: The patient is a ___ yo woman with PMH significant for afib
on coumadin, HLD, depression and hypothyroidism who presented as
a code stroke. The patient was last seen normal at 10pm on the
night prior to her presentation. She and her husband were up
watching television when they both fell asleep. The patient's
husband woke up around 2am and tried to get his wife to come to
bed, but found her unresponsive. He tried to carry her to bed
but
was unable to lift her and she fell to the floor from the chair.
The husband then called ___. Code stroke was called at 0341 and
I
began my evaluation at 0345.
Past Medical History:
afib on coumadin
anxiety/depression
hypothyroidism
HTN
osteoarthritis
DM
Social History:
___
Family History:
No known neurologic diseases. Positive for breast cancer in her
mother and diabetes in her father. There is no h/o dementia.
Physical Exam:
Admission Examination:
The patient's exam improved some what from initial evaluation.
She was able to follow some simple commands (close your eyes and
raise your hand) but unable to follow more complex commands for
ataxia testing. She was able to regard the examiner on the left
and not the right. She was able to hold Left arm and leg up for
10 sec. minimal response no noxious stim on the left, none on
the
right. toes up on the R, down on the left.
****************
Discharge exam:
MS: awake and alert. interactive. speaking very softly in
___. able to repeat some times. follows some commands
inconsistently.
CN: R facial droop. PERRL. EOMI.
Motor: flacid on the right (upper and lower). at least
antigravity on the left.
sensory: grimace to pain on the left.
Pertinent Results:
admit labs:
___ 03:50AM BLOOD WBC-6.8 RBC-4.71 Hgb-15.3 Hct-46.2 MCV-98
MCH-32.5* MCHC-33.1 RDW-13.0 Plt ___
___ 03:50AM BLOOD ___ PTT-31.5 ___
___ 03:50AM BLOOD Glucose-193* UreaN-22* Creat-0.9 Na-143
K-5.3* Cl-105 HCO3-26 AnGap-17
___ 03:56AM BLOOD Creat-1.7*
___ 06:10AM BLOOD ALT-18 AST-39 AlkPhos-43 TotBili-0.4
___ 06:10AM BLOOD Albumin-4.4 Mg-2.2 Cholest-225*
Stroke labs:
___ 06:10AM BLOOD Triglyc-107 HDL-51 CHOL/HD-4.4
LDLcalc-153*
___ 06:10AM BLOOD %HbA1c-5.7 eAG-117
studies:
___ NCHCT:
There also appears to be a hyperdense left MCA. Findings are
concerning for acute ischemia. Recommend MRI for further
evaluation.
___ MRI/MRA
Acute infarction in the left caudate putamen and temporal lobe
with
hemorrhagic transformation. Lack of flow related enhancement
beyond the
proximal left M1 MCA.
___ NCHCT
Evolving subacute infarct involving the left basal ganglia and
temporal lobe with stable hemorrhagic transformation.
___ CT chest
Airways are overall patent until the subsegmental level
bilaterally. Assessment of the lung parenchyma reveals biapical
scarring. Lingular nodule, 6, 159, is 7.6 x 9 mm, new and
although most likely represent atelectasis, should be reassessed
in 10 weeks for documentation of stability and to exclude the
remote possibility of a neoplasm.
No lytic or sclerotic lesions worrisome for infection or
neoplasm
demonstrated. Wedge compression fractures are demonstrated at
the level of T8-T10 as well as L2.
___ CT abd/pelvis
No evidence malignancy or in the abdomen or pelvis.
___ ___
Evolution of Re- demonstrated subacute infarction with
hemorrhagic
transformation involving the left basal ganglial and temporal
lobe. No new areas of hemorrhage or large infarction.
Medications on Admission:
Pravastatin 40mg
coumadin 5mg
vesicare 10mg
levoxyl 0.005mg
lexapro 10mg
cymbalta 60mg
mirtazapine 7.5mg
ritalin 10mg
metoprolol tartrate 20mg
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO TID
2. Atorvastatin 40 mg PO DAILY
3. CeftriaXONE 1 gm IV Q24H Duration: 5 Doses
5 day course started ___. Dabigatran Etexilate 150 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Vesicare (solifenacin) 10 mg oral daily
8. Escitalopram Oxalate 10 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Duloxetine 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- ACUTE ISCHEMIC STROKE with hemorrhagic conversion
- atrial fibrillation
- hypertention
- hyperlipidemia
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: CT HEAD W/O CONTRAST
INDICATION: History: ___ with right sided weakness // r/o ich
TECHNIQUE: Axial helical MDCT images were obtained through the brain without
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes and thin section bone algorithm reconstructed images were
acquired.
DOSE: DLP: 1003 mGy-cm
CTDI: 56 mGy
COMPARISON: Nonenhanced head CT dated ___
FINDINGS:
There is possible very subtle loss of gray-white differentiation in the left
MCA territory. There is no evidence of hemorrhage, edema or mass effect.
There is unchanged appearance of hypodensities in the bilateral lentiform
nuclei likely enlarged perivascular spaces. Prominent ventricles and sulci
suggest age related atrophy. Periventricular white matter hypodensities are
nonspecific but likely represent sequela of chronic small vessel ischemic
disease. The basal cisterns appear patent differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear. The globes are unremarkable.
Atherosclerotic mural calcification of the vertebral and internal carotid
arteries is noted.
IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Possible very subtle loss of gray-white differentiation in the left MCA
territory is equivocal but could represent early ischemic changes. Of note
MRI, would be more sensitive for detection of acute ischemic changes.
COMMENT ON ATTENDING REVIEW:
There also appears to be a hyperdense left MCA. Findings are concerning for
acute ischemia. Recommend MRI for further evaluation.
Radiology Report
INDICATION: History: ___ with ? fall // r/o fracture
TECHNIQUE: Axial helical MDCT images were obtained from the skullbase through
the C6 level. The entire T7 vertebral body was not imaged. Reformatted images
in sagittal and coronal axes were obtained.
DOSE: DLP: 711 mGy-cm
CTDIvol: 37 mGy
COMPARISON: ___
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. Multilevel
degenerative changes with loss of disc height and anterior and posterior
osteophytes are noted worse at C4-5. There is no evidence of prevertebral
soft tissue swelling. CT is not able to provide intrathecal detail compared to
MRI, but the visualized outline of the thecal sac appears unremarkable. No
lymphadenopathy is present by CT size criteria.
IMPRESSION:
No evidence of acute fracture or traumatic malalignment. Of note, the anterior
inferior corner of C7 was not included in the study. If high clinical concern
for lower cervical spine injury, could repeat to include the C7 level.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with stroke // stroke
TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR,
susceptibility and diffusion weighted images were obtained through the head.
Following the uneventful administration of intravenous contrast, multiplanar
T1 weighted images of the head were obtained. Three dimensional time of flight
MR arteriography of the head, and two dimensional time of flight and three
dimensional pre and post contrast enhanced MR arteriography of the neck were
performed with rotational reconstructions.
COMPARISON: ___
FINDINGS:
MRI HEAD: There is an acute infarction in the left caudate, putamen and
temporal lobe with hemorrhage on the gradient echo images. There is mild mass
effect on the left lateral ventricle There are chronic small vessel ischemic
changes in the supratentorial white matter and the pons. . There is no mass
effect, edema, or hydrocephalus. Ventricles and sulci are normal in size and
configuration. Principal vascular flow voids are preserved. There is no
abnormal parenchymal, vascular or meningeal enhancement after the
administration of gadolinium. Globes and soft tissues are unremarkable.
Visualized paranasal sinuses and mastoid air cells are well aerated.
HEAD MRA: There is lack of flow related enhancement beyond the proximal left
M1 MCA segment. Attenuated appearance of the right MCA branches could be
artifactual or could reflect atherosclerotic disease.
NECK MRA: There is no high-grade stenosis in the carotid and vertebral
arteries.
There is marked enlargement of the left thyroid lobe measuring up to 2.9 x 2.3
cm which could represent a goiter any appears unchanged from the CT from ___
IMPRESSION:
Acute infarction in the left caudate putamen and temporal lobe with
hemorrhagic transformation. Lack of flow related enhancement beyond the
proximal left M1 MCA.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with stroke s/p dobhoff placement // Confirm
dobhoff placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has received a Dobbhoff
catheter. The catheter is in correct position in the middle to distal parts of
the stomach. No evidence of complications. The lung volumes have decreased.
Mild fluid overload but no overt pulmonary edema.
Radiology Report
EXAMINATION: Video oropharyngeal fluoroscopy swallowing study.
INDICATION: Dysphagia.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was aspiration with thin nectar consistency.
IMPRESSION:
Aspiration with thin nectar consistency.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with afib on coumadin, presented with L MCA
infarct with some hemorrhagic conversion. // evaluate for interval change in
hemorrhage
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 935
CTDIvol (mGy): 54
COMPARISON: Brain MRI from ___
FINDINGS:
Redemonstrated is evolution of subacute infarct involving the left basal
ganglia and temporal lobe with stable appearance of hemorrhagic
transformation. No new hemorrhage is identified. Ventricles are unchanged in
size and configuration. Basal cisterns are patent.
Paranasal sinuses are notable for mild mucosal thickening of the ethmoid air
cells. Mastoid air cells and middle ear cavities are clear. Orbits are
unremarkable. Partially imaged nasogastric tube is noted.
IMPRESSION:
Evolving subacute infarct involving the left basal ganglia and temporal lobe
with stable hemorrhagic transformation.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with large R MCA stroke with INR of 3.1 // ?
occult malignancy
TECHNIQUE: Multidetector CT of the abdomen and pelvis was done as part of CT
torso with IV Contrast. 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-minute delay) phase. Coronal and sagittal
reformations were performed and submitted to PACS for review. Oral contrast
was not administered.
DOSE: DLP: 832 mGy-cm (chest, abdomen and pelvis.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Bibasilar atelectasis is noted at the lung bases. Please refer to
separate report of CT chest performed on the same day for description of the
thoracic findings. Small hiatal hernia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
SPLEEN: The spleen and accessory spleen shows normal size and attenuation
throughout, without evidence of focal lesions.
PANCREAS: The pancreas is largely fatty replaced, but has normal attenuation
throughout, without evidence of focal lesions or pancreatic ductal dilatation.
ADRENALS: The right and left adrenal glands are normal.
URINARY: The kidneys enhance symmetrically and excrete contrast promptly
without hydronephrosis.
GASTROINTESTINAL: A nasoenteric tube ends in the stomach. The small and large
bowel are normal in course and caliber without obstruction. Colon and rectum
are within normal limits. There is a large amount of stool within the rectum.
Oral contrast from a prior study is seen within the ascending colon as no oral
contrast was administered for this study. Appendix contains air, has normal
caliber without evidence of fat stranding.
MESENTERY AND RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric lymphadenopathy. There is no free fluid and no free air.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta and great abdominal arteries. The main portal
vein, splenic vein and SMV are patent.
PELVIS: The bladder is decompressed by a Foley catheter with a small amount of
air. There is no evidence of pelvic or inguinal lymphadenopathy. Small free
pelvic fluid in the presacral space and mesorectal fascia is nonspecific, and
may be related to constipation, new from ___. The uterus is small
with coarse calcifications, likely within fibroids. No adnexal mass is seen.
BONES AND SOFT TISSUES: No bone finding suspicious for infection or malignancy
is seen. Degenerative change is noted in the thoracolumbar spine. Severe
compression deformity of L2 and more mild compression deformities with
exaggerated kyphosis of the thoracic spine are similar to ___..
IMPRESSION:
1. No evidence malignancy or in the abdomen or pelvis.
2. CT chest reported separately.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with large right MCA
stroke, suspicion for occult malignancy.
COMPARISON: CT of the chest from ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS: Large goiter originating from the left thyroid lobe is
demonstrated, and appears to be overall similar to the prior study except for
one larger or new nodule demonstrated in its lower right portion, 5:7,
approaching 2.2 cm in diameter. The goiter provides pressure of the left and
posterior aspect of the trachea with mild-to-moderate narrowing of the
tracheal lumen. The NG tube tip is in the stomach. Thickening of the distal
esophagus is unchanged, most likely due to small hiatal hernia, unchanged
since the prior study.
No mediastinal, hilar or axillary enlarged lymph nodes demonstrated with small
hilar lymph nodes being unchanged as compared to previous imaging, interval
stability of the aortopulmonic lymph node, approaching 11 mm.
Heart size is enlarged. Predominantly, there is an enlargement of the left
atrium up to 5.6 cm in the anterior posterior diameter. No pleural or
pericardial effusion is present.
Airways are overall patent until the subsegmental level bilaterally.Assessment
of the lung parenchyma reveals biapical scarring. Lingular nodule, 6, 159, is
7.6 x 9 mm, new and although most likely represent atelectasis, should be
reassessed in 10 weeks for documentation of stability and to exclude the
remote possibility of a neoplasm.
No lytic or sclerotic lesions worrisome for infection or neoplasm
demonstrated. Wedge compression fractures are demonstrated at the level of
T8-T10 as well as L2.
Radiology Report
INDICATION: ___ year old woman with stroke and dysphagia // post stroke
swallow eval
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. aspiration with thin liquid and nectar thick liquid was
demonstrated. The aspiration was silent with small amount, but larger amount
triggered cough reflex.
IMPRESSION:
Aspiration with thin liquid and nectar thick liquids was demonstrated.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with L MCA infarct // f/u stroke, hemorrhagic
conversion
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 54 mGy
DLP: 891.93 mGy-cm
COMPARISON: CT head without contrast ___
FINDINGS:
Re- demonstrated subacute infarction with hemorrhagic transformation involving
the left basal ganglia and temporal lobe which is stable in appearance. No
New hemorrhage or large territorial infarction is identified.
The basal cisterns appear patent.
The visualized bony structures are grossly unremarkable. The paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
Evolution of Re- demonstrated subacute infarction with hemorrhagic
transformation involving the left basal ganglial and temporal lobe. No new
areas of hemorrhage or large infarction.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, ATRIAL FIBRILLATION
temperature: 98.0
heartrate: 128.0
resprate: 12.0
o2sat: 93.0
sbp: 158.0
dbp: 90.0
level of pain: 0
level of acuity: 1.0 | Transitional Issues:
[ ] Pt needs to have a repeat CT chest in 10 weeks to follow up
her prior CT findings
[ ] Pt is on day 2 of a 7 day course of IV ceftriaxone (started
___
[ ] Pt should continue to undergo speech and swallow evaulation
with the hopes of advancing her diet further.
[ ] Please monitor the patient for urinary retention with
Q-shift bladder scans as this was an issue for the patient early
on the her stay.
Ms. ___ is an ___ yo woman with PMH significant for afib on
coumadin, HLD, depression and hypothyroidism who presented as a
code stroke, found to have a left MCA ischemic stroke with
aphasia and R sided plegia. The patient had hemorrhagic
transformation of the infarct - anticoagulation was held.
Etiology of stroke is likely afib although patient was
supratherapeutic on coumadin (initial INR 3.3). She underwent a
CT of the chest/abd/pelvis to assess for occult malignancy which
was negative. She was initially monitored in the neuro ICU and
remained stable with slow improvement in her sytmptoms. Her
course was complicated by afib with RVR which corrected with
increased doses of metoprolol. She diet was advanced very slowly
with the help of speech therapy. She was started on Dabigatran
on ___ - repeat head CT 48 hours later was stable. HgbA1c 5.7;
LDL 153.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2? ()
Yes - (x) No
(patient therapeutic on coumadin)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
(patient therapeutic on coumadin)
4. LDL documented (required for all patients)? (x) Yes (LDL
=153) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
**10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / ciprofloxacin / Flagyl
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ with low factor 11 levels, now with a 1 day h/o mild RLQ
abdominal pain that initially started in the epigatric area.
She had an outpatient CT scan which was concerning for acute
appendicitis. She denies any fevers, but has had some chills.
She has had some mild nausea, without emesis, as well as
bloating. She denies any other symptoms, and has never had this
type of pain before. She reports that she is currently hungry.
Past Medical History:
PMH: strong family history of factor 11 deficiency, with her
level on the low end of normal for factor 11, anxiety, varicose
veins
PSH: varicose vein surgery (no bleeding problems)
Social History:
___
Family History:
strong family history of breast and ovarian cancer (BRCA
negative); mother - DM, HTN; sister - ovarian CA; MGM - ovarian
or uterine CA, cousins - breast CA, brother - lymphoma
Physical ___:
Admission PE:
97.6 66 160/86 16 100% RA
no acute distress, alert, responsive
unlabored breathing
regular rate and breathing
abd soft, nondistended, mildly tender in the RLQ, no rebound, no
guarding, non rigid
ext warm and well perfused
Discharge Physical Exam:
VS: 97.9 PO 105 / 70 L Lying 53 18 98 16
GEN: Awake, alert, pleasant and interactive.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended. Active bowel sounds.
EXT: Warm and dry. ___ pulses.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 06:35AM BLOOD WBC-4.3 RBC-3.35* Hgb-9.7* Hct-29.9*
MCV-89 MCH-29.0 MCHC-32.4 RDW-13.9 RDWSD-45.1 Plt ___
___ 07:50PM BLOOD WBC-6.1 RBC-3.70* Hgb-10.9* Hct-33.2*
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.0 RDWSD-45.5 Plt ___
___ 07:50PM BLOOD ___ PTT-31.8 ___
___ 06:35AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-141 K-4.2
Cl-107 HCO3-22 AnGap-12
___ 07:50PM BLOOD Glucose-84 UreaN-9 Creat-0.9 Na-137 K-3.8
Cl-102 HCO3-21* AnGap-14
___ 07:50PM BLOOD ALT-10 AST-13 AlkPhos-49 TotBili-0.3
___ 06:35AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8
___ 04:47PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
CT A/P:
Acute uncomplicated appendicitis with an appendicolith.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*18 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 9 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*27 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with RLQ abd pain,bloating,nausea ;tenderness//
r/o appendicitis(call MD on call,please)
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 657 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: Hemangioma within the right lobe of the liver. Additional
subcentimeter hypodensities within the liver are too small to characterize,
but likely represent cysts or biliary hamartomas. Otherwise, the liver
demonstrates homogenous attenuation throughout. There is no evidence of
suspicious enhancing 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. Small accessory spleen near the hilum.
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 appendix is dilated and fluid-filled with mild adjacent
fat stranding, compatible with acute uncomplicated appendicitis. There is
suggestion of an appendicolith(series 5, image 53). There are no focal fluid
collections. The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are also unremarkable in appearance.
PELVIS: The urinary bladder and distal ureters are unremarkable. Small volume
free fluid in the pelvis, likely physiologic.
REPRODUCTIVE ORGANS: Uterus is slightly bulbous in appearance, which may
reflect small fibroids. No adnexal masses.
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: Small sclerotic lesions throughout the pelvis likely represent bone
islands. There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute uncomplicated appendicitis with an appendicolith.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 7:11 pm, 5 minutes
after discovery of the findings.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by WALK IN
Chief complaint: Appendicitis, RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.6
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 160.0
dbp: 86.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ is a ___ yo F who presents to the Emergency
Department with epigastric abdominal pain and underwent
outpatient CT scan which was concerning for acute appendicitis.
The patient was hemodynamically stable, afebrile, and white
blood cell count was 5.1. Discussed options of possible
operative intervention versus
non-operative management with the patient. Reviewed risks and
benefits of both options, and patient decided to pursue
non-operative management with antibiotics. On HD2 diet was
advanced to regular with good tolerability. Antibiotics were
transitioned to oral.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Follow up was scheduled to discuss
future/interval appendectomy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bone pain, metastatic nonsmall cell lung cancer
Major Surgical or Invasive Procedure:
Fine needle aspiration
Radiation therapy
History of Present Illness:
___ with history of HTN, HLD, Depression admitted for pain
control with MRI/CT highly suggestive of metastatic disease,
etiology unknown. MRI of spine done at OSH on ___
revealed multiple lesions c/w mets. Patient also has severe
cutaneous and sub-cutaneous nodules suspicious for malignancy.
Lesions are located over RUQ of abdomen, lower left back, right
inner thigh - states she was told they are lipomas.
Non-painful, non-purulent. + history of subjective fevers and
weight loss. + headaches, + weakness in lower extremities - no
bowel or bladder incontinence or falls. No chest pain,
palpitations, SOB, cough, abdominal pain, N/V/D,
dysuria/hematuria. Regarding health screening, no colonoscopy,
last mammogram in ___.
.
In the ED, VS 98.5 123 167/91 20 98%, pain 6. Given morphine and
ativan. Chem 7, LFTs, CBC WNL except for WBC of 12.0 (N:81.2
L:11.3 M:5.0 E:1.5 Bas:0.9). Lactate 1.4. CT chest/abd/pelvis
performed just prior to arrival to the floor, negative for PE -
previous concerning bony/abdominal wall lesions noted.
.
On the floor, patient triggered for sustained HR in 130's,
asymptommatic, VSS. Pain ___ located in lower back.
Otherwise no complaints. On O2, no subjective SOB.
Past Medical History:
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia
New diagnosis of nonsmall cell lung cancer with mets to the skin
and bone (this admission)
Social History:
___
Family History:
dad with metastatic prostate cancer, grandmother with breast
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.5 BP: 154/82 P: 132 R: 20 O2: 94%3L
General: Alert, oriented, appears anxious, thin
HEENT: dry MM, no OP lesions
Neck: supple, JVP not elevated, no LAD
Lungs: poor inspiratory effort, decresed BS at left lower base,
minimal crakle at right posterior base. no rhonchi.
CV: tachycardic, regular rhythm. no m/g/r.
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: 1.5 cm elevated hard, indurated, non-supporative,
non-painful lesion on right upper quadrant of abdomen with
minimal surrounding erythema (appears chronic, not acute).
Hard, irregular subcutaneous nodule in lower left back and right
medial thigh. no other rash.
Neuro: anxious, CN II-XII grossly intact. strength ___ in all
4 extremities. no sensation deficits appreciated. no nystagmus.
Discharge Exam:
Vitals: Tm/c: 98.5 BP: 110/60, 69 22 96% 1L
General: Alert, oriented, more cooperative this morning, thin
HEENT: MMM, no OP lesions
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB. Breathing comfortably.
CV: RRR no m/g/r. Chest wall and sternum TTP
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: 1.5 cm elevated pupuric, hard, indurated,
non-supporative, non-painful lesion on right upper quadrant of
abdomen with minimal surrounding erythema, biopsy clean and not
bleeding. Hard, irregular subcutaneous nodule in lower left
back, LUQ, and right medial thigh. no rash.
Neuro: anxious, CN II-XII grossly intact. strength ___ in all
4 extremities. no sensation deficits appreciated.
Pertinent Results:
ADMISSION LABS:
___ 03:10PM WBC-12.0* RBC-4.79 HGB-14.8 HCT-43.8 MCV-92
MCH-30.8 MCHC-33.6 RDW-13.7
___ 03:10PM NEUTS-81.2* LYMPHS-11.3* MONOS-5.0 EOS-1.5
BASOS-0.9
___ 03:10PM PLT COUNT-353#
___ 03:10PM GLUCOSE-88 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-17
___ 03:10PM ALT(SGPT)-10 AST(SGOT)-25 ALK PHOS-100 TOT
BILI-0.3
___ 03:10PM LIPASE-17
___ 03:10PM ALBUMIN-4.1 CALCIUM-10.3 PHOSPHATE-3.2
MAGNESIUM-1.9
___ 03:10PM TSH-4.8*
___ 03:26PM LACTATE-1.4
___ 03:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 03:10PM URINE RBC-5* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-4
.
DISCHARGE LABS:
___ 07:00AM BLOOD Glucose-91 UreaN-14 Creat-0.5 Na-136
K-4.5 Cl-95* HCO3-33* AnGap-13
___ 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
.
Imaging:
___ CTA TORSO:
CHEST: There is no evidence of pulmonary embolus. There is no
aortic
dissection. In the superior portion of the left lower lobe,
there is a
heterogeneously enhancing spiculated mass measuring 4.2 x 5.3 cm
in AP and
transverse ___, respectively. The bulk of the mass is
nodular and
centered within the lung parenchyma; however, there is medial
linear extension which courses along the descending thoracic
aorta approximately 8.7 cm in craniocaudal dimension. There is
mild post-obstructive pneumonitis (5:51). The mass causes
narrowing of the coursing pulmonary arteries without evidence of
pulmonary embolus. There is mass effect on the lower lobe
bronchi with occlusion of the inferomedial bronchi (___).
6-mm right upper lobe pulmonary nodule is evident (2:27). There
is a 1-2 mm right lower lobe pulmonary nodule (5:41). Peripheral
ground-glass opacity in the right upper lobe, just superior to
the major fissure (2:32) is nonspecific. There is no pleural
effusion.
Extensive coronary artery and aortic atherosclerotic
calcifications are
evident. There appears to be mild irregularity/ulceration of the
left lateral margin of the aortic arch (5A:12). The ascending
aorta measures 3.1 cm. Left hilar and subcarinal adenopathy is
evident; measuring 1.5 cm in the left hilum and 1.1 cm in the
subcarinal region. There is no right hilar or axillary
adenopathy. The right atrium is enlarged.
Also at the right base, there is nodular opacity at the
periphery with
associated linear atelectasis (5a:72) which may represent
rounded atelectasis with attention on followup recommended.
ABDOMEN: Ill-defined 5-mm hypodensity in hepatic segment II
(5B:87) is too
small to accurately characterize. No additional liver lesions
are identified. The portal and hepatic veins are patent. The
spleen, pancreas and gallbladder are within normal limits.
Bilateral adrenal nodules which are heterogeneous in appearance
are evident. Nodule in the left adrenal gland measures 9 mm
(5B:85). The remainder of the left adrenal gland is thickened.
In the right adrenal gland, there is a hypodense 1.3-cm nodule
(5B:86).
There are bilateral hypodense renal lesions. The largest is in
the
mid-to-lower pole of the left kidney measuring slightly higher
than water
density in ___ units and 4.7 cm. This likely represents a
cyst with
possible hemorrhagic or proteinaceous debris. In the interpolar
region of the right kidney, there is an 8-mm hypodense lesion
which measures 97 in
___ units. Non-contrast imaging through the kidneys was
not performed to confirm enhancement. The kidneys demonstrate
symmetric uptake and excretion of contrast.
There is extensive atherosclerotic calcification within the
normal caliber
abdominal aorta. There is no obvious mesenteric or
retroperitoneal
adenopathy. Visualized bowel loops are grossly unremarkable.
Multiple enhancing subcutaneous nodules are evident; for
example, measuring
1.9 cm overlying the lateral right lower ribs, measuring 1.4 cm
in the left
flank and measuring 1.3 cm in the mid left anterior abdominal
wall. These are suspicious for subcutaneous metastases.
PELVIS: The bladder and rectum are grossly unremarkable. The
uterus is not
identified, possibly surgically absent. The ovaries are also not
identified. There is no pelvic adenopathy or free fluid.
OSSEOUS STRUCTURES: Multiple lytic osseous metastases are
identified in the
left tip of the scapula, T11 vertebral body, posterior ninth rib
on the right, left posterior iliac bone, right anterior iliac
bone, and sternum. In addition, there are multiple osseous
sclerotic lesions in the posterior left rib, left iliac bone
surrounding the lytic lesions, and left sacral ala.
IMPRESSION:
1. No pulmonary embolism.
2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x
7.7 cm,
concerning for a primary lung malignancy. The spiculated mass
runs along the descending thoracic aorta with its linear medial
component approximately 8.7 cm in craniocaudal dimension. There
are two small right pulmonary nodules, possibly representing
metastases measuring 6 and 2 mm.
3. Osseous metastatic disease with mixed lytic and sclerotic
lesions.
4. Enhancing subcutaneous nodules concerning for metastases.
5. Bilateral adrenal nodules, likely metastases.
6. 8mm inter-polar right renal lesion is incompletely evaluated
on this
examination. This does not measure fluid density. When
clinically
appropriate, further characterization with ultrasound may be
beneficial.
Additional simple left renal cyst and too small to characterize
lesions.
7. Significant aortic atherosclerotic disease and extensive
coronary artery
calcifications.
.
___ MRI head: There is a 20 x 11 mm measuring oval right
temporal-occipital calvarium lesion, which likely represents a
bone metastasis and is pushing on the dura without evidence of
adjacent FLAIR signal abnormality or involvement of the
intra-axial space. Additional osseous metastases are not
identified in the imaged volume.
A briskly enhancing 12 (AP) x 9 (TRV) x 15 (SI) left
parasagittal frontal
lesion appears to be extra-axial and is exerting mass effect on
the adjacent sulcus. There is no associated parenchymal FLAIR
signal abnormality and the lesion most likely corresponds to a
parafalcine meningioma. There is no evidence of intra-axial
metastatic lesions. Extensive periventricular, subcortical and
deep white matter FLAIR/T2 signal abnormalities are in keeping
with sequela of small vessel ischemic disease. Flow voids of the
major intracranial vessels are preserved. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Right occipital calvarium lesion, likely representing bony
metastasis.
2. Left frontal parasagittal mass, most likely representing a
meningioma.
3. There is no evidence of intraparenchymal metastatic disease
and no acute findings, such as hemorrhage or infarct.
.
___ L tib/fib XRAY
TWO VIEWS OF THE TIBIA AND FIBULA: No definitive lytic or
sclerotic lesions
are seen, however there is an area of trabecular rarefaction
within the distal fibula. While this may be projectional, please
correlate clinically and consider dedicated ankle radiographs.
.
___ CYTOLOGY
FNA, Right abdominal lesion:
POSITIVE FOR MALIGNANT CELLS,
consistent with a poorly differentiated non-small cell
carcinoma; see note.
.
___ PATHOLOGY
Cell block, right abdominal lesion, FNA:
Positive for malignant cells, consistent with a
poorly-differentiated non-small cell carcinoma; Note: By
immunohistochemistry, the tumor cells are positive for
cytokeratin cocktail (keratin AE1/AE3, Cam 5.2), CK7, and TTF-1
and are negative for CK20, CDX-2, S-100, and desmin. Smooth
muscle actin highlights background stromal cells. The histologic
and immunohistochemical findings are compatible with a tumor of
lung origin. Correlation with clinical and radiographic findings
is recommended.
Medications on Admission:
Fluticasone daily
Anaprox DS 550 mg q12 h prn back pain
synthroid ___ mcg daily
Lisinopril 10 mg daily
Ativan 1 mg TID
Vicodin 7.5/325 q4h prn pain
zofran prn
Discharge Medications:
1. fluticasone Nasal
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain: Please do not take if you are feeling tired
or confused. Do not operate heavy machinery or drive while on
this medication.
Disp:*90 Tablet(s)* Refills:*0*
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*160 Tablet(s)* Refills:*0*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. propranolol 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
12. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: Do not operate
heavy machinery or drive while on this medication.
Disp:*20 Tablet Extended Release 12 hr(s)* Refills:*0*
13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
Disp:*30 packets* Refills:*0*
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
patch to area of most significant pain (i.e. sternum). Leave
leave patch on for 12 hours only. Remove patch, and reapply 12
hours later.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for constipation.
Disp:*1 bottle* Refills:*0*
16. Supplemental Oxygen
___ continuous pulse dose for portability
Dx: metastatic nonsmall cell lung cancer
RA sat 84%
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Metastatic lung cancer
Secondary Diagonsis:
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CTA CHEST, ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST
DATE: ___.
COMPARISON: Reference MR lumbar spine ___.
CLINICAL INDICATION: ___ female with known spine lesions, low back
pain, tachycardia and hypoxic. Evaluate for PE as well as other lesions.
TECHNIQUE: Unenhanced low-dose axial images through the chest were obtained.
Subsequently, axial contrast-enhanced images of the chest were obtained in the
arterial phase to evaluate for pulmonary embolus after the uneventful
intravenous administration of 130 mL Optiray. Axial images of the abdomen and
pelvis were obtained in the portal venous phase subsequently. Coronal and
sagittal reformatted images were constructed.
TOTAL EXAM DLP: 555.6 mGy-cm.
FINDINGS:
CHEST: There is no evidence of pulmonary embolus. There is no aortic
dissection. In the superior portion of the left lower lobe, there is a
heterogeneously enhancing spiculated mass measuring 4.2 x 5.3 cm in AP and
transverse ___, respectively. The bulk of the mass is nodular and
centered within the lung parenchyma; however, there is medial linear extension
which courses along the descending thoracic aorta approximately 8.7 cm in
craniocaudal dimension. There is mild post-obstructive pneumonitis (5:51).
The mass causes narrowing of the coursing pulmonary arteries without evidence
of pulmonary embolus. There is mass effect on the lower lobe bronchi with
occlusion of the inferomedial bronchi (___). 6-mm right upper lobe
pulmonary nodule is evident (2:27). There is a 1-2 mm right lower lobe
pulmonary nodule (5:41). Peripheral ground-glass opacity in the right upper
lobe, just superior to the major fissure (2:32) is nonspecific. There is no
pleural effusion.
Extensive coronary artery and aortic atherosclerotic calcifications are
evident. There appears to be mild irregularity/ulceration of the left lateral
margin of the aortic arch (5A:12). The ascending aorta measures 3.1 cm. Left
hilar and subcarinal adenopathy is evident; measuring 1.5 cm in the left hilum
and 1.1 cm in the subcarinal region. There is no right hilar or axillary
adenopathy. The right atrium is enlarged.
Also at the right base, there is nodular opacity at the periphery with
associated linear atelectasis (5a:72) which may represent rounded atelectasis
with attention on followup recommended.
ABDOMEN: Ill-defined 5-mm hypodensity in hepatic segment II (5B:87) is too
small to accurately characterize. No additional liver lesions are identified.
The portal and hepatic veins are patent. The spleen, pancreas and gallbladder
are within normal limits. Bilateral adrenal nodules which are heterogeneous
in appearance are evident. Nodule in the left adrenal gland measures 9 mm
(5B:85). The remainder of the left adrenal gland is thickened. In the right
adrenal gland, there is a hypodense 1.3-cm nodule (5B:86).
There are bilateral hypodense renal lesions. The largest is in the
mid-to-lower pole of the left kidney measuring slightly higher than water
density in ___ units and 4.7 cm. This likely represents a cyst with
possible hemorrhagic or proteinaceous debris. In the interpolar region of the
right kidney, there is an 8-mm hypodense lesion which measures 97 in
___ units. Non-contrast imaging through the kidneys was not performed
to confirm enhancement. The kidneys demonstrate symmetric uptake and
excretion of contrast.
There is extensive atherosclerotic calcification within the normal caliber
abdominal aorta. There is no obvious mesenteric or retroperitoneal
adenopathy. Visualized bowel loops are grossly unremarkable.
Multiple enhancing subcutaneous nodules are evident; for example, measuring
1.9 cm overlying the lateral right lower ribs, measuring 1.4 cm in the left
flank and measuring 1.3 cm in the mid left anterior abdominal wall. These are
suspicious for subcutaneous metastases.
PELVIS: The bladder and rectum are grossly unremarkable. The uterus is not
identified, possibly surgically absent. The ovaries are also not identified.
There is no pelvic adenopathy or free fluid.
OSSEOUS STRUCTURES: Multiple lytic osseous metastases are identified in the
left tip of the scapula, T11 vertebral body, posterior ninth rib on the right,
left posterior iliac bone, right anterior iliac bone, and sternum. In
addition, there are multiple osseous sclerotic lesions in the posterior left
rib, left iliac bone surrounding the lytic lesions, and left sacral ala.
IMPRESSION:
1. No pulmonary embolism.
2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x 7.7 cm,
concerning for a primary lung malignancy. The spiculated mass runs along the
descending thoracic aorta with its linear medial component approximately 8.7
cm in craniocaudal dimension. There are two small right pulmonary nodules,
possibly representing metastases measuring 6 and 2 mm.
3. Osseous metastatic disease with mixed lytic and sclerotic lesions.
4. Enhancing subcutaneous nodules concerning for metastases.
5. Bilateral adrenal nodules, likely metastases.
6. 8mm inter-polar right renal lesion is incompletely evaluated on this
examination. This does not measure fluid density. When clinically
appropriate, further characterization with ultrasound may be beneficial.
Additional simple left renal cyst and too small to characterize lesions.
7. Significant aortic atherosclerotic disease and extensive coronary artery
calcifications.
Radiology Report
CLINICAL HISTORY: Metastatic cancer. Rule out lytic lesion.
COMPARISON: None.
TWO VIEWS OF THE TIBIA AND FIBULA: No definitive lytic or sclerotic lesions
are seen, however there is an area of trabecular rarefaction within the distal
fibula. While this may be projectional, please correlate clinically and
consider dedicated ankle radiographs.
Radiology Report
INDICATION: ___ patient with bone metastasis in the spinal axis.
Assess for metastatic disease to the brain.
COMPARISON: None available for comparison.
TECHNIQUE: Sagittal T1 and axial T1, T2, gradient echo, FLAIR and diffusion
with ADC map images were obtained without contrast. Following IV
administration of gadolinium, sagittal MP-RAGE and axial T1 spin echo
sequences were acquired.
FINDINGS: There is a 20 x 11 mm measuring oval right temporal-occipital
calvarium lesion, which likely represents a bone metastasis and is pushing on
the dura without evidence of adjacent FLAIR signal abnormality or involvement
of the intra-axial space. Additional osseous metastases are not identified in
the imaged volume.
A briskly enhancing 12 (AP) x 9 (TRV) x 15 (SI) left parasagittal frontal
lesion appears to be extra-axial and is exerting mass effect on the adjacent
sulcus. There is no associated parenchymal FLAIR signal abnormality and the
lesion most likely corresponds to a parafalcine meningioma. There is no
evidence of intra-axial metastatic lesions. Extensive periventricular,
subcortical and deep white matter FLAIR/T2 signal abnormalities are in keeping
with sequela of small vessel ischemic disease. Flow voids of the major
intracranial vessels are preserved. The visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
1. Right occipital calvarium lesion, likely representing bony metastasis.
2. Left frontal parasagittal mass, most likely representing a meningioma.
3. There is no evidence of intraparenchymal metastatic disease and no acute
findings, such as hemorrhage or infarct.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN, ABNL MRI
Diagnosed with MALIGNANT NEOPLASM NOS, BACKACHE NOS, HYPOTHYROIDISM NOS
temperature: 98.5
heartrate: 123.0
resprate: 20.0
o2sat: 98.0
sbp: 167.0
dbp: 91.0
level of pain: 6
level of acuity: 3.0 | ___ with history of anxiety and hypertension admitted with
worsening back pain in setting of concerning lesions on MRI/CT
for metastases. Hospital course was notable for diagnosis of
metastatic nonsmall cell carcinoma of the lung and radiation
therapy to metastatic bone lesions.
.
#Metastasic nonsmall cell lung cancer: Presented with widely
metastatic cancer with lesions in the lung, adrenals, skin as
well as diffuse bony disease. FNA of the RUQ subcutaneous nodule
demonstrated poorly differentiated non-small cell lung cancer.
Hematology oncology was consulted who recommended outpatient
oncology follow up which has been scheduled for ___. During this admission, she underwent mapping and
palliative XRT to the rib/sternum and L fibula/ilium. MRI of the
brain showed mets to the skulls, a meningioma, without
intraparenchymal disease.
.
# Bone Pain: From metastatic disease. She was started on
standing oxycontin and acetaminophen as well as prn oxycodone
and ibuprofen for pain control. She was additionally given a
lidocaine patch for her sternal pain. Her pain medications were
titrated until she was no longer requesting all of her prns and
was sleeping comfortably through the night. She appeared
comfortable on daily examinations and would only say her pain
was not well controlled if directly asked. She was discharged on
oral and topical pain control and advised to contact her PCP
___ Oncologist should she require adjustments to her home
pain medication regimen.
.
# Hypoxia: On admission, she was noted to be hypoxic, likely
related to her baseline decreased lung function (chronic
smoker), NSCLC with possible associated atelectesis, and
possibly decreased inspiratory volumes ___ sternum and rib pain
(bony metastasis). Physical therapy worked with the patient and
noted she was 84% on room air when sitting. She was discharged
on home oxygen ___ at rest.
.
# Tachycardia - She had sinus tachycardia on admission. CTA did
not show PE. Her tachycardia was believed to be from pain and
anxiety, possible hypermetabolic state ___ cancer. She was
started on pain control as above and her lisinopril was switched
to propanolol TID both for pain control and possibly better
control of her anxiety symptoms.
.
# Social Issues/Depression: The patient and brother are having a
very difficult time dealing with her new diagnosis and reduced
functional status. The patient has been nervous about being
discharged home, but physical therapy felt that she did not
require rehab and she has been arranged to have services at home
(she will be staying with a family friend). ___, her
brother has been staying at a local hotel and they have been
resistant to her going there. She lives in ___ but
was not interested in having her care in ME. Lastly, Ms.
___ was given the number for psychiatry as she is having a
difficult time coping with her diagnosis and speaking to someone
or starting on antidepressants may help her.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right acetabular
fracture; ___ ___.
History of Present Illness:
ORTHOPAEDIC SURGERY CONSULT NOTE
NAME: ___
MRN: ___
DATE: ___
RESIDENT: ___, MD
ATTENDING: Dr ___
___ SERVICE: Ortho trauma
CC: R hip pain
DATE OF INJURY: ___
MECHANISM: fall
SIDE: RIGHT
BONE: acetabulum , pubic ramus
LOCATION: PROXIMAL
PATTERN: COMMINUTED
DISPLACEMENT: DISPLACED
TYPE: CLOSED
TISSUE CLASSIFICATION: CLOSED
EPISODE OF CARE: SUBSEQUENT
HPI: ___ male patient with history of alcohol abuse
presenting as a transfer from ___ for comminuted
displaced right iliac wing, acetabular and superior inferior
pubic rami fractures as well as a minimally displaced left
superior and inferior pubic rami fracture. Patient was found
down at a liquor store last night and was brought to the outside
hospital where imaging was done and he was found to have the
above fractures. He was transferred here for orthopedic care.
He is not anticoagulated. He is a chronic alcoholic. He
currently complains of right hip pain but denies any numbness or
tingling.
PMH: Alcohol abuse
PSH:
Right hip surgery
Right ankle surgery
MEDS: Atenolol 50 mg daily
ALL: Amoxicillin
SHx: Daily alcohol use about ___ beers per day
ROS: A complete 10-point review of systems was completed and is
negative except as noted above.
PHYSICAL EXAMINATION:
General: Alert and oriented
Vitals: Afebrile vital signs stable
Right lower extremity:
Skin intact, closed injury but with tenderness palpation over
the right hip. Limited range of motion at the hip and knee
secondary to pain. Full range of motion of the ankle.
___ firing. SILT SPN/DPN/TN/saphenous/sural
distributions. 1+ ___ pulses, foot warm and well-perfused but
with significant pitting edema in the right lower extremity as
well as the right foot.
Significant amount of ecchymosis in the bilateral upper
extremities.
LABS: See ___ medical record
IMAGING: CT pelvis without contrast (OSH)
IMPRESSION:
1. Comminuted displaced right iliac wing, acetabulum and
superior and inferior pubic rami fractures. Surround right
pelvic sidewall/extraperitoneal hematoma.
2. Minimally displaced left superior and inferior pubic rami
fractures.
3. Probable nondisplaced sacral fracture.
4. Moderate compression fracture of L3 vertebral body, age
indeterminate. No significant bony retropulsion, into the spinal
canal.
5. Left inguinal hernia containing portion of colon.
ASSESSMENT/RECOMMENDATIONS:
___ male patient presenting as a transfer from outside
hospital status post fall, found to have comminuted displaced
right iliac wing, acetabular and superior and inferior pubic
rami fractures. He was also found to have left superior
inferior pubic rami fracture and nondisplaced sacral fracture.
He is neurovascularly intact distally.
At this time, we will treat this non-operatively. Recommend ED
observation overnight for physical therapy and case management.
Past Medical History:
Alcohol abuse
hypertension
Social History:
___
Family History:
non-contributory.
Physical Exam:
Exam on Discharge:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Right lower extremity fires ___
Right lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Right lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
labs reviewed and unremarkable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
RX *acetaminophen [8HR Muscle Ache-Pain] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*60 Tablet Refills:*0
2. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth every 8 hours Disp #*21
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
use while taking narcotic pain medication.
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*14 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QDAY
RX *enoxaparin 40 mg/0.4 mL 1 injection subcutaneously daily
Disp #*28 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
OK to request partial fill. Wean as tolerated.
RX *oxycodone 10 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily as needed Disp
#*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID
use when taking narcotic pain medication.
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 2 tablets by
mouth twice daily Disp #*28 Tablet Refills:*0
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
9. Atenolol 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right, closed acetabular fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ status post fall. Study performed to evaluate for rib
fracture or pneumonia.
TECHNIQUE: Chest: Frontal and Lateral views
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiomediastinal silhouettes are unremarkable.
There are chronic appearing deformities of the right lateral ribs. There is
an angulated appearance of the left lateral third rib, which could be acute in
nature. There is callus formation at the lateral fifth rib on the left, which
is chronic in appearance. No other acute osseous abnormalities are seen
within the limitations of the study.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Angulated appearance of the left lateral third rib, which could be acute in
nature. Correlation with prior imaging or dedicated rib series is recommended
as clinically indicated.
3. Other chronic appearing rib deformities as described above.
Radiology Report
INDICATION: ___ with r acetabular fx. pls do AP pelvis X-ray with inlet and
outlet views AND R hip with judet views// eval fx. pls do AP pelvis X-ray with
inlet and outlet views AND R hip with judet views
TECHNIQUE: AP, bilateral oblique, inlet and outlet views of pelvis. AP and
cross-table lateral views of the proximal right femur.
COMPARISON: CT pelvis from earlier the same day performed at an outside
institution.
FINDINGS:
Bones are diffusely demineralized. Mildly displaced fracture through the
right acetabulum is noted with step-off of the iliopectineal line. Known
nondisplaced right inferior pubic ramus fracture is better seen by CT. There
are fractures through the left superior and inferior pubic rami as well.
Femoroacetabular joints are anatomically aligned. Hardware from prior right
femoral neck ORIF is noted without periprosthetic lucency. No acute femoral
fracture identified. Lucency over the left groin is compatible with colonic
containing left inguinal hernia.
IMPRESSION:
Pelvic fractures as seen on prior CT.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with fall p/w trauma and rib fracture// eval for rib
fractures
TECHNIQUE: Multidetector helical scanning of the chest was performed without
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.
DOSE: DLP: 466 mGy cm.
COMPARISON: None
FINDINGS:
Thyroid is unremarkable. Supraclavicular, axillary, and mediastinal lymph
nodes are not enlarged. Moderate calcification is noted at the aortic valve.
Coronary artery calcification is moderate to severe. Thoracic aorta and main
pulmonary artery are normal size. There is no pericardial effusion.
There is no pleural effusion. Airways are patent to subsegmental levels.
Mild bronchial wall thickening is noted. Centrilobular emphysema is mild. 10
mm subpleural nodule is identified in the right lower lobe (4:177). 7 mm
nodule is identified in right lower lobe (4:137).
Limited evaluation of upper abdomen is notable for calcified granulomas in the
spleen. Colonic diverticulosis is noted.
Bilateral gynecomastia is noted. Minimally displaced fractures are identified
in right lateral 4, 5, and 6 ribs, of unknown chronicity. Bony bridge between
lateral right 7 and 8 ribs may be sequela of old trauma. T12 and L1 vertebral
body height loss is chronic in appearance.
IMPRESSION:
1. Minimally displaced fractures at right lateral 4, 5, and 6 ribs are of
unknown chronicity but likely chronic. To be correlated clinically.
2. 2 pulmonary nodules measuring up to 10 mm are identified in the right lower
lobe. Please see recommendation below.
3. Mild pulmonary emphysema.
4. Bilateral gynecomastia.
RECOMMENDATION(S):
1. For incidentally detected multiple solid pulmonary nodules bigger than
8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient,
with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both
a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
INDICATION: ___ year old man with acetab fx// eval pelvis fx
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 8.3 s, 40.6 cm; CTDIvol = 17.9 mGy (Body) DLP = 727.7
mGy-cm.
2) Spiral Acquisition 1.3 s, 6.4 cm; CTDIvol = 14.7 mGy (Body) DLP = 93.3
mGy-cm.
Total DLP (Body) = 821 mGy-cm.
COMPARISON: CT scan of the pelvis performed earlier the same day at 02:59.
FINDINGS:
PELVIS: There is a colonic containing left inguinal hernia without secondary
obstruction. The partially visualized small and large bowel are otherwise
unremarkable. The urinary bladder and distal ureters are unremarkable. There
is no free fluid in the pelvis. There is however right-sided pelvic sidewall
stranding compatible with hematoma.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are within normal limits.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderate atherosclerotic disease is noted.
BONES: Again seen are multiple pelvic fractures, specifically minimally
displaced left inferior pubic ramus fracture and mildly displaced left
superior pubic ramus fracture. Nondisplaced right inferior pubic ramus
fractures identified. Comminuted fracture through the right acetabulum is
identified with superior extension through the portion of the iliac wing and
involvement of the superior pubic ramus. Pubic symphysis is preserved.
Sacrum is within normal limits. SI joints are preserved. Orthopedic hardware
in the proximal right femur is noted without evidence of complication.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Bilateral superior and inferior pubic ramus fractures with comminuted right
acetabular fracture and pelvic sidewall hematoma.
Radiology Report
EXAMINATION: PELVIS (AP, INLET AND OUTLET)
INDICATION: RT ACETABULER FX.ORIF
TECHNIQUE: Intraoperative fluoroscopic images.
COMPARISON: CT ___.
FINDINGS:
Multiple intraoperative fluoroscopic images of the right acetabulum was
obtained without a radiologist present. Images demonstrate progressive
sideplate and screw fixation of acetabular fracture.
IMPRESSION:
Multiple intraoperative images were obtained during right acetabular fracture
ORIF. Please refer to operative report for further details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Found down, Transfer
Diagnosed with Oth fracture of right pubis, init encntr for closed fracture, Unspecified fall, initial encounter
temperature: 98.2
heartrate: 82.0
resprate: 20.0
o2sat: 97.0
sbp: 154.0
dbp: 86.0
level of pain: 5
level of acuity: 3.0 | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right acetabular fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable. The patient was monitored for
withdrawal on a CIWA scale given his history of ethanol use and
required no pharmacologic measures for withdrawal and showed no
hemodynamic instability secondary to withdrawal.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the right lower extremity
extremity, and will be discharged on enoxaparin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Aortic valve replacement with 25 mm Epic supra
valve. Coronary artery bypass grafting x 3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein grafts to the ramus intermedius and the posterior
descending artery.
History of Present Illness:
Mr. ___ is a nice ___ year old man with a history of coronary
artery disease, diabetes mellitus, hyperlipidemia, hypertension,
and prior NSTEMI. He was admitted to ___ for type
I NSTEMI, found to have 3 vessel CAD with 90% thrombotic
stenosis of proximal RCA s/p POBA to proximal and mid-RCA with
plans for future CABG, who was discharged from ___
___ and
now presents with unstable angina. He initially presented to
___ on ___, with chest pain and found
to have NSTEMI. Cardiac cath ___ was notable for 3 vessel CAD
(90% stenosis RI, 90% stenosis in distal LAD, 80% stenosis in
OM1, 70% stenosis in mid LCx, 90% stenosis in proximal RCA, 70%
mid-RCA, and sub-occlusive stenosis in distal RCA). He underwent
balloon angioplasty of proximal and mid RCA, with plan for CABG
in ___ weeks. He was discharged from ___ on ___.
Since then, he had been doing well and was chest pain free until
this morning at around 6:30AM. He reports recurrence of
intermittent left-sided, chest pressure at rest with radiation
to
R arm and axilla and associated shortness of breath. This is
similar to prior NSTEMI symptoms. On EMS arrival, he was treated
with ASA 324mg and SL nitro with improvement in symptoms. He was
taken to ___, where EKG was notable for T wave
inversions in inferior leads and elevated Trop I of 1.17
(although decreased from prior 6.69 on ___, 16.60 ___.
Past Medical History:
Basal Cell Carcinoma s/p Mohs
Coronary Artery Disease, s/p PCI ___
Diabetes Mellitus, Insulin Dependent
Glaucoma
Hyperlipidemia
Hypertension
Non-ST Elevation Myocardial Infarction ___
Prostate Cancer s/p XRT
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission:
VS: ___ Temp: 98.3 PO BP: 149/79 HR: 76 RR: 18 O2 sat:
96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ FSBG:
235
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic.
NECK: Supple. No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2.
Crescendo-decrescendo early-peaking systolic murmur, no 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
97.7
PO 119 / 73
L Sitting 81 18 98 Ra
.
General: NAD, complaining of arthritic pain
Neurological: A/O x3 [x] No focal deficits.
HEENT: PERRLA []
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Paced
[]
Respiratory: CTA [x] No resp distress [x] Intubated []
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 Trace
Left Lower extremity Warm [x] Edema Trace
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena [x]; Pacer site C/D/I
Lower extremity: Right [] Left [x] CDI [x]
Pertinent Results:
ADMISSION LABS:
___ 05:05PM BLOOD WBC-7.8 RBC-3.70* Hgb-11.1* Hct-32.8*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.2 RDWSD-42.5 Plt ___
___ 05:05PM BLOOD ___ PTT-25.1 ___
___ 05:05PM BLOOD Glucose-219* UreaN-17 Creat-1.0 Na-132*
K-4.2 Cl-97 HCO3-25 AnGap-10
___ 05:05PM BLOOD cTropnT-0.48*
___ 05:05PM BLOOD Calcium-9.0 Phos-3.6 Mg-1.6
___ 07:40AM BLOOD %HbA1c-9.0* eAG-212*
IMAGING:
TTE ___
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left
ventricular wall thickness with a normal cavity size. There is
mild regional left ventricular systolic dysfunction
with near akinesis of the basal inferior wall (see schematic)
and preserved/normal contractility of the
remaining segments. Quantitative 3D volumetric left ventricular
ejection fraction is 55 %. Left
ventricular cardiac index is low normal (2.0-2.5 L/min/m2).
There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size with normal free
wall motion. Tricuspid annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender with normal ascending aorta
diameter for gender. There is a normal descending aorta
diameter. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.0-1.5 cm2). There is a centrally directed jet
of mild [1+] aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The pulmonic
valve leaflets are not well seen. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: Moderate aortic valve stenosis. Mild aortic
regurgitation. Normal left ventricular
cavity size with mild regional systolic dysfunction most
consistent with single vessel coronary
artery disease (PDA distribution). Mild mitral regurgitation.
MICRO:
No relevant
DISCHARGE LABS:
___ 09:05AM BLOOD Hct-25.3*
___ 04:52AM BLOOD WBC-9.7 RBC-2.55* Hgb-7.6* Hct-23.8*
MCV-93 MCH-29.8 MCHC-31.9* RDW-14.8 RDWSD-50.6* Plt ___
___ 09:05AM BLOOD ___ PTT-24.9* ___
___ 04:52AM BLOOD Glucose-127* UreaN-21* Creat-1.1 Na-136
K-4.4 Cl-101 HCO3-25 AnGap-10
___ 03:23AM BLOOD Glucose-119* UreaN-25* Creat-1.3* Na-135
K-4.8 Cl-97 HCO3-29 AnGap-9*
___ 04:52AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Metoprolol Tartrate 50 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Detemir 34 Units Breakfast
Detemir 38 Units Bedtime
Novolog 6 Units Breakfast
Novolog 10 Units Lunch
Novolog 16 Units Dinner
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
3. Detemir 34 Units Breakfast
Detemir 38 Units Bedtime
Novolog 6 Units Breakfast
Novolog 10 Units Lunch
Novolog 16 Units Dinner
4. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
- IDDM
- Hypertension
- Dyslipidemia
- Glaucoma
- Prostatic CA s/p XRT
- Basal cell carcinoma
Past Surgical History:
- s/p MOHs surgery (___)
- left inguinal hernia repair (strangulated per pt but no bowel
resected)
Past Cardiac Procedures:
- CAD s/p proximal LAD PCI (___) after positive stress test for
angina symptoms
- NSTEMI (___) with coronary angiogram showing 3 vessel CAD
(90% RI, 90% distal LAD, 90% ___ RCA s/p POBA
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 multivessel CAD undergoing CABG w/u// acute
pulmonary process Surg: ___ (CABG)
IMPRESSION:
In comparison with the outside studies of ___, there is little
overall change. Cardiomediastinal silhouette is within normal limits. There
is diffuse prominence of reticular markings bilaterally, with hyperexpansion
of the lungs and flattening hemidiaphragms, worrisome for chronic fibrotic
interstitial lung disease. No evidence of acute focal consolidation or
definite vascular congestion.
Large hiatal hernia is seen.
Radiology Report
EXAMINATION: VEIN MAPPING-Lower extremities
INDICATION: ___ year old man with CAD with multivessel disease on LHC,
undergoing workup for CABG// vein mapping for CABG
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
lower extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT: The great saphenous vein is patent with diameters ranging from 0.20 to
0.53 cm. The right small saphenous vein is patent with diameters ranging from
0.15 to 0.24 cm.
LEFT: The great saphenous vein is patent with diameters ranging from 0.17 to
0.57 cm. The left small saphenous vein is patent with diameters ranging from
0.18 to 0.25 cm.
IMPRESSION:
The great and small saphenous veins are patent bilaterally. Please see
digitized image on PACS for formal sequential measurements.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG// FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___, Phone: 1
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The patient is post median sternotomy and CABG. The tip of the endotracheal
tube projects at the level of the clavicular heads. A right internal jugular
central venous catheter projects over the cavoatrial junction. Chest tubes
and mediastinal drains are present. Retrocardiac opacities likely reflect
atelectasis and small volume pleural fluid. Atelectasis is also present at
the right lung base. A trace right apical pneumothorax is noted. There is
unchanged prominence of reticular lung markings bilaterally.
IMPRESSION:
Trace right apical pneumothorax
Left lower lobe atelectasis and small pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABG with + AL and right apical ptx// eval
for ptx extension
IMPRESSION:
In comparison with the study of ___, the endotracheal tube and
nasogastric tube have been removed. Left chest tube remains in place and any
residual pneumothorax would be extremely small.
Little overall change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CABG/AVR// eval ptx-H2O Seal eval
ptx-H2O Seal
IMPRESSION:
Comparison to ___. With the chest tubes on waterseal, there is now
a 1 cm right apical pneumothorax. No evidence of tension. No change in
appearance of the lung parenchyma and the heart.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man s/p CABG, tiss AVR// please eval for pneumothorax
increase with CT clamped please eval for pneumothorax increase with CT
clamped
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild postoperative pulmonary edema after ___ has improved since ___.
No pneumothorax. Small left pleural effusion is stable or improved. Left
lower lobe atelectasis is moderate. Normal postoperative appearance the
cardiomediastinal silhouette. Heavy asbestos related calcified pleural plaque
noted.
Right jugular line ends in the low SVC. Midline and at least one pleural
drain in place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABGx3(LIMA-LAD; SVG-RI; SVG-PDA) AVR (25mm
SJ Epic)// please eval for pneumothorax s/p CT removal
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with stable interstitial edema. Right IJ line is
unchanged. Patchy parenchymal opacity in the left lower lobe is unchanged.
Lungs are low in volume. Small bilateral effusions left greater than right
are stable. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man s/p CABG/ AVR with dropping hct// eval for
hemothorax eval for hemothorax
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild pulmonary edema unchanged since ___. Small left pleural effusion is
likely. No pneumothorax. Normal postoperative appearance cardiomediastinal
silhouette.
Heavy asbestos related pleural calcification.
Right jugular line ends in the low SVC.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Query pneumothorax.
COMPARISON: Prior study from ___.
FINDINGS:
Trace right apical pneumothorax appears stable. No significant change.
IMPRESSION:
No short-term change in very small right apical pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with new PPM.// Check leads Check leads
IMPRESSION:
Right internal jugular line tip terminates at the level of mid to lower SVC.
Heart size and mediastinum are stable. Left sided pacemaker leads terminate
in right atrium and right ventricle. There is interval improvement in
pulmonary edema and better aeration of the lung fields.
Bilateral basal opacities and interstitial lung disease as well as calcified
pleural plaques are re-demonstrated.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs
temperature: 97.6
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 142.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | He was admitted on ___ and underwent routine preoperative
testing and evaluation. He remained stable and was taken to the
operating room on ___. He underwent aortic valve
replacement and coronary artery bypass grafting x 3. Please see
operative note for full details. He tolerated the procedure well
and was transferred to the CVICU in stable condition for
recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from vasopressor support. Beta
blocker was initiated and he was diuresed toward his
preoperative weight. He remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. He was
started on
beta blockers, though these were ultimately held. He was
initially A-V paced, though eventually the atrial lead stopped
sensing and pacing. On ___ he had ___lock,
each 7 seconds in duration. He reportedly had loss of
consciousness with one of these events. EP was consulted and he
underwent PPM placement on ___. He developed delirium
following this procedure. Geriatrics was consulted. Olanzapine
initiated with good effect. Delirium resolved and olanzapine
discontinued. Beta blocker resumed.
He was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 7 he
was ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. He was discharged home in good
condition with appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ hx of HTN, LHD and recent C2 decompression with
C1-C3 laminectomy/fusion on ___ who was sent in from rehab
facility due to altered mental status. Pt was in her usual state
of health until this morning when she was found to be confused.
Pt does promote feeling confused at the time. She and the
facility both deny a recent hx of fever, chills, or any
constitutional symptoms. She has been constipated and promotes
___ lower abdominal pain over this time. No hx of diarrhea. She
did have episode of hematuria yesterday but denies any dysuria
or increase freq. Denies any CP, lH, dizziness, or SOB. No pain
at surgical site. Denies any weakness. Continues to have b/l
lower extremity numbness which she says is her baseline and
unchanged.
In the ED, initial vitals were: 97.4 68 118/51 24 97%. She was
noted to be A&Ox3 but agitated. Labs were notable for UA with
pyuria, mod bacteria, large ___, blood, and nitrites. No
leukocytosis on CBC with stable H/H. Chem 7 notable for K+ of
5.5. A CT head was normal. CXR was normal. She was started on
CTX for UTI.
On the floor, she no longer feels confused and has no concerns.
She continues to promote mild lower abdominal/suprapubic
discomfort.
Past Medical History:
PMHx (per OMR and patient):
- Broke cervical vertebrae at ___, with C2 decompression on
___ C1-C3 laminectomy/fusion
- hypertension
- arthritis
- hyperlipidemia
- anxiety
Meds:
- Aspirin 325mg daily
- Bisacodyl 5mg tablet,delayed release daily
- Clonazepam 0.25mg BID
- Diltiazem ER 180mg capsule,extended release daily
- Losartan 100mg tablet daily
- Metoprolol tartrate 25mg daily
- Simvastatin 10mg qhs
- Oxycodone 5mg q3hrs PRN pain
- Melatonin 3mg qhs PRN insomnia
- Gabapentin 100mg TID
- OxyContin 10mg tablet,extended release BID
Allergies:
- NKDA
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission:
Vitals: T:98.2 BP: 96/50 P: 80 R: 16 O2: 94% RA
General: Pt appears comfortable laying in bed A&Ox3
HEENT: NCAT, EOMI, ___, OMM with no lesions
Neck: No masses appreciated, collar in place. Surgical scar
healing without erythema.
CV: RRR, no m/r/g, no JVD
Lungs: CTABL with no r/w/r
Abdomen: TTP in suprapubic region, also ttp in RUQ with deep
palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i
GU: no foley in place
Ext: No edema, no rashes
Neuro: CN ___ grossly intact with ___ strength in all extm, no
focal deficits.
Skin: No rashes or ecchymosis appreciated
Vitals: T:98.7 BP: 121/75 P: 88 R: 16 O2: 94% RA
General: Pt appears uncomfortable sitting up in bed A&Ox3
HEENT: NCAT, EOMI, ___, OMM with no lesions
Neck: No masses appreciated, collar in place. Surgical scar
healing without erythema.
CV: RRR, no m/r/g, no JVD
Lungs: CTABL with no r/w/r
Abdomen: TTP in suprapubic region, also ttp in RUQ with deep
palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i
GU: no foley in place
Ext: No edema, no rashes
Neuro: CN ___ grossly intact with ___ strength in all extm, no
focal deficits.
Skin: No rashes or ecchymosis appreciated
Pertinent Results:
Admission:
___ 09:10AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.8* Hct-32.7*
MCV-97 MCH-32.0 MCHC-32.9 RDW-12.9 Plt ___
___ 09:10AM BLOOD Neuts-84.7* Lymphs-10.1* Monos-3.9
Eos-0.9 Baso-0.4
___ 09:10AM BLOOD Glucose-102* UreaN-25* Creat-1.2* Na-136
K-7.5* Cl-102 HCO3-23 AnGap-19
___ 09:10AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4
Discharge:
___ 06:30AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.4* Hct-28.9*
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.2 Plt ___
___ 06:30AM BLOOD Neuts-82.3* Lymphs-13.7* Monos-2.9
Eos-1.0 Baso-0.1
___ 06:30AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-22 AnGap-18
___ 06:30AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 Iron-PND
Imaging:
CXR:
IMPRESSION:
Minimal left basilar atelectasis.
CT Head:
IMPRESSION:
No evidence of acute intracranial abnormality. MRI is more
sensitive in the detection of acute stroke.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Diazepam 5 mg PO Q6H:PRN spasm/anxiety
3. Diltiazem Extended-Release 180 mg PO DAILY
4. ClonazePAM 0.25 mg PO BID
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
10. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. ClonazePAM 0.25 mg PO BID
4. Diltiazem Extended-Release 180 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO DAILY
Hold for HR <60, Systolic blood pressure <100
8. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
Toxic Metabolic Encephalopathy
Stage 1 Sacral decubitus
Secondary Diagnosis
Status Post C1-C3 laminectomy/fusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status.
TECHNIQUE: AP view of the chest.
COMPARISON: ___.
FINDINGS:
The heart size is normal. The aortic knob is calcified. Mediastinal and
hilar contours are unremarkable. The pulmonary vascularity is normal.
Minimal patchy left basilar opacity likely reflects atelectasis. There is no
focal consolidation. No pleural effusion or pneumothorax is seen. Cervical
spinal fusion hardware is partially imaged.
IMPRESSION:
Minimal left basilar atelectasis.
Radiology Report
INDICATION: Altered mental status, found altered at 6 a.m.; last normal, last
night; evaluate for bleed or stroke.
COMPARISON: ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformatted
images were generated.
DLP: 897 mGy-cm.
FINDINGS:
Streak artifact from occipitocervical fusion hardware limits assessment of the
posterior fossa. There is no evidence of hemorrhage, edema, mass effect, or
acute large vascular territorial infarction. Prominent ventricles and sulci
likely reflect age-related involutional changes. Periventricular white matter
hypodensities are compatible with chronic small vessel ischemic disease.
Basal cisterns are patent and there is preservation of gray-white matter
differentiation. No acute fracture is identified. Mild mucosal thickening is
seen within the ethmoid air cells. Mastoid air cells and middle ear cavities
are clear. Orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality. MRI is more sensitive in the
detection of acute stroke.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ yo F with a history of HTN, hyperlipidemia and recent C2
decompression with C1-C3 laminectomy/fusion on ___ who was sent
in from rehab facility due to altered mental status and was
found to have urinary tract infection.
# Altered mental status: Patient presented with AMS which
resolved by the time of admission. Most likely secondary to
urinary tract infection and large doses of narcotics and
diazepam following surgery. Patient remained A&Ox3 entire
admission. Previously prescribed oxycodone was discontinued and
she was transitioned to standing tylenol with as needed
tramadol. She will also use ibuprofen as needed on a full
stomach. The risk of NSAIDS were discussed with patient but she
notes they offer the greatest relief. She was guaiac negative
this admission. Hematocrit should be monitored closely while
taking this medication. Patient should not take aspirin while
taking NSAIDS.
#UTI: Urine analysis was strongly suggestive of infection with
moderate bacteria and large ___ and nitrites. Urine culture grew
pansensitive entercocci. She was treated with a 7 day ___ of
amoxacillin for sensitive enterococcus. Infection most likely
secondary to foley placements during recent hospitalizations.
#Hx of C2 decompression with C1-C3 laminectomy/fusion: Incision
appeared clean and without signs of infection. Patient noted
extreme discomfort with ___ j collar. She was evaluated by
orthopedics who arranged for a new, smaller collar. Patient's
pain regimen was modified this admission by holding oxycodone
and adding tramadol due to AMS. She will also take ibuprofen as
needed (risks and side effects discussed). She will continue to
follow up with ortho as an outpatient. Patient deferred going
back to a rehab facility and will continue ___ at home.
#Weakness: Rehab facility noted weakness prior to admission but
patient found to have ___ strength on exam without focal
deficits. Neuro evaluated earlier this week without concern. MRI
without new findings.
#Anemia: Most likely secondary to chronic disease with high
ferritin and low TIBC. Guaiac negative this admission. Has been
downtrending over the last several admissions and should be
monitored going forth. Recommend outpatient hematocrit within
the next ___ days to ensure stability. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Thiazides
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ yo female past medical history significant for
Bechets vasculitis (on cyclophosphamide and prednisone) admitted
to ___ following concern for epidural abscess in setting of
increased low back pain following and LP
done approximately 3 weeks prior. The LP was done to r/o
Guillain
___ syndrome. Further review of imaging showed no evidence of
epidural abscess, however there is evidence of a subacute
fracture of L4 vertebral body height loss and mild spinal
stenosis. A chronic fracture at S1 was also observed. Plan to
brace ___ for management of the compression fracture.
Past Medical History:
Diagnosed with Behcets ___ years ago. Has history of
vaginal, lip, skin, and colon ulcers. Was previously
hospitalized for a colonic bleed. Has also had ulcers "in the
front of her eye".
Has history of 15 pulmonary emboli ___ years ago) related to
her Behcets disease now on chronic warfarin.
Has history of left median neuropathy.
Social History:
___
Family History:
Many women in her father's side of the family has autoimmune
disease including RA and Crohn's.
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 100.2 BP:140 /102 HR:112 R: 18 97% O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm reactive bilaterally, EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 3 5 3 5 5
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Proprioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
on DISCHARGE:
alert and oriented
___ strength in all extremities
senstation grossly intact
Pertinent Results:
___ MRI Lspine:
IMPRESSION:
1. Subacute fracture of L4 with mild to moderate vertebral body
height loss
and mild spinal canal stenosis. Enhancement of the anterior
epidural space at
L4 is either due to prominence of the venous plexus or a small
epidural
hematoma. Recommend CT scan for further evaluation
2. Chronic fracture of S1 without height loss.
___ CXR
No acute intrathoracic process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Tizanidine 2 mg PO Q8H:PRN muscle spasm
3. HydrOXYzine 25 mg PO BID:PRN anxiety
4. Methylprednisolone ACETATE 32 mg IM DAILY
5. Oxymorphone HCl 1 tab PO EVERY 8HRS
6. HYDROmorphone (Dilaudid) 10 mg PO Q4H:PRN Pain
7. Lorazepam 1 mg PO DAILY:PRN anxiety
8. Metoprolol Tartrate 25 mg PO BID
9. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. HYDROmorphone (Dilaudid) 12 mg PO Q4H:PRN Pain
RX *hydromorphone 12 mg 1 tablet(s) by mouth Q4H PRN pain Disp
#*42 Tablet Refills:*0
3. HydrOXYzine 25 mg PO BID:PRN anxiety
4. Lisinopril 20 mg PO DAILY
5. Lorazepam 1 mg PO DAILY:PRN anxiety
6. Metoprolol Tartrate 25 mg PO BID
7. Tizanidine 2 mg PO Q8H:PRN muscle spasm
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Atovaquone Suspension 750 mg PO BID
10. Cyclobenzaprine 10 mg PO TID:PRN leg tightness
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID PRN
pain/muscle spas, Disp #*90 Tablet Refills:*0
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth Q8 hours
PRN pain Disp #*90 Tablet Refills:*0
13. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Warfarin 2.5 mg PO DAILY16
HOLD THIS MEDICATION ON ___. Methylprednisolone ACETATE 32 mg IM DAILY
16. Outpatient Physical Therapy
outpatient ___ for mangement of SIJ arthopathy
Discharge Disposition:
Home
Discharge Diagnosis:
Subacute L4 compression fracture with no canal compromise
Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with Bechet's on immunosuppresants with back pain, fevers //
eval pna
COMPARISON: None
FINDINGS:
Upright AP and lateral views of the chest provided. Lung volumes are low
though the lungs appear clear. 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.
Clips noted in the right upper quadrant.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: MRI lumbar spine without and with intravenous contrast
INDICATION: History: ___ with bechet's disease with LP 2 weeks ago with new
LLE weakness and low back pain with fever // code cord : eval epidural
abscess/hematoma
TECHNIQUE: MRI of the lumbar spine was performed before and following the
intravenous administration of 8 cc Gadavist. Sagittal T2, sagittal STIR,
sagittal T1, axial T2, axial T1, sagittal T1 post-contrast, and axial T1 post
contrast images were obtained.
COMPARISON: CT lumbar spine ___
FINDINGS:
There is irregularity of the superior endplate of L4 that is T2 mixed
intensity, STIR hyperintense, T1 hypointense, and non-enhancing. The signal
characteristics and the intact nature of the adjacent L3 inferior endplate
suggests that L4 irregularity and height loss is due to a subacute fracture.
This is new from CT on ___. There is mild to moderate vertebral
body height loss of L4 and mild spinal canal stenosis. There is edema of the
L3-4 disc without enhancement, consistent with reactive edema. There is thin
enhancement of the anterior epidural space at L4, either prominence of the
venous plexus or a small epidural hematoma. There is no epidural abscess.
Alignment is preserved. The conus is normal in appearance and position,
terminating at L1.
There is a fracture of S1 without height loss, chronic in nature but new from
CT on ___.
IMPRESSION:
1. Subacute fracture of L4 with mild to moderate vertebral body height loss
and mild spinal canal stenosis. Enhancement of the anterior epidural space at
L4 is either due to prominence of the venous plexus or a small epidural
hematoma. Recommend CT scan for further evaluation
2. Chronic fracture of S1 without height loss.
NOTIFICATION: The discrepancy between the wet read and final read was
discussed with ___ of the Neurosurgery service at approximately
11:00 ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN FEVER
Diagnosed with INTRASPINAL ABSCESS
temperature: 100.3
heartrate: 112.0
resprate: 18.0
o2sat: 97.0
sbp: 140.0
dbp: 102.0
level of pain: 7
level of acuity: 2.0 | Patient was admitted to the neurosurgery. Further review of the
MRI showed no abscess and Neurosurgery was not concerned for
epidural hematoma. A subacute L4 compression fracture was noted
and a Aspen quick draw brace was ordered. Patient complained of
pain and required IV Dilaudid Q2hrs. Neurology continued to
follow. On HD 2, a social work consulted was called for patient
coping. Pain services was consulted and recommendations were
made after speaking with the ___ pain MD. ___ was
curbsided and felt that any steroid recommendations could be
made outpatient by the ___ rheumatologist. Neurology
signed off. Physical therapy worked with the patient and cleared
her for home. Patient refusing discharge until pain management
rediscussed. A pain managment was made and agreed upon.
On ___ IV dilaudid was discontinued. Her pain was well
controlled on oral pain regimen. She was discharged home with
instructions for follow and pain managment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor / Lisinopril / vancomycin
Attending: ___.
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo W with no psychiatric hx, MMP, including s/p R. MCA
stroke, CAD, DM, COPD, recent TKR, was sent from ___ at
___ for a change in mental status. Per
records from rehab, on ___ at 8 am pt requested to go home,was
refusing exam, medications, and when she was told that she
needed to wait for MD to see her she called ___. In addition,
she was screaming, verbally abusive and combative with staff.
Expressed paranoia that "you are just using my Medicare". Pt
sent to ED for eval.
In ED pt seen by psych. Was pleasant and cooperative. Did not
remember above incident.
On arrival to floor pt again pleasant and cooperative. Does not
know why she was brought to hospital. States she needs to go
home so she can pay her rent. No complaints.
ROS: Denies fever, chills, chest pain, shortness of breath,
cough abdominal pain, nausea, vomiting diarrhea, constipation,
or dysuria. A full review of systems was performed and is
otherwise unremarkable except as noted above.
Past Medical History:
per last discharge summary
-Rheumatoid Arthritis
-CAD s/p RCA stent ___, patent on ___ cath
-mild dCHF (EF 60% in ___
-COPD (2L NC at night only)
-CVA ___ (left sided weakness, speech affected)
-PVD/PAD
-DM type 2
-HTN
-AAA (MRI ___- 3.4cm, ___ 3.5cm)
-Right lacunar infarct (___) - on coumadin, then stopped ___
-erosive gastritis, angiodysplasia (Normal EGD ___
-diverticulosis, angioectasias on CSPY ___
-migraines manifest as left facial numbness
-Lumbar stenosis and cervical spondylosis, C5-7 radiculopathy
-OSA
-Neurologic bladder on daily bactrim per urol
-Depression/Anxiety
-Recurrent UTIs
-Anemia
-Hyponatremia (baseline Na low 130s)
-Right total knee replacement
Social History:
___
Family History:
no history of psych illness
Physical Exam:
VS: 98 150/90 67 18 98%ra
PAIN: 0
GEN: no acute signs of distress.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
Neuro: alert, oriented to person, place and time, follows
commands, moving all extremities
PSYCH: pleasant, cooperative
Pertinent Results:
___ 08:53PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:53PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 08:53PM URINE RBC-2 WBC-22* BACTERIA-FEW YEAST-NONE
EPI-3 TRANS EPI-<1
___ 08:53PM URINE HYALINE-10*
___ 08:53PM URINE MUCOUS-OCC
___ 06:00PM GLUCOSE-94 UREA N-18 CREAT-0.9 SODIUM-134
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
___ 06:00PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-1.9
___:00PM TSH-1.4
___ 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:00PM WBC-10.5 RBC-3.43* HGB-9.0* HCT-28.8* MCV-84
MCH-26.2* MCHC-31.2 RDW-16.2*
___ 06:00PM NEUTS-72.2* LYMPHS-15.9* MONOS-6.3 EOS-4.9*
BASOS-0.8
___ 06:00PM PLT COUNT-540*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Citalopram 10 mg PO DAILY
3. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
4. Valsartan 160 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Nifedical XL *NF* (NIFEdipine) 60 mg Oral daily
7. Nitroglycerin SL 0.3 mg SL PRN chest pain
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation daily
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q8H:PRN wheezing
13. Aspirin 81 mg PO DAILY
14. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral BID
15. Chlorthalidone 25 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. FoLIC Acid 1 mg PO DAILY
18. Lovastatin *NF* 40 mg Oral daily
19. melatonin *NF* 3 mg Oral hs
20. Methotrexate 15 mg PO 1X/WEEK (___)
21. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
22. Pantoprazole 40 mg PO Q24H
23. Polysaccharide Iron *NF* (polysaccharide iron complex) 150
mg iron Oral BID
24. Zolpidem Tartrate 5 mg PO HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q8H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP <110 and hold for HR <60.
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Pantoprazole 40 mg PO Q24H
12. Psyllium 1 PKT PO TID:PRN constipation
13. Valsartan 160 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
16. Linezolid ___ mg PO Q12H
17. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral BID
18. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral daily
19. Ferrous Sulfate 325 mg PO DAILY
20. Lovastatin *NF* 40 mg ORAL DAILY
21. melatonin *NF* 3 mg Oral hs
22. Methotrexate 15 mg PO 1X/WEEK (___)
Every ___
23. Multivitamins 1 TAB PO DAILY
24. Polysaccharide Iron *NF* (polysaccharide iron complex) 150
mg iron Oral BID
25. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation daily
26. Senna 1 TAB PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Delirium
Urinary Tract Infection
Secondary
Rheumatoid Arthritis
-CAD s/p RCA stent ___, patent on ___ cath
-mild dCHF (EF 60% in ___
-COPD (2L NC at night only)
-CVA ___ (left sided weakness, speech affected)
-PVD/PAD
-DM type 2
-HTN
-AAA (MRI ___- 3.4cm, ___ 3.5cm)
-Right lacunar infarct (___) - on coumadin, then stopped ___
-erosive gastritis, angiodysplasia (Normal EGD ___
-diverticulosis, angioectasias on CSPY ___
-migraines manifest as left facial numbness
-Lumbar stenosis and cervical spondylosis, C5-7 radiculopathy
-OSA
-Neurologic bladder on daily bactrim per urol
-Depression/Anxiety
-Recurrent UTIs
-Anemia
-Hyponatremia (baseline Na low 130s)
-Right total knee replacement
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
HISTORY: Delirium, status post fall.
COMPARISON: ___.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1410.36 mGy-cm.
FINDINGS: No hemorrhage, edema, mass effect or acute vascular territorial
infarct. There is re-demonstration of encephalomalacia in the right corona
radiata extending inferiorly into the insular white matter compatible with a
prior right MCA territory infarct. Prominent ventricles and sulci are
suggestive of age-related involutional change. Areas of confluent
periventricular and subcortical white matter hypodensity is compatible with
chronic small vessel ischemic disease. No fracture is identified. There is
re-demonstration of a significant mucosal wall thickening with aerated
material of the bilateral maxillary sinuses, sphenoid sinuses, frontal sinuses
and ethmoid air cells. The mastoid air cells and middle ear cavities are
clear. The globes are intact. Dense vascular calcifications are noted in the
vertebral arteries and carotid siphons.
IMPRESSION:
1. No acute intracranial process.
2. Encephalomalacia from prior right MCA territorial infarct.
3. Extensive sinus disease as above appears acute.
Radiology Report
HISTORY: Delirium, status post fall.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph, four views.
FINDINGS: The heart size is normal with tortuosity of the thoracic aorta.
The hilar contours are unchanged. The lungs are mildly hyperexpanded. Again
appreciated are diffuse increased interstitial lung markings suggestive of
chronic interstitial abnormality. There is no focal consolidation worrisome
for pneumonia. There is no pleural effusion or pneumothorax. The osseous
structures are grossly unremarkable.
IMPRESSION: No significant change compared to prior study with
redemonstration of mild hyperinflation and global increased interstitial
markings most compatible with emphysema.
Radiology Report
HISTORY: Delirium, status post fall with knee pain.
COMPARISON: Right knee radiographs ___.
TECHNIQUE: Right knee radiograph, three views.
FINDINGS: The patient is status post right total knee revision arthroplasty
with rotation hinge in place. There is no perihardware lucency or hardware
fracture. No fracture is identified. Surrounding heterotopic ossification is
unchanged from prior study. There is no effusion.
IMPRESSION: No fracture. Revision total arthroplasty in place without
hardware complication.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: ___
Diagnosed with URIN TRACT INFECTION NOS, SEMICOMA/STUPOR, HYPERTENSION NOS
temperature: 98.3
heartrate: 64.0
resprate: 18.0
o2sat: 98.0
sbp: 116.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | A/P: ___ yo W with MMP but no psychiatric hx, sent from ___ at
___ for a change in mental status and
resistance to care. This is most like secondary to a UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ w/ HTN, non-ischemic CMY (LVEF
45-50% TTE ___, LBBB, and recently diagnosed NSCLC (___) w/
brain mets s/p CK, on ___, course c/b afib
w/
RVR requiring ICU, subsegmental PE now on enoxaparin, who p/w
persistent n/v after her C8 on ___.
She received on ___ C8 pembrolizumab and pemetrexed, and at
that time she felt like she was just recovering from her
previous
cycles. ___ she presented to ED w/ N/V/dehydration and
improved
with IV hydration and antiemetics. SHe was discharged home.
Since
then she continues to have no appetite, persistent nausea,
unable
to hold down PO, and is feeling orthostatic. She presented again
to the ED today unable to keep anything down. IN fact, she has
been too weak to take her lovenox shots and not taking her
scheduled meds consistently.
She denied F/C, no diarrhea. Her last BM was about 7 days ago
and
it was normal then. She normally moves her bowels daily. She is
feeling orthostatic but denied any CP/SOB. SHe has a cough and
that is dry and unchanged from baseline. She lives at home w/
her
partner and does not have any exposure to sick contacts. Of
note,
with her recent cycles, she had N/V "iso not using
zofran/compazine/decadron" per her oncologist.
In the ED, Tmax 99.5F. HR 94, 102/61. She received IV morphine,
Zofran, and 1L NS and admitted. She does feel improved.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
1. Status post ___ cGy stereotactic brain radiotherapy to 2
left
cerebellar and 1 right temporal brain lesion on ___. 2.
Status post 6 cycles of carboplatin 5->4->3.5->0 AUC, pemetrexed
500 mg/m2 and pembrolizumab 200 mg fixed dose on ___
Ms. ___ is a ___ year-old white woman with a current smoking
history (10 pack-years) who presented to medical care with
possible post-obstructive pneumonia (requiring antibiotics),
cough and dyspnea with exertion. Some fatigue and anorexia was
also noted. A PET/CT Scan from ___ showed an FDG avid right
upper lobe mass with numerous scattered FDG-avid pulmonary
nodules and FDG avid mediastinal and right hilar
lymphadenopathy.
There was a small right pleural effusion, a 9mm artocaval lymph
node, and subtle focus of posterior right twelfth rib. Brain MRI
from ___ showed there are three new enhancing foci (left
cerebellar hemisphere and right temporal lobe) worrisome for
metastatic disease. A bronchoscopy was performed by
Interventional Pulmonology on ___ and the right lobe
lesion,
level 7 and level 4R nodes were positive for adenocarcinoma. The
tumor cells were positive for CK7 and negative for TTF-1 and
Napsin-A. Tumor has KRAS G12I mutation, STK11 splice site
464+2T>G mutation, KEAP1 T545fs*1 mutation and PD-L1 IHC TPS 0%
(not yet confirmed in second specimen). Material was
insufficient
for tumor mutation burden or microsatellite instability status.
It is noteworthy that the biopsy material from ___ showed
an
adenocarcinoma but without the pathognomonic markers of TTF-1
and
Napsin-A. Therefore, one cannot be completely certain of the
site
of origin. Imaging studies don't disclose another primary site
but some of the multiple lung lesions could be from a metastatic
process. The results from comprehensive genomic profiling with a
KRAS G12I mutation cannot pinpoint another primary site. She is
now status post ___ cGy stereotactic brain radiotherapy to 2
left cerebellar and 1 right temporal brain lesion on ___.
MRI brain from ___ showed mostly stable brain disease
burden. MRI brain from ___ showed some improvement in
previously treated lesions. She completed four cycles
___, but ___ was held for cycles 5 and 6 while
pemetrexed and pembro were continued. Her restaging scans
following 6 cycles demonstrated a "mixed response" with
improvement in all sites of disease except for increased FDG
avidity/enlargement of a R hilar node conglomerate, LLL nodule
and 1mm increase in size of dominant brain metastasis. Given
otherwise improved disease and overall clinical stability we
recommended continuation of pemetrexed/pembrolizumab for another
two cycles to be followed by re-staging scans. She did
additionally have new bone metastases in her sphenoid and left
frontal bones noted on her last brain MRI, appear to be causing
pain that is quite intense at times.
PAST MEDICAL HISTORY (per OMR):
- Unclear cardiac event/myocardial disorder with normal ejection
fraction in ___ (in follow-up);
- Prior ___ esophagus;
- Arthritis not active;
- Migraines not active;
- Hypertension under medical control;
- Prior depression.
Social History:
___
Family History:
Esophageal cancer in mother. No other recurrent cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 99.5 94 102/61 16 94% RA
General: NAD, Resting in bed comfortably with her sister at
bedside, notable for generalized weakness
HEENT: MM dry, no OP lesions, no thrush, raised prominence over
the L eye
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress but has
persistent
dry cough
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact, she has a
left
PSYCH: Thought process logical, linear, future oriented
ACCESS::KV
DISCHARGE PHYSICAL EXAM
VS: ___ 0748 Temp: 98.0 PO BP: 100/60 HR: 77 O2 sat: 100%
O2 delivery: Ra
GENERAL: Alert, NAD, appears well
HEENT: Anicteric, PERRL, no periorbital erythema appreciated,
mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
CBCs
___ 03:40PM BLOOD WBC-1.8* RBC-3.31* Hgb-10.7* Hct-33.4*
MCV-101* MCH-32.3* MCHC-32.0 RDW-12.4 RDWSD-45.9 Plt ___
___ 08:00AM BLOOD WBC-1.1* RBC-3.23* Hgb-10.5* Hct-32.3*
MCV-100* MCH-32.5* MCHC-32.5 RDW-12.5 RDWSD-45.7 Plt ___
___ 07:00AM BLOOD WBC-0.7* RBC-2.77* Hgb-9.0* Hct-27.5*
MCV-99* MCH-32.5* MCHC-32.7 RDW-12.4 RDWSD-45.0 Plt Ct-78*
___ 07:25AM BLOOD WBC-1.0* RBC-2.63* Hgb-8.5* Hct-26.1*
MCV-99* MCH-32.3* MCHC-32.6 RDW-12.4 RDWSD-44.9 Plt Ct-65*
___ 07:15AM BLOOD WBC-1.2* RBC-2.45* Hgb-8.0* Hct-24.4*
MCV-100* MCH-32.7* MCHC-32.8 RDW-12.3 RDWSD-44.3 Plt Ct-71*
___ 06:43AM BLOOD WBC-1.4* RBC-2.38* Hgb-7.8* Hct-23.8*
MCV-100* MCH-32.8* MCHC-32.8 RDW-12.4 RDWSD-45.2 Plt Ct-78*
___ 07:39AM BLOOD WBC-2.6* RBC-2.48* Hgb-8.0* Hct-24.6*
MCV-99* MCH-32.3* MCHC-32.5 RDW-12.3 RDWSD-44.5 Plt ___
Diffs
___ 03:40PM BLOOD Neuts-77.1* Lymphs-15.4* Monos-6.3
Eos-0.0* Baso-0.6 Im ___ AbsNeut-1.35* AbsLymp-0.27*
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.01
___ 08:00AM BLOOD Neuts-56.3 ___ Monos-9.8 Eos-0.9*
Baso-0.9 AbsNeut-0.63* AbsLymp-0.36* AbsMono-0.11* AbsEos-0.01*
AbsBaso-0.01
___ 07:00AM BLOOD Neuts-43.2 ___ Monos-20.3*
Eos-2.7 Baso-0.0 AbsNeut-0.32* AbsLymp-0.25* AbsMono-0.15*
AbsEos-0.02* AbsBaso-0.00*
___ 07:25AM BLOOD Neuts-58 Lymphs-17* Monos-22* Eos-3
Baso-0 AbsNeut-0.58* AbsLymp-0.17* AbsMono-0.22 AbsEos-0.03*
AbsBaso-0.00*
___ 07:15AM BLOOD Neuts-58.5 ___ Monos-15.3*
Eos-4.2 Baso-0.0 Im ___ AbsNeut-0.69* AbsLymp-0.25*
AbsMono-0.18* AbsEos-0.05 AbsBaso-0.00*
___ 06:43AM BLOOD Neuts-51.5 ___ Monos-19.1*
Eos-4.4 Baso-0.0 Im ___ AbsNeut-0.70* AbsLymp-0.30*
AbsMono-0.26 AbsEos-0.06 AbsBaso-0.00*
___ 07:39AM BLOOD Neuts-63.2 Lymphs-13.3* Monos-20.5*
Eos-1.5 Baso-0.4 Im ___ AbsNeut-1.67 AbsLymp-0.35*
AbsMono-0.54 AbsEos-0.04 AbsBaso-0.01
coag
___ 03:40PM BLOOD ___ PTT-30.0 ___
BMPs
___ 03:40PM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-134*
K-4.2 Cl-100 HCO3-23 AnGap-11
___ 07:15AM BLOOD Glucose-107* UreaN-5* Creat-0.6 Na-138
K-3.9 Cl-105 HCO3-24 AnGap-9*
LFTs
___ 08:00AM BLOOD ALT-11 AST-15 LD(LDH)-363* AlkPhos-61
TotBili-0.2
Other chemistry
___ 03:40PM BLOOD Albumin-3.4* Calcium-7.4* Phos-1.9*
Mg-2.2
___ 08:00AM BLOOD Albumin-3.1* Calcium-7.2* Phos-1.9*
Mg-2.1
___ 07:00AM BLOOD Calcium-6.3* Phos-1.7* Mg-1.9
___ 07:25AM BLOOD Calcium-7.0* Phos-2.7 Mg-1.8
___ 07:15AM BLOOD Calcium-7.2* Phos-2.1* Mg-1.8
___ 07:00AM BLOOD Cortsol-15.5
___ 08:00AM BLOOD freeCa-1.02*
___ 07:05AM BLOOD freeCa-0.92*
___ 03:13PM BLOOD freeCa-1.04*
___ 07:38AM BLOOD freeCa-1.01*
___ 08:08AM BLOOD freeCa-1.07*
___ 07:39AM BLOOD Glucose-96 UreaN-4* Creat-0.8 Na-137
K-3.4* Cl-104 HCO3-24 AnGap-9*
___ 07:39AM BLOOD Calcium-7.5* Phos-2.5* Mg-2.1
Blood cx ngtd
CT chest
IMPRESSION:
When compared to the PET-CT from ___, a new
consolidation is noted in the right upper lobe which is likely
related to recurrent atelectasis, post obstructive.
Again redemonstrated is a mass in the right upper lobe, known
lung cancer, slightly larger when compared to prior. Several
scattered lung nodules are relatively unchanged in size.
No new or growing lymphadenopathies or osseous lesions.
CT A/P
IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Sclerotic lesions in the L4 vertebral body and right iliac
bone consistent with known metastases.
3. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
MR brain
IMPRESSION:
1. A 1.4 x 1.3 cm rim enhancing metastasis in the left
cerebellar
hemisphere has increased in size, previously 1.2 x 1.1 cm.
Smaller enhancing metastases in the left cerebellar hemisphere
and lateral right temporal lobe are
unchanged. No new intra-axial lesions identified.
2. Metastatic infiltration of the left sphenoid wing and left
frontal bone has increased since the prior examination.
Evidence
of adjacent left temporalis muscle involvement is new.
Extensive
left cerebral pachymeningeal thickening
and enhancement is not appreciably changed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 70 mg SC Q12H
2. Benzonatate 100 mg PO TID
3. Escitalopram Oxalate 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN
wheezing/cough
6. LORazepam 0.5 mg PO BID:PRN nausea
7. Omeprazole 20 mg PO BID
8. Amiodarone 200 mg PO DAILY
9. Dronabinol 2.5 mg PO BID:PRN nausea or lack of appetite
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rash
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
17. Senna 8.6 mg PO BID:PRN Constipation
18. Fluticasone Propionate NASAL ___ SPRY NU DAILY
19. Morphine SR (MS ___ 15 mg PO Q12H
20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six (6)
hours Disp #*240 Capsule Refills:*0
2. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*14 Tablet Refills:*0
3. Calcium Carbonate 1000 mg PO TID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet 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 #*18 Tablet Refills:*0
6. Dronabinol 2.5 mg PO BID nausea or lack of appetite
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL ___very twelve (12) hours
Disp #*60 Syringe Refills:*0
8. Amiodarone 200 mg PO DAILY
9. Benzonatate 100 mg PO TID
10. Escitalopram Oxalate 20 mg PO DAILY
11. Fluticasone Propionate NASAL ___ SPRY NU DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN
wheezing/cough
14. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rash
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. LORazepam 0.5 mg PO BID:PRN nausea
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 20 mg PO BID
19. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth up to three times
daily as needed Disp #*90 Tablet Refills:*0
20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
21. Prochlorperazine 10 mg PO Q8H:PRN nausea
22. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and vomiting
Pancytopenia due to chemotherapy
Febrile neutropenia
Preseptal cellulitis
Hypocalcemia
Hypophosphatemia
Metastatic non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT
and persistent nausea/vomiting// rule out progressive brain mets and evaluate
for possible hypophysitis
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: ___ brain MRI and ___ brain MRI
FINDINGS:
A ring-enhancing lesion in the left cerebellar hemisphere has increased in
size and measures 1.4 x 1.3 cm, previously 1.2 x 1.1 cm. Adjacent vasogenic
edema is unchanged with no significant effacement of the fourth ventricle.
Subtle associated susceptibility artifact is unchanged and likely reflects
prior hemorrhage. A 4 mm enhancing nodule located more laterally within the
left cerebellar hemisphere is essentially unchanged (series 14, image 38). A
4 mm enhancing nodule in the lateral right temporal lobe is unchanged (series
14, image 69). No new enhancing intra-axial lesions identified.
Extensive T1 marrow signal hypointensity with associated enhancement and
slowed diffusion in the left sphenoid wing and left frontal bone has increased
since ___. Expansion of the adjacent left temporalis muscle
associated with T2 signal hyperintensity and enhancement and loss of fat
striations is new since the prior examination. Extensive left cerebral
pachymeningeal enhancement is similar to the prior examination.
There is no evidence of new hemorrhage or infarction. Nonenhancing
periventricular and subcortical white matter T2/FLAIR hyperintensities are
nonspecific and unchanged, likely sequelae of chronic small vessel ischemic
disease. The major arteries of the circle of ___ in the proximal branches
appear unremarkable. The dural venous sinuses are patent. There is mild
paranasal sinus mucosal thickening. A left lens replacement is noted.
IMPRESSION:
1. A 1.4 x 1.3 cm rim enhancing metastasis in the left cerebellar hemisphere
has increased in size, previously 1.2 x 1.1 cm. Smaller enhancing metastases
in the left cerebellar hemisphere and lateral right temporal lobe are
unchanged. No new intra-axial lesions identified.
2. Metastatic infiltration of the left sphenoid wing and left frontal bone has
increased since the prior examination. Evidence of adjacent left temporalis
muscle involvement is new. Extensive left cerebral pachymeningeal thickening
and enhancement is not appreciably changed.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT
and persistent nausea/vomiting// please assess for disease progression and/or
infection
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen was done with IV
contrast. A single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by scan of the abdomen
in equilibrium (3-min delay) phase.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol =
7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 0.8 s, 0.2 cm;
CTDIvol = 13.7 mGy (Body) DLP = 2.7 mGy-cm. 3) Spiral Acquisition 9.9 s, 64.4
cm; CTDIvol = 9.3 mGy (Body) DLP = 593.9 mGy-cm. 4) Spiral Acquisition 4.9 s,
31.9 cm; CTDIvol = 9.0 mGy (Body) DLP = 281.4 mGy-cm. Total DLP (Body) = 880
mGy-cm.
COMPARISON: PET-CT ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Few
subcentimeter hypodensities are too small to characterize, but grossly stable
from recent PET-CT where they did not appear FDG avid. 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.
No hydronephrosis. Subcentimeter hypodensity in the interpolar region of the
left kidney likely represents a simple cyst. There is no perinephric
abnormality.
GASTROINTESTINAL: Small hiatal hernia. Stomach is otherwise 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: Uterus is unremarkable. No adnexal abnormalities are
seen.
LYMPH NODES: Few prominent left periaortic lymph nodes are unchanged, grossly
stable, and not pathologically enlarged by CT size criteria. No mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES: Sclerotic lesion in the anterior L4 vertebral body measures 1.4 cm and
is concerning for metastasis (5:75). A 3.3 cm area of sclerosis in the right
iliac bone which was avid on recent PET-CT is also consistent with a
metastasis (5:97).
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Sclerotic lesions in the L4 vertebral body and right iliac bone consistent
with known metastases.
3. 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: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT
and persistent nausea/vomiting// please assess for disease progression and/or
infection
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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.7 mGy (Body) DLP =
2.7 mGy-cm.
3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 593.9
mGy-cm.
4) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 9.0 mGy (Body) DLP = 281.4
mGy-cm.
Total DLP (Body) = 880 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Multiple prior chest CTs, most recently ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is mildly heterogeneous with small hypodense nodules, unchanged.
No enlarged lymph nodes in either axilla or thoracic inlet. No abnormalities
on the chest wall. No atherosclerotic calcifications in the head and neck
arteries.
HEART AND VASCULATURE:
The heart is normal size and shape. No pericardial effusion. No
atherosclerotic calcifications in the coronary arteries, aorta or cardiac
valves. The pulmonary arteries and aorta are normal in caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria size some borderline enlarged, for
example in the prevascular station measuring 7 mm (previously 10 mm). No left
hilar lymphadenopathy.
PLEURA:
Small right pleural effusion. Mild bilateral apical scarring.
LUNGS:
Several nodules ranging in size from 2-11 mm scattered throughout both lungs,
the largest in the left lower lobe, (6:192), all relatively unchanged in size.
The right upper lobe which substantially re-expanded between ___ and the ___
PET-CT on ___, has now largely collapsed again due to probable growth
of the large right hilar and upper lobe mass which continues to obstruct the
upper lobe bronchus. Admittedly, it is difficult to measure the mass
precisely given the adjacent atelectasis and/or postobstructive pneumonia
CHEST CAGE:
No acute fractures. No suspicious lytic or sclerotic lesions. Mild dorsal
spondylosis.
UPPER ABDOMEN:
Please refer to same day abdominal CT report for subdiaphragmatic findings.
IMPRESSION:
Progressive right upper lobe collapse since PET-CT on ___ due to
persistent obliteration of the right upper lobe bronchus by the likely growth
of the large right hilar mass. There may be a component of postobstructive
pneumonia.
Several scattered lung nodules are relatively unchanged in size since ___.
No new or growing lymphadenopathy or osseous lesions.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fatigue, N/V
Diagnosed with Adult failure to thrive
temperature: 99.3
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 112.0
dbp: 63.0
level of pain: 7
level of acuity: 3.0 | ___ is a ___ year old woman with HTN, non-ischemic
CMY (LVEF 45-50% TTE ___, LBBB, and recently diagnosed NSCLC
(___) w/ brain mets s/p CK, on ___, prior
course c/b afib w/ RVR requiring ICU, subsegmental PE now on
enoxaparin, who p/w persistent N/V after her C8 on ___, found
to have likely L preseptal cellulitis, neutropenia,
hypocalcemia, hypophosphatemia, and mild progression of disease
on re-staging scans.
# Nausea, Vomiting, Dehydration, Weakness
# Pancytopenia / moderate neutropenia
# Severe malnutrition
Patient presented with nausea, vomiting, and poor PO intake
during cycle 8 of chemotherapy. Symptoms improved with
supportive treatment, so suspect they were primarily driven by
chemotherapy, although likely also has some baseline symptoms
from malignancy as well. Low suspicion for pembro-related
autoimmune hypophysitis based on cortisol and TSH. By discharge
was tolerating regular diet with PRN PO antiemetics. Also
changed dronabinol from PRN to scheduled per oncology
recommendations, as this has helped with appetite. Seen by
nutrition and given suppleents.
#Borderline febrile neutropenia
#Pancytopenia
#Suspected L preseptal cellulitis
Developed periorbital erythema and edema within 24 hours prior
to arrival on the floor, suspected to be preseptal cellulitis.
Exam/history reassuring against orbital involvement. Had temp to
100.5x1 overnight ___ and then developed severe neutropenia
___ with nadir ANC in 300s. ANC >500 since ___. Continued on
vanc/cefepime through discharge, and then then transitioned to
bactrim/amoxicillin to complete 7 day course from recovery of
ANC (___). Periorbital erythema improved rapidly on
treatment.
# NSCLC - progressive
Treatment history as per above, currently cycle 8 of
chemotherapy. Unfortunately CT C/A/P and MRI brain notable for
mild progression of one cerebellar met and left scalp/bony met,
as well as progression of primary with worsening
post-obstructive atelectasis. Other disease mostly stable. She
has a persistent cough and intermittent headache. As noted
above, it is unclear to what degree nausea/vomiting and poor PO
intake have been related to her mets vs chemo. Discussed with
medical oncology, neurooncology, and radiation oncology during
the admission, and Dr. ___ oncology met with patient to
discuss goals and future plans. Patient is uncertain whether she
will consider any second line chemotherapy. She will be
following up closely in oncology, neurooncology, and rad-onc.
Steroids were considered for symptoms, but ultimately not given
since her symptoms were mostly resolved and since per rad-onc
her lack of edema makes steroids less likely to help.
# Hypocalcemia:
Severe hypocalcemia initially, likely from zometa ___.
Initially required IV repletion. Trialed on higher doses of tums
1000 mg PO TID and calcium levels were maintained in the
low-normal range.
# Hypophosphatemia:
Moderate hypophosphatemia likely from zometa, improved with
neutraphos. Stopped neutraphos ___, and phos levels remained
stable.
# Afib/HTN/cardiomyopathy:
- continued on home metoprolol (fractionated) and amiodarone;
metoprolol intermittently being held for soft BP, so discharged
on 25 mg instead of 50 mg
# Subsegmental PE:
Lovenox continued however the dose was reduced from ___ID
to ___ID based on her weight of ~60 kg.
# ___: PPI continued
# Headaches: overall improved
# free T4 elevation
TSH lower normal range. Would recheck as outpatient
===================================
===================================
TRANSITIONAL ISSUES
- needs close monitoring of calcium and phos
- has follow-up in neuroonc, rad-onc, and onc
- recheck thyroid studies as outpatient
===================================
=================================== |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin
Attending: ___.
Chief Complaint:
altered mental status and rash
Major Surgical or Invasive Procedure:
temporary HD line placement under general anesthesia
History of Present Illness:
___ yo M with h/o CAD, CHF, a-fib, AVR, ? prior CVA, DM, HTN, HLD
and recent admission (___) for MSSA bacteremia that
was c/b ___ felt to be due to AIN at the time, requiring 2
sessions of HD, prednisone tx (Cr improving at d/c), NSTEMI,
possible stroke or recrudescence of an old infarct, afib w/ RVR
requiring CV and a new onset rash at time of discharge who is
brought from the ___ for an evaluation of worsening ___ edema,
worsening rash and confusion.
Please see recent d/c summary for this gentleman's complicated
recent hospital course. He was discharged on a prednisone taper,
vancomycin IV (completed ___ and amiodarone as new
medications. Since discharge to rehab, he was noted to have
episodes of confusion as noted by staff and family. During the
nights he was often agitated, combative and rude to staff. His
sleep was disrupted with daytime sleepiness and nightime
agitaion. His daughter noted that although initially he would
respond appropriately to questions, over the past 3 days she
noted increasing incongruence in his resopnses (e.g. "Dad would
you like to return to the hospital?" -> "No there are lawyers
there and I am hungry."). At other times he would be noted to
trail off to sleep in the middle of a sentence and require
awakening to maintain conversation. There were some neologisms
noted as well as mild dysarthria. No reported falls. Daughter
also noted that his leg rash had spread b/l to LEs and UEs as
well as his head. She also noted an ulceration on the left
dorsal aspect of the foot.
There is some report of him receiving valium per ED notes,
however, none per daughter or rehab notes.
Re: his rash, notably at time of discharge on ___ his skin
exam was:
"the original skin reaction to the antibiotic is resolving with
some lingering drying ulcers. However, there is a new petechial
rash on the back of his right leg . No excoriations. The same
petechial rash is present on the back of his left elbow, but in
a more limited area. I did not notice the rash there yesterday
but I may have missed it."
In the ED, initial VS: 97 69 153/69 20 100%. Pt. underwent an
evaluation that revealed a PMN predominant leukocytosis of 17K,
hyperkalemia of 6.0 and hypochloremia w/ AG of 14, INR of 4.2
and lactate of 1.7. BCx were collected. He did not receive any
interventions and was admitted to Medicine.
Past Medical History:
IDDM c/b neuropathy
HTN
HLD
CAD s/p CABG in ___ and ___ and multiple stents
s/p biologic AVR ___ c/b transient heart block post op treated
with
pacer insertion ___ Sensia dual-chamber pacemaker).
Paroxysmal Atrial Fibrillation (last pacer interrogation
demonstrated no episodes of AF)
Chronic Systolic Heart Failure (EF 35% to 40% in ___
BPH
Hypothyroidism
CKD
Social History:
___
Family History:
Notable for a mother who died at ___ and had a brain tumor and a
sibling with Alzheimer disease. There is also thyroid, lung
cancer in other family members.
Brother: pancreatic and liver cancer in his brother.
No family history of CAD or sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
VS - 98.1F 172/79 69 18 93%RA
GENERAL - confused, non-toxic appearing man, looking around the
room, grabbing at his clothes.
HEENT - NC/AT,sclerae anicteric, MMM, OP clear w/o petechiae.
There are petechial and ulcerated lesions over the vertex of his
head.
NECK - supple, no meningismus, neg. ___.
LUNGS - crackles at bases b/l.
HEART - PMI non-displaced, RR, ___ SM at apex. nl S1-S2
ABDOMEN - Obese, soft/NT/ND, no masses or HSM, no
rebound/guarding, there is a band like erythematous, nonpapular,
nonpalpable rash on the abdomen.
EXTREMITIES - 2+ edema to mid thigh. unable to assess pulses.
There is a clean based, nectrotic ulcer on L dorsal aspect of
the foot, it is non-tender. Blistering lesion on R foot.
SKIN - petechial, palpable rash on LEs, UEs head and trunk.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, oriented to ___, ___. DOWf intact, DOWb could not get past ___, took 5 tries.
Able to name glasses, nose bridge and stethoscope. Able to read.
No apraxia. Some L /R confusion. Unable to follow 2 step
commands. Able to follow axial commands readily. Unwilling for
memory assessment.
CNs: VF unable to assess due to inattention, EOMI, 4-2mm b/l,
some slight RLF flattening, there is R ocular muscle weakness.
tongue midline, palate elevates symmetricaly. Shoulder shrug nl.
Motor: nl tone. Full at D/Tri/Bi/WE/FE b/l and ___ are full at
IP/Q/H/TA b/l.
Sensory - unable due to inattention, but notes discomfort w/
pressure b/l.
No true pronator drift, left arm falls inferiorly.
He has profound asterisis notable w/ estension of wrists. There
is occasional myoclonus as well.
Impaired FNF b/l, unable to assess HKS or tap due to
inattention. Gait deferred for safety concerns.
.
DISCHARGE EXAM:
Discharge changes:
Mental status: Patient is alert and plesent but still somewhat
confused.
Extremities 1+ edema, Lungs clear and without crackles,
resolving rash with no new lesions on hands or legs,
Pertinent Results:
ADMISSION LABS:
___ 04:10PM BLOOD WBC-16.6* RBC-3.16* Hgb-8.6* Hct-28.2*
MCV-90 MCH-27.3 MCHC-30.5* RDW-16.9* Plt ___
___ 04:10PM BLOOD Neuts-93.2* Lymphs-5.3* Monos-1.3* Eos-0
Baso-0.1
___ 11:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Ellipto-1+
___ 04:10PM BLOOD ___ PTT-36.0 ___
___ 04:10PM BLOOD Glucose-195* UreaN-177* Creat-5.0* Na-135
K-6.1* Cl-95* HCO3-26 AnGap-20
___ 04:10PM BLOOD ALT-36 AST-82* LD(LDH)-720* AlkPhos-116
TotBili-0.5
___ 04:10PM BLOOD Calcium-9.0 Phos-7.0* Mg-2.7*
___ 11:10AM BLOOD Hapto-325*
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-9.6 RBC-3.22* Hgb-8.2* Hct-27.4*
MCV-85 MCH-25.6* MCHC-30.1* RDW-15.3 Plt ___
___ 04:30AM BLOOD Neuts-80* Bands-0 Lymphs-14* Monos-4
Eos-2 Baso-0 ___ Myelos-0
___ 04:30AM BLOOD ___
___ 08:50AM BLOOD Glucose-252* UreaN-62* Creat-2.9* Na-140
K-3.5 Cl-99 HCO3-31 AnGap-14
___ 04:30AM BLOOD Glucose-47* UreaN-70* Creat-2.8* Na-140
K-3.4 Cl-100 HCO3-30 AnGap-13
___ 05:30AM BLOOD Glucose-84 UreaN-68* Creat-2.6* Na-137
K-3.7 Cl-99 HCO3-27 AnGap-15
___ 05:30AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8
___ 04:10PM BLOOD ___
___ 08:50AM BLOOD ANCA-NEGATIVE B
___ 11:30AM BLOOD TSH-0.20*
___ 08:50AM BLOOD HIV Ab-NEGATIVE
MICRO DATA:
___ 11:24PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:24PM URINE RBC-19* WBC-14* Bacteri-MOD Yeast-NONE
Epi-0 TransE-<1
___ 11:24PM URINE Hours-RANDOM UreaN-766 Creat-83 Na-20
K-40 Cl-19
___ 4:10 pm BLOOD CULTURE x2
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 am URINE TAKEN FROM HEM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:12 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 12:53 pm STOOL CONSISTENCY: FORMED Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST:
negative
___ 10:40AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:40AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:40AM URINE RBC-6* WBC-7* Bacteri-NONE Yeast-NONE
Epi-0
___ 10:40AM URINE CastHy-1*
___ 10:40AM URINE Mucous-RARE
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks
___ 6:15 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Blood cultures no growth and pending.
___ EKG
Normal sinus rhythm, rate 70. Left axis deviation. Right
bundle-branch block. Low voltage in the inferior leads. These
changes are unchanged compared with the previous tracing of
___.
CXR ___
Low lung volumes. Cardiomegaly without pulmonary edema.
CT HEAD W/O CONTRAST ___
1. No acute intracranial process.
2. Chronic atrophy, microvascular changes, and multifocal
infarcts.
3. Mild pansinus mucosal thickening, with resolution of prior
left sphenoid air-fluid level.
DOPPLER RENAL U/S ___
1. No hydronephrosis. Two simple left renal cysts.
2. Arterial and venous flow is seen in the right kidney;
however, the Doppler examination is limited as the patient is
unable to hold his breath. Note is made that the patient
declined to complete the Doppler examination and consequently
the exam is very limited and no Doppler images were obtained of
the left kidney.
ART EXT (REST ONLY) ___
IMPRESSION: Moderate left tibial disease.
Echo ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
inferior and inferolateral akinesis. The remaining segments
contract normally (LVEF = 35-40%). Right ventricular chamber
size and free wall motion are normal. A bioprosthetic aortic
valve prosthesis is present. The aortic valve prosthesis appears
well seated, with normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. The mitral valve leaflets are mildly thickened. No mass
or vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild to moderate left ventricular systolic
dysfunction, c/w CAD. Moderate mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
mitral and tricuspid regurgitation severity has increased. The
other findings are similar.
Medications on Admission:
-- clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
-- aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
-- multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY
-- metoprolol succinate 100 mg BID
-- cholecalciferol 1000 unit Tablet Sig: Two (2) Tablet PO DAILY
-- amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
-- camphor-menthol 0.5-0.5 % Lotion QID as needed for itching.
-- hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal BID
-- albuterol sulfate 2.5 mg /3 mL neb Q6H prn
-- senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
-- bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
-- calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
- vancomycin completed on .....
-- prednisone 50 mg tapering by 5mg Q3 days, currently at 40 mg
-- insulin lispro SS
-- atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
-- furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
-- levothyroxine 25 mcg daily
-- warfarin 1 mg daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
once a day.
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. insulin glargine 100 unit/mL Solution Sig: Fifteen (15)
Units Subcutaneous at bedtime.
14. insulin lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous qac.
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritis.
18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
19. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for hemorrhoids.
20. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
21. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic kidney disease, acute interstitial
nephritis, Uremia, Vasculitic skin rash
Secondary: Coronary artery disease, diabetes, hyperthyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Worsening renal failure.
COMPARISON: ___.
UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy,
CABG, and left-sided pacemaker device with leads terminating in the right
atrium and right ventricle. Right PICC tip terminates in the region of the
SVC. There are low lung volumes. The heart size remains moderate-to-severely
enlarged, but the mediastinal contour appears stably widened. There is
crowding of the bronchovascular structures, but no overt pulmonary edema is
present. Retrocardiac opacity likely reflects atelectasis as does minimal
linear opacity within the right lung base. No large pleural effusion or
pneumothorax is identified. The right internal jugular central venous
catheter has been removed.
IMPRESSION: Low lung volumes. Cardiomegaly without pulmonary edema.
Radiology Report
INDICATION: ___ male with paroxysmal atrial fibrillation and
pacemaker, history of prior CVAs, now with supratherapeutic INR of 4.2 and
altered mental status. Assess for intracranial hemorrhage or infarct.
___.
TECHNIQUE: Contiguous non-contrast axial images were obtained through the
brain, and reconstructed at 5-mm intervals.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or
vascular territorial infarct. The ventricles and sulci are prominent,
consistent with age-related involutional changes. Multiple periventricular
and subcortical white matter hypodensities reflect small vessel ischemic
disease. Lacunes are also noted in the bilateral temporal and occipital
lobes. There is additional encephalomalacia in the right anterolateral
cerebellum, with coarse calcifications suggesting laminar necrosis and/or
dystrophic changes. Dense calcifications of the bilateral cavernous carotid
and vertebral arteries.
Mild pansinus mucosal thickening is present. Prior left sphenoid air-fluid
level has resolved. The mastoid air cells and middle ear cavities are clear.
Orbits and intraconal structures are symmetric.
IMPRESSION:
1. No acute intracranial process.
2. Chronic atrophy, microvascular changes, and multifocal infarcts.
3. Mild pansinus mucosal thickening, with resolution of prior left sphenoid
air-fluid level.
Radiology Report
INDICATION: A ___ man with renal failure.
COMPARISON: Renal ultrasound ___.
FINDINGS: The right kidney measures 10.0 cm and the left kidney measures 11.8
cm. There is no hydronephrosis. A simple cyst which measures 1.9 cm is again
seen at the lower pole of the left kidney. A simple cyst is also seen at the
upper pole of the left kidney measuring 1.5 cm.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were
obtained. Note is made that this is a very limited study of the right kidney
only as the patient declined the completion of the exam. This exam is also
limited due to the patient's inability to hold his breath. Arterial waveforms
are seen in the main right renal artery and in the intraparenchymal arteries
of the right kidney. No antegrade diastolic flow can be seen on these
waveforms; however, it is unclear whether this finding is related to the
technically limited nature of this exam. Venous flow is seen in the main
right renal vein.
IMPRESSION:
1. No hydronephrosis. Two simple left renal cysts.
2. Arterial and venous flow is seen in the right kidney; however, the Doppler
examination is limited as the patient is unable to hold his breath. Note is
made that the patient declined to complete the Doppler examination and
consequently the exam is very limited and no Doppler images were obtained of
the left kidney.
Radiology Report
INDICATION: Acute renal failure, for emergent dialysis, place temporary line.
OPERATORS: Dr. ___, and ___ performed the
procedure. Dr. ___ attending radiologist, supervised the procedure.
PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and
placed supine on the angiography table. Written informed consent had
previously been obtained from the patient's wife, his healthcare proxy, after
thorough discussion of the risks, benefits and alternatives. Monitored
anesthesia care was administered due to the patient's mental status. A
preprocedure timeout was performed using three patient identifiers.
The left neck was prepped and draped in usual sterile fashion. 1% buffered
lidocaine was instilled in the subcutaneous tissues for local anesthesia.
Subsequently, under sonographic guidance, a micropuncture needle was advanced
into the patent left internal jugular vein. Pre- and post-venipuncture
sonographic images were printed. A 0.018 nitinol wire was advanced through
the needle into the superior vena cava. The needle was exchanged for a
micropuncture sheath and subsequently the inner dilator and nitinol wire were
removed. A short ___ wire was inserted into the micropuncture sheath, but
could not be advanced into the inferior vena cava and as a result was
exchanged for a 0.035 ___ wire. This was successfully advanced into the
inferior vena cava. The ___ wire was exchanged for an Amplatz wire
through the use of a 4 ___ Kumpe catheter. Over the Amplatz wire,
sequential dilatation was performed with subsequent insertion of a ___
double-lumen 20 cm hemodialysis catheter. Tip was left in the lower SVC with
approximately 1 cm of catheter exterior to the venotomy site. Final scout
image was obtained demonstrating tip in appropriate position. The line was
then aspirated and flushed and secured in position with two single 0 silk
interrupted sutures and dressed with a sterile dressing. The patient
tolerated the procedure well without immediate post-procedure complication.
The line is ready for use.
IMPRESSION: Successful insertion of a ___ temporary dialysis catheter
in the left internal jugular vein with tip in the lower SVC. The line is
ready for use.
Radiology Report
NON-INVASIVE ARTERIAL STUDY AT REST
INDICATION: ___ man with diabetes mellitus, acute renal failure on
hemodialysis with vasculitis rash on the lower extremities, presenting with
cold toes and nonpalpable, but dopplerable dorsalis pedis pulses. Evaluation
for vascular disease.
No studies available for comparison.
TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood
pressures were obtained in lower extremities bilaterally at rest.
FINDINGS: There is normal triphasic Doppler waveform at the right common
femoral, popliteal, posterior tibial, and dorsalis pedis arteries and at the
left common femoral, popliteal, and posterior tibial arteries. There is a
monophasic Doppler waveform at the level of the left dorsalis pedis artery.
The ABI index on the right is 1.13 and on the left is 1.26. Pulse volume
recordings are symmetrical bilaterally.
IMPRESSION: Moderate left tibial disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLE EDEMA/INCREASED CONFUSION
Diagnosed with OTHER FLUID OVERLOAD, NONSPECIF SKIN ERUPT NEC, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.0
heartrate: 69.0
resprate: 20.0
o2sat: 100.0
sbp: 153.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with recent admission
___ for post-procedure MSSA bacteremia that was
complicated by presumed Nafcillin-induced AIN requiring
temporary HD, who re-presented on ___ with renal failure
requiring HD, confusion that continued despite HD, and worsened
petechial leg rash. During his stay, he underwent hemodialysis.
His mental status cleared throughout the admission and he no
longer required dialysis and will be followed by nephrology. He
was discharged to ___ on the ___.
ACTIVE ISSUES
#. ___ on CKD: requiring HD but resolving.
Presumed to be AIN (though diagnosis not ___ certain and he was
a poor candidate for renal biopsy) vs. sequelae of cholesterol
emboli (though his cardiac cath was more than a month prior).
Never had a very active sediment to suggest RPGN. Opthomology
did a dilated fundoscopic exam and did not see cholesterol
emboli. Dermatology did not biopsy the skin. On admission, he
underwent temporart HD line placement and underwent HD. Line
was removed at discharge and patient was to follow up with renal
at discharge and Dr. ___. He was discharged on 10mg
prednisone with intention to decrease with renal follow up.
#. Altered mental status: continued delirium.
Very disoriented, intermittently agitated. At first, it seemed
likely that this was all related to uremia but per Nephrology he
should have cleared by now. No clear infectious etiology to
blame (UCx negative ___, BCx from admission negative,
CXR ___ negative, C.diff pending). CT head negative for
bleed. Did have very suppressed TSH on last hospitalization and
he is on Amiodarone, but hyperthyroidism causing delirium is
less likely without other systemic manifestations. C.diff
negative. B12 and Folate unrevealing. RPR and HIV negative.
#. Leukocytosis: no obvious infection.
He did complete a course of Vancomycin for MSSA bacteremia, but
he had a rising leukocytosis up to 25.9 on ___ so Vanc was
restarted from ___ (stopped per ID recs). Prednisone or
drug reaction could possibly explain leukocytosis. Resolved to
9 on discharge. Cultures all negative at time of discharge.
#. Leg rash: ?vasculitis.
Upon prior discharge, the patient had a rash thought to be from
Nafcillin-related AIN which appeared to be resolving, but it
worsened as an outpatient. Per Dermatology, appearance
consistent with vasculitis and he is already on Prednisone for
AIN so would not necessarily biopsy. Other etiologies include
purpura from platelet dysfunction (Plavix and uremia). Patient
was continued on topical Clobetasol per Derm recs but patient
was refusing.
#. Cool feet: per Vascular, unlikely ischemic.
Has non-palpable DPs (but Dopplerable and other pulses
palpable), and occasional foot pain. Ulcerations on bilateral
dorsum of feet. Per Vascular Surgery, unlikely to be ischemic
in origin.
#. DM2: on insulin. Exacerbated by steroids and patient eating
secret cookies in room. Has had issues with hypoglycemia, much
improved with ___ recs. We appreciated ___ recs.
#. Hypothyroidism: on replacement.
TFTs on last admission showed hyperthyroidism; Synthroid dose is
low so this may be due to Amiodarone. Held Synthroid for now
-recheck TSH ___
INACTIVE ISSUES
#. CAD s/p DES to LAD and distal PDA 1 month ago: stable.
Patient was cotinued on ASA, Plavix, Metoprolol, Atorvastatin
#. Afib: rate controlled. Held anticoagulation for line
placement, but restarted at discharge. Given PFO and afib and
prior strokes, is on lifelong Warfarin. We continued
Metoprolol, Amiodarone
#. CVD: with intermittent facial droop/dysarthria.
Concern for prior CVAs based on imaging (multifocal
ncephalomalacia, of which a prominent example involves the left
temporo-occipital region). Facial droop seems to correlate with
times of severe confusion. We continued ASA/Plavix
TRANSITIONAL ISSUES
CODE STATUS: DNR/DNI
EMERGENCY CONTACT: ___ ___ ___
(daughter) ___
-Recheck TSH ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
___ y/o M with chronic AF (on dabigatran) and prior TIA, sent to
ED from ___ clinic for abnormal holter findings with tachy-brady
syndrome.
Five days PTA, patient had rigorous hiking. Afterwards, he felt
faint in the car and lost consciousness for a few seconds. Upon
awakening, he was alert and denied confusion. His PCP, ___.
___ holter monitor on ___, which showed
atrial fibrillation nearly 100% of the time, with ventricular
rates ranging from 37 to 240 bpm (average 79 bpm). Longest pause
was 3+ seconds. There were 8 runs of nonsustained WCT, with the
longest run lasting 14 beats at 219 bpm and the fastest run
lasting 6 beats at 240 bpm. He had been hiking during
monitoring and the most strenuous episode correlated with the
14-beat run of WCT, which was asymptomatic. Due to these
findings, he was advised to present to ED for admission for PPM.
In the ED, initial vitals were HR 120 BP 136/105 RR18 100%RA.
Patient was asymptomatic. CXR unremarkable. CBC, chem 10 and
coags are wnl. Transfer vitals are 70 140/101 18 98% RA.
Patient went to EP labs prior from ED and received single lead
RV pacemaker on the right.
Past Medical History:
1) permanent atrial fibrillation, on dabigatran
2) strokes, with brain MRI showing multiple areas of subacute
infarct in the right occipital lobe, right temporoparietal area,
and right central sulcus area
3) hyperlipidemia
Social History:
___
Family History:
--Mother died at 80 of unknown causes
--Father died at ___ with Alzheimers disease
--3 Daughters: All healthy
Physical Exam:
Admission PE:
VS: 97.8; 135/93; 82; 16; 99%RA
General: well appearing, NAD
HEENT: PERRLA
Neck: no JVP
CV: irregularly irregular, normal S1, S2. no MRG, L sided
dressing in place and sling, no oozing
Lungs: CTAB
Abdomen: NDNT, normal BS
Ext: no edema
Neuro: AAOx3, CN II-XII grossly intact
PULSES: 2+ ___, DP
Discharge PE:
Pacemaker site C/D/I, nontender
otherwise unchanged
Pertinent Results:
Labs:
___ 02:00PM BLOOD WBC-6.5 RBC-5.00 Hgb-16.2 Hct-49.1 MCV-98
MCH-32.5* MCHC-33.1 RDW-12.6 Plt ___
___ 02:00PM BLOOD Neuts-60.3 ___ Monos-7.8 Eos-2.4
Baso-0.7
___ 02:00PM BLOOD ___ PTT-38.7* ___
___ 02:00PM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-137
K-4.9 Cl-101 HCO3-24 AnGap-17
___ 02:00PM BLOOD Calcium-9.7 Phos-3.0 Mg-2.3
CXR ___
IMPRESSION: PA and lateral chest compared to ___:
Transvenous right ventricular pacer lead tip projects over the
anterior wall of the right ventricle, continuous from the left
pectoral generator. There is no pneumothorax, mediastinal
widening or appreciable pleural effusion. Lungs are clear and
the heart size is normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 150 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Testim (testosterone) unknown transdermal unk
5. Cialis (tadalafil) unknown oral unk
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 capsule, extended release(s) by mouth
daily Disp #*30 Capsule Refills:*0
4. Cialis (tadalafil) 0 tab ORAL UNK
5. Testim (testosterone) 0 gel TRANSDERMAL UNK
6. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Cephalexin 500 mg PO Q6H Duration: 2 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*8 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pacemaker
Tachy-brady syndrome
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Ventricular tachycardia, to get a pacer today. Pre-operative
assessment.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs are clear and
the pulmonary vasculature is normal. No pleural effusion or pneumothorax is
seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
PA AND LATERAL CHEST.
HISTORY: Recent RV pacemaker.
IMPRESSION: PA and lateral chest compared to ___:
Transvenous right ventricular pacer lead tip projects over the anterior wall
of the right ventricle, continuous from the left pectoral generator. There is
no pneumothorax, mediastinal widening or appreciable pleural effusion. Lungs
are clear and the heart size is normal.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL HOLTER STUDY
Diagnosed with PAROX VENTRIC TACHYCARD, SYNCOPE AND COLLAPSE
temperature: 95.0
heartrate: 120.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with permanent atrial
fibrillation with recent syncopal episode and holter showing
evidence of tachy-___ syndrome.
# Tachy- ___ syndrome: Patient with permanent afib and recent
syncopal episode during exertion. Holter monitor showing afib
with rates ranging from ___. Admitted to the hospital for
RV single lead PPM. Course was unremarkable. Post-op he
continues to be in afib with ventricular rates in the 70-80s and
intermittent pacing (threshold 50). Diltiazem 180mg daily
started to help avoid extreme tachycardia with exertion. He
will continue dabigatran for stroke prevention. Keflex for 2
days for prophylaxis. Follow up in device clinic.
# Hypercholesterolemia: simvastatin decreased from 20mg to 10mg
daily due to interaction with diltiazem. lipids need to be
rechecked as outpatient.
# Transitional issues:
- code status: full code
- recheck lipid panel given simvastatin reduced due to
interaction with dilt. consider switching to different statin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfamethoxazole / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical history of atrial
fibrillation, on Coumadin, CKD stage IV, and heart failure with
a preserved ejection fraction, spinal stenosis presents with
several days of feeling unwell, fatigue, bilateral leg aches,
new onset of nonbloody diarrhea one day prior to admission.
Patient states that she has been feeling generally unwell for
several days, with lightheadedness and generalized weakness. She
usually ambulates with a walker at home and is feels too weak to
walk. In addition to her fatigue, she has bilateral pain in her
calves that only occurs when she walks around. One day prior to
admission, she began having watery diarrhea, without blood. She
is unsure how many episodes of diarrhea she had. She has not had
a bowel movement since this time. She has not had fevers,
abdominal pain, nausea, vomiting, melena, or BRBPR. She has not
had cough, SOB, or dysuria. She thinks that she has been eating
less because she just does not enjoy food anymore.
Reports shortness of breath with ambulation, which she thinks
started around the time of her atrial fibrillation and
cardioversion during her admission in ___. The shortness of
breath has not increased in severity recently. She has no
orthopnea. She reports that she has some lower extremity edema
at baseline, which is helped by her Lasix. She does endorse
urinary frequency since her Lasix dose was increased at a
nephrology appointment in ___. She has to urinate more
frequently but thinks that her stream is not as good.
Of note she had a recent admission in ___ for bradycardia and
hypotension in the setting of being on beta blockers. She is now
managed with amiodarone. She underwent a successful TEE
cardioversion in ___, and continues on amiodarone and Coumadin
In the ED, her initial vitals were: 97.8, HR 62, BP 160/30, RR
18, 98% RA
CXR showed mild pulmonary edema and cardiomegaly.
She received: 1 L IVF, home amiodarone, lidocaine patch,
tylenol, and omeprazole.
ROS: Full 10 pt review of systems negative except for above.
Past Medical History:
-Hypertension
-CHF with preserved EF
-Afib
-CKD
-hyperlipidemia
-spinal stenosis
-glaucoma
-osteoarthritis
-gastroesophageal reflux
-Anemia
-thalassemia minor
-bilateral breast cancer
Social History:
___
Family History:
Her mother was diagnosed with breast cancer at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vitals: 98.7 PO 169 / 72 L 67 16 93 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD, no visible JVD
Lungs: Bilateral crackles up to the midlung, no wheezes or
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: 2+ pitting edema up to the mid shins. Warm, well perfused,
2+ pulses, no clubbing, cyanosis.
Neuro: CNII-XII intact, ___ strength in upper and lower
extremities, sensation grossly intact
DISCHARGE PHYSICAL EXAM
===========================
Vitals: 98.___
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD, no visible JVD
Lungs: Bibasilar crackles, no wheezes or 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: 2+ pitting edema up to the mid shins. Warm, well perfused,
2+ pulses, no clubbing, cyanosis.
Neuro: CNII-XII intact, ___ strength in upper and lower
extremities, sensation grossly intact
Pertinent Results:
ADMISSION LABS
========================
___ 10:50PM BLOOD WBC-8.9 RBC-3.34* Hgb-7.6* Hct-23.7*
MCV-71* MCH-22.8* MCHC-32.1 RDW-16.8* RDWSD-42.5 Plt ___
___ 10:50PM BLOOD Neuts-81.1* Lymphs-8.2* Monos-8.6
Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.24* AbsLymp-0.73*
AbsMono-0.77 AbsEos-0.07 AbsBaso-0.03
___ 10:50PM BLOOD ___ PTT-37.7* ___
___ 10:50PM BLOOD Ret Aut-2.2* Abs Ret-0.07
___ 10:50PM BLOOD Glucose-131* UreaN-34* Creat-1.9* Na-138
K-4.7 Cl-104 HCO3-20* AnGap-19
___ 10:50PM BLOOD LD(___)-303*
___ 10:50PM BLOOD Calcium-8.8 Phos-4.6* Mg-2.3
___ 10:50PM BLOOD Hapto-210*
DISCHARGE LABS
==========================
___ 07:47AM BLOOD WBC-12.3* RBC-3.61* Hgb-8.1* Hct-26.5*
MCV-73* MCH-22.4* MCHC-30.6* RDW-16.7* RDWSD-43.3 Plt ___
___ 07:47AM BLOOD Glucose-99 UreaN-29* Creat-1.7* Na-141
K-3.9 Cl-106 HCO3-20* AnGap-19
___ 07:47AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.2
IMAGING
===========================
CXR ___ IMPRESSION: Mild pulmonary edema with mild
cardiomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lisinopril 2.5 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Warfarin 2.5 mg PO 5X/WEEK (___)
10. Warfarin 3.75 mg PO 2X/WEEK (MO,FR)
11. Acetaminophen 500 mg PO BID:PRN Pain - Mild
12. Ascorbic Acid ___ mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Docusate Sodium 100 mg PO DAILY:PRN constipation
15. Ferrous Sulfate 325 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild
2. Amiodarone 200 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Lisinopril 2.5 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
15. Vitamin D ___ UNIT PO DAILY
16. Warfarin 3.75 mg PO 2X/WEEK (MO,FR)
17. Warfarin 2.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis:
Volume depletion likely due to diarrhea
Secondary diagnoses:
Atrial fibrillation
HTN
Chronic kidney 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: PA and lateral chest radiographs
INDICATION: ___ with weakness, lightheadedness // Evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiographs ___ chest radiographs
FINDINGS:
The lungs are well-expanded. There is mild pulmonary edema. No focal
consolidation. No pleural effusion or pneumothorax. Mild cardiomegaly.
Cardiomediastinal hilar silhouettes are otherwise unremarkable. An apparent
compression deformity in the lower thoracic spine is unchanged.
IMPRESSION:
Mild pulmonary edema with mild cardiomegaly.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Lightheaded
Diagnosed with Anemia, unspecified
temperature: 97.8
heartrate: 62.0
resprate: 18.0
o2sat: 98.0
sbp: 161.0
dbp: 38.0
level of pain: 6
level of acuity: 3.0 | ___ yo female with h/o afib s/p cardioversion in ___, CHF with
preserved EF, CKD, spinal stenosis presenting with diarrhea of 1
day's duration and lightheadedness, weakness. Afebrile and with
stable vital signs, initial evaluation significant for anemia at
Hgb 7.6 (baseline ___, mild Cr elevation at 1.9 (baseline
1.5-1.8), and mild pulmonary edema on CXR. She received gentle
IV hydration in ED and remained hemodynamically stable. Based on
the short time course and relatively benign clinical status, her
diarrhea was most consistent with a viral gastroenteritis. Mild
___ was thought to be ___ to volume depletion, while anemia may
be related to known thalassemia, iron deficiency, and CKD (no
symptoms of bleeding, stool guaiac negative). Received 20 mg IV
Lasix for mild volume overload on exam. While admitted the
patient was able to take good PO. Hgb came up to 8.1 without
transfusion and Cr downtrended to 1.7. Because the patient had
no further episodes of diarrhea while admitted and because she
was able to ambulate with ___, she was determined to be stable to
be discharged.
Transitional Issues
===============================
[] Please consider repeating CBC, chem to ensure that anemia and
Cr continue to be at baseline
[] Furosemide and lisinopril were initially held in the setting
___ but were restarted on discharge at regular home doses
# CONTACT: sister ___ ___
# CODE: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left tibia and fibula fracture
Major Surgical or Invasive Procedure:
placement of left tibial IM nail ___
History of Present Illness:
___ is a ___ male with a history of hypertension who
was transferred from an outside hospital with a left tibia and
fibula fracture. He was reduced and splinted at the outside
hospital before being transferred. He was at work when he fell
backwards and a utility pole fell onto his left tibia. No head
strike or LOC. He was transferred here for further management.
He denies any numbness or tingling into the left foot or pain
elsewhere.
Past Medical History:
PMH/PSH:
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
LLE -
primary DSD/ace thigh to foot ___ edema.
- compartments soft, appropriately tender
- Full, painless PROM of digits, knee, some tenderness with
ankle
PROM
- wiggling toes
- SILT throughout exposed toes
- 2+ distal pulses, brisk cap refill
Pertinent Results:
___ 05:25PM BLOOD WBC-11.1* RBC-4.76 Hgb-14.4 Hct-43.0
MCV-90 MCH-30.3 MCHC-33.5 RDW-15.1 RDWSD-49.2* Plt ___
___ 07:05AM BLOOD WBC-10.2* RBC-3.86* Hgb-11.6* Hct-35.9*
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 RDWSD-49.3* Plt ___
___ 05:25PM BLOOD Neuts-65.7 ___ Monos-8.2 Eos-1.4
Baso-0.5 Im ___ AbsNeut-7.28* AbsLymp-2.64 AbsMono-0.91*
AbsEos-0.15 AbsBaso-0.06
___ 07:05AM BLOOD Plt ___
___ 05:25PM BLOOD ___ PTT-28.9 ___
___ 05:25PM BLOOD Plt ___
___ 05:25PM BLOOD Glucose-87 UreaN-7 Creat-0.7 Na-142 K-4.0
Cl-101 HCO3-29 AnGap-12
___ 07:05AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-140
K-4.3 Cl-99 HCO3-29 AnGap-12
___ 07:05AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth three times a
day Disp #*60 Tablet 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. crutch miscellaneous as needed for ambulation
RX *crutch Disp #*1 Each Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left tibia 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: TIB/FIB (AP AND LAT) LEFT
INDICATION: History: ___ with reduction// reduction reduction
TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula.
COMPARISON: None
FINDINGS:
Evaluation for fine detail is limited due to overlying cast material. There
is comminuted fracture of the distal fibula with 1.6 cm overriding of the
midshaft with slight apex anterior angulation. There is minimal apex anterior
angulation of tibial fracture. Transverse fracture through the distal tibial
diaphysis demonstrates half bone width lateral translation of the distal
fracture fragment. Limited assessment of the knee demonstrates apparent mild
degenerative changes.
IMPRESSION:
Transverse fracture of the distal diaphysis of the tibia with half bone width
lateral translation of the distal fracture fragment and mild apex anterior
angulation.
Comminuted fracture of the distal fibula with 1.6 cm overriding at the
midshaft.
Radiology Report
EXAMINATION: Left tibia-fibula intraoperative radiographs
INDICATION: Operative fixation, surgical guidance.
TECHNIQUE: A total of 209.6 seconds continuous fluoroscopic time was employed
without a radiologist present.
COMPARISON: Prior exam performed same day.
FINDINGS:
5 intraoperative images were acquired without a radiologist present.
Images show placement of a tibial IM rod with 1 proximal and 1 distal
interlocking screw traversing a distal shaft tibial fracture with near
anatomic alignment. A segmental proximal and midshaft fracture of the fibula
is again noted.
IMPRESSION:
Intraoperative images were obtained during ORIF. Please refer to the
operative note for details of the procedure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg injury, Leg pain
Diagnosed with Displaced comminuted fracture of shaft of left tibia, init, Oth cause of strike by thrown, projected or fall obj, init
temperature: 99.5
heartrate: 86.0
resprate: 14.0
o2sat: 96.0
sbp: 161.0
dbp: 97.0
level of pain: 5
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IM nail, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
without services was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on aspirin 325mg daily for 4 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
OBSTRUCTING NEPHROLITHIASIS, ACUTE RENAL INJURY, ETOH ABUSE
Major Surgical or Invasive Procedure:
CYSTOSCOPY, BILATERAL RPG W/ LEFT LASER LITHO AND URETERAL STENT
PLACEMENT
History of Present Illness:
___ yo M with MMP including nephrolithiasis, CKD who was found to
be in ARF with creatinine to 3.4 in PCP's office. Sent to ED.
Known 1.2 cm L UPJ stone with hydronephrosis. No flank pain. No
fevers/chills/n/v. Urology was consulted.
Past Medical History:
PMH:
HTN
HLD
DM2
Nephrolithiasis
Dermatitis
CKD
Depression
Obesity
PSH:
SWL
PCNL on the left
URS
Social History:
___
Family History:
MI
CHF
Nephrolithiasis
Physical Exam:
WDWN male, NAD, AVSS
abdomen obese, nt/nd
extremities w/out edema, pitting
Pertinent Results:
CT Scan ___:
Mild-to-moderate hydronephrosis of the left kidney with
perinephric
stranding. Limited evaluation of the renal parenchyma for
underlying pyelonephritis due to lack of IV contrast. Partially
obstructing 1.8-cm stone is seen in the left UPJ. A partially
obstructing 1.4-cm stone is seen in the right. Cortical atrophy
likely from prior insults.
___ 07:45AM BLOOD WBC-6.7 RBC-4.04* Hgb-12.2* Hct-35.5*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.6 Plt ___
___ 04:05PM BLOOD WBC-7.4 RBC-4.27* Hgb-13.5* Hct-37.7*
MCV-88 MCH-31.7 MCHC-35.9* RDW-13.4 Plt ___
___ 07:45AM BLOOD Glucose-132* UreaN-33* Creat-2.6* Na-138
K-4.9 Cl-106 HCO3-21* AnGap-16
___ 06:55AM BLOOD Glucose-128* UreaN-38* Creat-3.1* Na-140
K-4.8 Cl-109* HCO3-19* AnGap-17
___ 04:05PM BLOOD Glucose-87 UreaN-37* Creat-3.1* Na-140
K-5.2* Cl-107 HCO3-23 AnGap-15
___ 11:13AM BLOOD UreaN-34* Creat-3.2*# Na-140 K-5.8*
Cl-108 HCO3-22 AnGap-16
___ 07:45AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8
___ 11:13AM BLOOD Calcium-10.0
Medications on Admission:
allopurinol ___ daily
amlodipine/atorvastatin ___ one daily
carvedilol 25 b.i.d.
doxazosin 4 mg daily
gemfibrozil 600mg bid
glyburide
hydrochlorothiazide 12.5 daily
lisinopril 40 mg daily
glimiperide 1 mg bid
Allergies:
NKDA
Discharge Medications:
1. acetaminophen 325 mg tablet Sig: ___ tablets PO Q6H (every 6
hours) as needed for pain or fever.
2. allopurinol ___ mg tablet Sig: One (1) tablet PO DAILY
(Daily).
3. amlodipine 5 mg tablet Sig: One (1) tablet PO DAILY (Daily).
4. atorvastatin 20 mg tablet Sig: One (1) tablet PO DAILY
(Daily).
5. carvedilol 12.5 mg tablet Sig: Two (2) tablet PO BID (2 times
a day).
6. doxazosin 1 mg tablet Sig: Two (2) tablet PO HS (at bedtime).
7. gemfibrozil 600 mg tablet Sig: One (1) tablet PO BID (2 times
a day).
8. glimepiride 1 mg tablet Sig: One (1) tablet PO daily ().
9. oxycodone 5 mg tablet Sig: ___ tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*25 tablet(s)* Refills:*0*
10. Colace 100 mg capsule Sig: One (1) capsule PO twice a day:
take to prevent constipation.
Disp:*60 capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolithiasis, obstructing
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left kidney stone.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
15 spot fluoroscopic images, obtained without a radiologist present, were
submitted for review. Images demonstrate catheterization of the right ureter
with contrast opacification demonstrate a filling defect in the right renal
pelvis consistent with stone seen on CT. A complex diverticulum with layering
stones is seen off the superior pole collecting system. Subsequently contrast
opacification of the left ureter demonstrates moderate hydronephrosis. The
wire was then introduced into the left renal pelvis followed by placement of a
double-J stent with the upper coil in the left renal pelvis and the lower coil
is in the bladder. For further details see operative note in the ___
medical record.
Radiology Report
HISTORY: Left renal and ureteral stones question left stone.
COMPARISON: ___.
FINDINGS:
There is a new double J stent on the left. There are few scattered radio
opacities in the abdomen but none are definitively within the left kidney or
in the course of the left ureteral stent. Given patient body habitus small
stones could be missed. Gas is seen in multiple loops of small and large
bowel. The transverse colon is mildly dilated at 8 cm.
IMPRESSION:
No definite kidney stones. The study is limited by patient body habitus.
Ileus.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: ABNL LABS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, CALCULUS OF KIDNEY
temperature: 99.2
heartrate: 60.0
resprate: 18.0
o2sat: 97.0
sbp: 171.0
dbp: 95.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ male with a long
history of uric acid and calcium oxalate nephrolithiasis. He
sought a second opinion from me on ___. I noted that he
had approximately 1.5 to 2 cm of left ureteropelvic junction
stone and was in acute on chronic renal failure with a
creatinine of 3.1 with his last baseline creatinine being
1.9. I urged him to come to our emergency department, and he
ultimately presented on ___ to our ED. His
creatinine was again noted to be 3.1 with a potassium of 4.8.
Plans were made to bring him to the operating room for
retrograde pyelography on the right to delineate the anatomy
of what appears to be a complex right calyceal diverticulum
with stones as well as to place a left ureteral stent and
potentially treat his left proximal ureteral stones.
He was admitted from the emergency room and prepped for
operative intervention. He was taken to the operating room where
he underwent cystoscopy, bilateral retrograde pyelograms with
interpretation,
left ureteroscopy and laser lithotripsy of left ureteral calculi
and finally left ureteral stent placement. Foley catheter was
placed for urine output monitoring. He was recovered and taken
to the PACU and subsequently transferred back to the general
surgical floor where he remained overnight. See the detailed
operative note for full details. His pain was well controlled on
the general surgical floor and on postoperative day one, his
foley catheter was removed. After voiding he was discharged
home. His post-operative course was unremarkable. Postoperative
labs reflected improved creatinine and improvement in his acute
kidney injury. He was discharged home with explicit instructions
to return for ureteral stent removal and further intervention as
necessary. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Zocor / tramadol
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with h/o CAD and ischemic cardiomyopathy who
presents with chest pain. Reports the pain started while she was
in bed at 3AM on ___. She describes the pain as piercing L
parasternal pain and experienced 4 quick episodes. The pain went
away when she called EMS at 5 AM. Denies nausea, vomiting or
SOB. No pleuritic component. Denies cough. Patient did receive
full-dose ASA prior to transfer.
In the ED, initial vitals were: 97.7 82 106/55 20 97% 3L
- ECG: LAD, QRS widening, stable TWF in V4-V6
- Labs notable for: H/H 10.5/34.8, otherwise normal labs
- Pt given: nothing
- Pt admitted for ? cath
- Vitals on transfer: 81 107/58 15 96% 3L NC
Past Medical History:
Depression, schizoaffective disorder, NIDDM, cataracts, hx of C.
difficile enterocolitis, hypertension, elevated cholesterol, hx
of DVT, constipation, seasonal allergies, osteoarthritis and
osteoporosis.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
>>Admission:
General: NAD, comfortable, pleasant, dysarthric
HEENT: NCAT, PERRL, EOMI, noticed a left sided facial droop
(mouth and eyelid), facial sensation in tact
Neck: supple, JVP
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: CN II-XII grossly in tact, moving all extremities
grossly, ___ strength in b/l ___ , ___ strength in b/l UE
.
>>Discharge:
VS: 98.4 122/76 65 18 97% RA
General: NAD, comfortable, pleasant, dysarthric
HEENT: NCAT, PERRL, EOMI, noticed a left sided facial droop
(mouth and eyelid), facial sensation in tact
Neck: supple, no JVP
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: CN II-XII grossly in tact, moving all extremities
grossly, ___ strength in b/l ___ , ___ strength in b/l UE
Pertinent Results:
>>Admission:
___ 10:35AM BLOOD WBC-5.2 RBC-3.89* Hgb-10.5* Hct-34.8*
MCV-89 MCH-27.1 MCHC-30.3* RDW-14.7 Plt ___
___ 10:35AM BLOOD ___ PTT-32.4 ___
___ 10:35AM BLOOD Glucose-112* UreaN-26* Creat-0.8 Na-137
K-4.5 Cl-100 HCO3-27 AnGap-15
.
>>Imaging:
ECHO: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate to severe regional left
ventricular systolic dysfunction with focal severe hypokinesis
to akinesis of the inferior and inferolateral walls, and
hypokinesis of the inferior septum and apex. (EF 30%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Moderate left ventricular dilatation with moderate
to severe regional variation c/w multivessel CAD. Normal right
ventricular cavity size and systolic function. Right ventricle
not well-visualized. Mild mitral and aortic regurgitation. No
cardiac source of embolism identified.
.
MRI Head w/o contrast, MRA head and neck:
1. Subtle focus of slowed diffusion adjacent to the cortex of
the right
parietal lobe is concerning for a focus of infarction.
2. Small micro-hemorrhage in the right temporal lobe series 16,
image 11 is likely subacute.
3. Diffuse bifrontal and right frontoparietal T2 and FLAIR
hyperintensities is
consistent with patient's known encephalomalacia.
.
>>Discharge:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs q6hr PRN SOB
2. Alendronate Sodium 70 mg PO 1X/WEEK (___)
3. Aripiprazole 10 mg PO DAILY
4. Duloxetine 60 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Gabapentin 100 mg PO TID
7. Lactulose 15 mL PO BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Pravastatin 10 mg PO DAILY
12. QUEtiapine extended-release 200 mg PO QHS
13. Aspirin 81 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Senna 8.6 mg PO BID
Discharge Medications:
1. Aripiprazole 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 60 mg PO DAILY
5. Gabapentin 100 mg PO TID
6. Lactulose 15 mL PO BID
7. Omeprazole 40 mg PO BID
8. QUEtiapine extended-release 200 mg PO QHS
9. Senna 8.6 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Alendronate Sodium 70 mg PO 1X/WEEK (___)
12. Furosemide 40 mg PO DAILY
Please do not start this medication until ___.
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Metoprolol Succinate XL 12.5 mg PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs q6hr PRN SOB
16. Pravastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Atypical chest pain, CVA
Secondary diagnosis: ischemic cardiomyopathy
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: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with CAD, ischemic cardiomyopathy, HTN, HLD,
SDH s/p craniotomy with associated R frontal lobe encephalomalacia who is
admitted to the cardiology service after presenting to ___ with chest
pain which started at 3am this morning // questionable stroke
TECHNIQUE: MRI of the head, MRA of the brain, MRA of the neck with contrast.
COMPARISON: CT from ___.
FINDINGS:
MRI: There is a subtle focus of slowed diffusion adjacent to the cortex of
the right parietal lobe series 4, image 15, concerning for a focus of
infarction. There is no evidence of an acute intracranial mass, mass effect
or shift of the normally midline structures. The prominence of the ventricles
and sulci is likely related to age-related involutional changes. The basilar
cisterns are patent. On the gradient echo sequences, there is a area of
blooming artifact consistent with a small micro hemorrhage in the right
temporal lobe series 16, image 11 measuring up to 4 mm. Diffused bifrontal
and right frontoparietal T2 and FLAIR hyperintensity is consistent with
patient's known encephalomalacia.
MRA: There is no evidence of significant stenosis, aneurysm or occlusion. The
vessels of the neck and circle of ___ appear to be patent. Note is made of
mild narrowing at the origin of the left vertebral artery which otherwise
appears patent throughout its intracranial course.
Burr holes are seen throughout the calvaria. Patient is status post right
parietal craniotomy with adjacent areas of magnetic susceptibility.
IMPRESSION:
1. Subtle focus of slowed diffusion adjacent to the cortex of the right
parietal lobe is concerning for a focus of infarction.
2. Small micro-hemorrhage in the right temporal lobe series 16, image 11 is
likely subacute.
3. Diffuse bifrontal and right frontoparietal T2 and FLAIR hyperintensities is
consistent with patient's known encephalomalacia.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ by phone
at 4:30p on the day of the exam.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: 97.7
heartrate: 82.0
resprate: 20.0
o2sat: 97.0
sbp: 106.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o CAD, ischemic cardiomyopathy presents with chest
pain.
.
>> Acute Issues:
# Chest pain: This patient has a history of CAD s/p MI in
___. During her hospitalization, she had two sets of
negative cardiac enzymes and EKG showed non specific ST changes,
unchanged from last EKGs. Due to her negative cardiac enzymes,
unchanged EKG, and brevity of symptoms before presentation
without recurrence, patient will follow up as an outpatient for
catheterization. Patient was discharged on all of her home
medications. The cardiology fellow spoke to pt's OP cardiologist
who agreed to plan for OP cath.
.
# Hypotension: The patient's SBPs went into the ___ on
arrival to floor. She received 250 cc bolus NS and her SBP
responded appropriately (SBPs in 100s-110s). This was most
likely due to hypovolemia and antiHTn meds given at BIN before
transfer. Through rest of the hospital course, her SBPs remains
in the 110s-120s and she remained asymptomatic (no dizziness,
lightheadedness). Home metop and lasix were restarted without
issue.
.
# Neuro deficits: On examination of the patient on admission, it
was noted that she had dysarthria, facial asymmetry, and mild
ptosis. The stroke team was consulted and she received an MRI
and MRA head/neck. These images revealed small micro-hemorrhage
in the right temporal lobe and subtle focus of slowed diffusion
adjacent to the cortex of the right parietal lobe, concerning
for a focus of infarction. She got a TTE which showed: Moderate
left ventricular dilatation with moderate to severe regional
variation c/w multivessel CAD, Normal right ventricular cavity
size and systolic function, Right ventricle not well-visualized,
Mild mitral and aortic regurgitation, and No cardiac source of
embolism identified. She got HbA1c (6.9) and lipid levels drawn
(Chol 142, LDL 60). Neurology believes that her dysarthria is
readily explained by her penetrating arttery brain lesions and
her prior stroke and her long term use of antipsychotics and
there is no evidence of recent brain ischemia. Neurology thought
anticoagulation may be appropriate for the patient, but deferred
to cardiology. Cardiology attending did not feel as though
anticoagulation is indicated.
>>Chronic Issues
# CHF: patient has known ischemic cardiomyopathy, with most
recent ECHO showing EF ___ and severe regional left
ventricular systolic dysfunction with global hypokinesis and
akinesis of the septum, apex, distal two thirds of the inferior
wall. She presented with a proBNP 3707, but lower than her
baseline of >4000. Patient's lungs clear, however patient does
have elevated JVP. Her heart failure medications were held for a
day due to hypotension, but were resumed during the hospital
course and she maintained hemodynamic stability.
# DM: The patient's glucose was monitored qAHCS and she was put
on an ISS. Her HbA1C was 6.9. She was discharged on her home
diabetic medications.
>>Transitional issues:
- Patient will go to rehab on DC for ___ and OT
- needs to follow up with cardiologist to plan for outpatient
cath
- She should follow up with psychiatrist (or PCP if she does not
have a psychiatrist) to discuss her antipsychotic medications
and doses. Neuro recommends that she decrease her antipsychotic
meds as it may be exacerbating her neuro symptoms.
- Please consider restarting lisinopril as an outpt if BPs will
tolerate |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Novahistine / Benadryl Decongestant / seasonal allergies
Attending: ___
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
from Dr. ___ note:
___ is a ___ F with h/o autism and epilepsy who is
transferred from ___ after having 2
breakthrough seizures today. The patient was at her group home
earlier today eating lunch when she had a generalized tonic
clonic seizure. She was brought to ___ and
subsequently discharged back to her group home. Later in the
evening while eating dinner, the patient had a second
genearlized tonic clonic seizure. She was sitting in a chair
eating and fell to the ground. The event is reported to have
lasted 5 minutes, but her mother is not sure if the actual
seizure event lasted this long or she perhaps had a shorter
seizure and was post ictal afterwards. She was again taken to
___ where she was given a dose of lorazepam and
transferred to ___. The patient is non-verbal at baseline.
A thorough history of the patient's epilepsy is available in
clinic notes from Dr. ___ and Dr. ___.
She is currently treated with zonisamide 700mg nightly, which
has provided good seizure control. Her mother reports that her
last seizure was in ___. Prior to that she had 2
seizures on ___ and ___, the provokation of which
was not clear. Today mom reports that she has not been ill
recently and she has been taking her zonisamide regularly. Mom
does state that while ___ was at home over the weekend she
had 2 large, "explosive" type bowel movements, which were not
diarrhea per ___ tends to have contipation resulting in
some abdominal distention followed by these types of large bowel
movements. Per the group home she has been having regular bowel
movements recently.
In the past ___ has been treated with phenobarbital,
dilantin, tegretol, carbatrol, trileptal and gabapentin. As
stated above, she has recently been treated with zonisamide
alone, which has provided good control. Per OMR notes, if a
second agent is needed, Dr. ___ like to start
Lamictal.
Unable to obtain ROS as patient is non-verbal.
Past Medical History:
epilepsy
autism, non-verbal at baseline
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals:
99.8 ___ 18 99%
GEN: sleeping, arousable, NAD
HEENT: acne rosacea, ecchymoses over left orbit and cheek
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Sleeping, easily arousable, non-verbal, does not participate
with
exam
CN:
II:
PERRLA 3 to 2mm and brisk.
___, IV, VI: EOM passivly intact, no nystagmus.
VII: Facial musculature symmetric.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Spontaneous movement of all extremities symmetrically with good
strength.
Sensory: Reacts appropriately to LT throughout
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2
Toes downgoing bilaterally
Coordination:
No ataxia
DISCHARGE EXAM:
General: Thin young woman lying in bed in NAD, father at
bedside.
HEENT: L periorbital eccymosis
Neuro:
MS: Sleeping but wakens to voice. Alert, looks around at team.
Does not speak but reaches out to her father. ___ with
the exam with encouragement from her father.
CN:
___, IV, VI: EOMI to casual gaze around room.
VI: Face activates symmetrically.
Motor: Moves all extremities spontaneously and to command.
Coordination: Reaches for her father and examiner's hand with no
dysmetria.
Pertinent Results:
Admission Labs:
___ 10:15AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-138
K-3.4 Cl-107 HCO3-20* AnGap-14
___ 10:15AM BLOOD ALT-26 AST-21 AlkPhos-39 TotBili-0.4
___ 10:15AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1
___ 10:15AM BLOOD WBC-7.5 RBC-3.72* Hgb-11.9* Hct-35.7*
MCV-96 MCH-32.1* MCHC-33.4 RDW-12.7 Plt ___
___ 10:15AM BLOOD Plt ___
EEG: final read pending, but no preliminary read of seizures
CXR:
FINDINGS: AP semi-upright and lateral views of the chest were
obtained.
Heart is normal size and cardiomediastinal silhouette is
unremarkable. Lungs are clear. There is no pleural effusion or
pneumothorax.
IMPRESSION: No evidence of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Lorazepam 0.5 mg PO X2 PRN seizure
3. Zonisamide 700 mg PO QPM
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Calcium Carbonate 400 mg PO DAILY
6. melatonin unknown oral daily
7. Multivitamins 1 TAB PO DAILY
8. colloidal oatmeal 43 % topical PRN unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Calcium Carbonate 400 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Multivitamins 1 TAB PO DAILY
5. Zonisamide 700 mg PO QPM
6. colloidal oatmeal 43 % topical PRN unknown
7. Lorazepam 0.5 mg PO X2 PRN seizure
8. melatonin 1 dose ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
epilepsy
autism
Discharge Condition:
Mental status: Nonverbal, alert, follows some commands,
cooperates with exam.
Ambulatory status: weight bearing as tolerated
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with epilepsy presents with two seizures, no
history of cough, rule out pneumonia.
COMPARISON: None.
FINDINGS: AP semi-upright and lateral views of the chest were obtained.
Heart is normal size and cardiomediastinal silhouette is unremarkable. Lungs
are clear. There is no pleural effusion or pneumothorax.
IMPRESSION: No evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 99.8
heartrate: 103.0
resprate: 18.0
o2sat: 99.0
sbp: 96.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | ___ was admitted to the Neurology floor in stable
condition. A workup for infectious etiologies was negative. A
zonisamide level was sent and is pending. She underwent extended
routine EEG monitoring with no evidene of seizure activity. Her
mental status returned to baseline. After consultation with Dr.
___ AED regimen was left unchanged and she will
continue zonisamide 700 mg monotherapy. She was discharged to
the care of her parents to return to her group home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, fatigue, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with h/o IVDU c/b endocarditis
s/p mitral valve replacement in ___, with recurrent prosthetic
valve endocarditis in ___ and ___, presenting with
intermittent
substernal chest pain, fatigue, and malaise in setting of recent
IV cocaine use. History was obtained directly from the patient
but was somewhat limited by his poor memory and difficulty
describing symptoms.
His reports his chest pain started about 5 days ago after he
injected and smoked cocaine. Lasted about 1 minute, then
resolved
without intervention. Felt like someone punched him in the
chest,
then burning. No radiation to back, arm, or jaw. No tearing or
ripping sensation. Pain was associated with dizziness, dyspnea,
palpitations, diaphoresis, and nausea. He later vomited several
times.
He has continued having intermittent chest pain since then -
both
a stabbing/poking sensation and burning. Hard for him to
quantify
how often. Comes and goes without clear trigger. Pain not
associated with exertion, though he has been getting dizzy when
walking.
Also reports feeling terrible overall - fatigued, drained. At
first thought this was just a hangover from partying but became
worried when it didn't get better. No subjective fevers or
chills. +Dry cough. +Dyspnea on exertion. No wheezing.
Regarding his cocaine use, he was abstinent for several years
but
relapsed this week when an acquaintance was staying with him and
offered him cocaine for free. He has been using "a lot" of
cocaine all week, about ___ grams per day. He mostly smoked it
but also injected several times. He last injected ___ days ago,
and last smoked cocaine 2 days ago.
Regarding other substance use, he smoked marijuana this week as
well but denies any other recreational drugs, including opioids
and MDMA. He drinks about ___ beers per night at baseline but
says he has actually been drinking less this week. He normally
does not smoke daily but has been smoking about 10 cigarettes
per
day this week. He previously smoked up to 1ppd for about ___
years.
In the ED, initial VS were: 97.5 74 192/103 18 100% RA
BP improved to the 140s-160s/90s-100s without intervention.
Exam, EKG, and CXR were unremarkable.
Labs were notable for trop <0.01, WBC 10.2 (72% PMNs), chem10
wnl, ALT/AST 77/90, AP/Bili wnl.
Blood and urine cultures were sent and patient was admitted for
further evaluation. No medications were given.
On arrival to the floor, patient reports no ongoing chest
pain/burning, palpitations, dyspnea, or dizziness.
Past Medical History:
Enterococcal Endocarditis s/p MVR with 29mm porcine valve
___
DVT
Strep viridans bacteremia with MV vegetation suggestive of
endocarditis secondary to dental procedure
Hep C, s/p vaccination for hep A&B
neg for HIV ___ yrs ago
IVDU, including cocaine
GERD
h/o multiple abcess I&D
Social History:
___
Family History:
Positive for alcoholism
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Middle-aged man in NAD.
HEENT: No icterus or injection. MMM.
CV: Bradycardic, regular, normal S1, loud S2 in mitral area, no
murmurs/rubs/gallops.
RESP: Normal work of breathing. Diffuse coarse breath sounds. No
wheezes or crackles.
GI: Soft, NDNT, no palpable HSM.
EXTR: No stigmata of endocarditis. No c/c/e.
SKIN: Large soft mobile nodule on back c/w lipoma. No other
lesions or rashes.
NEURO: Alert, oriented, attentive. CN ___ intact. Normal
strength and coordination.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Middle-aged man in NAD.
HEENT: No icterus or injection. MMM.
CV: Bradycardic, regular, normal S1, loud S2 in mitral area, no
murmurs/rubs/gallops.
RESP: Normal work of breathing. Diffuse coarse breath sounds. No
wheezes or crackles.
GI: Soft, NDNT, no palpable HSM.
EXTR: No stigmata of endocarditis. No c/c/e.
SKIN: Large soft mobile nodule on back c/w lipoma. No other
lesions or rashes.
NEURO: Alert, oriented, attentive. CN ___ intact. Normal
strength and coordination.
Pertinent Results:
ADMISSION LABS
==============
___ 12:20AM BLOOD WBC-10.2* RBC-4.78 Hgb-14.6 Hct-45.2
MCV-95 MCH-30.5 MCHC-32.3 RDW-14.0 RDWSD-48.7* Plt ___
___ 12:20AM BLOOD Glucose-70 UreaN-19 Creat-1.0 Na-140
K-5.4 Cl-100 HCO3-30 AnGap-10
___ 12:20AM BLOOD ALT-77* AST-90* CK(CPK)-506* AlkPhos-48
TotBili-0.3
DISCHARGE LABS
==============
___ 08:23AM BLOOD WBC-8.3 RBC-4.64 Hgb-14.4 Hct-44.1 MCV-95
MCH-31.0 MCHC-32.7 RDW-13.8 RDWSD-48.4* Plt ___
___ 08:23AM BLOOD Glucose-89 UreaN-15 Creat-1.1 Na-145
K-4.3 Cl-103 HCO3-30 AnGap-12
___ 08:23AM BLOOD ALT-73* AST-67* LD(LDH)-433* AlkPhos-56
TotBili-0.5
RELEVANT IMAGING
================
CXR ___
IMPRESSION:
No acute intrathoracic process.
CTA Chest ___
IMPRESSION:
No pulmonary emboli.
The pulmonary artery is mildly enlarged, pulmonary arterial
hypertension
should be excluded.
No pneumonia. No suspicious pulmonary nodules or masses.
Mild, but diffuse bronchial wall thickening is nonspecific, most
likely
reflecting underlying bronchial inflammation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
4. Levothyroxine Sodium 150 mcg PO EVERY OTHER DAY
5. Lisinopril 10 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Ibuprofen 200-400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
5. Levothyroxine Sodium 150 mcg PO EVERY OTHER DAY
6. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Cocaine use
SECONDARY DIAGNOSIS:
====================
History of intravenous drug use complicated by endocarditis
status-post mitral valve replacement
Recurrent prosthetic valve endocarditis
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 with prior heart valve surgery for endocarditis
presents with recent IV drug use and subjective fevers chills and chest pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs performed ___ and ___.
FINDINGS:
Interval removal of a left PICC line. Lungs are well expanded. No focal
consolidation is seen. No large pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. Patient is status post
mitral valve replacement and median sternotomy. Mild compression deformities
of the thoracic spine are unchanged.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with h/o IVDU and endocarditis, here with burning
chest pain and malaise after cocaine use// eval for aortic dissection, PE,
septic emboli
TECHNIQUE: Multidetector CT PA
DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 34.9 cm; CTDIvol =
7.1 mGy (Body) DLP = 246.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm;
CTDIvol = 1.7 mGy (Body) DLP = 0.8 mGy-cm. 3) Stationary Acquisition 0.6 s,
0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.8 mGy-cm. 4) Stationary Acquisition
2.4 s, 0.5 cm; CTDIvol = 6.8 mGy (Body) DLP = 3.4 mGy-cm. Total DLP (Body) =
251 mGy-cm.
COMPARISON: Prior CT chest study done ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Slightly bulky appearance of the
thyroid, but no focal thyroid lesions. No supraclavicular or axillary
adenopathy. No gross breast lesions.
UPPER ABDOMEN: No subdiaphragmatic pathology.
MEDIASTINUM: Subcentimeter mediastinal lymph nodes.
HILA: Mildly increased hilar peribronchial soft tissue/lymph nodes.
HEART and PERICARDIUM: Evidence of prior mitral valve replacement. Left
atrial enlargement. There is no pericardial effusion.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: Mild biapical pleural-parenchymal scarring. Mild centrilobular
pulmonary emphysematous changes. No suspicious pulmonary nodules or masses.
No confluent airspace consolidation.
2. AIRWAYS: Small small tracheal diverticulum (series 301, image 81). The
airways are patent to the subsegmental level. Mild, but diffuse bronchial
wall thickening.
3. VESSELS: The pulmonary artery is mildly enlarged (34 mm) and pulmonary
hypertension should be excluded.
CHEST CAGE: Degenerative changes of the thoracic spine. No lytic/destructive
bony lesions.
IMPRESSION:
No pulmonary emboli.
The pulmonary artery is mildly enlarged, pulmonary arterial hypertension
should be excluded.
No pneumonia. No suspicious pulmonary nodules or masses.
Mild, but diffuse bronchial wall thickening is nonspecific, most likely
reflecting underlying bronchial inflammation.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Other fatigue
temperature: 97.5
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 192.0
dbp: 103.0
level of pain: 1
level of acuity: 3.0 | ___ with h/o IVDU and recurrent endocarditis involving
bioprosthetic mitral valve, presenting with intermittent central
chest pain, fatigue, and malaise after recent heavy cocaine use.
Currently pain free and hemodynamically stable. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx hypothyroidism, ___ disorder (___) presents
after having been found down for up to 36 hours in his
apartment. Difficult to obtain details from the patient who is
oriented x 3 but confused as to day of week. Upon further
review, the patient notes that he was walking in his house when
he might have slipped on the sawdust in his house which is
undergoing construction. Limited history possible at the time of
assessment given the patient's hoarse voice. Information
corroborated with the patient's son. Son notes that there is at
least 36 hours of elapsed time during which his father was
unaccounted. He advised neighbors and police who entered the
house to find the patient down.
Vitals upon arrival to ED, 97.6 86 127/76 16 100% . Underwent CT
C-spine which revealed pre vertebral edema without fracture;
NCHCT without acute intracranial process; TSH 16; fT4 5.1; CK
2193.; SCr 0.8; lactate 1.8. Received 2L IVF and transferred to
the floor.
Upon arrival to the floor, 98.1 138/62 85 20 99%/RA
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:
___ Disease (Diagnosed ___, Followed by ___
MD, PhD at ___, ___, ___
Thyroid nodule s/p partial thyroidectomy
Hypothyroidism
Orthostatic Hypotension
Social History:
___
Family History:
(Per OMR, unable to review with patient)
Sibling deceased from Hodgkin's lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
------
Vitals: 98.1 138/62 85 20 99%/RA
General: Alert, oriented
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: Unable to assess.
Lungs: Limited exam. 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: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, In hard collar. Frothy sputum at mouth.
DISCHARGE PHYSICAL EXAM:
----------------
VSS
General: Alert, oriented
HEENT: Sclera anicteric, MM dry, oropharynx clear
Lungs: Decreased at the left base.
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: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, in soft collar. + cog wheeling. strength
___ bilateral upper and lower extremities
Pertinent Results:
ADMISSION LABS:
-------
___ 10:50AM BLOOD WBC-11.9* RBC-4.72# Hgb-14.3# Hct-44.5#
MCV-94 MCH-30.3 MCHC-32.2 RDW-12.6 Plt ___
___ 10:50AM BLOOD Neuts-84.6* Lymphs-11.1* Monos-3.1
Eos-0.4 Baso-0.7
___ 10:50AM BLOOD Glucose-116* UreaN-27* Creat-0.8 Na-145
K-3.9 Cl-106 HCO3-23 AnGap-20
___ 10:50AM BLOOD ALT-40 AST-74* CK(CPK)-2193* AlkPhos-75
TotBili-1.0
___ 10:50AM BLOOD Lipase-14
___ 10:50AM BLOOD cTropnT-0.02*
___ 10:50AM BLOOD TSH-16*
___ 10:50AM BLOOD Cortsol-27.4*
___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:59AM BLOOD Lactate-1.8
DISCHARGE LABS:
------
___ 06:45AM BLOOD WBC-7.9 RBC-3.63* Hgb-10.9* Hct-35.2*
MCV-97 MCH-30.1 MCHC-31.0 RDW-12.4 Plt ___
___ 06:45AM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-146*
K-3.5 Cl-109* HCO3-26 AnGap-15
___ 06:30AM BLOOD Calcium-8.6 Phos-1.6* Mg-1.7
IMAGING:
-----
TRAUMA TORSO PLAIN FILM ___
FINDINGS:
CHEST: Underlying trauma board partially obscures the view.
The lungs are
relatively hyperinflated. No definite focal consolidation is
seen. There is
no pleural effusion or evidence of pneumothorax. The cardiac
silhouette is
not enlarged. The aorta is slightly tortuous. There is a
minimally displaced
fracture of the anterolateral left ninth rib with subtle
suggestion of
adjacent sclerosis indicating that it may be subacute. There is
also a
fracture of the lateral left eighth rib again with subtle
evidence of callus
suggesting that it may not be acute. There are old-appearing
fractures of the
posterior left ninth and tenth ribs. A non-displaced fracture
of the lateral
right eighth to ninth ribs on the right is not excluded.
PELVIS: There is slight irregularity along the inferomedial
aspect of the
right femoral neck and a non-displaced possibly slightly
impacted fracture is
not excluded. Recommend clinical correlation and if clinical
concern,
dedicated imaging of the right hip. There is no diastasis of
the pubic
symphysis or sacroiliac joints.
IMPRESSION: Left-sided rib fractures as above, some of which
appear old,
others of which may be subacute. Non-displaced fracture of the
lateral right
eighth to ninth ribs of indeterminate age not excluded. Please
correlate
clinically.
Slight irregularity along the inferomedial aspect of the right
femoral neck,
correlate with site of pain and dedicated imaging of the right
hip.
___ ___
FINDINGS: There is no evidence of acute intracranial
hemorrhage, mass effect,
edema or vascular territorial infarction. Ventricles and sulci
are
appropriate in size and configuration for the patient's age, and
periventricular and subcortical white matter hypodensities are
likely sequela
of chronic small vessel ischemic disease. The basilar cisterns
appear patent,
and there is preservation of normal gray-white matter
differentiation. No
fracture is identified. The globes are intact.
IMPRESSION: No acute intracranial abnormality.
CT C-Spine ___
FINDINGS: There is no evidence of acute fracture or
malalignment. There is
prevertebral edema seen from C1-C4/C5, ligamentous injury is not
excluded. A
5 mm left apical lung nodule is again seen (3:69) along with
pleural
thickening and scarring. The thyroid gland is unremarkable.
IMPRESSION:
1. Prevertebral/retropharyngeal edema anterior to the C1-C4/C5
cervical spine,
non-specific but ligamentous injury not excluded. Recommend
further
evaluation and clinical correlation with MRI.
2. Left 5 mm apical lung nodule. Recommend CT imaging to assess
stability in
___ months if patient is at high risk for lung cancer,
otherwise in 12
months.
Findings were discussed with Dr. ___ by Dr. ___
telephone at
approximately 1:30 p.m. on ___ immediately
following wet read
change.
MRI C-Spine ___
FINDINGS:
Exaggerated lordosis of the cervical spine is present.
Vertebral body
alignment is maintained without evidence of subluxation. There
is mild loss
of height of the C6 vertebral body and with associated STIR
hyperintensity and
T1 hypointensity. Mildy increased STIR signal is seen within
the C5-C6 disc
as well mainly at its right aspect.
Mild prevertebral edema extends from the level of C2 -through
C4- C5, slightly
diminished compared to the previous CT examination. There is no
evidence for
ligamentous disruption.
There are areas of focal fat within the T1, T2 and T4 vertebral
bodies.
C2-C3: A small posterior disc protrusion effaces the ventral
subarachnoid
space. There is mild right neural foraminal narrowing secondary
to uncinate
and facet hypertrophy. The left neural foramen is patent.
C3-C4: There is a posterior disc protrusion which completely
effaces the
ventral subarachnoid space and abuts the anterior cervical cord.
Mild
bilateral neural foraminal narrowing secondary to uncinate and
facet
hypertrophy.
C4-C5: A disc osteophyte complex effaces the ventral
subarachnoid space and
abuts the anterior cervical cord. Moderate bilateral neural
foraminal
narrowing at this level secondary to uncinate and facet
hypertrophy.
C5-C6: A posterior disc bulge is present which effaces the
ventral
subarachnoid space and abuts the ventral cervical cord. There
is moderate
bilateral neural foraminal narrowing, right slightly greater
than left,
secondary to uncovertebral hypertrophy.
C6-C7: A posterior disc osteophyte complex partially effaces
the ventral
subarachnoid space but does not contact the cord although there
is mild
flattening of the ventral cord at this level. There is moderate
left and mild
right neural foraminal narrowing secondary to uncovertebral
hypertrophy.
C7-T1: No significant spinal canal or neural foraminal
narrowing is present.
IMPRESSION:
Mild loss of height of the C6 vertebral body with associated
STIR
hyperintensity consistent with marrow edema from trauma or
degenerative
change. Mild prevertebral edema has slightly diminished
compared to the
previous study CT examination. There is no evidence for
ligamentous
disruption.
Multilevel degenerative changes as described above with disc
bulging indenting
the cord from C2-3 to C4-5 levels without frank cord compression
or abnormal
signal within the cervical cord.
Medications on Admission:
Acetylsalicylic Acid (ASPIRIN) 81 MG PO QD
Fludrocortisone Acetate 0.2 MG PO QD
Levothyroxine Sodium 100 MCG PO QD
Ropinirole Extended Release 12 MG (12 MG TAB ER 24H Take 1) PO
TID (Yes, this is the correct dosage and formulation, if Q's
call Dr. ___ at ___
Selegiline Hcl 5 MG PO BID
Sinemet ___ (CARBIDOPA/LEVODOPA ___ ) 25MG-100MG TABLET 1
tab every 3 hrs, 2 at bed, for total of 8/day;
Tasmar (TOLCAPONE) 50 MG with each dose of SInemet (7x/day)
Vitamin B12 (CYANOCOBALAMIN) PO QD; No Change (Taking)
Discharge Medications:
1. Carbidopa-Levodopa (___) 2 TAB PO Q3H
*** THIS IS DOUBLE HOME DOSE WHILE PATIENT IS UNABLE TO TAKE
TOLCAPONE***
2. Carbidopa-Levodopa (___) 2 TAB PO HS
*** THIS IS DOUBLE HOME DOSE WHILE PATIENT IS UNABLE TO TAKE
TOLCAPONE***
3. Fludrocortisone Acetate 0.2 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Selegiline HCl 5 mg PO BID
6. Ropinirole 12 mg PO TID
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 50 mcg PO DAILY
9. Senna 1 TAB PO BID
10. Tasmar (tolcapone) 50 mg ORAL Q3H
***PATIENT IS CURRENTLY UNABLE TO TAKE THIS AS IT CANNOT BE
CRUSHED-- SINEMET DOUBLED FOR NOW***
11. trospium 20 mg oral bid
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
RETROPHARYNGEAL EDEMA
___ DISEASE
RHABDOMYOLYSIS
DEHYDRATION
SECONDARY DIAGNOSES:
HYPOTHYROIDISM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Single supine AP portable view of the chest and single supine AP
portable view of the pelvis.
CLINICAL INFORMATION: Found down.
___.
FINDINGS:
CHEST: Underlying trauma board partially obscures the view. The lungs are
relatively hyperinflated. No definite focal consolidation is seen. There is
no pleural effusion or evidence of pneumothorax. The cardiac silhouette is
not enlarged. The aorta is slightly tortuous. There is a minimally displaced
fracture of the anterolateral left ninth rib with subtle suggestion of
adjacent sclerosis indicating that it may be subacute. There is also a
fracture of the lateral left eighth rib again with subtle evidence of callus
suggesting that it may not be acute. There are old-appearing fractures of the
posterior left ninth and tenth ribs. A non-displaced fracture of the lateral
right eighth to ninth ribs on the right is not excluded.
PELVIS: There is slight irregularity along the inferomedial aspect of the
right femoral neck and a non-displaced possibly slightly impacted fracture is
not excluded. Recommend clinical correlation and if clinical concern,
dedicated imaging of the right hip. There is no diastasis of the pubic
symphysis or sacroiliac joints.
IMPRESSION: Left-sided rib fractures as above, some of which appear old,
others of which may be subacute. Non-displaced fracture of the lateral right
eighth to ninth ribs of indeterminate age not excluded. Please correlate
clinically.
Slight irregularity along the inferomedial aspect of the right femoral neck,
correlate with site of pain and dedicated imaging of the right hip.
Radiology Report
HISTORY: Found down, evaluate for fracture or dislocation.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast material. Reformatted coronal and
sagittal and thin section bone algorithm reconstructed images were obtained.
COMPARISON: Non-enhanced CT of the head from ___.
FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,
edema or vascular territorial infarction. Ventricles and sulci are
appropriate in size and configuration for the patient's age, and
periventricular and subcortical white matter hypodensities are likely sequela
of chronic small vessel ischemic disease. The basilar cisterns appear patent,
and there is preservation of normal gray-white matter differentiation. No
fracture is identified. The globes are intact.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
HISTORY: Found down, evaluate for fracture or dislocation.
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base to
the T2 level. Reformatted coronal and sagittal axis images were obtained.
COMPARISON: CT C-spine from ___.
FINDINGS: There is no evidence of acute fracture or malalignment. There is
prevertebral edema seen from C1-C4/C5, ligamentous injury is not excluded. A
5 mm left apical lung nodule is again seen (3:69) along with pleural
thickening and scarring. The thyroid gland is unremarkable.
IMPRESSION:
1. Prevertebral/retropharyngeal edema anterior to the C1-C4/C5 cervical spine,
non-specific but ligamentous injury not excluded. Recommend further
evaluation and clinical correlation with MRI.
2. Left 5 mm apical lung nodule. Recommend CT imaging to assess stability in
___ months if patient is at high risk for lung cancer, otherwise in 12
months.
Findings were discussed with Dr. ___ by Dr. ___ telephone at
approximately 1:30 p.m. on ___ immediately following wet read
change.
Radiology Report
HISTORY: ___ man with ___ and fall with prevertebral swelling
on CT cervical spine now with difficulty managing secretions.
TECHNIQUE: Multiplanar, multi sequence MR images of the cervical spine were
obtained without the use of intravenous contrast.
COMPARISON: CT cervical spine dated ___.
FINDINGS:
Exaggerated lordosis of the cervical spine is present. Vertebral body
alignment is maintained without evidence of subluxation. There is mild loss
of height of the C6 vertebral body and with associated STIR hyperintensity and
T1 hypointensity. Mildy increased STIR signal is seen within the C5-C6 disc
as well mainly at its right aspect.
Mild prevertebral edema extends from the level of C2 -through C4- C5, slightly
diminished compared to the previous CT examination. There is no evidence for
ligamentous disruption.
There are areas of focal fat within the T1, T2 and T4 vertebral bodies.
C2-C3: A small posterior disc protrusion effaces the ventral subarachnoid
space. There is mild right neural foraminal narrowing secondary to uncinate
and facet hypertrophy. The left neural foramen is patent.
C3-C4: There is a posterior disc protrusion which completely effaces the
ventral subarachnoid space and abuts the anterior cervical cord. Mild
bilateral neural foraminal narrowing secondary to uncinate and facet
hypertrophy.
C4-C5: A disc osteophyte complex effaces the ventral subarachnoid space and
abuts the anterior cervical cord. Moderate bilateral neural foraminal
narrowing at this level secondary to uncinate and facet hypertrophy.
C5-C6: A posterior disc bulge is present which effaces the ventral
subarachnoid space and abuts the ventral cervical cord. There is moderate
bilateral neural foraminal narrowing, right slightly greater than left,
secondary to uncovertebral hypertrophy.
C6-C7: A posterior disc osteophyte complex partially effaces the ventral
subarachnoid space but does not contact the cord although there is mild
flattening of the ventral cord at this level. There is moderate left and mild
right neural foraminal narrowing secondary to uncovertebral hypertrophy.
C7-T1: No significant spinal canal or neural foraminal narrowing is present.
IMPRESSION:
Mild loss of height of the C6 vertebral body with associated STIR
hyperintensity consistent with marrow edema from trauma or degenerative
change. Mild prevertebral edema has slightly diminished compared to the
previous study CT examination. There is no evidence for ligamentous
disruption.
Multilevel degenerative changes as described above with disc bulging indenting
the cord from C2-3 to C4-5 levels without frank cord compression or abnormal
signal within the cervical cord.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with DEHYDRATION, RHABDOMYOLYSIS
temperature: 97.6
heartrate: 86.0
resprate: 16.0
o2sat: 100.0
sbp: 127.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | ___ PMHx hypothyroidism, ___ disorder (Dx ___, and
recent falls who presented after been having been found down in
his apartment for up to 36 hours. Noted to have mild
rhabodomyolysis and C1-C4 prevertebral edema due to cervical
trauma without evidence of fracture or ligamenetal injury. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pelvic pain
Major Surgical or Invasive Procedure:
bilateral percutaneous nephrostomy tube placement
History of Present Illness:
___ yo male with advanced prostate cancer, with suprapubic
catheter and home hospice care for past month presents with
right groin/pelvic pain and renal failure.
Per patient and wife, home hospice care had been working well
until a few weeks ago, when he started developing constant
bladder spasms, right groin pain, and urgency. Oxycontin was
converted to methadone, and various anti-spasmodics have been
tried; he is currently on Pyridium.
This week, his home hospice nurse attempted to replace
suprapubic catheter, has since noted drainage of blood tinged
fluid from around suprapubic catheter. Continues to have urine
output from cath, although minimal over past few days.
Approximately 3 days prior to presentation patient noted shaking
chills and fever to 100.8, and was started on levofloxacin.
On the morning prior to ED presentation, he had worsening
symptoms, not relieved with oxycodone, and presented to the ED
later on that day. In the ED, urology replaced his suprapubic
catheter without complication, and patient was admitted for
further evaluation and management. He received morphine 5 mg IV
x 3 ED with excellent pain control.
Currently, the patient is without complaint, and feels well
resting in bed.
12 point ROS as noted above, otherwise negative.
Past Medical History:
Hypertension
Colonic polyps
Hyperlipidemia
Cataract
Macular degeneration
history of Zoster
Social History:
___
Family History:
not pertinent to this hospitalization
Physical Exam:
VS: 98.4 BP 112/64 HR 80 RR 18 93% RA
General: elderly male, very pleasant, hard of hearing, no
distress
HEENT: anicteric sclerae, temporal wasting
CV: RRR, normal S1, S2, no m,r,g
Pulm: clear lungs bilaterally, comfortable
Abdomen: suprapubic catheter in place, minimal output, no
abdominal tenderness, no evidence of suprapubic distention
MSK: bilateral ___ edema, trace; hips without pain on passive
range of motion, no spinal process tenderness
Neuro: CNs II-XII intact, strength and sensation grossly
intact, ambulatory with cane and one assist
Psych: appropriate, insightful
Pertinent Results:
___ 07:15AM BLOOD WBC-15.0* RBC-3.02* Hgb-8.5* Hct-27.1*
MCV-90 MCH-28.1 MCHC-31.2 RDW-15.7* Plt ___
___ 07:15AM BLOOD WBC-12.6* RBC-3.10* Hgb-8.5* Hct-28.7*
MCV-93 MCH-27.5 MCHC-29.8* RDW-15.4 Plt ___
___ 07:55AM BLOOD WBC-14.9* RBC-3.48* Hgb-9.7* Hct-31.5*
MCV-91 MCH-27.9 MCHC-30.8* RDW-16.4* Plt ___
___ 08:00AM BLOOD WBC-12.7* RBC-3.58* Hgb-9.8* Hct-32.5*
MCV-91 MCH-27.5 MCHC-30.3* RDW-15.3 Plt ___
___ 04:25AM BLOOD WBC-8.9 RBC-3.09* Hgb-8.5* Hct-27.6*
MCV-89 MCH-27.6 MCHC-30.8* RDW-15.4 Plt ___
___ 09:05PM BLOOD WBC-8.5 RBC-3.24* Hgb-8.9*# Hct-28.7*
MCV-89 MCH-27.5# MCHC-31.1 RDW-15.4 Plt ___
___ 09:05PM BLOOD Neuts-93.1* Lymphs-3.6* Monos-1.8*
Eos-1.3 Baso-0.1
___ 04:25AM BLOOD ___
___ 07:15AM BLOOD Glucose-96 UreaN-26* Creat-1.4* Na-139
K-4.7 Cl-102 HCO3-26 AnGap-16
___ 07:15AM BLOOD UreaN-35* Creat-1.8* Na-137 K-5.1 Cl-102
HCO3-26 AnGap-14
___ 07:55AM BLOOD Glucose-110* UreaN-38* Creat-2.6* Na-139
K-5.4* Cl-102 HCO3-28 AnGap-14
___ 04:25AM BLOOD Glucose-105* UreaN-55* Creat-4.6*#
Na-131* K-5.5* Cl-99 HCO3-24 AnGap-14
___ 07:15AM BLOOD Phos-2.4*# Mg-2.0
___ 08:00AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.8*
___ 04:25AM BLOOD Calcium-7.8* Phos-4.3 Mg-3.0*
___ 04:25AM BLOOD Osmolal-290
.
___ URINE URINE CULTURE-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{CANCELLED} EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{CANCELLED} EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY
.
Renal u/s:
IMPRESSION: New bilateral hydronephrosis, mild on the right and
mild to
moderate on the left. The urinary bladder could not be
assessed.
___ 07:10AM BLOOD WBC-12.7* RBC-3.24* Hgb-8.9* Hct-28.2*
MCV-87 MCH-27.5 MCHC-31.6 RDW-17.1* Plt ___
___ 07:10AM BLOOD WBC-15.3* RBC-3.27* Hgb-9.1* Hct-28.3*
MCV-87 MCH-27.9 MCHC-32.2 RDW-16.8* Plt ___
___ 07:10AM BLOOD Glucose-116* UreaN-24* Creat-1.1 Na-135
K-4.5 Cl-99 HCO3-25 AnGap-16
___ 07:10AM BLOOD Glucose-110* UreaN-25* Creat-1.2 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
hold for SBP < 100, HR < 55
2. Docusate Sodium 100 mg PO BID
3. Enablex *NF* (darifenacin) 15 mg Oral daily
4. Furosemide 20 mg PO DAILY
5. Methadone 2.5 mg PO TID
6. Polyethylene Glycol 17 g PO DAILY
7. Phenazopyridine 100 mg PO TID
8. Mirtazapine 7.5 mg PO HS
9. Senna 2 TAB PO TID
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. atropine *NF* ___ drops SL Q4H secretions
12. Bisacodyl ___AILY:PRN constipation
13. Fleet Enema ___AILY:PRN constipation
14. Haloperidol 0.5-2 mg PO TID:PRN restlessness
15. Ibuprofen 400 mg PO Q8H:PRN pain
16. Lorazepam 0.5-2 mg PO Q4H:PRN restlessness
17. Ondansetron 8 mg PO Q8H:PRN nausea
18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
19. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q1H:PRN pain,
respiratory distress
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. Mirtazapine 7.5 mg PO HS
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 2 TAB PO TID
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
can be purchased over the counter
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Amlodipine 5 mg PO DAILY
10. atropine *NF* ___ drops SL Q4H secretions
11. Fleet Enema ___AILY:PRN constipation
12. Haloperidol 0.5-2 mg PO TID:PRN restlessness
13. Lorazepam 0.5-2 mg PO Q4H:PRN restlessness
14. Lidocaine 5% Patch 1 PTCH TD DAILY
15. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO
Q1H:PRN pain/dyspnea
concentration=50mg/ml.
dispense 60ml
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by
mouth q1hr prn. Disp ___ Milliliter Refills:*0
16. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*21 Tablet Refills:*0
17. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain
___ q3hrs. PLease given 30mg ___
RX *morphine 15 mg ___ tablet(s) by mouth q3hrs Disp #*60 Tablet
Refills:*0
18. Fentanyl Patch 25 mcg/h TD Q72H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Renal failure due to post obstructive uropathy
Advanced prostate cancer
Constipation
Discharge Condition:
Mental Status: Clear and coherent, occasionally confused with
medication.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Advanced prostate cancer, suprapubic catheter, admitted from home
with pelvic pain and renal failure, likely post-obstructive. Please evaluate
for urinary tract obstruction.
COMPARISON: Renal ultrasound of ___.
TECHNIQUE: Renal ultrasound.
FINDINGS: The right kidney measures 12.9 cm. The left kidney measures 11.0
cm. There is bilateral hydronephrosis, mild on the right and mild-to-moderate
on the left, which is new from the prior ultrasound. The ureters are not well
visualized, and the urinary bladder could not be visualized due to dressing
material and the presence of a suprapubic catheter. No renal stones or masses
are appreciated.
IMPRESSION: New bilateral hydronephrosis, mild on the right and mild to
moderate on the left. The urinary bladder could not be assessed.
Results were discussed via telephone with ___ by Dr. ___ on ___ at 4:32 p.m.
Radiology Report
INDICATION: ___ man with advanced prostate cancer admitted with renal
failure and bilateral hydronephrosis, please place bilateral percutaneous
nephrostomy tube.
PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
MEDICATION: The patient received 100 mcg of fentanyl and 2 mg of Versed in
divided doses for a total intraservice time of 1 hour and 3 minutes, during
which time the patient's hemodynamic parameters were continuously monitored.
In addition, the patient received 1 g of cefazolin prior to the procedure.
RADIATION: 11.1 minutes of fluoroscopy time.
PROCEDURE:
1. Bilateral 8 ___ percutaneous nephrostomy placement.
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 prone on the table. A preprocedure timeout was
performed using three patient identifiers. The skin overlying both kidneys
was prepped and draped in the usual sterile fashion. Initial limited
ultrasound demonstrated bilateral hydronephrosis. Approximately 6 cc of 1%
lidocaine was infiltrated into the skin and subcutaneous tissues bilaterally
prior to accessing the lower pole calices using a Cook 21-gauge needle.
Contrast was injected via the needle to confirm access to the collecting
system and a nitinol wire was advanced through the needle. A small skin
incision was made and an AccuStick sheath was advanced over the needle. On
the left side using a combination of a Glidewire and a 5 ___ sheath, we did
attempt to access the distal ureter. The proximal ureter was readily
navigated; however, the distal ureter was extremely tortuous and although the
Glidewire did eventually pass into the bladder, the patient experienced mild
discomfort at the sensation. Therefore, we elected not to place a
nephroureteral stent at this time. ___ wire was advanced
through the AccuStick sheath which was removed and dilatation was performed
over the wire with an 8 ___ dilator followed by placement of bilateral 8
___ nephrostomy tube. Positioning of both tubes was confirmed by injection
of a small amount of contrast. Both catheters were sutured to the skin with a
0 silk suture and a Flexi-Trak was also placed for security. Sterile
dressings were applied and the catheters were attached to bag for free
drainage. There were no immediate post-procedure complications.
IMPRESSION:
1. Technically successful placement of bilateral 8 ___ nephrostomy tube.
2. Tortuous distal left ureter consistent with extrinsic compression.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SUPERPUBIC PAIN
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, SECOND MALIG NEO GENITAL, HX-PROSTATIC MALIGNANCY, HYPERTENSION NOS
temperature: 98.6
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 148.0
dbp: 66.0
level of pain: 9
level of acuity: 3.0 | # Renal failure- due to post-renal obstruction ___ tumor
invasion of bladder wall. Discussed with patient and wife prior
to obtaining ultrasound. IVF overnight did not improve
creatinine. ___ consulted for bilateral nephrostomy tube
placement to relieve obstruction as a palliative procedure to
extend his quality of life. Attempt was made to internalize the
tubes, but ___ unable to do so, so external tubes with collection
bags were means of decompression. His hospice nurse has
experience caring for patients with percutaneous nephrostomy
tubes, and should they cause discomfort at home, they can be
removed. Following placement, creatinine improved from 4.6 to
1.1 on the day of discharge.
++ Nephrostomy tube care, wash with ___ saline and ___ hydrogen
peroxide and cover with dressing daily. Flush with ___ NS if
bloody or clogged.
++ suprapubic tube care-wash with ___ saline and ___ hydrogen
peroxide and cover with dressing daily. Flush with 30cc saline
if bloody or clogged.
# Advanced pancreatic cancer-the patient wishes to pursue only
palliative therapy. Symptoms were well controlled with morphine
5 mg IV Q3H PRN. With input from palliative care, regimen was
converted to MS ___ 30 mg BID and MSIR ___ Q3hrs.
However, this regimen again proved challenging as pt would go
from periods of confusion to severe pain. Therefore, the patient
was converted to a fentanyl patch at 25mcg q72hrs and continued
to use MSIR for breakthrough pain. AT a dose of ___ Q3hrs
prn. Difficulty balance as pt often with pain using 15mg and
somewhat confused/sedated with 30mg. Pt should get 30mg MS ___
___. Can trial ___ at intervals during the day, depending on
symptoms. Could also uptitrate fentanyl patch. Pyridium was
discontinued given significant anti-cholinergic effect that was
likely exacerbating constipation. However, the urology team felt
that pt was having bladder spasms and pt was started on
oxybutynin therapy TID with good effect and improvement in
spasms.
# Fever- treated at home with levofloxacin for empiric UTI
coverage. Ceftriaxone continued initially on admission.
Initial urine culture from chronic suprapubic catheter was
indeterminate, repeat cultures from each nephrostomy tube were
negative. However, pt with another low grade temperature on ___
and culture was sent from suprapubic tube which showed mixed
flora. Antibiotics were discontinued.
.
# Constipation- pt given an aggressive bowel regimen, with
enemas, which relieved constipation.
.
#anemia/thrombocytosis, leukocytosis-felt to be related to above
process. No signs of C.diff, or PNA.
# HTN- continued amlodipine
.
# FEN- IVF, replete lytes, regular diet
# Contact- patient, wife ___ ___
# Code- DNR/DNI
.
Transitional care
1.continue titration of pain medication prn. Pt currently on
25mcg fentanyl patch and MSIR ___ Q3hrs pain. Occasionally
15mg works, occasionally needs 30mg. Would give 30mg ___. 30mg
occasionally too sedating. Could also uptitrate fentanyl patch
prn. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
REASON FOR CONSULTATION: headache, vomiting
HPI:
Mr. ___ is a ___ man with past medical history of
HTN, HLD, poorly controlled DM, CAD, and recent admission for
right ICA and MCA occlusion s/p TPA, ICA stent placement, and
thrombectomy with TICI3 reperfusion with ___ hemorrhagic
transformation who presented as a transfer from ___ for severe
headache, nausea and vomiting.
Patient was interviewed with telephone ___ interpreter. Per
patient he has had a persistent daily headaches since his stroke
though they have always been tolerable. He says the headaches
are usually all over his head none one particular location.
Today at 2 ___ at his rehab the headache gradually became quite
severe. Headache was initially located posteriorly and then
migrated to the front of his head. He describes the pain as a
"tight" pain that was holocephalic. The severe headache was
associated with nausea and vomiting in addition to photophobia
and phonophobia. He says the headache improved some
after vomiting. He was taken to ___ where
he was given Zofran, Tylenol with some improvement of his
headache. His vitals on arrival at ___ were: T98.2, HR 102,
RR16, BP 183/93.
He had a CT at the outside hospital that showed area of prior
infarct and hemorrhagic conversion. ___ was unable to compare to
prior imaging and transferred patient for further evaluation and
workup.
In addition to his headache he has some mild neck pain but
thinks it is due to the pillow. He also endorses some diarrhea
and mild abdominal pain. The diarrhea he says started on
___ and has continued. Otherwise he denies any new or
worsening weakness, sensory changes, difficulty speaking, or
difficulty understanding what other people are saying. The
dizziness and nausea have
completely resolved now though he does still have a mild
headache.
He says he has had headaches before his stroke but they were
never this severe. He denies any history of migraines. In
reguards to his recent admission patient was discharge on ___
after R ICA and MCA occlusion s/p TPA, thrombectomy and ICA
stenting, with ___ hemorrhagic conversion. His deficits at
discharge were largely left hemiparesis. He was discharged on
ASA 81mg and Plavix 75mg. He also had issues with urinary
retention during that hospitalization that required straight
catheterization. Per patient he did not have a foley at rehab
but one was placed when he was at ___ this evening.
On neuro ROS, pertinent positives in HPI, currently the pt
denies loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
new focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait. On
___ review of systems, patient endorses diarrhea and mild
abdominal pain, nausea and vomiting with headache. 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. No recent change in bowel
or bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Time (and date) the patient was last known well:1400 ___
(24h
clock)
___ Stroke Scale Score: 9
t-PA given: No Reason t-PA was not given or considered: outside
window, recent IPH, recent ischemic stroke
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
The NIHSS was performed:
Date: ___
Time: 0400
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 9
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2*
5a. Motor arm, left: 2*
5b. Motor arm, right: 0
6a. Motor leg, left: 2*
6b. Motor leg, right: 0
7. Limb Ataxia: 1*
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1*
11. Extinction and Neglect: 0
*Prior deficits noted in discharge exam from right MCA infarct*
Past Medical History:
Diabetes mellitus
Hypertension
Hyperlipidemia
Social History:
Currently patient is living at ___
___.
He does not smoke cigarettes, drink alcohol or use any drugs
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[x] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No family history of strokes in members younger than ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T98.8, HR82, BP 176/90, RR18, 97% RA
___: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty in ___. 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. +Dysarthria most significant
with lingual and labial, 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. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages on the
left, unable to visualize on the right
V: Facial sensation decreased to light touch and pinprick on the
left V2-V3
VII: left facial droop, mild left ptosis, eye closure is strong
bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in SCM bilaterally, right shoulder shrug ___,
left sluggish movement at least ___
XII: Tongue protrudes to the left, slow movements to the left.
Strength full with tongue-in-cheek testing on right, weak on
left
-Motor: Normal bulk, increased tone in left upper and lower
extremity
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc
L 4- 4 4+ 3+ ___ 4- 3 5
R ___ ___ 5 5 5 5
-Sensory: Decreased sensation to light touch on the left upper
extremity compared to the right, decreased pinprick on the left
upper extremity compared to the right, intact in bilateral lower
extremities, early extinction to vibration in bilateral toes (5
seconds bilaterally), intact in upper extremities though
slightly
less on left (10 seconds on left, 15 on right), proprioception
intact in upper extremities and intact to large movements in
bilateral lower extremities, no extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3+ 2 3+ 3+ 4
R 2 2 2 2 1
Plantar response was flexor on right, mute on left
+sustained clonus on left
suprapatellar reflex on left patella
-Coordination: Right FTN is fast and smooth, left is slow with
overshoot, slightly out of proportion to his weakness. Finger
tapping is slowed and clumsy on left, fast and smooth on right
-Gait: deferred as patient is non ambulatory after stroke
====================================================
DISCHARGE EXAM:
Vitals: T98.1, HR 72, BP 140/85, RR 16, 96% RA
___: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert Language is fluent Normal prosody. There
were no paraphasic
errors. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
VII: mild left facial droop, mild left ptosis, eye closure is
strong bilaterally
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in SCM bilaterally, right shoulder shrug ___,
left sluggish movement at least ___
-Motor: Normal bulk, increased tone in left upper and lower
extremity No adventitious movements, such as tremor, noted. No
asterixis noted. Pronator drift on left UE. Left UE ___ with
increased tone, left ___ ___.
-Sensory: Reports symmetric and intact on both sides to light
touch, no extinction to DSS.
-Coordination: intact FTN with right arm
Pertinent Results:
___ 04:46AM URINE HOURS-RANDOM
___ 04:46AM URINE UHOLD-HOLD
___ 04:46AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:46AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-300* KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD*
___ 04:46AM URINE RBC-12* WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 04:46AM URINE MUCOUS-RARE*
___ 03:41AM GLUCOSE-268* UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11
___ 03:41AM estGFR-Using this
___ 03:41AM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 03:41AM WBC-10.1* RBC-4.87 HGB-14.2 HCT-41.4 MCV-85
MCH-29.2 MCHC-34.3 RDW-12.9 RDWSD-39.8
___ 03:41AM NEUTS-70.9 LYMPHS-18.4* MONOS-7.9 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-7.14* AbsLymp-1.85 AbsMono-0.80
AbsEos-0.21 AbsBaso-0.04
___ 03:41AM PLT COUNT-219
___ 03:41AM ___ PTT-31.2 ___
___ 06:19AM BLOOD WBC-6.4 RBC-4.58* Hgb-13.2* Hct-39.3*
MCV-86 MCH-28.8 MCHC-33.6 RDW-13.0 RDWSD-39.8 Plt ___
___ 03:41AM BLOOD Neuts-70.9 Lymphs-18.4* Monos-7.9 Eos-2.1
Baso-0.4 Im ___ AbsNeut-7.14* AbsLymp-1.85 AbsMono-0.80
AbsEos-0.21 AbsBaso-0.04
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD ___ PTT-32.2 ___
___ 06:19AM BLOOD Glucose-118* UreaN-5* Creat-0.6 Na-143
K-3.9 Cl-104 HCO3-24 AnGap-15
___ 06:19AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1
___ 06:38AM BLOOD Triglyc-100 HDL-35* CHOL/HD-5.3
LDLcalc-131*
___ 06:38AM BLOOD %HbA1c-9.9* eAG-237*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Famotidine 20 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Sertraline 25 mg PO DAILY
9. Baclofen 5 mg PO TID:PRN Pain - Moderate
10. Finasteride 5 mg PO DAILY
11. Tamsulosin 0.4 mg PO DAILY
12. Artificial Tears 1 DROP BOTH EYES TID
13. Artificial Tear Ointment 1 Appl LEFT EYE QHS
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H
2. amLODIPine 5 mg PO DAILY
3. Artificial Tear Ointment 1 Appl LEFT EYE QHS
4. Artificial Tears 1 DROP BOTH EYES TID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Baclofen 5 mg PO TID:PRN Pain - Moderate
8. Clopidogrel 75 mg PO DAILY
9. Famotidine 20 mg PO BID
10. Finasteride 5 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Sertraline 25 mg PO DAILY
14. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sequelae of Right MCA stroke with hemorrhagic transformation
___ edema
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with prior R MCA infarct s/p TPA and thrombectomy
with new headache and sensory changes, worsening edema on OSH scan// evaluate
for new vessel occlusion, infarct *Please get CVT to evaluate for CVST*
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
3) Spiral Acquisition 2.5 s, 19.7 cm; CTDIvol = 30.0 mGy (Head) DLP = 592.2
mGy-cm.
4) Spiral Acquisition 5.1 s, 39.8 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,238.4 mGy-cm.
5) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 3,466 mGy-cm.
COMPARISON: Brain MR and MRA ___. Head CT ___.
FINDINGS:
CT head: Evolving right basal ganglia intraparenchymal hematoma appears
overall unchanged measuring approximately 2.2 x 2.1 cm. Surrounding edema
which extends inferiorly into the right temporal lobe is overall unchanged or
minimally increased from the most recent CT given differences in scan.
Similarly mass effect of the right lateral ventricle is overall unchanged.
Minimal 1-2 mm of leftward midline shift appears minimally increased. The
basal cisterns are patent. Slight asymmetric prominence of the temporal horn
of the right lateral ventricle with trace surrounding edema may be minimally
increased suggesting trapping with very mild hydrocephalus versus extension
the existing edema (08:12). No new intracranial hemorrhage or definite
infarct.
CTA head: Patent circle ___ and ___ tributaries. There is narrowing and
irregularity dense calcification of the right greater than left vertebral
artery V4 segment with moderate focal narrowing on the right and are widely
patent distally. Dural venous sinuses are patent. Atherosclerotic
calcification the supraclinoid internal carotid arteries bilaterally causes
mild narrowing on the left.
CTV neck: Bolus timing moderately limits evaluation. Crossing the right
carotid bifurcation, a metallic stent demonstrates intraluminal enhancement
and unchanged vessel caliber proximal and distal to it suggesting patency.
Within the limits of the study, the visualized carotid and vertebral arteries
appear patent.
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. Evolving right putaminal and adjacent white matter hematoma with edema and
mass-effect. The edema appears unchanged to slightly more prominent compared
to ___ but markedly increased since ___.
2. Limited view of the neck due to bolus timing. The vertebral and internal
carotid arteries appear patent but are not well characterized.
3. Right carotid stent in place with apparent patency of the vessel.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with h/o right ICA and MCA occlusion w
hemorrhagic transformation of stroke, now with worsening of headache, no DVST
on CTV// eval for stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI and MRA of the brain from ___ and CTA of the head and
neck from ___
FINDINGS:
Redemonstration of evolution of the putaminal intraparenchymal hematoma which
appears unchanged from the prior CT, measuring approximately 2.3 x 2.1 cm (AP
X TR).
There is surrounding edema that extends inferiorly into the right temporal
lobe, unchanged from the most recent prior CT. There is similar mass effect
on the right lateral ventricle with partial effacement and 1 to 2 mm leftward
midline shift, unchanged. The basal cisterns remain patent. There is no
crowding at the level of the foramen magnum.
There is no evidence of new hemorrhage.
There is mild mucosal thickening in the left maxillary sinus. The remainder
of the paranasal sinuses mastoid air cells appears clear. The orbits appear
grossly unremarkable.
IMPRESSION:
1. Evolution of the right putamen hematoma with surrounding edema, unchanged
from the most recent prior CT but increased from initial presentation.
2. No significant change of mild 1-2 mm leftward midline shift with partial
effacement of the right lateral ventricle and mild asymmetric prominence of
the temporal horn of the right lateral ventricle.
3. No new intracranial abnormality identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Headache, Transfer
Diagnosed with Headache
temperature: 98.8
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 176.0
dbp: 90.0
level of pain: 1
level of acuity: 2.0 | HOSPITAL COURSE:
___ man with past medical history of HTN, HLD, poorly
controlled DM, CAD, and recent admission for right ICA and MCA
occlusion s/p TPA, ICA stent placement, and thrombectomy with
TICI3 reperfusion with ___ hemorrhagic transformation who
presented as a transfer from ___ for severe headache, nausea and
vomiting. At ___, neurological exam stable. On imaging, no new
hemorrhage but had increased ___ edema around the
known old hemorrhage. Patient was observed and had spontaneous
resolution of symptoms with stable neurological exam. He was
found to have Enterococcus UTI, treated initially with IV
Ceftriaxone, then narrowed to IV ampicillin and discharged to
Rehab on oral amoxicillin.
=======================================
## Headache, known Right MCA stroke with hemorrhagic
transformation:
On arrival to ___, patient reported that he had mild headache
over the past few days. It became worse day before admission &
improved with Tylenol. He then vomited once. He had no
complaints when evaluated in the ED, specially no headache. On
initial presentation, his exam was largely stable from most
recent documented discharge physical exam with stable left
hemiparesis, dysarthria, left facial droop. New findings on
initial exam were decreased sensation to light touch and
pinprick in the left side of his face in the V2 and V3
distribution, in addition to decreased light touch and pinprick
in his left upper extremity compared to the right upper
extremity. On repeat exam in ED, his sensory exam was noted to
be symmetric without any difficulty to light touch, exam was
thus essentially unchanged from discharge exam after previous
hospitalization: VSS. Awake & alert. ___ seem intact. +
flattening of L NLF. No field cut. + pronation of L UE. L
hemiparesis (___) w/ increased tone. L sided hyperreflexia.
Sensations intact.
CT head showed stable left basal ganglia hemorrhagic
transformation with increased surrounding hypodensity
___ edema) resulting in increased effacement of
the R lateral ventricle and 1-2 mm midline shift. CTA showed
patent R ICA stent; scattered calcifications in the ICAs, and
narrowing of R ___.
He was thus admitted for observation due to increased ICP due to
increased ___ edema. Given resolution of symptoms
and stable exam, hyperosmolar therapy was not given. He remained
stable during the hospitalization. Overall exam is largely
stable from most recent documented discharge physical exam with
stable left hemiparesis, dysarthria, left facial droop. We
continued aspirin (81 mg) and Plavix given his ICA stent. Repeat
___ evaluation was done, and ___ rehab was recommended,
therefore patient was discharged to ___ rehab on ___.
[ ] continue aspirin 81 mg and Plavix
[ ] continue atorvastatin 80 mg
##Enterococcus UTI:
He was found to have Enterococcus UTI, treated initially with IV
Ceftriaxone (___), then narrowed to IV ampicillin
(___) and discharged to Rehab on oral amoxicillin 500 mg
TID till ___ (for a total 7 day course).
============================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Tb rule out; rash
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old woman
with a PMH of HIV, HCV, IVDU, chronic pain admitted from ___
to ___ with MRSA vertebral osteomyelitis, paraspinal abscess
and arachnoiditis/meningeal enhancement.
.
The patient presented on her PREVIOUS Admission to an OSH with
severe lumbar pain. An LP was performed and showed WBC 59K with
cultures growing MRSA. Blood cultures also grew MRSA. MRI was
performed after the LP showed a 3.1 x 1.6 cm abscess in the
right paraspinal musculature at the L3-5 level with involvement
of the right L4-5 facet joint and the L4 spinous process with
additional
leptomeningeal enhancement. It was unclear if the LP fluid that
was obtained was from the abscess or from the spinal fluid,
given the close proximity and the unknown presence of abscess at
the time of LP. The patient was given
vancomycin, ceftriaxone and acyclovir and was transfered to
___. On arrival to ___ she was intubated due to altered
mental status.
.
Neurosurgery evaluated the patient and she underwent ___ guided
drainage of her paraspinal abscess, cultures also grew MRSA. She
was continued on vancomycin alone. She was taken back for repeat
___ guided drainage of her abscess on ___ with and a drain
was removed prior to discharge. TTE revealed no
vegetations. She was discharged on vancomycin with a planned
prolonged duration of therapy. Her ID follow up was transitioned
to her PCP prior to discharge.
.
After discharge her ___ abscess fluid grew AFB with speciation
pending. Due to this, and a truncal rash, she was referred back
to the ___ for admission ___
At the time of admission, she reported feeling better and her
abscess continuing to heal. She still doesn't walk back to
normal, but is constantly improving. No
fevers/chills/SOB/CP/N/V/D/C.
In the ED, 98.4 84 100/73 16 98%.
On the floor, patient is comfortable, NAD, but anxious.
Past Medical History:
HIV
IVDA - including heroin. on methadone.
h/o PE
chronic low back pain
Social History:
___
Family History:
Unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.2 BP:108/82 P:88 R:20 O2:98RA
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, S4 gallop
appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present.
Escoriations throughout abdomen.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Scatterred rash on upper right back, chest, and on
extremities. Erythematous, partially blanching, macules.
Neuro: A and O x3. CN II-XII grossly intact. Strength ___ in b/l
upper and lower extremities. 2+ reflexes in knees,
brachioradialis. Gait with limp due to favoring R side
DISCHARGE
Pertinent Results:
ADMISSION:
___ 05:45PM BLOOD WBC-7.4 RBC-4.00* Hgb-10.9* Hct-33.3*
MCV-83 MCH-27.3 MCHC-32.7 RDW-14.3 Plt ___
___ 05:45PM BLOOD Neuts-69.8 ___ Monos-6.9 Eos-1.1
Baso-0.6
___ 07:45AM BLOOD WBC-5.4 Lymph-22 Abs ___ CD3%-91
Abs CD3-1083 CD4%-35 Abs CD4-413 CD8%-54 Abs CD8-642
CD4/CD8-0.6*
___ 05:45PM BLOOD Glucose-99 UreaN-9 Creat-0.9 Na-139 K-4.1
Cl-97 HCO3-28 AnGap-18
___ 07:45AM BLOOD ALT-50* AST-74* AlkPhos-82 TotBili-0.3#
___ 07:45AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.8 Iron-57
___ 07:45AM BLOOD calTIBC-324 Ferritn-103 TRF-249
DISCHARGE:
___ 07:50AM BLOOD WBC-5.7 RBC-4.13* Hgb-11.5* Hct-35.0*
MCV-85 MCH-27.9 MCHC-32.9 RDW-15.0 Plt ___
___ 07:50AM BLOOD Neuts-59.2 ___ Monos-8.6 Eos-2.5
Baso-0.9
___ 07:50AM BLOOD ESR-82*
___ 07:50AM BLOOD Glucose-106* UreaN-8 Creat-0.9 Na-137
K-4.3 Cl-99 HCO3-29 AnGap-13
___ 07:50AM BLOOD ALT-86* AST-113* CK(CPK)-21* AlkPhos-101
TotBili-0.3
___ 07:50AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.9
___ 07:50AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 07:50AM BLOOD CRP-3.0
MICRO:
___ BCx: Pending
___ Sputum: ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ Sputum: ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 10:07 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ HIV VL Pending:
___ HCV VL Pending:
___ Mycolytic BCx Pending:
STUDIES:
___ CXR: No acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Raltegravir 400 mg PO BID
3. Acetaminophen 325-650 mg PO Q8H:PRN pain/HA
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 1 TAB PO BID
7. Vancomycin 1250 mg IV Q 8H
8. Heparin 5000 UNIT SC TID
9. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
10. Oxycodone SR (OxyconTIN) 45 mg PO QHS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN pain/HA
2. Docusate Sodium 100 mg PO BID
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Raltegravir 400 mg PO BID
6. Senna 1 TAB PO BID
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
8. Oxycodone SR (OxyconTIN) 45 mg PO QHS
9. Linezolid ___ mg PO Q12H
day 1 = ___
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Methadone 30 mg PO DAILY
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
Discharge Disposition:
Home
Discharge Diagnosis:
Tuberculosis rule out
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Positive AFB cultures with paraspinal abscesses.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
Right PICC terminates at the SVC/right atrial junction. Cardiac, mediastinal
and hilar contours are normal. Pulmonary vascularity is normal. Lungs are
clear. No pleural effusion or pneumothorax is present. No acute osseous
abnormalities are present.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: + AFB
Diagnosed with OTHER NONSPECIFIC FX ON EXAM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | ___ pmHx HIV, HCV, IVDA who recently was discharged with
epidural abscess who p/w concern for Tb and with ___ rash ?drug
related
# AFB+ Abscess Cx: Patient with growth of AFB on abscess that
previously was known positive for MRSA. Patient was admitted
from rehab for r/o Tb.
- 3 induced sputums with AFB sputum was smear negative on gram
stain
- Dr. ___ with ID will f/u State lab to return
speciation and contact patient
# MRSA Abscess: Patient on extended course of Vancomycin s/p
multiple drainages of epidural abscess. Derm consulted, felt
rash was due to Vanco and this was stopped. Daptomycin was
started at the recommendation of ID. She declined the
opportunity to go to rehab for continued abx with Daptomycin,
so PICC line was removed give hx of IVDU and pt was d/c with 4
weeks of linezolid ___ PO BID. She will f/u with Dr. ___ in
___ for weekly CBC, CMP, ESR, CRP and
LFTs. She will also f/u at ___ in ___ clinic in 4 weeks.
# Transaminitis: LFTs slightly elevated, trending up. Risk for
hepatitis due to IVDA as well as known Hep C. Could be due to
medications. Hep B surface antigen was negative.
# Normocytic Anemia: Hct 33 on admission, stable at this level
during last admission. Iron studies normal.
# HIV: Low CD4 count measured here thought to be secondary to
acute illness (171 on ___. ID did not feel prophylactic
bactrim was indicated at that time. CD4 ___. She was
contniued on home truvada and raltegravir. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / morphine / Macrobid / Biaxin
Attending: ___.
Chief Complaint:
right upper abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a ___ yo F with a PMHx of gastric by pass, depression
with recent suicide attempt and was at ___ on a
___ after a reported alcohol and clonodine overdose who
was transfered for c/o abdominal pain X5 days.
.
Patient was seen at ___ for similar complaints and
had a CT was was reportedly normal. Her intial evalaution there
was for OD with 40-60 clonodine tablets while drinking alcohol.
She was intially admitted to the ICU for close monitoring. She
had self limiting bradycardia and hypotension at ___.
LFT's and lipase also wnl. At that time, reports last normal BM
was 5 days ago and since has only had small stools. Was
medically cleared and sent to ___, sent to ___ ___ for
continued abdominal pain.
.
In our ED, VSS. Rectal exam done in ED showed hard dark stool
in rectal vault, guaiac negative without CVA tenderness. The
patient was teary in the ED and anxious due husbands death ___
years ago from complications of gastric bypass. Enemas given
with moderate amounts of BM after. Patient placed on 1:1 sitter
and sent to the floor.
.
On the floor the patient reports that she began to have sharp
pains in her abdomen about 1 month ago. Theses pains got worse
in intensity and duration shortly after her overdose 5 days ago.
The pains prior to her OD lasted seconds and now they are
lasting minutes to hours. The pains are usually related to po
intake. The patient also reports constipation X5 days that was
releived by an enema in the ED. The patient has never had an
EGD and had a colonoscopy at ___ in ___ of this
year due to LGIB which was thought to be due to a bleeding
polyp. The polyp was removed and the bleed stopped. The
patient does reported black stools recently but her medications
on transfer included iron. The patient denies a h/o
pancreatitis or ulcers. The patient has had multiple suicide
attempts in the past, most recently ___ when she was
inpatient. The suicide attempts were in the setting of alcohol
abuse. Denies current HI or SI.
.
10 point ROS is otherwise negative except above
.
Past Medical History:
PMH:
1) polysubstance abuse including alcohol
2) suicide attempt recently with clonodine and alcohol
3) anxiety/depression
4) history of SVT
5) asthma
6) colonic polyps - per patient c-scope for mild bleeding in
___, improved after polypectomy-at ___
7) neuropathy ___ to accident
8) idiopathic intermitent abdominal pain
9) ADD
Past Surgical Hx:
1) Roux en y gastric bypass + chole ___ at ___.
Incisions consistent with Lap-assisted procedure.
2) Multiple ortho surgeries - left shoulder, upper spine, lower
back, left knee.
3) Patient recalls appendectomy "long time ago"
4) desmoid tumor resection in thoracic spine X3
Social History:
___
Family History:
Mother: positive for DM
Father: positive for gout, gastric ulcers
Brother:healthy
Physical ___:
Admission PE:
VS: 98 124/70 70 18 99 RA
General: AAOX3, NAD
HEENT: OP clear, MMM
CV: RRR, no RMG
Lungs: CTAB no WRR
Abdominal: obese, active BS X4, no rebound or guarding, mild TTP
in epigastric region, soft
Extremities: WWP, pulses 2+ and equal
Neuro: CN's, MS, sensation and strength wnl
Psyc: mood and affect wnl
.
Discharge PE
VS Tm-98.5 Tc-97.5 BP 116/62 HR 56 RR 20 SaO2: 100 RA
General: AAOX3, NAD
HEENT: OP clear, MMM
CV: bradycardic, otherwise RRR, no RMG
Lungs: CTAB, no WRR
Abdomen: ND, mild TTP in epigastrum, no HSM, no rebound and no
guarding
Extremities: WWP, no edema, pulses 2+ and equal
Neuro: CNs and MS wnl, strength, sensation wnl, and gait wnl
Psyc: patient continues to have mood lability and is tearful at
times
.
Pertinent Results:
___ 11:54PM LACTATE-1.4
___ 11:46PM GLUCOSE-94 UREA N-7 CREAT-0.7 SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13
___ 11:46PM ALT(SGPT)-7 AST(SGOT)-15 ALK PHOS-114* TOT
BILI-0.3
___ 11:46PM LIPASE-21
___ 11:46PM ALBUMIN-4.3
___ 11:46PM WBC-6.3 RBC-4.55 HGB-12.9 HCT-37.8 MCV-83
MCH-28.3 MCHC-34.0 RDW-15.1
___ 11:46PM NEUTS-54.8 ___ MONOS-6.1 EOS-2.9
BASOS-0.7
___ 11:46PM ___ PTT-32.0 ___
.
OSH ___ ___ Ct with contrast
-Imp: no explaination for acute abdominal pain
-s/p gastric bypass and ccy, no obstruction, 14 cm spleen,
liver adrenal, kidneys and pancreas and remaining bowel are
unremarkable, uterus and ovaries are wnl
-moderate amount of stool present within the colon, appendix is
not defintately visualized, lung bases are clear
.
___ AXR
IMPRESSION:
1. Nonspecific bowel gas pattern without definite evidence of
obstruction.
2. 5-mm nodular opacity overlying the left base should be
further evaluated
with conventional chest radiographs.
.
___ CXR
IMPRESSION:
1) No acute pulmonary process identified.
2) No free air detected beneath the diaphragm
.
CT AP ___
IMPRESSION:
1. Large quantity of oral contrast material within the excluded
stomach,
without clear evidence of reflux via the pancreatobiliary limb,
indicating a
likely communication between the gastric pouch and excluded
stomach. Further
evaluation could be performed with direct visualization or an
upper GI barium
study.
3. Extrahepatic and central intrahepatic biliary ductal
dilation, without
evidence of an obstructing lesion, a finding that can be seen in
patients who
have undergone prior cholecystectomy, although correlation with
right upper
quadrant abdominal pain and LFT's is recommended. Further
evaluation could be
performed with MRCP, if clinically indicated.
3. Possible hepatic steatosis.
4. Mild splenomegaly.
.
___ 11:00 am SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. BuPROPion (Sustained Release) 150 mg PO QPM
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Ferrous Sulfate 325 mg PO DAILY
5. Gabapentin 800 mg PO BID
6. Nicotine Polacrilex 2 mg PO Q1H:PRN tobacco craving
7. Thiamine 100 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Calcium Carbonate 1250 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. BuPROPion (Sustained Release) 150 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. Gabapentin 800 mg PO BID
6. Thiamine 100 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Calcium Carbonate 1250 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H
10. Bismuth Subsalicylate 30 mL PO QID Duration: 14 Days
11. Docusate Sodium 100 mg PO BID
12. Doxycycline Hyclate 100 mg PO Q12H
please do not take with calcium within 2 hours
13. Lorazepam 0.5 mg PO Q4H:PRN anxiety
14. MetRONIDAZOLE (FLagyl) 250 mg PO Q6H Duration: 14 Days
15. Multivitamins 1 CAP PO DAILY
16. Nicotine Patch 14 mg TD DAILY:PRN Tobacco withdrawal
17. Omeprazole 20 mg PO BID
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN severe pain
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Sucralfate 1 gm PO QID
CRUSH AND ADD WATER TO MAKE LIQUID FORM
22. TraMADOL (Ultram) 50 mg PO Q6H:PRN moderate pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Marginal ulcer near the g-j anastomosis
Gastro-gastric fistula
Depression
Anxiety
SVT
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 tenderness. Evaluate for
small bowel obstruction.
COMPARISON: None.
FINDINGS: Upright and supine views of the abdomen were obtained. There is
gaseous distention of a few loops of small bowel. A few air-fluid levels are
identified in the left lower quadrant on the upright view. Oral contrast is
present in the large bowel, which is non-distended. No pneumatosis or
pneumoperitoneum. A 5-mm nodular opacity overlies the left base. Several
surgical clips overlie the right upper abdomen.
IMPRESSION:
1. Nonspecific bowel gas pattern without definite evidence of obstruction.
2. 5-mm nodular opacity overlying the left base should be further evaluated
with conventional chest radiographs.
Findings were communicated via phone call by Dr. ___ to Dr. ___
___ on ___ at 0756 am.
Radiology Report
HISTORY: Gastric bypass. Now acute abdominal pain, question free air,
opacity.
CHEST, TWO VIEWS: No previous chest x-rays on PACS record for comparison.
Possible hyperinflation, consistent with COPD. The heart is not enlarged.
There is no CHF, focal infiltrate, or gross effusion. There is slight
blunting of the left and ? right costophrenic angle posteriorly. At the
periphery of these films, fusion hardware in the cervical spine is
incompletely imaged.
No free air detected beneath the diaphragm. No dilated loops of bowel are
identified in the visualized portion of the upper abdomen. Increased density
in the splenic flexure of the colon suggests oral contrast. Surgical clips are
also noted at the level of the diaphragm posteriorly.
IMPRESSION:
1) No acute pulmonary process identified.
2) No free air detected beneath the diaphragm.
Radiology Report
INDICATION: History of gastric bypass with recurrent abdominal pain. Assess
for presence of ulcer at anastomosis, biliary duct dilatation, pancreatic
pathology, or hernia with strangulation at incision site.
COMPARISON: None.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following the administration of both oral and intravenous contrast material.
A total of 150 cc of Omnipaque intravenous contrast material was administered.
Multiplanar reformats were performed. The total DLP is 883 mGy-cm.
ABDOMEN CT: There is minimal dependent bilateral lower lobe atelectasis. The
liver may be slightly hypodense, possibly indicating fat deposition. No focal
liver lesions are seen. There is mild central intrahepatic biliary duct
dilatation. The common duct is dilated, measuring up to 13 mm, although
tapers to a normal caliber at the level of the pancreatic head (300B:29).
There is no evidence of an intra- or periductal mass. The portal vein is
patent. The patient is status post cholecystectomy. The spleen is mildly
enlarged, measuring up to 13.9 cm in its greatest axial dimension. The spleen
is otherwise unremarkable. The pancreas is normal, without evidence of ductal
dilatation. The adrenal glands are normal. The kidneys are unremarkable,
with symmetric excretion of intravenous contrast material.
The patient is status post Roux-en-Y gastric bypass. A large quantity of oral
contrast material is seen within the excluded stomach and duodenum, as well as
within the proximal portion of the pancreatobiliary limb but with no contrast
within the distal portion of the pancreatobiliary limb, signifying a likely
communication between the gastric pouch and the remnant stomach. Patulousness
of several contrast filled loops of small bowel in the mid right abdomen is
noted without transition point, likely the result of this segment of bowel
being filled with oral contrast material. Oral contrast material passes into
the colon, which is normal in appearance. There is no evidence of bowel
obstruction or wall thickening. No free fluid or free air is seen in the
abdomen. There are no pathologically enlarged abdominal lymph nodes. The
abdominal aorta is normal in caliber. Scattered aortic calcifications are
noted. Surgical clips are seen within the central mesentery.
PELVIS CT: The bladder is unremarkable. The uterus and adnexa are grossly
normal. There is no free fluid in the pelvis. No pathologically enlarged
pelvic lymph nodes are seen.
BONE WINDOW: A 15-mm sclerotic lesion within the right iliac bone (2:71) is
likely a bone island. Additional scattered smaller sclerotic lesions are seen
throughout the pelvis, also most consistent with bone islands. Multilevel
degenerative changes of the thoracolumbar spine are noted, most severe at
L4-L5 and L5-S1. Small metallic densities overlying and within the right
paraspinous musculature are of uncertain etiology (___).
IMPRESSION:
1. Large quantity of oral contrast material within the excluded stomach,
without clear evidence of reflux via the pancreatobiliary limb, indicating a
likely communication between the gastric pouch and excluded stomach. Further
evaluation could be performed with direct visualization or an upper GI barium
study.
3. Extrahepatic and central intrahepatic biliary ductal dilation, without
evidence of an obstructing lesion, a finding that can be seen in patients who
have undergone prior cholecystectomy, although correlation with right upper
quadrant abdominal pain and LFT's is recommended. Further evaluation could be
performed with MRCP, if clinically indicated.
3. Possible hepatic steatosis.
4. Mild splenomegaly.
Updated findings were discussed with Dr. ___ by Dr. ___ at 6:56
p.m. via telephone on the day of the study.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN PERIUMBILIC, UNSPECIFIED CONSTIPATION
temperature: 97.8
heartrate: 88.0
resprate: 20.0
o2sat: 99.0
sbp: 121.0
dbp: 88.0
level of pain: 8
level of acuity: 3.0 | This is a ___ yo F with a PMHx of gastric by pass, idiopathic
intermittent abdominal pain who initially p/t ___
for a clonidine and alcohol overdose, course c/b self limiting
bradycardia and hypotension, transferred to ___ for
psychiatric treatment now transferred to ___ for further
evaluation of about 5 days of RUQ abdominal pain with prior
normal imaging and labs, found to have h. pylori with an
anastomotic ulcer and a gastro-gastric fistula
.
# Gastro-gastric fistula
The patient was evaluated by the ___ surgery team and they
recommended a GI evaluation for further work up. The patient
got an EGD on ___ which showed a marginal ulcer at the g-j
anastomosis and a gastro-gastric fistula which was not amenable
to endoscopic therapy due to the size of the fistula. The
patient was also found to have h. pylori serology. These
findings were discussed with the ___ surgery team and they
felt as though a trial of medical therapy was appropriate with
follow up as an outpatient in ___ weeks. The patient was
agreeable to this and will follow up initially at ___,
although her surgery was done else where.
.
# marginal ulcer in the setting of h. pylori positive serology
A component of the patients pain is also likely due to her ulcer
found on EGD. The patients h/o overdose, alcohol use and h/o
gastric bypass puts her at risk for ulcers and fistulas. The
patients h. pylori serology also came back positive. Her Hgb
was stable during this hospitalization. She will be treated
with quadruple therapy for this with omeprazole 20 BID, bismuth
525 QID, metronidazole 250 QID and doxycycline 100 Q12H for 14
day course (start date is ___ ending ___. This is a
non-conventional regimen due to the patients allergies to pcn
and biaxin (rash) and unavailability of tetracycline at ___.
This issues was discussed with both pharmacy and ID and they
agreed with this regimen. The patients abdominal pain
associated with both her ulcer and fistula were an ongoing
problem in house but did improved and she was able to tolerate a
bariatric diet. She was initially on Dilaudid IV and was
eventually transitioned to oxycodone. Given the patient has
issues with alcohol in past, narcotics should attempt to be
weaned off as her symptoms resolve. The patient had times when
she appears very comfortable and other times where she is in
tears. Her pain has been relatively well controlled for the
past several days on Carafate 1 g QID, oxycodone 15 Q3H prn and
tylenol ___ Q8H standing. Tramadol can also be considered as
the patient is attempting to come off narcotics. There is a
small risk of serotonin syndrome with her current medication
regimen, but pharmacy indicated that this is not a
contra-indication to using this medication.
.
# SVT with episode of symptoms in house
The patient has a known h/o SVT and has had a prior evaluation
by a Cardiologist who suggested a possible ablation in the
future. Anxiety related to pain and her condition seemed to
drive the onset of SVT (which appeared to be AVNRT by EKG). Her
symptoms terminated with vagal maneuvers. The patient was
attempted to be started on metoprolol 12.5 BID, but she had
borderline bradycardia, so this was deferred. She should follow
up with a Cardiologist as an outpatient. Serial cardiac enzymes
were negative following this episode.
.
# Anxiety/Depression with recent suicide attempt with clonidine
and alcohol
The patient has a history in the past of suicide attempts and
alcohol abuse. The patient denies active SI or HI while in
house here. She was followed by psychiatry and had a 1:1 sitter
for the duration of her stay. She had mood lability and was
often tearful during medical evaluations, specifically about her
deceased husband. Much of her anxiety was in regards to having
her pain treated.
.
# Transitional Issues
[] follow up with Bariatric Surgery at ___ in ___ weeks for
further management of her gastro-gastric fistula and
consideration of surgical management
[] complete her 14 day course of antibiotics for her h. pylori
positive ulcer and follow up with her PCP and confirm
eradication with a urea breath test, fecal antigen test, or
upper endoscopy performed four weeks or more after completion of
therapy
[] follow up with Cardiology regarding further management of her
SVT
[] further management and outpatient Psyc services per inpatient
Psyc at ___
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim / rosuvastatin /
atorvastatin
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with history of ESRD from T2DM s/p renal transplant
___, complicated by chronic rejection, currently on Rituxan),
Afib on Coumadin, CAD s/p CABG, TIA, Roux-en-Y bypass,
hypertension, recent admission for diastolic CHF exacerbation,
presenting with dyspnea. Patient reports that after discharge
from recent hospitalization, she felt well and without cough.
About a week ago she noticed increased dyspnea both on exertion
and at rest. Today she started wheezing. Her husband has a pulse
oximeter which showed sats lower ___ on RA. Consulted with their
PCP who recommended she come to the ED for evaluation.
In the ED, initial vitals were: 97.8 91 136/69 18 92% RA
- Exam notable for:
Crackles bilateral lung bases
Bilateral lower extremity edema, left greater than right, at
baseline per patient
- Labs notable for:
Cr 2.1
INR 3.9
BNP 11k
WBC 11.1
Top 0.03 with MB of 3
- Imaging was notable for:
CXR PA & LAT
Stable mild cardiomegaly and central pulmonary vascular
congestion without frank pulmonary edema or focal consolidation.
Renal US
1. Persistent elevated intrarenal artery resistive indices,
overall slightly increased compared to prior (0.82 to 0.87 today
compared to 0.77-0.82 prior study).
2. No hydronephrosis.
- Transplant nephrology was consulted:
- Concern for dCHF exacerbation, OK for diuresis, can use 40mg
IV Lasix.
- If any infectious symptoms, would obtain flu swab
- Renal transplant ultrasound unchanged from prior
- INR elevated, hold warfarin
- Continue home IS in the ED: mycophenolate sodium 360mg QID,
prednisone 5mg daily, tacrolimus 2mg q12h. Check AM tacrolimus
trough.
- Continue home ppx: valganciclovir 450mg daily, dapsone 100mg
daily
- Patient was given: ___ 21:34 IV Furosemide 40 mg
- Vitals prior to transfer: 99.2 86 151/83 22 95% Nasal Cannula
Upon arrival to the floor, patient reports she has been taking
home Lasix as prescribed. Her tacrolimus has been increased to
2mg bid by her nurse manager. She denies history of asthma. No
chest pain, fevers, dysuria. She has been urinating ___ times
daily, which is normal for her. Leg swelling has recently
increased.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
- ESRD s/p living related renal transplant ___. Formerly on
HD via tunneled catheter.
- Type 2 diabetes mellitus.
- History of urinary stones about ___ years ago, status post
prior light lithotripsies
- Hypertension.
- Hypercholesterolemia.
- History of TIA
- Osteoporosis
- Obesity, status post Roux-en-Y gastric bypass in ___.
- Glaucoma
- Abdominal hernia status post repair
- CCY
- C-section
Social History:
___
Family History:
Sister with MI at age ___.
Father died at age ___ due to heart failure.
Mother was a smoker, died at age ___ due to chronic obstructive
pulmonary disease.
No family history of renal disease.
Physical Exam:
Admission
=========
Vital Signs: 98.2 133/70 87 18 96 4L
General: somewhat distressed breathing
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: JVP appears up to mid neck when patient sitting at 90
degrees
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: no crackles, some scattered wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 2+ pitting edema up to knees bilaterally
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge
=========
Vital Signs: 97.8 152/75 81 20 95 Ra
General: Middle-aged female, breathing comfortably on room air.
HEENT: No icterus or injection. No nasal discharge. MMM.
Neck: JVP <10cm.
CV: Irregularly irregular. No m/r/g. No thrills or heaves.
Lungs: Speaking comfortably. No accessory muscle use. Few
scattered wheezes. Mildly decreased breath sounds at lung cases.
No rhonchi or crackles.
Abdomen: Soft, non-distended, non-tender
GU: No suprapubic tenderness
Ext: trace edema
Neuro: Normal mental status. No asterixis.
Pertinent Results:
Admission Labs
==============
___ 07:55PM BLOOD WBC-11.1*# RBC-2.68* Hgb-8.7* Hct-27.6*
MCV-103* MCH-32.5* MCHC-31.5* RDW-15.9* RDWSD-59.9* Plt ___
___ 07:55PM BLOOD Neuts-92.5* Lymphs-1.5* Monos-4.9*
Eos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.25*#
AbsLymp-0.17* AbsMono-0.54 AbsEos-0.01* AbsBaso-0.02
___ 07:55PM BLOOD ___ PTT-47.6* ___
___ 07:55PM BLOOD Glucose-193* UreaN-56* Creat-2.1* Na-134
K-3.8 Cl-100 HCO3-19* AnGap-19
___ 07:55PM BLOOD CK(CPK)-248*
___ 07:55PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
Discharge Labs
==============
___ 04:49AM BLOOD WBC-1.9* RBC-2.38* Hgb-7.5* Hct-24.2*
MCV-102* MCH-31.5 MCHC-31.0* RDW-15.0 RDWSD-55.7* Plt ___
___ 04:49AM BLOOD Neuts-73.0* Lymphs-12.7* Monos-9.0
Eos-3.7 Baso-0.5 Im ___ AbsNeut-1.38*# AbsLymp-0.24*
AbsMono-0.17* AbsEos-0.07 AbsBaso-0.01
___ 04:49AM BLOOD Plt ___
___ 04:49AM BLOOD Glucose-162* UreaN-56* Creat-1.8* Na-137
K-3.6 Cl-103 HCO3-21* AnGap-17
___ 04:49AM BLOOD ALT-48* AST-73* LD(LDH)-403* AlkPhos-54
TotBili-0.8
___ 04:49AM BLOOD Albumin-3.6 Calcium-8.1* Phos-4.0 Mg-2.1
Pertinent Interval Labs
========================
___ 06:13AM BLOOD CK-MB-2 cTropnT-0.03*
___ 07:55PM BLOOD cTropnT-0.03*
___ 07:55PM BLOOD CK-MB-3 ___
___ 04:49AM BLOOD tacroFK-5.4
___ 04:38AM BLOOD tacroFK-4.8*
___ 06:13AM BLOOD tacroFK-4.0*
Imaging & Studies
=================
Renal u/s ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal.
Specifically,
the cortex is of normal thickness and echogenicity, pyramids are
normal, there
is no urothelial thickening, and renal sinus fat is normal.
There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.82 to
0.87, compared
to 0.77-0.82 on the prior study slightly elevated. The main
renal artery
shows a normal waveform, with prompt systolic upstroke and
continuous
antegrade diastolic flow, with peak systolic velocity of 64.3
centimeters/second. Vascularity is symmetric throughout
transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Persistent elevated intrarenal artery resistive indices,
overall slightly
increased compared to prior (0.82 to 0.87 today compared to
0.77-0.82 prior
study).
2. No hydronephrosis.
CXR ___
FINDINGS:
The lungs are well expanded. There is mild central pulmonary
vascular
congestion without frank pulmonary edema. No focal
consolidation is seen.
Postoperative mediastinum with sternotomy wires, surgical clips,
sternotomy
cerclage wires appears unchanged. Mild cardiomegaly is stable.
No pleural
effusion or pneumothorax is seen.
IMPRESSION:
Stable mild cardiomegaly and central pulmonary vascular
congestion without
frank pulmonary edema or focal consolidation.
Microbiology
============
__________________________________________________________
___ 3:39 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to Influenza PCR (results listed under "OTHER" tab)
for further
information..
Respiratory Viral Antigen Screen (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to Influenza PCR (results listed under "OTHER" tab)
for further
information..
__________________________________________________________
___ 1:56 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 1:56 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. Calcitriol 0.25 mcg PO 5X/WEEK (___)
3. Carvedilol 6.25 mg PO BID
4. ClonazePAM 0.5 mg PO QHS:PRN insomnia
5. Dapsone 100 mg PO DAILY
6. HydrALAZINE 100 mg PO BID
7. Mycophenolate Sodium ___ 360 mg PO QID
8. PredniSONE 5 mg PO DAILY
9. Pregabalin 50 mg PO DAILY
10. Simvastatin 20 mg PO QPM
11. Sodium Bicarbonate 650 mg PO BID
12. ValGANCIclovir 450 mg PO Q24H
13. bimatoprost 0.01 % ophthalmic QHS
14. Fish Oil (Omega 3) 1000 mg PO BID
15. Furosemide 40 mg PO BID
16. Tacrolimus 2 mg PO Q12H
17. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
18. Benzonatate 100 mg PO TID
19. Warfarin 2 mg PO DAILY16
20. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
21. Glargine 34 Units Bedtime
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath,
wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
Every 6 hours as needed Disp #*1 Inhaler Refills:*0
2. OSELTAMivir 30 mg PO Q12H
Continue until ___
RX *oseltamivir 30 mg 1 capsule(s) by mouth Twice a day Disp #*5
Capsule Refills:*0
3. Tacrolimus 3.5 mg PO Q12H
RX *tacrolimus 0.5 mg 7 capsule(s) by mouth Twice a day Disp
#*60 Capsule Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. Alendronate Sodium 70 mg PO QMON
6. Benzonatate 100 mg PO TID
7. bimatoprost 0.01 % ophthalmic QHS
8. Calcitriol 0.25 mcg PO 5X/WEEK (___)
9. Carvedilol 6.25 mg PO BID
10. ClonazePAM 0.5 mg PO QHS:PRN insomnia
11. Dapsone 100 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO BID
13. Furosemide 40 mg PO BID
14. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
15. HydrALAZINE 100 mg PO BID
16. Glargine 34 Units Bedtime
17. Mycophenolate Sodium ___ 360 mg PO QID
18. PredniSONE 5 mg PO DAILY
19. Pregabalin 50 mg PO DAILY
20. Simvastatin 20 mg PO QPM
21. Sodium Bicarbonate 650 mg PO BID
22. ValGANCIclovir 450 mg PO Q24H
23. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Flu
Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea, hx CHF// Eval for volume overload
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
CT chest from ___.
FINDINGS:
The lungs are well expanded. There is mild central pulmonary vascular
congestion without frank pulmonary edema. No focal consolidation is seen.
Postoperative mediastinum with sternotomy wires, surgical clips, sternotomy
cerclage wires appears unchanged. Mild cardiomegaly is stable. No pleural
effusion or pneumothorax is seen.
IMPRESSION:
Stable mild cardiomegaly and central pulmonary vascular congestion without
frank pulmonary edema or focal consolidation.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with renal transplant, poss CHF exacerbation// Eval
for evidence of rejection, vascular occlusion to transplant
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound from ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.82 to 0.87, compared
to 0.77-0.82 on the prior study slightly elevated. The main renal artery
shows a normal waveform, with prompt systolic upstroke and continuous
antegrade diastolic flow, with peak systolic velocity of 64.3
centimeters/second. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Persistent elevated intrarenal artery resistive indices, overall slightly
increased compared to prior (0.82 to 0.87 today compared to 0.77-0.82 prior
study).
2. No hydronephrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified, Acute pulmonary edema
temperature: 97.8
heartrate: 91.0
resprate: 18.0
o2sat: 92.0
sbp: 136.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with PMH significant for LRRT ___ and
recent diagnosis of humoral rejection s/p IVIG and rituximab who
presented with dyspnea, cough, wheezing, and hypoxemia. BNP was
elevated to 11,000 and patient had evidence of mild fluid
overload on exam. Additionally, she tested positive for
influenza A. She was diuresed with IV lasix, ultimately with a
lasix ggt at 5mg/hr. She was also started on oseltamivir 30mg
q12h for treatment of influenza and duonebs. Her respiratory
status improved significantly and she was stable on room air on
the day of discharge with ambulatory sat in 92-94% range. Her
tacro level was at 4.8, so her tacro was increased from 2g q12h
to 3.5g BID. She was discharged on her home dose of diuretics
with plan to continue Tamiflu 30mg q12 for 5 day course to end
on ___. She will need repeat labs drawn on ___ at her
follow-up appointment with transplant nephrology.
#Acute on chronic HFpEF (EF 65-70%)
#Acute hypoxic respiratory failure ___ influenza A infection
BNP was elevated at admission to 11k, likely acute on chronic
diastolic HF ___ influenza infection. She was diuresed with
Lasix intravenous bolus and placed on a Lasix ggt at 5mg/hr. Her
respiratory status improved and she was transitioned back to
Lasix 40mg PO BID. She was also found to have influenza A
infection that was likely contributing to acute hypoxic
respiratory failure. Patient was placed on Tamiflu 30mg q12h
(renal dosing) and she had duonebs standing. Her respiratory
status improved significantly and she was stable on room air
after requiring 3L O2 at admission. Ambulatory O2 sat ranged
from 92-94% on the day of discharge. Will be discharged on
albuterol inhaler. 5 day course of Tamiflu will end on ___
(renally dosed to 30mg q12h)
-preload: lasix 40mg BID
-NHBK: c/w carvedilol
-afterload: c/w hydralazine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Hydrocodone
Attending: ___.
Chief Complaint:
RUQ pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy on ___ by Interventional
Radiology
History of Present Illness:
Ms. ___ is a ___ yo F with PMH significant for HLD, CAD s/p
CABG
and multivessel PCI, GERD, HTN, DM initially presenting with
right upper abdominal pain. Patient was in her normal state of
health until approximately 2 days prior to admission when she
began experiencing abdominal pain in her RUQ. This pain
progressed through the day prior to admission, described as a
burning pain that was constant and occasionally sharp. The pain
did not radiate, and was associated with nausea, providing her
with minimal appetite. On the day prior to admission, she
attempted to drink Sprite and eat bread, though had an episode
of
bilious yellow emesis afterwards. She denied any associated
fevers, though did note chills. She also endorsed 5 episodes of
watery brown diarrhea.
Of note, she also denied any night sweats, SOB, dysuria,
hematochezia, or hematuria. She endorses chronic exertional
substernal chest pressure/tightness that has been stable since
her open heart surgery approximately ___ years ago. She did have a
similar episode of chest tightness earlier on the day of
admission, which resolved without intervention
In the ED:
Initial vital signs: T96.3, HR60, BP164/58, RR18, PO298% RA
Exam notable for:
Awake, alert, slightly confused about day of week but
appropriate
responses to all questions, slightly slowed mentation (unclear
baseline), Slightly dry mucous membranes, unable to take a deep
breath due to severe RUQ pain when doing so; severely tender to
moderate (but not light) palpation of the RUQ; she does not have
signs of generalized peritonitis and is not tender to firm
palpation or percussion in LUQ or LLQ.
Labs were notable for:
WBC 11.3, hgb 11.9, ANC 9, INR 1.2, Cr 0.9, UA large ___
protein/10 ketones/49 WBCs/few bacteria/10 epis, AST 25, ALT 17,
AP 70, Tbili 0.4, albumin 4.4, troponin negative x1,
Studies performed include:
-RUQUS: Cholelithiasis in a distended gallbladder, with
gallstone
at the gallbladder neck. Unable to accurately assess for
sonographic ___ sign since the patient was given pain
medication. Ensuing acute cholecystitis not excluded. In
addition, while the common hepatic duct is normal in diameter,
CBD is dilated, and a distal obstructing process such as stone
or
lesion not excluded. Correlate with LFTs and consider MRCP/ERCP
as clinically warranted.
-EKG: NSR rate 60, normal axis, nl intervals, TWI in V1-4 (old)
Patient was given:
IV Morphine Sulfate 4 mg
IV Ondansetron 4 mg
IV Morphine Sulfate 4 mg
IV Ondansetron 4 mg
IV Morphine Sulfate 4 mg
IV Ampicillin-Sulbactam 3 g
IV Morphine Sulfate 4 mg
IV Ampicillin-Sulbactam 3 g
PO Acetaminophen 1000 mg
IV Ondansetron 4 mg
Consults:
- Surgery
- ___
Vitals on transfer: T100.3, HR99, BP161/79, RR16, PO2 97% RA
Upon arrival to the floor, patient is in significant pain and is
endorsing nausea. She denies any fevers or chills, though still
does not have an appetite.
Past Medical History:
-HLD
-CAD s/p CABG and multiple PCI
-HTN
-DM
-OA
-GERD
-s/p partial hysterectomy (remote)
*is scheduled for right rotator cuff repair soon
Social History:
___
Family History:
-Mother: CHF
-Father: died of stroke
-Brother: died of leukemia
-Brother: died of lung disease (heavy smoker)
-Brother: living, has DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: REVIEWED IN ___
GENERAL: Sitting on side of bed, moaning in pain
HEENT: Sclera anicteric, MMM
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. Decreased respiratory
effort ___ pain
ABDOMEN: Normal bowels sounds, tender to palpation in RUQ,
worse
with inspiration
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM:
VITALS: ___ ___ Temp: 98.0 PO BP: 145/71 R Lying HR: 91
RR: 18 O2 sat: 93% O2 delivery: Ra
GENERAL: Elderly woman sitting in chair with eyes open, in NAD
HEENT: Sclera anicteric, MMM
CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB
ABDOMEN: Hypoactive bowels sounds, tender to palpation in RUQ,
worse with inspiration, no rebound or guarding
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm, no rash.
Pertinent Results:
============================
LABS
============================
ADMISSION LABS
___ 07:06PM BLOOD WBC-11.3* RBC-4.42 Hgb-11.9 Hct-36.9
MCV-84 MCH-26.9 MCHC-32.2 RDW-13.3 RDWSD-41.1 Plt ___
___ 07:06PM BLOOD Neuts-79.7* Lymphs-12.0* Monos-6.5
Eos-1.0 Baso-0.4 Im ___ AbsNeut-9.01* AbsLymp-1.36
AbsMono-0.74 AbsEos-0.11 AbsBaso-0.04
___ 07:06PM BLOOD ___ PTT-32.1 ___
___ 07:06PM BLOOD Glucose-156* UreaN-12 Creat-0.9 Na-142
K-4.5 Cl-102 HCO3-24 AnGap-16
___ 01:55PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.2 Mg-1.6
___ 08:39PM BLOOD Lipase-21
___ 08:39PM BLOOD cTropnT-<0.01
___ 08:39PM BLOOD ALT-17 AST-25 AlkPhos-70 TotBili-0.4
DISCHARGE LABS
___ 07:30AM BLOOD WBC-13.4* RBC-3.75* Hgb-10.2* Hct-32.0*
MCV-85 MCH-27.2 MCHC-31.9* RDW-13.6 RDWSD-42.3 Plt Ct-92*
___ 07:30AM BLOOD ___ PTT-24.9* ___
___ 07:30AM BLOOD Glucose-163* UreaN-13 Creat-0.8 Na-133*
K-4.1 Cl-97 HCO3-20* AnGap-16
___ 07:30AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.1*
Mg-1.9
___ 07:30AM BLOOD ALT-26 AST-50* LD(___)-337* AlkPhos-63
TotBili-0.7
============================
IMAGING
============================
___ RUQUS
IMPRESSION
Cholelithiasis in a distended gallbladder, with gallstone at the
gallbladder neck. Unable to accurately assess for sonographic
___ sign since the patient was given pain medication.
Ensuing acute cholecystitis not excluded.
In addition, while the common hepatic duct is normal in
diameter, CBD is
dilated, and a distal obstructing process such as stone or
lesion not
excluded. Correlate with LFTs and consider MRCP/ERCP as
clinically warranted.
___ PERCUTANEOUS CHOLECYSTOSTOMY
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail
catheter into the gallbladder. Samples was sent for microbiology
evaluation.
___ MRCP
IMPRESSION:
1. Findings of acute gangrenous cholecystitis with a
percutaneous
cholecystostomy tube appearing well positioned. There is
persistent mild
distension of the gallbladder lumen and new perihepatic ascites,
which raises concern for a leak around the tube or tube
obstruction. Correlation with tube output is recommended and
confirmation of placement by injection of contrast under
fluoroscopy could be considered.
2. No choledocholithiasis. Mild extrahepatic biliary ductal
dilatation
attributable to a periampullary duodenal diverticulum.
3. Mild hepatic steatosis.
___ T-TUBE CHOLANGIO (POST-OP)
IMPRESSION:
Patent cystic duct with contrast passing into the common bile
duct. No
definite evidence of leak.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
2. Clopidogrel 75 mg PO DAILY
3. diclofenac sodium 1 % topical TID:PRN
4. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO)
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Gabapentin 900 mg PO QHS
10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
11. Humalog ___ 95 Units Breakfast
Humalog ___ 95 Units DinnerMax Dose Override Reason: home
dosage
12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
13. Lactulose 30 mL PO BID
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Nystatin-Triamcinolone Cream 1 Appl TP QID:PRN rash
17. Potassium Chloride 20 mEq PO DAILY
18. promethazine-codeine 6.25-10 mg/5 mL oral Q6H:PRN
19. Ranitidine 300 mg PO DAILY
20. Simvastatin 5 mg PO QPM
21. TraMADol 50 mg PO TID
22. Venlafaxine XR 150 mg PO DAILY
23. Aspirin 81 mg PO DAILY
24. Cetirizine 10 mg PO DAILY
25. Niacin 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID
5. Glargine 75 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
7. Aspirin 81 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Furosemide 20 mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Gabapentin 900 mg PO QHS
15. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
16. Metoprolol Succinate XL 100 mg PO DAILY
17. Niacin 500 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Nystatin-Triamcinolone Cream 1 Appl TP QID:PRN rash
20. Ranitidine 300 mg PO DAILY
21. Simvastatin 5 mg PO QPM
22. TraMADol 50 mg PO TID
23. Venlafaxine XR 150 mg PO DAILY
24. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO)
25. HELD- diclofenac sodium 1 % topical TID:PRN This medication
was held. Do not restart diclofenac sodium until you follow-up
with your PCP
26. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
Pain - Moderate This medication was held. Do not restart
HYDROcodone-Acetaminophen (5mg-325mg) until you follow-up with
your PCP
27. HELD- Lactulose 30 mL PO BID This medication was held. Do
not restart Lactulose until you follow-up with your PCP
28. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you follow up
with your physician (risk of high potassium with bactrim use)
29. HELD- promethazine-codeine 6.25-10 mg/5 mL oral Q6H:PRN
This medication was held. Do not restart promethazine-codeine
until you follow-up with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
===================
PRIMARY DIAGNOSIS
===================
Acute cholecystitis
===================
SECONDARY DIAGNOSIS
===================
Coronary artery disease
Type 2 diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with acute cholecystectomy and ?CBD dilatation,
evaluate for stone.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Liver gallbladder ultrasound dated ___.
FINDINGS:
Lower Thorax: There is no pleural or pericardial effusion. There is mild
elevation of the right hemidiaphragm.
Liver: Liver morphology is normal. There is no suspicious liver lesion. Drop
in signal intensity on T1-weighted GRE out of phase imaging compared with in
phase imaging is consistent with mild hepatic steatosis with an estimated fat
fraction of 7.5%. Portal and hepatic veins are patent.
Biliary: There is extensive gallbladder wall edema and surrounding fat
stranding with areas of hypoenhancement of gallbladder wall consistent with
acute partially gangrenous cholecystitis. A cholecystostomy tube appears to
terminate within the lumen, however the lumen remains mildly distended and
there is new small to moderate perihepatic ascites. There is a large stone
lodged at the gallbladder neck with surrounding hyperemia (16:58, 4:31). The
common bile duct is mildly dilated measuring up to 9 mm in diameter (04:35).
There is no choledocholithiasis. There is an abrupt transition point in bile
duct caliber in the region of a large periampullary duodenal diverticulum.
Pancreas: Normal in signal intensity and morphology without focal lesion or
ductal dilatation.
Spleen: Normal in size.
Adrenal Glands: Unremarkable.
Kidneys: There is no suspicious renal lesion or hydronephrosis.
Gastrointestinal Tract: Visualized loops of large small bowel are
unremarkable.
Lymph Nodes: No suspicious lymphadenopathy.
Vasculature: Unremarkable.
Osseous and Soft Tissue Structures: No suspicious osseous lesion.
IMPRESSION:
1. Findings of acute gangrenous cholecystitis with a percutaneous
cholecystostomy tube appearing well positioned. There is persistent mild
distension of the gallbladder lumen and new perihepatic ascites, which raises
concern for a leak around the tube or tube obstruction. Correlation with tube
output is recommended and confirmation of placement by injection of contrast
under fluoroscopy could be considered.
2. No choledocholithiasis. Mild extrahepatic biliary ductal dilatation
attributable to a periampullary duodenal diverticulum.
3. Mild hepatic steatosis.
Radiology Report
INDICATION: ___ year old woman with acute cholecystitis; on ASA Plavix for
stable CAD w/ remote hx of stents ___ last dose of both ASA Plavix
was ___// placement of cholecystostomy for acute cholecystitis**Please send
any fluid obtained for gram stain culture**
COMPARISON: Ultrasound from ___
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ personally supervised the trainee
during the key components of the procedure and reviewed and agrees with the
trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in aslight left decubitus position on the ultrasound
table. Limited preprocedure imaging was performed to localize the gallbladder.
An appropriate skin entry site was chosen and the site marked. Local
anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ drainage catheter
was advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the collection. The plastic
stiffener was removed. The pigtail was deployed. The position of the pigtail
was confirmed within the collection via ultrasound. Ultrasound images were
stored on PACS.
Approximately 110 cc of serosanguinous fluid was drained with a sample sent
for microbiology evaluation. The gallbladder was under pressure. The catheter
was secured by a StatLock. The catheter was attached to bag. Sterile dressing
was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 75 mcg fentanyl throughout the total intra-service time of 14
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
There is redemonstration of the distended gallbladder.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Radiology Report
EXAMINATION: T-TUBE CHOLANGIO (POST-OP)
INDICATION: ___ year old woman with acute gangrenous cholecystitis s/p PCN.
Looking more septic clinically and with new perihepatic ascites on MRCP
concerning for tube leak// ? PCN leak given MRCP finding of new perihepatic
ascites
TECHNIQUE: Water soluble contrast was hand injected into the pre-existing
cholecystostomy tube. Selected fluoroscopic images were obtained.
DOSE: Acc air kerma: 21 mGy; Accum DAP: 513.6 uGym2; Fluoro time: 01:22
COMPARISON: MRCP dated ___
FINDINGS:
Contrast readily opacified the gallbladder and cystic duct, passing freely
into the common bile duct and retrograde into the intrahepatic ducts. Filling
defect at the fundus of the gallbladder corresponds to gallstone seen on
recent MRCP.
IMPRESSION:
Patent cystic duct with contrast passing into the common bile duct. No
definite evidence of leak.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Upper abdominal pain
Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction, Unspecified abdominal pain
temperature: 96.3
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 164.0
dbp: 58.0
level of pain: 10
level of acuity: 3.0 | P - Patient summary statement for admission
===========================================
___ with PMH of HLD, CAD s/p CABG and multiple PCI, GERD, HTN,
DM presenting with RUQ abdominal pain, nausea, and vomiting.
A - Acute medical/surgical issues addressed
===========================================
# Acute cholecystitis
Patient presented with acute onset progressive RUQ pain, fevers,
and leukocytosis consistent with acute cholecystitis. Initially
tachycardic to HR 110s but otherwise HDS and reassuringly, LFTs
and lipase wnl. ___ performed percutaneous cholecystostomy on
___. She was kept NPO, received IVF resuscitation and IV
morphine and acetaminophen for pain control, and was initially
treated with Unasyn. Bile culture from cholecystostomy grew E.
coli resistant to ampicillin and intermediate resistance to
Unasyn. ___ MRCP demonstrated acute gangrenous cholecystitis
without choledocolithiasis. New perihepatic ascites was noted on
MRCP, however ___ tube study did not show definite evidence of
leak. Afebrile since the morning of ___, when she was switched
from Unasyn to Zosyn. Clinically improved on conservative
management with decreased pain (last dose of morphine on ___
am) and improvement in leukocytosis and tachycardia. On day of
discharge she was tolerating full PO diet without issue and she
was transitioned from Zosyn to Bactrim on ___ with plan to
continue Bactrim until cholecystectomy. Surgery (ACS) evaluated
patient and recommended continuing conservative management
followed by cholecystectomy as outpatient after acute infection
is cleared. Physical Therapy evaluated patient and recommended
___ rehab.
# CAD
Pt has an extensive history of CAD with chronic stable angina
s/p CABG in ___, and most recently DES to PL in ___.
Positive cardiac stress test (___). Patient follows with Dr.
___ was evaluated in the ED by Cardiology. She has chronic
exertional angina but reassuringly EKG with no interval change
and trop negative this admission. At last appointment with Dr.
___ was discussion regarding possible diagnostic
angiogram if symptoms worsened. Exertion at level of ___ METS
brings on typical angina. Cardiology was consulted when surgical
intervention during this admission was being considered,
recommended holding clopidogrel for 3 days prior to
cholecystectomy if warranted. Home clopidogrel 75mg QD was
initially while surgical intervention during this admission was
considered, then restarted on ___ as clinical status improved.
Continued home ASA, simvastatin, fractionated home metoprolol.
Home Lasix was held ___ infection and relative hypotension.
# IDDM
On home Humalog ___ 95 units SC daily. While NPO she was given
50U Lantus qhs with HISS.
C - Chronic issues pertinent to admission
===========================================
#HTN
Continued home metoprolol tartrate 25mg Q6H (fractionated). Home
isosorbide mononitrate and lasix held in setting of infection
and SBPs ___.
#HLD
Continued home simvastatin 5mg po daily.
#GERD
Continued home ranitidine 300mg po daily.
#Vitamin D Deficiency
On home 50,000 ergocalciferol q2 weeks.
#Chronic Pain
#Diffuse Osteoarthritis
Continued home tramadol 50mg po TID. Continued gabapentin 300mg
po am and afternoon and gabapentin 900mg po qhs. Vitamin D
supplementation as above. Home Vicodin held while patient
received morphine.
#Asthma
#Allergic Rhinitis
Continued albuterol inhalers prn and home cetirizine.
#Depression
Continued venlafaxine 150mg po daily
T - Transitional Issues
===========================================
[] Plan for cholecystectomy after acute infection: We will
continue antibiotic treatment with Bactrim (sensitive on bile
culture) until patient follows up with surgery in clinic. Per
surgery team, will arrange follow-up in ___ weeks and likely
plan for surgery in ___ weeks. Percutaneous cholecystostomy
tube management per surgery team.
[] Clarify plan with Cardiology regarding how long to hold
Plavix prior to cholecystectomy. Patient has follow-up
appointment on ___ during which a plan should be made
detailing went to stop Plavix prior to surgery.
[] F/u BP and electrolytes in 1 week: home isosorbide
mononitrate, Lasix 20mg QD and potassium repletion 20mEq QD held
this admission in setting of infection and SBPs ___
restart as tolerated.
[] F/u blood glucose levels, insulin regimen: on home Humalog
___ 95 units SC daily, has been getting 50U glargine QHS
during this admission while mostly NPO. FSBGs mostly in
100s-200s, but had a BG of 409 the morning of discharge after
having breakfast. Would recommend uptitrating towards home dose
prn as PO intake increases.
[] Consider changing to high intensity statin if able given
significant cardiovascular disease.
#CODE: Full, confirmed
#CONTACT: ___ (husband) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
metformin
Attending: ___.
Chief Complaint:
Diplopia and vertigo
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male presented after a fall tonight. He was recently
diagnosed with a large cerebellar mass which he has been
symptomatic from, with double vision and ataxia. The fall
occurred after he had difficulty judging where a step was. Per
the patient, after he had a MRI demonstrating a large right
mostly cystic cerebellar lesion which extends into the
cerebellar
pontine angle, he has been attempting to establish care with a
neurosurgeon. The patient has been symptomatic since ___ of
this
year with right facial numbness, diplopia, and ataxia. He
endorses a number of recent frequent falls.
Past Medical History:
HLD
Hypothyroidism
Diabetes
Social History:
___
Family History:
mother and sister had breast CA
Physical Exam:
Upon Discharge:
Exam:
Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious
Orientation: [X]Person [X]Place [X]Time
Follows commands: [ ]Simple [X]Complex [ ]None
Pupils: Right ___ Left ___
EOM: [ ]Full [X]Restricted / bilateral partial ___ nerve palsy
Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No
Pronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No
Comprehension intact [X]Yes [ ]No
Bilateral dysmetria L>R
Motor:
DeltoidBicepTricepGrip
IPQuadHamATEHLGast
Pertinent Results:
OSH MRI: Right cerebellopontine angle mass which is enhancing
and mostly
cystic. Approximately 3x4cm in size and likely represents a
vestibular schwannoma. Significant mass effect on ___ ventricle
but no hydrocephalus.
___ CTA Head:
IMPRESSION:
1. No evidence of dissection, occlusion, stenosis, or aneurysm
formation
within the great vessels of the head or neck.
2. Re-demonstration of a hypodense mass at the right
cerebellopontine angle measures 4 cm x 3 cm and is pressing upon
the brainstem, compatible with likely vestibular schwannoma as
visualized on prior MR from ___.
3. Basilar artery and right vertebral artery appear closely
adjacent to the previously characterized mass, however neither
appears to be encased by the mass.
Medications on Admission:
atorvastatin, Humalog, lisinopril, levothyroxine, victiva
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 4 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Senna 8.6 mg PO QHS
7. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Humalog 22 Units Breakfast
Humalog 22 Units Lunch
Humalog 22 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Atorvastatin 20 mg PO QPM
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right cerebellopontine angle mass
Bilateral partial ___ nerve palsy
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with history of CPA lesion. Pre-operative
evaluation.
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 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 =
746.8 mGy-cm.
2) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 13.3 mGy (Body) DLP = 522.6
mGy-cm.
3) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 24.3 mGy (Body) DLP =
12.1 mGy-cm.
Total DLP (Body) = 535 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Head CT from ___. MRA from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
A hypodense mass at the right cerebellopontine angle measuring 4 cm x 3 cm is
pressing upon the brainstem, compatible with likely vestibular schwannoma as
visualized on prior MR from ___. No evidence of infarction or
hemorrhage. The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without dissection, stenosis, occlusion, or aneurysm formation.
The right ___ appears mildly enlarged/dominant, while the right AICA is not
visualized on this exam. The hypodense mass at the right cerebellopontine
angle appears to abut the basilar artery as well as the right vertebral
artery, however neither appears to be encased by the mass. The dural venous
sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
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. No evidence of dissection, occlusion, stenosis, or aneurysm formation
within the great vessels of the head or neck.
2. Re-demonstration of a hypodense mass at the right cerebellopontine angle
measures 4 cm x 3 cm and is pressing upon the brainstem, compatible with
likely vestibular schwannoma as visualized on prior MR from ___.
3. Basilar artery and right vertebral artery appear closely adjacent to the
previously characterized mass, however neither appears to be encased by the
mass.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Disorder of brain, unspecified, Fall on same level, unspecified, initial encounter
temperature: 97.7
heartrate: 104.0
resprate: 22.0
o2sat: 95.0
sbp: 150.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to neurosurgery service after a fall
with large cystic cerebellopontine angle mass.
#CPA mass
He was started on Decadron for cerebral edema. He underwent CTA
for operative planning. Ophthalmology evaluated patient and
findings were consistent with bilateral ___ nerve compression,
causing his diplopia. Given the mass location, Dr. ___
___ transfer to ___, Dr. ___. Patient and HCP
were updated and in agreement. An Audiogram was done on ___
prior to transfer to ___.
#Dysphagia
SLP evaluated patient and he was found to have intermittent
aspiration with thin liquids. He was put on nectar thick diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Compazine / Compazine Tablets / Reglan
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy/ lysis of adhesions
History of Present Illness:
___ well known to surgical service, with history of
multiple SBOs s/p exploratory laparotomies for the same (last
one
___ who presents with diffuse abdominal pain associated with
several episodes of nausea and one episode of bilious emesis. Of
note, admitted to ___ surgical service on ___ for same
issue. Treated with conservative measures and was discharged
home
with normal return of bowel function and tolerating regular
diet.
After discharge, reports feeling weak at home with intermittent
chronic abdominal pain, episodic cramping. Overall poor oral
tolerance. Nausea began acutely last night and lasted throughout
day. Per daughter, pt vomited approximately 750 ml dark brown
material. Patient claims to continue passing flatus with small
BM
this AM. Pain is now severe and diffuse with distention. NGT
placed but pt still nauseous even with NGT.
ROS:
(+) per HPI, otherwise negative
Past Medical History:
multiple SBOs, atrial fibrillation, SMA atherosclerosis,
blindness secondary to juvenile glaucoma, osteoarthritis,
neurogenic bladder requiring straight caths, s/p open
appendectomy (approx ___, s/p open cholecystectomy (approx
___, s/p ex-lap/LOA for SBO ___ ___,
ex-lap for SBO (___), s/p ex-lap for SBO (___), s/p right
shoulder surgery, s/p bilateral hip surgery, s/p multiple eye
surgeries
Social History:
___
Family History:
Sisters with breast and cervical Ca, both parents
with CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Temp 97.0 HR 85 BP 101/66 RR 18 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregularly irregular, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Distended, diffusely tender but more in RLQ with TTP,
voluntary, guarding, no rebound, no palpable masses
Rect - deferred
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
VS: 98.4 97.9 54 134/66 18 97ra
Gen: NAD, A/Ox3
Card: RRR
Lungs: CTA bil
Abd: soft, no rebound/guarding, minimally tender to palpation,
mildy distended
Wound: C/D/I, mild erythema around staples
Ext: no CCE
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-14.6*# RBC-5.58*# Hgb-16.6*#
Hct-49.5*# MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 Plt ___
___ 08:30PM BLOOD ___ PTT-29.8 ___
___ 08:30PM BLOOD Glucose-169* UreaN-23* Creat-1.7* Na-138
K-4.7 Cl-96 HCO3-27 AnGap-20
___ 09:05AM BLOOD Albumin-3.4* Calcium-8.3* Phos-2.9 Mg-1.9
___ 08:46PM BLOOD Lactate-3.4*
___ 01:28PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-3.4* RBC-3.56* Hgb-10.5* Hct-32.2*
MCV-90 MCH-29.4 MCHC-32.5 RDW-14.6 Plt ___
___ 05:35AM BLOOD Glucose-118* UreaN-24* Creat-0.4 Na-135
K-4.4 Cl-105 HCO3-24 AnGap-10
___ 05:35AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.8
___ 08:59AM BLOOD Triglyc-391*
___ 08:59AM BLOOD PREALBUMIN-Test
IMAGING:
CT A/P - High grade small bowel obstruction with transition
point
in right lower quadrant. No evidence of ischemia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lisinopril 10 mg PO BID
5. Metoprolol Succinate XL 25 mg PO HS
6. Travatan Z (travoprost) 0.004 % OD DAILY
7. ___ 128 (sodium chloride) 5 % OS BID
8. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES
___
9. Cephalexin 250 mg PO EVERY OTHER DAY
10. Combigan (brimonidine-timolol) 0.2-0.5 % ___ BID
11. AcetaZOLamide S.R. 500 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES
___
2. Travatan Z (travoprost) 0.004 % OD DAILY
3. Senna 1 TAB PO BID:PRN constipation
4. Pantoprazole 40 mg PO Q24H
5. ___ 128 (sodium chloride) 5 % OS BID
6. Metoprolol Succinate XL 25 mg PO HS
7. Lisinopril 10 mg PO BID
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*1
9. Digoxin 0.25 mg PO DAILY
10. Combigan (brimonidine-timolol) 0.2-0.5 % ___ BID
11. Cephalexin 250 mg PO EVERY OTHER DAY
12. Aspirin 325 mg PO DAILY
13. AcetaZOLamide S.R. 500 mg PO DAILY
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
15. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg ___ tablet(s) by mouth every 8 hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of SBO, one day of nausea and vomiting; evaluate for SBO.
COMPARISON: CT abdomen and pelvis on ___.
TECHNIQUE: MDCT images were obtained through the abdomen and pelvis with IV
and oral contrast. Coronal and sagittal reformations were performed.
FINDINGS: There is mild dependant atelectasis bilaterally. The visualized
heart and pericardium are unremarkable. An enteric tube ends in the stomach.
The liver enhances homogeneously and there are no focal hepatic lesions. The
gallbladder is not well visualized. The pancreas enhances normally and there
are no focal pancreatic lesions. The spleen is normal. The adrenal glands
are normal. There are subcentimeter hypodensities in the kidneys that are too
small to characterize. Otherwise, kidneys are unremarkable. No
hydronephrosis.
The stomach is distended. Multiple loops of dilated small bowel and a
transition point in the right lower quadrant (601B, 26), with collapsed distal
ileum. The colon is also relatively decompressed. There is no bowel wall
thickening or ascites. There is no pneumatosis or portal venous gas. There
is no retroperitoneal or mesenteric lymphadenopathy. There is no free air.
There is a relatively narrow channel for the duodenum and left renal vein
between the aorta and superior mesenteric artery, unchanged, but without clear
evidence for functional obstruction.
PELVIS: The rectum is normal. The bladder contains a Foley catheter and air.
No free fluid in the pelvis. The uterus and adnexa are not well visualized.
The aorta is normal in caliber and there are mild-to-moderate atherosclerotic
calcifications.
BONES: There are multiple compression fractures throughout the lower thoracic
and lumbar spine, unchanged compared to ___.
IMPRESSION:
High-grade small-bowel obstruction with a transition point in the right lower
quadrant.
These findings were discussed with Dr. ___ by Dr. ___ at 2:15
a.m. on ___ in person at the time of discovery.
Radiology Report
ABDOMEN FILMS ON ___
HISTORY: Worsening distention and nausea.
FINDINGS: Again seen are multiple dilated loops of small bowel with air-fluid
levels compatible with patient's known small bowel obstruction. A loop in the
mid abdomen measures up to 7.6 cm. There is a paucity of colonic gas. No
free air is identified.
IMPRESSION: Continued small-bowel obstruction with worsening dilatation of
small bowel loop in the mid abdomen.
Radiology Report
CHEST, ___
HISTORY: New left PICC line.
FINDINGS: There is a new left-sided PICC line. the tip crosses midline and
extends more laterally than typical before pointing centrally. it is unclear
if this is in the SVC. Lateral radiograph would be helpful. There is volume
loss in both lower lungs. NG tube tip is in the stomach. Again seen are
dilated loops of bowel in the visualized portions of the abdomen.
Radiology Report
CHEST, TWO VIEWS, ___
HISTORY: Small-bowel obstruction. Check PICC line.
FINDINGS: Again seen are dilated loops of bowel with air-fluid levels in the
upper abdomen. There is volume loss at both bases. The PICC line appears to
be in the distal SVC.
Radiology Report
CHEST ON ___
HISTORY: New PICC line.
FINDINGS: PICC line tip is in the SVC. NG tube tip is in the stomach. Again
seen are dilated loops of bowel in the abdomen. There is volume loss at both
bases.
Radiology Report
HISTORY: Recurrent SBO. Preop for possible small bowel resection.
CHEST, SINGLE AP PORTABLE VIEW.
___ chest x-ray.
An apparent NG tube is present, coiled in the stomach with tip overlying the
expected site of the fundus. A left-sided PICC line is present, tip over
proximal/mid SVC. No pneumothorax is detected.
Heart size is at the upper limits of normal and the aorta is tortuous,
unchanged. No CHF, focal infiltrate or gross effusion is identified. New
minimal blunting of the right costophrenic angle is seen. Trace
atelectasis/scarring at both bases is again noted. No CHF or focal
infiltrate.
IMPRESSION: No significant change compared with ___. Possible small right
effusion. Otherwise, no acute pulmonary process identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Vomiting
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 96.2
heartrate: 94.0
resprate: 16.0
o2sat: 95.0
sbp: 113.0
dbp: 70.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the ___ ED on ___, two days out
from prior discharge due to intermittent chronic abdominal pain,
cramping and increaing nausea. An NG tube was placed and CT
abdomen/pelvis showed high grade small bowel obstruction. She
was subsequently admitted to the ___ surgery service
and treated intially with bowel rest, NG tube and TPN. Given her
reoccurrance and the fact she was not showing signs of
improvement she ultimately underwent an exploratory laparotomy
with Dr. ___.
GI: She was made NPO and IV fluids were initiated. Nausea was
treated with IV ondasetron and ativan. Due to poor nutritional
status a PICC line was placed and patient was placed on TPN. Her
diet was advanced as her bowel function returned slowly until
she was placed on a regular diet on POD10, which she tolerated
well. She was tolerating a regular diet at discharge on POD11,
passing flatus and stool.
CV: Vital signs were routinely monitored and the patient
remained hemodynamically stable
Pulm: There were no respiratory issues. Extubated after surgery
without issues.
Neuro: Pain was controlled with IV morphine and acetaminophen.
She was transitioned to PO medications upon d/c.
GU: Foley ___ was placed upon admission for urinary output
monitoring and discontinued; the patient returned to straight
caths for neurogenic bladder which she had been preforming at
home. She did have a urine analysis and urine culture performed
as there was residue seen on the foley cathater tubing, but no
urinary tract infection was found to be treated.
PPX: The patient received subq heparin and wore SCDs.
-------------------- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine / Tramadol
Attending: ___.
Chief Complaint:
Abdominal pain, coffee ground emesis
Major Surgical or Invasive Procedure:
R IJ placement
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history
of Type 1 diabetes on insulin, ESRD on HD (___), and
gastroparesis with history ___ tears who presents
with abdominal pain, nausea, and dark brown emesis. Pt was
recently discharged from ___ on ___ for hematemesis vs
hemoptysis and gastroparesis and her abdominal pain had been
controlled. Since her discharge, she went to HD on ___ and
was feeling well through the weekend. This morning, the patient
awoke complaining of severe ___ epigastric pain. She also was
vomiting with small amounts of dark-brown emesis and unsure if
"coffee-ground" appearance. She reports taking her medications
including her insulin up until yesterday, though did not take
her insulin this morning as she was feeling ill.
In the ED, initial vitals: 97.9 ___ 98% RA
Exam/labs were notable for: WBC 12.1 Hct 32.8 Plt 174
NA 127 K 5.6 Cl 87 HC03 24 BUN 53 Cr 7.5 Glucose 1245
Imaging showed: 1. Right central venous catheter with tip in the
upper right atrium. No pneumothorax. 2. Severe pulmonary edema,
significantly worsened since the previous exam.
Patient was given: Zofran, Dilaudid, labetalol 10 mg IV x1
On transfer, vitals were: HR 105 BP 200/122 RR 20 99% 2L NC
On arrival to the MICU T:97.5 BP:167/109 P:92 R:18 O2: 98% 2L
Past Medical History:
- DM1 complicated by nephropathy, gastroparesis
- ESRD, started HD ___
- Severe anxiety and panic attacks
- Depression with psychotic features followed by Dr. ___
- Hyperlipidemia
- Esophagitis due to H. pylori s/p triple therapy in ___
- Chronic low back pain s/p MVA in ___
Social History:
___
Family History:
Grandmother (deceased) with DM
Physical Exam:
ADMISSION
Vitals- T:97.5 BP:167/109 P:92 R:18 O2: 98% 2L
GENERAL: Alert, tired appearing, moaning
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, R IJ in place, oozing blood
LUNGS: Bibasilar crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, diffusely tender
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Tired but oriented x3
.
DISCHARGE
Vitals- 98.4 HR 90 BP 153/92 RR17 98% O2sat RA
blood glucose: 573->300s->200s
General- A+Ox3, drowsy
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- well healed midline scare, soft, minimally 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, RUE fistula with palpaple thrill and audible bruit
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 11:59AM BLOOD WBC-12.1*# RBC-3.04* Hgb-9.0* Hct-32.8*
MCV-108*# MCH-29.6 MCHC-27.4* RDW-17.0* Plt ___
___ 11:59AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 ___ Myelos-0
___ 11:59AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-1+ Envelop-OCCASIONAL Bite-OCCASIONAL
___ 12:15PM BLOOD ___ PTT-58.6* ___
___ 11:59AM BLOOD Glucose-1245* UreaN-53* Creat-7.5*#
Na-127* K-5.6* Cl-87* HCO3-24 AnGap-22*
___ 11:59AM BLOOD ALT-102* AST-96* AlkPhos-307* TotBili-0.4
___ 11:59AM BLOOD Lipase-50
___ 11:59AM BLOOD Albumin-3.9 Calcium-8.9 Phos-8.3*# Mg-2.6
___ 12:05PM BLOOD ___ Temp-36.6 pO2-84* pCO2-35
pH-7.43 calTCO2-24 Base XS-0 Comment-PERIPHERAL
___ 12:05PM BLOOD Glucose-GREATER TH Lactate-1.5
___ 03:25PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:25PM URINE Blood-SM Nitrite-NEG Protein->600
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 03:25PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-16
.
DISCHARGE LABS
.___ 05:03AM BLOOD WBC-8.6 RBC-3.20* Hgb-9.4* Hct-31.9*
MCV-100* MCH-29.3 MCHC-29.4* RDW-16.6* Plt ___
___ 05:03AM BLOOD Glucose-573* UreaN-51* Creat-8.5*#
Na-128* K-5.5* Cl-90* HCO3-25 AnGap-19
___ 05:03AM BLOOD Calcium-8.8 Phos-5.8* Mg-2.5
IMAGING
___ Imaging UNILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ Imaging CHEST (PORTABLE AP)
1. Right central venous catheter with tip in the upper right
atrium. No pneumothorax.
2. Severe pulmonary edema, significantly worsened since the
previous exam.
___ Imaging Chest (AP/Lateral)
No acute cardiopulmonary abnormalities resolved pulmonary edema
MICROBIOLOGY
___ URINE CULTURE - Contaminated
___ BLOOD CULTURE - pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Benzonatate 100 mg PO TID
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 40 mg PO DAILY
5. Labetalol 400 mg PO TID
6. Lorazepam 0.5 mg PO DAILY:PRN anxiety
7. Metoclopramide 5 mg PO QIDACHS
8. Nephrocaps 1 CAP PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
11. Pantoprazole 40 mg PO Q12H
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Labetalol 400 mg PO TID
4. Lorazepam 0.5 mg PO DAILY:PRN anxiety
5. Metoclopramide 5 mg PO QIDACHS
6. Nephrocaps 1 CAP PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
9. Pantoprazole 40 mg PO Q12H
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
11. Furosemide 40 mg PO DAILY
12. Glargine 6 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. hyperglycemia
2. insulin dependent diabetes mellitus
3. end stage renal disease, on hemodialysis
4. hypertension
5. gastroparesis
6. abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with RIJ CVL // presence of ptx, proper CVL placement
TECHNIQUE: Single AP view of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
A new right internal jugular approach central venous catheter is present with
tip terminating in the upper right atrium.There is no pneumothorax or large
pleural effusion. Moderate cardiomegaly is unchanged. The mediastinal and
hilar contours are unremarkable. The lungs are well-expanded without focal
consolidation concerning for pneumonia. Severe pulmonary edema, again showing
a more confluent pattern in the right lower lung but now also affecting the
upper lobes and the left perihilar area, is worsened compared to the most
recent prior study.
IMPRESSION:
1. Right central venous catheter with tip in the upper right atrium. No
pneumothorax.
2. Severe pulmonary edema, significantly worsened since the previous exam.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 2:05 ___.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ y/o poorly controlled T1DM, ESRD on HD, and gastroparesis who
presented with hemoptysis, nausea, vomiting, and abdominal pain found to have
elevated blood sugars in and acidosis, consistent with DKA with left leg pain.
Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity DVT study from ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Prominent but
morphologically normal lymph nodes are noted in the left groin, the largest
measuring 1.4 (Trv) x 0.7 (Short axis, AP) x2.4 (CC) cm.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with IDDM, ESRD, and HTN admitted for abdominal
pain, hyperglycemia, and volume overload. // Prior CXR on this admission
showed ?interstitial changes. Are these still present now that pt is
euvolemic?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Mild to moderate cardiomegaly is stable. The lungs are clear. There is no
pneumothorax or pleural effusion. The osseous structures are unremarkable
right IJ catheter tip is in the lower SVC
IMPRESSION:
No acute cardiopulmonary abnormalities resolved pulmonary edema
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with DIAB HYPEROSM COMA IDDM, DIAB NEURO MANIF IDDM, GASTROPARESIS, GASTROINTEST HEMORR NOS, RENAL FAILURE, UNSPECIFIED
temperature: 97.9
heartrate: 100.0
resprate: nan
o2sat: 98.0
sbp: 208.0
dbp: 134.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of poorly controlled
T1DM, ESRD on HD, and gastroparesis who presented with
hemoptemesis, nausea, vomiting, and abdominal pain found to have
elevated blood sugars in and acidosis, most consistent with HHS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / fentanyl
Attending: ___
Chief Complaint:
Chest pain and headache
Major Surgical or Invasive Procedure:
Cardiac catheterization (no stents placed)
History of Present Illness:
Ms. ___ is a ___ yo woman with multiple cardiovascular risk
factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p stent
with prior MI in ___, CVAs x2 including left occipital stroke
in ___, lung CA s/p chemotherapy and surgery, atypical chest
pain, who presents with headache and chest pain.
She reports having an ___ headache that started 4 days ago and
___ chest pain that started on ___. She reports
that the CP radiated to her neck and arm and she experienced a
tingling in her right hand. She took her morning aspirin on
___ and then again in the evening when she had the chest
pain and nitroglycerin x2 which "helped a little" to relieve the
CP. She reports that her current symptoms are identical to those
she had several months ago. Because the CP and headache did not
resolve she presented the next day on ___ to the ___ ED.
Per cardiology note from the ED, she has continued to have CP
since her cath in ___. Her hx is variable and she is a
poor/vague historian. Activity is limited. The CP comes on at
any time, including at rest. No apparent provocation by eating
or exertion. She has been tried on pantoprazole, without effect,
and was given nitro to take prn by Dr. ___. Her cardiologist.
About 10 ___ last night, she began to have recurrent lower
retrosternal and L parasternal chest pressure, which incr with
breathing in, and rad into the neck and the arms. She describes
taking ASA and nitro without effect, but then says that she had
recurrent epis which lasted ___ sx. Says that sx are similar to
those prior to card stent and similar to CP which has been
recurring since the stenting. Has been having a HA for 4 days.
In the ED, her BP was 111/68, HR 80, 96% sat on RA, afebrile.
Per the cardiology evaluation in the ED, there was no evidence
JVD at 45% on stretcher. Her lungs were clear and she had
discomfort to pressure on the lower sternal and L parasternal
areas. She had no audible M/R/G. No palp liver. No edema or calf
tenderness.
LABS: Hgb 10.0 (prior Hgb 9.9-10.8 in ___. Nl W and plat. BS
___. Nl BUN/Cr and lytes. Nl LFT's. Trop <0.01 x 2. Nl D-dimer.
EKG in ambulance and here: within normal limits. No change CPT
of ___.
On transfer to the floor, vital signs were Tc 97.5 BP 132/51 HR
70 RR 20 O2 100% on RA. She continues to endorse ___ chest pain
and ___ headache and is frustrated at having to recount her
history and confirm her medications. She was upset that an
allergy to fentanyl was listed in her OMR. She endorses nausea,
but no vomiting. She denies SOB, D/C.
REVIEW OF SYSTEMS: As per HPI
Past Medical History:
-Major depressive disorder (started after CVA in ___, with 2
prior psych admissions (___)
-Metastastic lung adeno involving lung and bronchus w/thoracic
___ and taxol s/p 6 cycles in ___. Near complete
response to therapy. PET scan: clear in ___. Avastin q 3
weeks from ___ (maintenance). Managed by Dr. ___
at ___.
-Left occipital stroke ___ (on plavix)
-CAD s/p MI in the ___
-Hyperlipidemia
-Hypertension
-Chronic low back pain
-Chronic atypical chest pain
-GERD
-Hypothyroidism
-Acute confusional state
-Urge incontinence
-Pre-diabetes, HbA1c 6.3% ___
-HTN, off medications
Social History:
___
Family History:
Stroke in daughter, cousin, aunt. MI in ___ in mother, uncle,
grandfather. ___ in grandmother, uncle, mother. DM in
paternal grandmother and maternal uncle.
Physical Exam:
On admission:
Vitals: Tc 97.5 BP 132/51 HR 70 RR 20 O2 100% on RA
General: Elderly woman laying in bed in NAD eating dinner,
talking on the phone with religious texts on her bed. Annoyed at
having to answer questions again.
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated
Lungs: CTAB, no wheezes/rales/rhonchi
CV: TTP on sternum, RRR, normal S1/S2, no MRG
Abdomen: Soft, obese, NT, ND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact. ___ strength in RLE
versus ___ strength in LLE (per pt, ___ stroke). ___ strength in
upper extremities bilaterally.
On discharge:
Vitals: Tm 98.7 Tc 98.7 HR 78 BP 99/59-112/52 RR 18 O2 99% on
RA
General: AAOx3, in no acute distress, walking around her room
and concerned because she was having diarrhea after receiving
docusate and senna
HEENT: sclera anicteric, EOM grossly intact
Neck: supple, JVP not elevated
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi; has discomfort over right rib on deep inspiration
CV: TTP on sternum and on right rib, RRR, normal S1/S2, no MRG
Abdomen: Soft, obese, NT, ND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII intact, with mildly reduced abduction of
the right eye c/w mild right CN6 palsy and decreased visual
field on the right c/w h/o left occipital stroke, 4+/5 strength
in RLE versus 5+/5 strength in LLE (per pt, ___ stroke). 4+/5
strength in RUE versus 5+/5 in left upper extremities c/w h/o of
left sided stroke.
Pertinent Results:
LABS
==================
On Admission:
___ 02:10AM BLOOD WBC-8.8 RBC-3.41* Hgb-10.0* Hct-30.7*
MCV-90 MCH-29.3 MCHC-32.6 RDW-14.3 RDWSD-46.5* Plt ___
___ 02:10AM BLOOD Neuts-61.6 ___ Monos-6.3 Eos-1.7
Baso-0.5 Im ___ AbsNeut-5.44 AbsLymp-2.59 AbsMono-0.56
AbsEos-0.15 AbsBaso-0.04
___ 02:10AM BLOOD ___ PTT-32.1 ___
___ 02:10AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-141
K-4.2 Cl-105 HCO3-24 AnGap-16
___ 02:10AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD cTropnT-<0.01
___ 03:46PM BLOOD CK-MB-4 cTropnT-<0.01
On discharge:
___ 11:25AM BLOOD WBC-10.2* RBC-3.42* Hgb-9.8* Hct-31.6*
MCV-92 MCH-28.7 MCHC-31.0* RDW-14.5 RDWSD-48.9* Plt ___
___ 11:25AM BLOOD Glucose-80 UreaN-20 Creat-1.0 Na-140
K-5.2* Cl-106 HCO3-25 AnGap-14
___ 11:25AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
IMAGING
==================
___ CHEST (PA & LAT)
IMPRESSION: No acute intrathoracic process.
___ HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormality. Specifically no acute
intracranial hemorrhage or territorial infarct.
2. Nonspecific white matter hypodensities are unchanged and
commonly seen in setting of chronic microangiopathy in a patient
of this age.
3. If there remains high clinical suspicion for infarct, MRI
would be more sensitive if there no contraindications.
PROCEDURE NOTES
==================
___ Cardiac catheterization notes
Impression: Double vessel CAD with widely patent mild RCA stent
and long CTO of a small OM1 with brisk collateral flow. The LAD
has no significant disease and LV size and function are normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. nitroglycerin 0.4 mg sublingual Q5MIN PRN CHEST PAIN
2. melatonin 3 mg oral QHS
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
7. Gabapentin 600 mg PO TID
8. Clopidogrel 75 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Cyanocobalamin 1000 mcg PO DAILY
11. TraZODone 150 mg PO QHS
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
13. HydrOXYzine 10 mg PO TID:PRN pruritus
14. Cetirizine 10 mg PO DAILY:PRN allergy
15. Nicotine Patch 14 mg TD DAILY
16. Multivitamins 1 TAB PO DAILY
17. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
18. Calcium 500 + D (calcium carbonate-vitamin D3) unknown mg
oral unknown
19. sennosides unknown oral unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. Pantoprazole 40 mg PO Q24H
9. Cetirizine 10 mg PO DAILY:PRN allergy
10. melatonin 3 mg oral QHS
11. Nicotine Patch 14 mg TD DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
13. nitroglycerin 0.4 mg sublingual Q5MIN PRN CHEST PAIN
14. HydrOXYzine 10 mg PO TID:PRN pruritus
15. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Unstable Angina
Secondary Diagnosis:
2. Headache
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 pain // eval for chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: PA and lateral views of the chest dated ___
FINDINGS:
The cardiomediastinal silhouette and pulmonary vasculature are unremarkable.
The lungs are clear. There is no pleural effusion or pneumothorax.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with hx cva, headache // eval for stroke
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: Total DLP (Head) = 702 mGy-cm.
COMPARISON: CT head dated ___, MRI head of ___
FINDINGS:
There is no evidence of large territorial infarction, hemorrhage, edema, or
mass effect. There is mild cortical volume loss, which is age-related.
Subcortical and periventricular white matter hypodensities are noted, likely
consistent with small vessel ischemic disease and unchanged from prior exam.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. Specifically no acute intracranial
hemorrhage or territorial infarct.
2. Nonspecific white matter hypodensities are unchanged and commonly seen in
setting of chronic microangiopathy in a patient of this age.
3. If there remains high clinical suspicion for infarct, MRI would be more
sensitive if there no contraindications.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dizziness
Diagnosed with Other chest pain, Headache
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 96.0
sbp: 111.0
dbp: 68.0
level of pain: 9
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with multiple cardiovascular
risk factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p
stent with prior MI in ___, CVAs x2 including left occipital
stroke in ___, lung CA s/p chemotherapy and surgery, atypical
chest pain, who presents with headache and chest pain found to
have a normal EKG and negative troponins.
# Chest pain: Given her normal EKG, negative troponins, and
history of atypical CP with a negative workup, and reproducible
chest pain on palpation, an acute coronary process was
considered unlikely during her presentation. We started her on
naproxen, continued her home aspirin, and continued to monitor
her clinically. However, she complained of chest pain on
hospital day one and had a negative EKG and negative troponins.
Cardiology was consulted and recommended cardiac
catheterization. The cardiac catheterization was unchanged from
her prior evaluation and a cardiac etiology for her chest pain
was felt to be unlikely.
# Headache: She had a CT head that showed no acute intracranial
abnormality. We continued her home Oxycodone-Acetaminophen
(5mg-325mg) ___ and avoided IV opioids after she had transient
opioid-induced delirium. Her headache had resolved prior to
discharge.
# Opioid-induced transient delirium: During her hospitalization,
she had an episode of pin-point pupils, slurred speech,
somnolence, decreased respiratory rate to ___ breathes per
minute, and dry mouth which was likely secondary to receiving
oxycodone and IV morphine. She was hemodynamically stable,
satting well on room air, and mentating during the episode and
was without focal neurological signs with unchanged baseline
weakness in her right upper and right lower extremity. She was
back to her baseline within 30 minutes of the episode. We held
IV pain medications and she did not have any similar episodes
before she was discharged.
# H/o stent and CVA: We continued her home clopidogrel.
# Cardiovascular risk factors: We continued her home aspirin and
atorvastatin.
# GERD: We continued her home pantoprazole.
# Hypothyroidism: We continued her home levothyroxine.
# Chronic back pain: We continued her home gabapentin 600mg and
oxycodone-acetaminophen.
# Insomnia: We held her home TraZODone 150 mg and gave her
trazodone 50mg PRN instead. We held her home melatonin.
# Allergies: We held her home hydrOXYzine and cetirizine.
# ?Asthma: We held her ProAir HFA (albuterol sulfate).
# Vitamins: We continued her home multivitamins, cyanocobalamin,
and held her home fish Oil.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (sister, HCP) ___
TRANSITIONAL ISSUES
[] Follow-up with cardiologist Dr. ___. Consider
starting low-dose beta blocker (ie. Lopressor 12.5mg BID) if her
blood pressures allow. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Concern for Portal Vein Thrombosis
Major Surgical or Invasive Procedure:
EGD with dobhoff placement ___
Diagnostic paracentesis ___
Diagnsotic paracentesis ___
History of Present Illness:
Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for
alcoholic hepatitis who presents as a transfer for c/f portal
vein thrombosis.
Pt was recently admitted in ___ for abdominal pain,
found to have alcohol hepatitis. She was continued on prednisone
40 mg daily (ending on ___. Since then, she saw her PCP,
who reports that patient has continued drinking alcohol since
discharge.
She reports 4 days of persistent nausea, vomiting, and inability
to tolerate PO. She endorses continued RUQ abdominal pain, but
says it is improved from when she last left the hospital. She
has
unfortunately continued drinking alcohol, approximately ___
drinks per day. Her last drink was on ___. She denies
confusion, but reports she has not had a BM recently and has not
been taking her lactulose. She says she has been taking the rest
of her medications. She denies fevers, chills, chest pain,
cough, dyspnea.
She is not sure if she has ever had withdrawal seizures.
Pt presented to ___ on ___ because of the above
symptoms. RUQUS there showed no flow related Doppler signal in
the main portal vein and apparent flow reversal in splenic vein,
c/f PVT. She was given 1mg/kg Lovenox and transferred to ___.
In the ED, initial vitals were T 98.8, HR 100, BP 110/50, RR 19,
O2 98% RA. Exam notable for TTP in the epigastric region but
otherwise soft/nondistended abdomen. Labs notable for WBC 5.2,
Hgb 11.3 (baseline 11.0), Plt 48, INR 2.0, Cr 0.6, Na 132, K 3.0
(repleted, K 5.2), ALT 44, AST 245 (increased from 111 on recent
discharge), Alk phos 157, Tbili 4.4 (down from 5.1), EtOH level
213, lactate 3.8. Blood and urine cx drawn.
CXR with no acute intrathoracic process.
Hepatology was consulted and recommended no further
anticoagulation, MRI Liver, CIWA scale, pan-culture, and
admission to ET.
She was given diazepam 10 mg IV x1 and Zofran.
Upon arrival to the floor, the patient provides the above
history. She endorses RUQ abdominal pain and feeling "shaky" all
over.
K was 2.8, so she was ordered for 60 of IV and 40 of PO K. She
was started on mIVF.
EKG showed QTc 511 so Zofran and amitryptiline were stopped. EKG
showed NSR, no ischemic changes.
REVIEW OF SYSTEMS:
+ per HPI, - otherwise
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
? h/o acute intermittent coproporhyria
h/o HCV (treated with ___ years ago at ___
with unknown medication with SVR)
Hypothyroidism
History of headaches
Low folic acid
Abdominal pain
NASH
PAST SURGICAL HISTORY:
Right knee surgery (___)
LN removal for unknown reason (she reports maybe it was from
infectious mononucleosis)
Ovarian cyst removal
Social History:
___
Family History:
Not-pertinent to the current admission. Not aware of anyone in
the family with hemochromatosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.8, BP 121 / 74, HR 105, RR 20, O2 96 Ra
General: Alert, oriented x3, appears calm, no asterixis, mild
tremor present
HEENT: Sclerae anicteric, MMM
NECK: supple, JVP not elevated
CV: Tachycardic, regular rhythm, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-distended, markedly tender in RUQ and
epigastric region
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Normal speech
DISCHARGE PHYSICAL EXAM:
VITALS: T 98.4 PO BP 108 / 56 L HR 51RR 18O2 94Ra
HEENT: Sclerae mildly icteric, MMM
CV: reg rate, regular rhythm, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: normal bowel sounds. Soft, mildly distended, nontender
in all quadrants
Ext: 1+ pitting edema b/l, WWP, no rash
Neuro: Normal speech; moves all 4 extremities, AAOx4, no
asterixis
Pertinent Results:
ADMISSION LABS:
================
___ 09:20PM BLOOD WBC-5.2 RBC-3.07* Hgb-11.3 Hct-30.9*
MCV-101* MCH-36.8* MCHC-36.6 RDW-12.4 RDWSD-45.7 Plt Ct-48*
___ 09:20PM BLOOD Neuts-44.5 ___ Monos-14.9*
Eos-0.4* Baso-1.0 Im ___ AbsNeut-2.31 AbsLymp-2.02
AbsMono-0.77 AbsEos-0.02* AbsBaso-0.05
___ 09:20PM BLOOD ___ PTT-50.1* ___
___ 09:20PM BLOOD Glucose-106* UreaN-4* Creat-0.6 Na-132*
K-3.0* Cl-87* HCO3-31 AnGap-14
___ 09:20PM BLOOD ALT-44* AST-245* AlkPhos-157*
TotBili-4.4*
___ 09:20PM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.0*
Mg-1.7
DISCHARGE LABS:
=================
___ 01:05PM ASCITES TNC-118* RBC-82* Polys-0 Lymphs-4*
___ Mesothe-2* Macroph-94*
___ 05:45AM BLOOD WBC-8.9 RBC-2.84* Hgb-9.9* Hct-30.2*
MCV-106* MCH-34.9* MCHC-32.8 RDW-14.1 RDWSD-55.0* Plt Ct-56*
___ 05:45AM BLOOD ___ PTT-36.2 ___
___ 05:45AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-7*
___ 05:45AM BLOOD ALT-37 AST-76* AlkPhos-144* TotBili-5.1*
IMAGING AND STUDIES:
======================
MRI ___
IMPRESSION:
Cirrhosis, portal hypertension and splenomegaly without any
evidence of portal vein thrombosis. Newly developed liver
steatosis, not present on ___. Mild to moderate
ascites. Very small low suspicious liver lesion in the lateral
segments which is amenable to consideration of attention in
followup.
EGD ___:
1. 2 cords of Grade II varices in distal esophagus
2. portal hypertensive gatropathy
Paracentesis ___:
IMPRESSION:
1. Technically successful ultrasound guided diagnostic
paracentesis.
2. 20 cc of fluid were removed and sent for requested analysis.
KUB ___:
IMPRESSION:
1. Mildly distended loops of small bowel with air-fluid levels
most likely
consistent with mild ileus.
PERITONEAL FLUID:
___ 01:05PM ASCITES TNC-118* RBC-82* Polys-0 Lymphs-4*
___ Mesothe-2* Macroph-94*
___ 05:45AM BLOOD WBC-8.9 RBC-2.84* Hgb-9.9* Hct-30.2*
MCV-106* MCH-34.9* MCHC-32.8 RDW-14.1 RDWSD-55.0* Plt Ct-56*
___ 05:45AM BLOOD ___ PTT-36.2 ___
___ 05:45AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-7*
___ 05:45AM BLOOD ALT-37 AST-76* AlkPhos-144* TotBili-5.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Thiamine 100 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Propranolol LA 80 mg PO BID
10. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Baclofen 5 mg PO TID
RX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply patch as directed daily Disp
#*14 Patch Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Simethicone 40-80 mg PO TID:PRN gas, bloating
RX *simethicone 80 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
6. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Propranolol LA 80 mg PO DAILY
RX *propranolol 80 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
8. FoLIC Acid 1 mg PO DAILY
9. Lactulose 30 mL PO BID
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
13. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Thiamine 100 mg PO DAILY
15. HELD- Amitriptyline 25 mg PO DAILY This medication was
held. Do not restart Amitriptyline until until discussed with
your ___. This was held because of prolonged QTc
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
====================
Alcoholic hepatitis
Alcohol use disorder
Secondary Diagnosis:
======================
Ileus
HCV/ alcoholic cirrhosis
Prolonged Qtc
Thrombocytopenia
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 ETOH cirrhosis here w/ possible PVT// r/o infection
COMPARISON: None
FINDINGS:
AP portable upright view of the chest provided. Lung volumes are slightly low
bilaterally. 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 cardiopulmonary process.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for alcoholic
hepatitis who presents as a transfer for portal vein thrombosis.// eval portal
vein thrombosis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: MRCP from ___.
FINDINGS:
Lower Thorax: No pleural effusion or focal consolidation. No pericardial
effusion.
Liver: Fat fraction of 8.7%, consistent with mild steatosis. Heterogeneous
arterial enhancement also suggests acute or active component to parenchymal
disease. The liver is mildly nodular in contour, there is hypertrophy of the
left lobe in keeping with cirrhosis. There is mild-to-moderate ascites in the
upper abdomen. The pelvis was not imaged.
There is no evidence of any highly suspicious liver nodule, no abnormal
enhancement. A small hypoenhancing focus is found in the left lateral
segments measuring only 8 mm on delayed images only (84: 84). It is not found
on the last contrast-enhanced series but the latter is affected by motion
artifact. It correlates to a slightly hypointense lesion on T2-weighted
images but is otherwise isointense and/or inconspicous on all other sequences.
The portal vein is unremarkable and is of normal size without evidence of
thrombus or occlusion.
Biliary: No intrahepatic or extrahepatic bile duct dilation. The walls of the
gall bladder are thickened, likely due to the presence of ascites and liver
disease. There is no gallstone.
Pancreas: The pancreas is unremarkable. The main pancreatic duct is not
dilated.
Spleen: There is splenomegaly, the spleen measures 15.2 cm.
Adrenal Glands: The adrenal glands are unremarkable.
Kidneys: There is bilateral symmetrical nephrogram. There is an 8 mm simple
appearing cyst in the right kidney. The left kidney is unremarkable. There
is no hydronephrosis.
Gastrointestinal Tract: The stomach and visualized bowel are unremarkable
without dilation or significant wall thickening.
Lymph Nodes: Mildly prominent retroperitoneal nodes, are probably due to
underlying liver disease.
Vasculature: There is conventional hepatic arterial anatomy. The portal and
hepatic veins are patent. There are left large esophageal and paraesophageal
varices as well as collateral vessels arising from the falciform ligament,
possibly including umbilical vein in addition to others. Varices are also
prominent along gastric cardia.
Osseous and Soft Tissue Structures: There is no evidence of suspicious bony
lesion.
IMPRESSION:
Cirrhosis, portal hypertension and splenomegaly without any evidence of portal
vein thrombosis.
Newly developed liver steatosis, not present on ___.
Mild to moderate ascites.
Very small low suspicious liver lesion in the lateral segments which is
amenable to consideration of attention in followup.
Radiology Report
EXAMINATION: Ultrasound-guided diagnostic paracentesis
INDICATION: ___ year old woman with alcoholic hepatitis and moderate ascites//
Diagnostic and therapeutic paracentesis
TECHNIQUE: Limited images of the abdomen were obtained to identify a suitable
pocket, followed by ultrasound-guided paracentesis.
COMPARISON: Ultrasound dated ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a trace
amount of ascites. A suitable target in the deepest pocket in the right upper
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic paracentesis
Location: right upper quadrant
Fluid: 20 cc of clear, straw-colored fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(chemistry, hematology, microbiology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key components of
the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 20 cc of fluid were removed and sent for requested analysis.
Radiology Report
INDICATION: ___ year old woman with alcoholic hepatitis, abdominal
distension// Evaluate for air fluid levels, evidence of ileus
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dating ___
FINDINGS:
Mild distension of the small bowel with mild air-fluid levels are seen. Air
is seen in the large bowel, there is no evidence of obstruction. Paucity of
bowel gas most likely consistent with abdominal ascites.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Mildly distended loops of small bowel with air-fluid levels most likely
consistent with mild ileus.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED DIAGNOSTIC AND THERAPEUTIC PARACENTESIS
INDICATION: ___ year old woman with alcoholic cirrhosis/hepatitis with
worsening abdominal distension and pain c/f worsening ascites and SBP.
Evaluation for diagnostic and therapeutic paracentesis
TECHNIQUE: Limited abdominal ultrasound was performed to determine a suitable
fluid pocket, followed by ultrasound-guided paracentesis.
COMPARISON: Comparison to prior ultrasound-guided paracentesis from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: right lower quadrant
Fluid: 2.75 L of clear, straw-colored fluid
Samples: Fluid samples were submitted to the laboratory for the requested
analysis (chemistry, hematology, microbiology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 2.75 L of clear, straw-colored fluid were removed and sent for requested
analysis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Portal vein thrombosis, Transfer
Diagnosed with Portal vein thrombosis, Alcoholic hepatitis without ascites
temperature: 98.8
heartrate: 100.0
resprate: 19.0
o2sat: 98.0
sbp: 110.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for
alcoholic hepatitis who presented as a transfer w/ concern for
PVT but was found not to have PVT by MRI and found to have
worsening alcoholic hepatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain w/Breathing
Major Surgical or Invasive Procedure:
___ CT-guided left lower lobe lung mass/consolidation
biopsy.
History of Present Illness:
This is a ___ male with no significant past medical history who
presented as transfer from ___ due to abnormal
CTA chest.
The patient reports that he woke up around 4AM on the day of
presentation with pain in his back while breathing. He states
that the pain is localized to the left scapular area. For ___
days prior to presentation he felt like he had a "virus" in
which
he had chills and general malaise and fatigue, though no cough,
sputum production, SOB, congestion, ST, or fevers. He smokes
marijuana daily -- smokes it from concentrate and also flower.
No
tobacco use.
He went to ___ where he was initially noted to
be
tachycardic to the 110s. His labs were notable for a WBC 12,
other wise normal CBC and Chem-10. He received 1 L IV fluids and
ceftriaxone/azithromycin for presumed community-acquired
pneumonia coverage based on a RLL infiltrate on CXR. Flu was
negative. Given the nature of his pain and his tachycardia, a
CTA
was done which showed no evidence of PE but did show
ground-glass
opacity in the periphery with halo sign concerning for
bronchoalveolar carcinoma versus fungal infection. He was
transferred to ___ for admission to medicine for pulmonary
consult likely bronchoscopy.
On arrival to the ED, the patient only reported having pain in
left scapular area when he takes a deep breath but no chest pain
or no shortness of breath. His vitals were notable for
tachycardia to the 120s, T-99.5, BPs 157/93, RR 18, O2 96% RA.
Exam was unremarkable with the exception of tachycardia. Labs
done at ___ included a lactate which was normal and blood
cultures which were pending (see above for labs from ___.
He
was given acetaminophen and ketorolac for pain and then admitted
to medicine for pulmonary consult and possible bronchoscopy.
On the floor, patient reports feeling well. Pain in left upper
back is overall improved, thinks that pain meds helped. History
reported as above. Asking for sleep meds to help with insomnia.
Past Medical History:
None
Social History:
___
Family History:
Maternal GM had COPD
Paternal GF had stomach cancer in his ___
Maternal GF had some kind of lung disease late in life
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.6PO,156 / 84,114,20,95Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: borderline tachycardic, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Back: no TTP
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
======================
Vital Signs: ___ 0722 Temp: 98.1 PO BP: 141/78 R Lying HR:
98 RR: 20 O2 sat: 97% O2 delivery: Ra
General: NAD, alert, anxious appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, neck
supple
CV: borderline tachycardic, regular 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
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal
Pertinent Results:
ADMISSION LABS:
==============
___ 07:35PM BLOOD WBC-10.7* RBC-4.71 Hgb-13.3* Hct-41.1
MCV-87 MCH-28.2 MCHC-32.4 RDW-11.9 RDWSD-38.0 Plt ___
___ 07:35PM BLOOD Neuts-70.9 Lymphs-14.7* Monos-13.1*
Eos-0.6* Baso-0.3 Im ___ AbsNeut-7.55* AbsLymp-1.57
AbsMono-1.40* AbsEos-0.06 AbsBaso-0.03
___ 07:35PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-23 AnGap-13
___ 07:35PM BLOOD ALT-28 AST-22 AlkPhos-70 TotBili-0.6
___ 07:35PM BLOOD Calcium-9.4 Phos-2.7 Mg-2.0
MICROBIOLOGY:
============
___ 4:24 pm TISSUE Source: Lung, left lower lobe.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___ Legionella Urinary Antigen: NEGATIVE FOR SEROGROUP
1 ANTIGEN.
___ Blood Culture x3: NGTD
___ Streptococcus pneumoniae Antigen DetectionResults
Pending
___ ASPERGILLUS GALACTOMANNAN ANTIGENResults Pending
___ B-GLUCANResults Pending
STUDIES:
========
CTA chest ___
___
IMPRESSION: Exam is limited due to respiratory motion artifact.
However, within these limitations:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Large solitary 5 cm dense left lower lobe peripheral mass
with surrounding ground-glass opacity is concerning for
malignancy such as a bronchoalveolar carcinoma, particularly in
the setting of unilateral hilar lymphadenopathy. Alternatively,
this may represent a fungal infection, particularly if the
patient is in immunocompromised state, or an atypical bacterial
infection. Infarction is less likely as associated pulmonary
arterial vasculature appears well
opacified. Considering location, differential diagnosis also
includes a pleural based mass such as a benign fibrous tumor or
plasmacytoma.
3. Hilar lymphadenopathy may represent nodal metastasis, or may
be reactive.
CXR ___
No evidence of pneumothorax.
DISCHARGE LABS:
===============
___ 05:33AM BLOOD WBC-8.9 RBC-4.58* Hgb-12.8* Hct-40.3
MCV-88 MCH-27.9 MCHC-31.8* RDW-12.1 RDWSD-38.9 Plt ___
___ 05:33AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-144
K-5.0 Cl-105 HCO3-23 AnGap-16
___ 05:33AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Lung mass
Back pain
Sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with no PMH but heavy inhaled marijuana use,
presenting with large left lower lobe lung mass, concerning for malignancy vs
infection. Patient asymptomatic except for left subscapular pain.// micro and
pathology of LLL lung mass
COMPARISON: Prior CT chest done ___
PROCEDURE: CT-guided left lower lobe lung mass/consolidation biopsy.
OPERATORS: Dr. ___, radiology trainee and Dr.
___ radiologist. Dr. ___
supervised the trainee during the key components of the procedure and reviewed
and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the CT
findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain 3
core biopsy specimens, which were sent for pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence: 1) Spiral Acquisition 11.4 s, 34.9 cm; CTDIvol =
13.7 mGy (Body) DLP = 467.0 mGy-cm. 2) Spiral Acquisition 11.1 s, 34.0 cm;
CTDIvol = 13.4 mGy (Body) DLP = 444.2 mGy-cm. 3) Stationary Acquisition 13.0
s, 1.4 cm; CTDIvol = 98.9 mGy (Body) DLP = 142.4 mGy-cm. Total DLP (Body) =
1,065 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
21 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. 3 x 18 gauge core biopsy was performed of the left lower lobe lung
mass/consolidation.
IMPRESSION:
Technically successful CT-guided biopsy of the left lower lobe lung
mass/consolidation. No immediate complications.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Status post CT-guided lung biopsy of the left lower lobe nodule.
COMPARISON: Radiographs and CT from ___.
FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. Rounded pleural based
opacity is again demonstrated in the lateral left lower chest. Otherwise,
lungs appear clear. There is no pneumothorax or pleural effusion.
IMPRESSION:
No evidence of pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Back pain, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 99.0
heartrate: 105.0
resprate: 18.0
o2sat: 97.0
sbp: 154.0
dbp: 77.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ with no significant past medical
history who presented to OSH with pleuritic back pain, found to
have abnormalities with lung mass on CTA chest, transferred to
___ for further workup, ultimately underwent lung biopsy for
suspected malignancy vs infection.
#Left lower lobe peripheral lung mass
#Pleuritic back pain
Patient presented with back pain increased with inspiration. CTA
performed at ___ showed a left lower lobe peripheral lung
mass with surrounding ground-glass opacity. Differential
included bronchoalveolar carcinoma, fungal infection, atypical
bacterial infection. No family history of lung cancers at young
age. He does smoke marijuana on a daily basis. He was treated
initially with CTX/azithromycin which was stopped at ___.
Pulmonary and ___ were consulted. Patient underwent CT guided
percutaneous lung biopsy targeting the left lower lobe mass on
___ after multidisciplinary discussions. CXR after the
procedure showed no pneumothorax. His pathology and other
results will be followed by the pulmonary team, followup to be
arranged after discharge. He should have an appointment within
the next 4 weeks.
# Sinus Tachycardia
He had sinus tach in 100s to 110s intermittently. CTA did not
show any PE. Likely there was an element of pain and anxiety
contributing. He received 25 mg Hydroxyzine with a calming
effect.
# Normocytic anemia
Hb 12.8 on HD 3, possibly in setting of receiving IVF, would
recheck as an outpatient.
TRANSITIONAL ISSUES:
==================
[] f/u biopsy micro and path |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
tree nut
Attending: ___.
Chief Complaint:
Ms. ___ is a ___ woman with relapsing remitting
multiple sclerosis who presents with vision changes.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with relapsing remitting
multiple sclerosis who presents with vision changes.
Last ___, she had a headache that gradually worsened, eyes
somewhat sensitive to light, better with Tylenol and coffee.
Does not usually get headaches (although it seems she does get
headaches on chart review). Headache got better, but then on
___, she started seeing little square-like black and
quite shapes in her peripheral vision. Was also seeing lightning
bolts and squiggly lines. The was constant until ___, when
the shapes changed and became circles and developed into
different colors. This is what brought her into the hospital to
be evaluated. She has also had more blurry vision since ___
despite getting new glasses.
Earlier last evening, she developed another headache where
everything "really hurt," unable to describe why, endorsed
photophobia and phonophobia. Sleep made it better, worse with
stress/crying. ___ radiation.
___ recent infections. ___ urinary frequency or urgency. ___
coughs/colds/rhinorrhea.
Per Dr. ___ recent note on ___, she presented with
blurred vision in the left eye in ___. Brain MRI showed white
matter lesions in the corpus callosum, left parietal
periventricular area, and L frontal area consistent with MS. ___
enhancement of the L optic nerve. Also had some headaches with
the left eye and slight blurring of her vision for which she got
steroids. Usually gets headaches twice per month, better with
fioricet.
Due to LFT elevation, she has stopped Aubagio and is not on any
medications for her multiple sclerosis. She has tried copaxone
and tecfidera in the past.
Past Medical History:
PMH/PSH: MS, depression/anxiety, headaches, TMJ
Social History:
___
Family History:
FAMILY HISTORY: mother with ?migraines, ___ history of MS, brain
aneurysms in aunts and uncles
Physical Exam:
Admission PHYSICAL EXAMINATION
Vitals: T: 98.4F HR: 97 BP: 107/60 RR: 18 SaO2: 100% RA
General: NAD
HEENT: NCAT, ___ oropharyngeal lesions, neck supple
___: RRR, ___ M/R/G
Pulmonary: CTAB, ___ crackles or wheezes
Abdomen: Soft, NT, ND, +BS, ___ guarding
Extremities: Warm, ___ edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, speech is fluent with
full sentences and intact verbal comprehension. ___ paraphasias.
___ dysarthria. Normal prosody. ___ evidence of hemineglect. ___
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 8->6 brisk. VF full to movement. ___ red
desaturation. Visual acuity: R ___ +2, L ___ -2, trouble
with C's and O's, Ds and Bs. Optic disc on L looks different
than the R, R disc crisp, L disc perhaps mildly paler. EOMI, ___
nystagmus. V1-V3 without deficits to light touch bilaterally. ___
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. ___ drift. ___ tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: ___ deficits to light touch or pin prick throughout
- Coordination: ___ dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: deferred
DISCHARGE Examination:
MS: During hospitalization would often forget the details which
had been discussed in prior conversations.
CN: R homonymous hemianopsia.
Otherwise unchanged.
Pertinent Results:
Admission labs:
WBC-15.3*# HGB-11.6 HCT-37.4 PLT COUNT-289
NEUTS-79.7* LYMPHS-14.4* MONOS-5.1 EOS-0.0* BASOS-0.1 IM
___
AbsNeut-12.20*# AbsLymp-2.20 AbsMono-0.78 AbsEos-0.00*
AbsBaso-0.02
___ PTT-26.7 ___
SODIUM-140 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-20* UREA N-15
CREAT-0.9 GLUCOSE-147*
ALT(SGPT)-19 AST(SGOT)-13 ALK PHOS-79 TOT BILI-<0.2
ALBUMIN-4.1
UTox: bnzodzpn-POS* barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
STox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
UA: Contaminated
Imaging:
MRI Brain/Orbits ___
IMPRESSION:
1. Interval development of multiple lesions demonstrating
hyperintense FLAIR signal abnormality compatible with multiple
sclerosis, with majority demonstrating abnormal enhancement and
slow diffusion suggestive of an acute process. The largest of
these lesion is involving the left calcarine cortex and optic
radiation tracks, likely attributing to patient's symptomology.
2. ___ evidence of optic neuritis.
Medications on Admission:
These medications were not verified.
- klonopin 0.5mg BID
- lamotrigine 150mg BID for depression
- venlafaxine 150mg BID
Discharge Medications:
1. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Duration: 2
Doses
RX *methylprednisolone sodium succ 1,000 mg 1000 mg IV Q24h Disp
#*2 Vial Refills:*0
2. Omeprazole 40 mg PO DAILY
3. TraMADol 100 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth Q6:PRN Disp #*20
Tablet Refills:*0
4. ClonazePAM 0.5 mg PO BID
5. Topiramate (Topamax) 25 mg PO BID
6. Venlafaxine XR 150 mg PO BID
7. Venlafaxine XR 37.5 mg PO DAILY
8. Vitamin D 4000 UNIT PO DAILY
9.Sodium Chloride 0.9% Flush 3 mL IV; pre- and post- infusion
and PRN replacement of IV. Dispense 8 flushes.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multiple sclerosis flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI BRAIN AND ORBITS PT4 MR ___
INDICATION: ___ female with multiple sclerosis presenting with right
homonymous hemianopsia.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 10 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations. Orbit images acquired at 3 mm slice thickness. Precontrast
sequences included axial and coronal T1, coronal STIR. Postcontrast sequences
included axial and coronal T1 with fat saturation.
COMPARISON: ___
FINDINGS:
MRI BRAIN:
There is interval development of multiple FLAIR hyperintense foci within
bilateral cerebral white matter and the cerebellum compatible with known
multiple sclerosis. Majority of these lesions demonstrate corresponding
enhancement and slow diffusion compatible with active process. The largest of
these lesions is seen within the left occipital lobe involving the calcarine
cortex in the region of the optic radiation tracts (8:11 and 11:11).
The ventricles are normal in size. There is no mass effect or midline shift.
There is no hemorrhage or cortical infarction. The paranasal sinuses and
mastoid air cells appear clear.
MRI ORBITS:
There is no evidence of optic nerve enlargement or enhancement to suggest
optic neuritis. The globes are intact and normal in appearance. The
extraocular muscles are uniform in size and normal in signal.
IMPRESSION:
1. Interval development of multiple lesions demonstrating hyperintense FLAIR
signal abnormality compatible with multiple sclerosis, with majority
demonstrating abnormal enhancement and slow diffusion suggestive of an acute
process. The largest of these lesion is involving the left calcarine cortex
and optic radiation tracks, likely attributing to patient's symptomology.
2. No evidence of optic neuritis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Visual changes
Diagnosed with Multiple sclerosis
temperature: 98.0
heartrate: 101.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | ___ presented with one week of right-sided visual
artifacts and difficulty seeing on the right. She was found to
have a right homonymous hemianopsia. MRI brain showed multifocal
FLAIR hyperintensities with contrast enhancement, consistent
with an acute MS flare. She was treated with IV
methylprednisolone. She received three doses as an inpatient and
will complete two doses as home infusion. She will follow up
with her outpatient neurologist to start long term MS therapy.
Her course was otherwise notable for headache which responded to
tramadol and mildly elevated blood sugars while on prednisone.
Her home medications for headache, depression and anxiety were
continued.
She was discharged with a peripheral IV in place for the purpose
of her home IV infusions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leaking biliary drain
Major Surgical or Invasive Procedure:
___ Billiary drain placement and replacement
History of Present Illness:
Mr. ___ is a ___ man with history notable for
prostate cancer s/p XRT, complex renal cysts, colonic tubular
adenoma, and ___ esophagus who was recently found to have
a liver mass biopsied to be adenocarcinoma with markers not
consistent with colonic or lung origin who presented from the
___ clinic with fevers and a left biliary tube leak.
He was having abdominal pain during ___ and had a CT at
___ that showed a liver mass. He underwent liver
biopsy at ___ on ___ with severe bleeding
complications leading to hemorrhagic shock. He was transferred
to ___ and underwent ___ embolization followed by exploratory
laparotomy Argon-beam coagulation of liver with abdomen left
open
status post procedure and ultimately closed on ___. He had a
very complicated course during a prolonged hospitalization from
___.
Per OMR- Hematology/Oncology consult during the admission raised
the likelihood that this was a metastatic cancer to his liver
from a GI source and that he was likely not a candidate for
chemotherapy due to his performance status at the time. The
findings suggested an upper gastrointestinal, pancreatic or
biliary primary. There does not appear to be extra-hepatic
disease, and the mass is causing biliary obstruction.
He presented to the GI ___ clinic today endorsing a one
week history of fevers, nausea, vomiting. Blood cultures from
___ grew VRE in 1 of 2 bottles. He was started on
ampicillin, gentamicin, and metronidazole. He continued to spike
intermittent fevers on ___ and again on ___. He was
switched to ceftriaxone, linezolid, and metronidazole on
___. Per verbal report from ___ Rehab, no additional
blood or urine cultures have been positive.
In the setting of biliary leakage and fevers he was referred to
the ED for further evaluation.
In the ED, VS: 98.4 HR 100 BP 95/63 RR 20 100% RA
Notable labs: WBC 12.3, Hgb 7.5 Hct 23.6 Plt 511, AP 1355,
T.bili 1.6, Dbili 1.2, AST 64, Albumin 2.5, Total protein 5.6,
lactate 1.9
Consults: ___
Recommendations: NPO at midnight for tomorrow: Cholangiogram +
exchange + possible drainage of new ?bilomas
As he was awaiting a bed on the oncology floor he became
tachycardic and hypotensive to ___. He received 3L NS,
Vancomycin and Zosyn, and was started on phenylephrine through
his PICC prior to transfer to the FICU.
On arrival to the FICU, he appears comfortable and is without
complaint. His daughter who is at bedside provides additional
history that he has been febrile up to 102-103 for the past ___s nausea, vomiting, and poor PO intake for the
past week.
Past Medical History:
Prostate cancer s/p XRT, colonic tubular adenoma, ___
esopahgus, hypertension, renal mass (left kidney, 1.3 cm)
PSH:
None
Social History:
___
Family History:
No Family History of liver disease/cancer
Physical Exam:
==================
ADMISSION PHYSICAL
==================
Vitals: T:99 BP: 106/65 P:113 R:18 O2:98% RA
GENERAL: Lying in bed, comfortable appearing
HEENT: Anicteric sclera, dry mucous membranes
NECK: Soft, supple, full ROM, no JVD
LUNGS: Crackles at the right lung base
CV: Tachycardic but regular
ABD: Soft, non-distended, mid-line surgical scar. Two biliary
drains in place draining bilious fluid
EXT: Warm and well perfused, no edema
==================
DISCHARGE PHYSICAL
==================
Vitals: T:98. BP: 115/82 P: 85 R: 17 O2: 99 ra
Gen: NAD
___: regular
Lungs: bibasilar crackles, coughing, no increase WOB
Abd: Soft, non-distended, mid-line surgical scar. Two biliary
drains in place draining bilious fluid
Ext no edema
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-12.3*# RBC-2.56* Hgb-7.5* Hct-23.6*
MCV-92 MCH-29.3 MCHC-31.8* RDW-19.8* RDWSD-67.2* Plt ___
___ 11:45AM BLOOD Neuts-84.1* Lymphs-10.1* Monos-4.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.33* AbsLymp-1.24
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.02
___ 11:45AM BLOOD ___ PTT-33.8 ___
___ 11:45AM BLOOD UreaN-9 Creat-0.7 Na-132* K-3.4 Cl-100
HCO3-23 AnGap-12
___ 11:45AM BLOOD ALT-35 AST-64* AlkPhos-1355* TotBili-1.6*
DirBili-1.2* IndBili-0.4
___ 11:45AM BLOOD TotProt-5.6* Albumin-2.5* Globuln-3.1
___ 11:45AM BLOOD TSH-0.68
___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 11:45AM BLOOD AFP-3.6
___ 11:45AM BLOOD HCV Ab-NEGATIVE
___ 03:54PM BLOOD Lactate-1.1
___ 08:11PM BLOOD Lactate-1.9
___ 11:45AM BLOOD HCV Ab-NEGATIVE
___ 11:45AM BLOOD AFP-3.6
___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 11:45AM BLOOD TSH-0.68
=============
PERTINENT LABS
============
___ 05:05AM BLOOD calTIBC-91* Hapto-287* Ferritn-548*
TRF-70*
___ 11:45AM BLOOD TSH-0.68
___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 11:45AM BLOOD AFP-3.6
___ 11:45AM BLOOD HCV Ab-NEGATIVE
___ 08:11PM BLOOD Lactate-1.9
___ 03:54PM BLOOD Lactate-1.1
==============
DISCHARGE LABS
==============
___ 04:04AM BLOOD WBC-9.7 RBC-2.79*# Hgb-8.3* Hct-25.7*
MCV-92 MCH-29.7 MCHC-32.3 RDW-19.1* RDWSD-64.4* Plt ___
___ 04:04AM BLOOD ___ PTT-36.6* ___
___ 04:04AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-134 K-3.4
Cl-107 HCO3-21* AnGap-9
___ 04:04AM BLOOD ALT-23 AST-52* AlkPhos-731* TotBili-1.2
___ 04:04AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.1
================
MICROBIOLOGY
================
___ 3:43 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFTAZIDIME----------- S
CIPROFLOXACIN--------- R
GENTAMICIN------------ S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ BLOOD CX WITH VRE, SENSITIVITIES ARE PENDING
================
STUDIES
================
___ CT ABD&PELVIS
IMPRESSION:
1. At least 3 new hypodensities noted within the liver, 1 of
which is adjacent to the recently inserted left-sided biliary
drainage catheter with additional months in segment ___ and
segment 7 respectively, likely represent bilomas. These do not
have enhancement pattern suggestive of cholangitic abscesses.
2. Residual dilatation of the intrahepatic biliary ducts as
described above, post placement of bilateral internal external
percutaneous biliary drains. Underlying cholangitis cannot be
excluded.
3. Right lower lobe subsegmental consolidation as detailed
above, concerning for focal aspiration pneumonitis.
4. The large heterogeneously enhancing mass in the right lobe of
the liver compatible with the known tumor appears more solid on
today's exam. There is an exophytic component of the tumor that
appears to be invading the hepatic flexure of the colon, there
is however no bowel obstruction.
5. Revisualization of the solid 1.7 cm renal lesion within the
right kidney, suspicious for renal cell carcinoma.
6. Stable lucency at the T12 vertebral body, which should
eventually be
evaluated with a bone scan as previously recommended.
___ CXR
IMPRESSION:
As compared to the previous radiograph, no relevant change is
seen. Elevation of the hemidiaphragm with subsequent right
basilar atelectasis. The ventilated lung parenchyma shows no
evidence of pneumonia, pulmonary edema or pleural effusions.
Unchanged silhouette
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
3. Docusate Sodium 100 mg PO BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QAM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoclopramide 10 mg PO QIDACHS
7. Nystatin Oral Suspension 5 mL PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion
11. Pantoprazole 40 mg PO Q24H
12. Piperacillin-Tazobactam 4.5 g IV Q8H
13. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
14. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
Discharge Medications:
1. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
2. Docusate Sodium 100 mg PO BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QAM
4. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Piperacillin-Tazobactam 4.5 g IV Q8H
7. Senna 8.6 mg PO BID:PRN constipation
8. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Linezolid ___ mg IV Q12H
11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
12. Metoclopramide 10 mg PO QIDACHS
13. Nystatin Oral Suspension 5 mL PO BID
14. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
15. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
SEPTIC SHOCK
BILLIARY OBSTRUCTION
CHOLANGITIS
SECONDARY DIAGNOSIS:
ADENOCARCINOMA IN LIVER (UNKNOWN PRIMARY)
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 scan of the abdomen and pelvis.
INDICATION: dx gi malignancy with mets to liver,fevers,rule out
intra-abdominal abcess // dx gi malignancy with mets to liver,fevers,rule out
intra-abdominal abcess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: This study involved 5 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 = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Stationary Acquisition 14.5 s, 0.2 cm; CTDIvol = 246.4 mGy (Body) DLP =
49.3 mGy-cm.
5) Spiral Acquisition 5.1 s, 61.1 cm; CTDIvol = 5.0 mGy (Body) DLP = 278.8
mGy-cm.
Total DLP (Body) = 330 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: There is focal consolidation within the medial right lower lobe,
aspiration pneumonitis is a possibility.
Stable 8 mm cardiophrenic lymph node.
ABDOMEN:
HEPATOBILIARY: Again visualized is a large lobulated heterogeneously enhancing
mass in the right lobe of the liver. It appears overall unchanged in size
when compared to previous,measuring 12.6 x 6.6 by 7.7 cm.
There has been interval placement of percutaneous internal external biliary
drainage catheters, traversing both the right as well as the left main ducts
with the internal component terminating appropriately within the duodenum.
There is interval development of a new bilobed fluid ___ lesion along the left
biliary drainage catheter measuring approximately 6.3 cm in total length with
2 bulbous components measuring 2.0 x 1.9 and 1.8 x 2.7. This likely
represents a bilobed biloma.
A second new hypodense lesion is seen in segment ___ (07:33) measuring
approximately 1.8 by 1.4 by 4.0 cm (AP by trans by CC). A third lesion is
seen more cranially, in segment 7 measuring 1.7 x 2.2 cm (05:17). These
latter 2 lesions likely represent additional bilomas versus metastatic
lesions. Although cholangitic abscesses are a possibility, they do not have a
rim enhancement pattern to suggest the same.
A new linear hypodense lesion is seen at the periphery of segment 6. It
measures 1.9 cm in length and 4 mm in thickness, and may represent
postprocedural changes, possibly a needle tract.
There is persistent dilatation of left hepatic lobe (segment 3 posterior and
segment 2) bile ducts. Segment 7 and 8 ducts also remain moderately dilated,
slightly prominent than before.
There is narrowing of the right proximal portal vein, however it remains
patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: A 1.6 cm lesion is seen within the right kidney, at the mid polar
region is unchanged from previous. Although no precontrast images available,
it does have some internal density suggestive of internal enhancement, and is
concerning for small renal cell carcinoma. This could be further evaluated
with dedicated non urgent ultrasound or MRI after the acute episode resolves.
There are multiple bilateral simple appearing renal cysts, unchanged from
previous.
GASTROINTESTINAL: The appendix is mildly thickening measuring up to 8 mm.
This appearance however is unchanged when compared to previous, there is no
significant periappendiceal fat stranding. Focal appendicitis is unlikely.
First there is concentric wall thickening of the hepatic flexure of the colon
with an exophytic component of the mass closely abutting the hepatic flexure
(07:18) suspicious for invasion of the hepatic flexure of the colon. No bowel
obstruction noted.
A 1.0 cm portacaval lymph node is once again seen, unchanged from previous.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There are 3 fiducial markers within the prostate.
LYMPH NODES: There is a 1 cm necrotic lymph node anterior to the IVC (05:37).
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is linear calcification/ossification noted
posterior to the right acetabulum within the right gluteus minimus muscles.
This was not seen on prior examinations, and may represent focal myositis
ossificans. Divarication of recti noted. There is a small fat containing
umbilical hernia as before.
Focal lucency is seen at the posterior aspect of the T12 vertebral body,
unchanged from previous.
IMPRESSION:
1. At least 3 new hypodensities noted within the liver, 1 of which is adjacent
to the recently inserted left-sided biliary drainage catheter with additional
months in segment ___ and segment 7 respectively, likely represent bilomas.
These do not have enhancement pattern suggestive of cholangitic abscesses.
2. Residual dilatation of the intrahepatic biliary ducts as described above,
post placement of bilateral internal external percutaneous biliary drains.
Underlying cholangitis cannot be excluded.
3. Right lower lobe subsegmental consolidation as detailed above, concerning
for focal aspiration pneumonitis.
4. The large heterogeneously enhancing mass in the right lobe of the liver
compatible with the known tumor appears more solid on today's exam. There is
an exophytic component of the tumor that appears to be invading the hepatic
flexure of the colon, there is however no bowel obstruction.
5. Revisualization of the solid 1.7 cm renal lesion within the right kidney,
suspicious for renal cell carcinoma.
6. Stable lucency at the T12 vertebral body, which should eventually be
evaluated with a bone scan as previously recommended.
NOTIFICATION: The treating Hematology/Oncology Team was made aware of the
findings at 12:10 On ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with PMH adenocarcinoma of liver mass presents with fever,
diarrhea, biliary tube leakage
COMPARISON: ___ and CT abdomen pelvis from ___.
FINDINGS:
AP portable upright view of the chest. A right upper extremity PICC line is
seen with its tip likely in the upper SVC. Biliary drainage catheters project
over the right upper quadrant. There is elevation of the right hemidiaphragm
which is unchanged. Lungs appear clear without large effusion or
pneumothorax. Cardiomediastinal silhouette appears stable. No bony
abnormalities.
IMPRESSION:
1. Stable elevation the right hemidiaphragm.
2. PICC line positioned appropriately.
3. Biliary drainage catheters overlie the right upper quadrant.
4. No signs of pneumonia.
Radiology Report
INDICATION: ___ year old man with likely cholangitis // PTBD check/change
COMPARISON: ___.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow, Dr.
___ resident), and Dr. ___ radiologist
performed the procedure. Dr. ___ supervised the trainee during
the key components of the procedure and has reviewed and agrees with the
trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 40 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse.
CONTRAST: 20 ml of Optiray contrast.
Fluoroscopy time: 7 min 32 seconds.
Fluoroscopy dose: 1364 cGy-cm2
PROCEDURE:
1. Bilateral over-the-wire sheath cholangiograms.
2. Bilateral exchange of existing percutaneous trans-hepatic biliary drainage
catheters with a new 10 ___ PTBD catheters.
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 abdomen was prepped and draped in the usual sterile fashion.
Initial scout images showed biliary drains in the appropriate position.
The left PTBD was injected with contrast and demonstrated opacification of
left lobe biloma but no distal opacification. The hub of the catheter was cut
and a Glidewire was advanced into the small bowel. The glidewire was
exchanged for ___ wire using a Kumpe catheter. A 6 ___ sheath was
advanced over the ___ wire and a pull-back cholangiogram was performed,
findings below.
The right PTBD was injected with contrast and demonstrated patency of the tube
and biliary system. The decision was made to replace the right PTBD to
facilitate placement of the left PTBD. The hub of the catheter was cut and a
___ wire was advanced into the small bowel. A 6 ___ sheath was
advanced over the ___ wire and a pull-back cholangiogram was performed,
findings below.
The left sheath was removed over the wire and a 10 ___ percutaneous trans
hepatic biliary drainage catheter was advanced into the duodenum. Side holes
were positioned above and below the level of obstruction to facilitate
internal drainage. The wire and inner stiffener were removed, the catheter was
flushed, the loop was formed, the catheter was attached to a bag and sterile
dressings were applied.
Similarly, on the right, the right sheath was removed over the wire and a 10
___ percutaneous trans hepatic biliary drainage catheter was advanced into
the duodenum. Side holes were positioned above and below the level of
obstruction to facilitate internal drainage. The wire and inner stiffener were
removed, the catheter was flushed, the loop was formed, the catheter was
attached to a bag and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Existing bilateral 10 ___ percutaneous transhepatic biliary drainage
catheters in appropriate position.
2. Occlusion of existing left PTBD with contrast injection demonstrating
opacification of biloma without contrast passing distally.
3. Patent existing right PTBD.
4. Left cholangiogram demonstrating patent left ducts.
5. Right cholangiogram demonstrating patent right ducts.
6. Successful placement of new appropriately positioned 10 ___ PTBDs.
IMPRESSION:
1. Occluded left PTBD.
2. Successful exchange for new bilateral 10 ___ PTBDs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mr. ___ is a ___ year old gentleman with a history of
adenocarcinoma of unknown primary causing biliary obstruction now s/p biliary
drain placement x2 during his prior admission, who is admitted to the MICU w/
sepsis likely ___ biliary source, now c/o worsening cough. Also now noted to
have new onset of air in biliary drain. // eval PNA, pulm edema or PTX; also
please evaluate upright CXR to look for air
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Elevation
of the hemidiaphragm with subsequent right basilar atelectasis. The
ventilated lung parenchyma shows no evidence of pneumonia, pulmonary edema or
pleural effusions. Unchanged silhouette
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Fever, Diarrhea
Diagnosed with CHOLANGITIS
temperature: 98.4
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 95.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with a history of
adenocarcinoma of unknown primary causing biliary obstruction
now s/p biliary drain placement x2 during his prior admission,
who is admitted to the MICU with septic shock secondary to
cholangitis/infected bilomas.
# Septic shock: Cholangitis vs infected bilomas. Biliary
obstruction likely caused by adenocarcinoma. Patient presented
with hypotension requiring pressors, tachycardia, leukocytosis,
and fever. He was found to have new bilomas on CT imaging.
Recent blood cultures from ___ revealed VRE in ___
bottles. Blood Cx at ___ grew pseudomonas sensitive to zosyn.
Given linezolid and zosyn (first dose ___. Pressures
improved with IVF, pt required pressors only briefly during ___
procedure for replacement of billiary drains (see bellow).
#Billiary Obstruction: Secondary to adenocarcinoma. Billiary
drains placed, found to be clogged, replaced on ___. During
procedure, SBP was in the ___, patient responded to brief
administration of phenylephrine. Did not require pressors on
floor after procedure. LFTs downtrending.
#Adenocarcinoma: Based on path markers is not of colon or lung
origin. Mass causing biliary obstruction with increased total
bilirubin. He will be seen for follow up in Liver Tumor MDC on
___ by hepatology, medical oncology, and interventional
radioloty where consideration will be given to systemic
chemotherapy.
# Anemia: Normocytic anemia. Patient recieved 1u pRBC with
appropriate response. Hemolysis labs negative. Iron studies
consistant with anemia of chronic disease.
TRANSITIONAL ISSUES
- Continue linezold/zosyn for at least 2 week course (day 1:
___ - ___ for VRE bacteremia and pseudomonas bacteremia
- Please obtain weekly CBC/differential with BUN/creatinine
while patient is on linezolid
- Please obtain infectious disease input regarding course of
antibiotics
- Call ___ rehab ___ to follow up blood cultures
with VRE & ___, MD ___
- Patient was discharged with 2 biliary drains drained to
gravity. Please let interventional radiology know if patient has
any pain, tenderness, redness, or unusual discharge at the drain
or around the drain site. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Shellfish / Ferrous
Sulfate / Orange Syrup / metronidazole
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of crohns disease and collagenous colitis s/p
colectomy, chronic abdominal pain on narcotics, history of
multiple previous central lines complicated by possible ___
syndrome presenting with increasing watery diarrhea over the
last month. Pt presented today after she had difficulty walking
up stairs as she was too weak to climb. She promoted
palpipations, lh, and dizziness at tis time. In terms of her
diarrea, she has chronic watery stools which have increased in
freq over the last several weeks. She promotes having ___
loose bm daily. Often times notes bright red blood in them. She
did travel to ___ in early ___ after which symptoms
worsened. Infectious work up on ___ as an outpatient was
unrevealing. She completed a course of cipro/flagyl without
improvement in symptoms. Patient denies any fevers or chills.
She denies any chest pain. Does promote shortness of breath with
exertion. She denies any urinary symptoms. Pt believes symptoms
are secondary to crohns flare.
She also notes increased swelling over her neck, L>R over the
last month. Asymptomatic from swelling, causing mostly just
discomfort. She is concerned her prev dx ___ syndrome is
returning. Had initially resolved in ___ following stent
placement and angioplasty.
In the ED, initial vs were: 98.3 ___ 31 100%. Labs were
notable for an INR of 4, cr 2.4 (baseline .9), Na 130 and
lactate 3.7. Im the ED he received pain control with dilaudid
and zofran for nausea. CT abd/pelvis without any acute findings.
Vascular surg was consulted for with recs pending at the time of
admission.
Vitals on Transfer: 98.2 78 125/88 16 98%
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
1. Question collagenous colitis dx'd by bx ___ status post
laparoscopic ileostomy in ___ followed by colectomy with
ileorectal anastomosis in ___
2. Question Crohn's disease treated with Remicade in past c/b
?serum sickness and Pentasa.
3. Question seronegative spondyloarthropathy treated
with methotrexate--off since ___.
4. Chronic abdominal pain for which she is maintained on chronic
narcotic medications and followed by the pain clinic
5. Multiple prior central venous lines Hickman catheter in the
right subclavian in ___ and a Port-A-Cath in the left
subclavian in ___, Hickman in the right, removed ___ in
setting of VRE bacteremia. She has had recurrent ___
syndrome with narrowing of the L subclavian s/p venoplasty in
___. She had a nonocclusive thrombus of the ___ stent ___.
Most recently MRV ___ showed patent vasculature. She had been
on coumadin and fondaparanox in the past, now on coumadin with a
current goal INR of 2.5-3.5; some notes indicate an even higher
goal of ___.
6. History of bilateral pneumothoraces
7. Raynaud's phenomenon
8. Migraine headaches
9. Irregular menses
10. Anxiety/depression, pt has not wanted to see psychiatry.
11. Acid reflux
12. Macrocytic anemia
13. Right-sided lumpectomy for benign mass
14. Question ___ syndrome; per Dr. ___ is s/p ___ stent
placement (NO filter) in the setting of chronic indwelling
catheter status post failed attempt at ___ in ___,
resolution of swelling upon line removal ___. H/o multiple PE - on coumadin
16. H/o Klebsiella bacteremia
17. H/o Thrush
18. Polyclonal gammopathy.
19. Pancreatic insufficiency
20. Mult rib fractures
21. Osteonecrosis
22. ?TIA ___ years ago)
Social History:
___
Family History:
father - polycythemia, melanoma
mother - melanoma
Physical ___:
ADMISSION:
Vitals: T: 98.1 134/67 P72 RR16 99% RA
General: Ill appear, flat affect, A&Ox3
HEENT: , NCAT, EOMI, ___, dry mucous membranes
Neck: Notable swelling of neck, L>R
CV: RRR, No m/r/g
Lungs: CTABl no w/r/r
Abdomen:ttp in all quadrants, tenderness appears superficial vs
viceral, prior surgical scars well healed inferior to umbilicus.
No ostomy.
Ext: No edema, rash, clubbing
Neuro: Cn ___ grossly intact, ___ strength in all extm, no
focal deficits
Skin: No rashes or skin shanges
DISCHARGE:
VS: 98.2 135/75 61 19 99RA
Gen: middle aged female, laying in bed comfortably in NAD
HEENT: NCAT, significant supraclavicular soft tissue swelling
encircling neck, no erythema or plethora
CV: nl s1, s2, rrr, no mrg
Resp: CTA ___ no w/r/c
Abd: Right sided stoma scar well healed, infra-umbilical scar is
well healed. soft, tender to minimal palpation in RLQ, LLQ
(improved from prior), hyperactive bowel sounds
Ext: no cce
Pertinent Results:
ADMISSION:
___ 12:45PM BLOOD WBC-9.2 RBC-5.16 Hgb-12.8 Hct-39.7
MCV-77* MCH-24.8* MCHC-32.2 RDW-18.6* Plt ___
___ 12:45PM BLOOD ___ PTT-52.3* ___
___ 12:45PM BLOOD Glucose-73 UreaN-15 Creat-2.5*# Na-130*
K-6.2* Cl-88* HCO3-22 AnGap-26*
___ 06:25AM BLOOD Albumin-3.0* Calcium-7.1* Phos-2.8 Mg-1.7
___ 12:44PM BLOOD Lactate-3.7*
___ 05:28PM BLOOD Lactate-1.6
DISCHARGE:
___ 09:00AM BLOOD WBC-6.3 RBC-3.29* Hgb-8.2* Hct-26.2*
MCV-80* MCH-24.8* MCHC-31.1 RDW-19.5* Plt ___
___ 09:00AM BLOOD ___ PTT-54.7* ___
___ 09:00AM BLOOD Glucose-86 UreaN-4* Creat-0.8 Na-140
K-3.4 Cl-104 HCO3-29 AnGap-10
___ 09:00AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.7
TRYPTASE 7 ___ ng/mL
STRONGYLOIDES IGG
ANTIBODY, ___ <1.00 LESS THAN
1.00
REPORTS:
CT ABD/PELVIS
IMPRESSION:
1. Status post total colectomy. Mild dilatation of the ileoanal
J-pouch
without evidence of obstruction.
2. Unchanged wide-mouth ventral hernia containing small bowel
without evidence
of strangulation.
3. Unchanged perisplenic and adnexal cystic structures.
4. Unchanged presacral soft tissue thickening which is likely
postoperative in
nature.
MRV CHEST:
IMPRESSION:
1. Assessment of the superior vena cava is slightly limited by
the indwelling
stent however the vessel opacifies well with no direct or
secondary evidence
of ___ thrombosis.
2. Slightly prominent nodes within the lower neck which are
unchanged/borderline enlarged when compared to the prior CT.
Further
assessment with ultrasound could be performed if clinically
relevant.
U/S NECK:
FINDINGS: Ultrasound of cervical lymph node levels II, III, VI
bilaterally
reveal only normal lymph nodes. Supraclavicular stations also
contain lymph
nodes of normal size and morphology. The location of the
patient's concern
contains only normal subcutaneous fat and benign lymph nodes.
Based on
physical examination and ultrasound appearance of
supraclavicular region,
lipodystrophy should be considered as a potential etiology. No
fluid
collection or mass is seen.
IMPRESSION: Area of swelling contains only normal fat, without
lymphadenopathy or other mass. Lipodystrophy should be
considered as a
potential etiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO BID
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Apply to affected area
Avoid face and intrigenous areas
3. gabapentin *NF* 250 mg/5 mL Oral TID
10ml TID
4. Opium Tincture 10 DROP PO Q6H:PRN Diarrhea
5. Dronabinol 10 mg PO TID:PRN nausea and cramping
6. ClonazePAM 1 mg PO BID
please take in morning and afternoon
7. ClonazePAM 2 mg PO QHS
8. Warfarin Dose is Unknown PO DAILY16
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Fentanyl Patch 75 mcg/h TP Q72H
11. HYDROmorphone (Dilaudid) ___ mg PO Q4-6HOURS:PRN Pain
Hold for sedation or RR<12
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Omeprazole 40 mg PO BID
14. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
15. Citalopram 40 mg PO DAILY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Calcium Carbonate 500 mg PO BID
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 1 mg PO BID
5. ClonazePAM 2 mg PO QHS
6. Dronabinol 10 mg PO TID:PRN nausea and cramping
7. Fentanyl Patch 75 mcg/h TP Q72H
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. HYDROmorphone (Dilaudid) ___ mg PO Q4-6HOURS:PRN Pain
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 40 mg PO BID
12. Opium Tincture 10 DROP PO Q6H
RX *opium tincture 10 mg/mL (morphine) 10 drop by mouth q6 Disp
#*1000 Milliliter Refills:*0
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
14. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
15. Warfarin 12 mg PO DAILY16
RX *warfarin 4 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. gabapentin *NF* 250 mg/5 mL Oral TID
18. Enoxaparin Sodium 80 mg SC DAILY Duration: 5 Days
please take until INR>2
RX *enoxaparin 80 mg/0.8 mL 80 mg sc daily Disp #*5 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Diarrhea
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Multiple complaints including diarrhea abdominal pain and dyspnea.
History of Crohn's status post colectomy.
TECHNIQUE: PA and lateral chest radiograph 2 views.
COMPARISON: ___.
FINDINGS:
Heart size is normal. Cardiomediastinal silhouette and hilar contours are
unremarkable. There is redemonstration of a superior vena caval stent
unchanged in position. Lungs are clear. There is no pleural effusion or
pneumothorax. The visualized osseous structures are grossly unremarkable.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
HISTORY: Multiple complaints including diarrhea, abdominal pain and dyspnea.
History of Crohn's status post colectomy.
TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis
after the administration of oral contrast only. Multiplanar reformatted
images were generated in the coronal and sagittal planes.
DLP: 283.24 mGy-cm.
COMPARISON: CTA abdomen and pelvis ___.
FINDINGS:
The imaged lung bases are clear.
CT Abdomen: The study was performed without contrast which somewhat limits
evaluation of the intra-abdominal structures. The liver is grossly
unremarkable without focal lesion or intrahepatic biliary duct dilatation.
The gallbladder is nondilated and is without stones. The pancreas and adrenal
glands are unremarkable. A 2.7 cm cystic structure at the inferior margin of
the spleen is unchanged. There is redemonstration of the atrophic left
kidney. The kidneys are otherwise unremarkable without stones or
hydronephrosis.
The patient is status post colectomy with multiple scattered surgical clips.
The small bowel is unremarkable in appearance without evidence of obstruction
or focal wall thickening. There is re- demonstration of a wide-mouth ventral
hernia (2:33) containing small bowel with clear fat planes without evidence of
strangulation.
The abdominal aorta is of normal caliber with mild atherosclerotic mural
calcifications. There are no enlarged mesenteric or retroperitoneal lymph
nodes by CT size criteria.
CT pelvis: The bladder and uterus are unremarkable. A 1 cm right adnexal
cyst is unchanged. There is dilatation of the ileo anal J-pouch with
air-fluid level and there appears to have been passage of contrast into the
J-pouch. Mild presacral soft tissue thickening is unchanged from prior study
and is likely postoperative in nature. There is no pelvic free fluid or air.
Osseous structures: There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Status post total colectomy. Mild dilatation of the ileoanal J-pouch
without evidence of obstruction.
2. Unchanged wide-mouth ventral hernia containing small bowel without evidence
of strangulation.
3. Unchanged perisplenic and adnexal cystic structures.
4. Unchanged presacral soft tissue thickening which is likely postoperative in
nature.
Radiology Report
HISTORY: History of SVC syndrome with some neck swelling. Query SVC
syndrome.
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T
magnet, including dynamic 3D imaging obtained prior to, during and subsequent
to the intravenous administration of 16 mL of MultiHance.
COMPARISON: CT ___ and MRI ___.
FINDINGS:
There is some irregularity of the lumen of the superior vena cava, likely
related to artifact from the indwelling stent. Within this limitation, the SVC
appears patent. The veins of the upper chest and neck are normal in caliber
and are unchanged from the prior study. No evidence of venous
collateralization to suggest new venous thrombosis.
The thoracic aorta is of normal caliber. No aneurysm or dissection. The
great vessels are normal in appearance. The heart is unremarkable on this non
dedicated study. No pericardial effusion.
No hilar or mediastinal lymphadenopathy or mass lesion. There are bilateral
trace pleural effusions. There is a small amount of atelectasis bilaterally,
no suspicious pulmonary lesion identified on this non dedicated study.
Small lymph nodes are noted within the lower neck bilaterally. These measure
up to 1.3 x 0.9 cm (2, 9). When compared to the prior CT these are
unchanged/borderline enlarged.
Normal signal within the remainder of the soft tissues and visualized skeletal
system.
IMPRESSION:
1. Assessment of the superior vena cava is slightly limited by the indwelling
stent however the vessel opacifies well with no direct or secondary evidence
of SVC thrombosis.
2. Slightly prominent nodes within the lower neck which are
unchanged/borderline enlarged when compared to the prior CT. Further
assessment with ultrasound could be performed if clinically relevant.
Radiology Report
INDICATION: ___ woman with ulcerative colitis with clinical concern
for enlarging lower neck mass. Evaluate for lymphadenopathy or mass.
COMPARISON: MRV of the chest from ___.
FINDINGS: Ultrasound of cervical lymph node levels II, III, VI bilaterally
reveal only normal lymph nodes. Supraclavicular stations also contain lymph
nodes of normal size and morphology. The location of the patient's concern
contains only normal subcutaneous fat and benign lymph nodes. Based on
physical examination and ultrasound appearance of supraclavicular region,
lipodystrophy should be considered as a potential etiology. No fluid
collection or mass is seen.
IMPRESSION: Area of swelling contains only normal fat, without
lymphadenopathy or other mass. Lipodystrophy should be considered as a
potential etiology.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: TACHYCARDIA
Diagnosed with DEHYDRATION
temperature: nan
heartrate: 161.0
resprate: nan
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ female with a hx of crohns disease and collagenous colitis
s/p colectomy, ___ syndrome s/p stenting to ___, depression
who presents with acute on chronic abdominal pain, diarrhea, and
swelling of left face with MRV not showing signs of ___
syndrome.
#Diarrhea/abdominal pain: Acute on chronic for last 4 weeks. Has
baseline malabsorption/diarrhea secondary to collagenous colitis
and colectomy. Given that patient has had ___ BMs daily, this
appears more likely to be part of chronic diarrhea state ___ to
colectomy rather than crohn's flare. Stool studies as noted
below pending. Patient was previously prescribed tincture of
opium, however she had not started it. She was started on
tincture of opium and did well as a result. Once she started on
___, she did not have issues with ___ (despite being NPO and not
receiving IVF for ~20 hours for her imaging study). She has
follow up appointment with ___ in ___ who has been
following her for her chronic abdominal pain and diarrhea.
#Soft tissue swelling: Patient presented with worsening neck and
supraclavicular swelling which was concerning for ___ syndrome
given that patient has hx of subclavian stenosis s/p stent. MRV
did not reveal vascular source of neck swelling and plethora,
this was originally thought to be ___ lymph node enlargement so
an ultrasound was performed which only showed prominent
subcutaneous fat.
___ Syndrome: First dx in ___ and has been difficult to
manage. Thought to be ___ to frequent central line placement. In
___ a stent was placed in ___ but quickly clotted but
revascularized following in-stent balooon angioplasty. ___ has
been well controlled this then. However, INR has proven
difficult to control given frequent diarrhea, poor intestinal
absoprtion, poor diet, and alcohol use. Target INR 2.5-3.5 given
history of recurrent thromboembolic disease. On PE, pt does have
L>R facial swelling which she says is consistent with previous
IJ clots, however MRV was unrevealing. Started Lovenox on
___ to bridge INR (see below for anticoagulation)
-warfarin 12mg PO daily with follow up with ___
clinic
-after compromising with patient, will bridge INR with 1.5mg/kg
lovenox until INR>2, then may discontinue
___: Patient presented with Cr 2.5 from baseline 1. Most
likely prerenal from poor po intake and recent exacerbation of
diarrhea. Patient was resuscitated with IVF and started on ___
as noted above. Patient was encouraged to take PO liquids and
did well.
#Depression: Pt has long standing depression. While denies SI,
has made overtures that she would consider hurting herself.
-continue with SSRI
-patient should follow up with her PCP regarding her depression |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
malaise, hypoglycemia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Patient is a ___ with history of atrial fibrillation on Coumadin
(chads2 4), HFpEF (LVEF 63% ___, hypertension, and T2DM who
presents with weakness in setting of hypoglycemia.
History is limited by patient participation. Patient by report
had not been feeling well since early this weak, he describes
overall weakness as well as some low-level nausea. He also
endorses a recent headache. A concerned neighbor called for EMS
and patient was brought to ___ ED for further evaluation and
treatment.
In the ED, initial vital signs were: 97.8 80 139/88 18 99% RA
- Labs were notable for:
INR >13.1 -> 11.6
PTT 107.5
___ 150
Prolatctin 7.7
Mg 1.5
VBG ___
UA: 46RBCs, 30 Prot, 300 Glu
Upon arrival, patient was noted to be quite lethargic and slow
to respond. Head imaging subsequently obtained showed a 3.5x
1.3cm hyperdensity in the sella eroding into the sphenoid sinus
(see below). Neurosurgery was consulted and recommended INR
reversal and admission to medicine for further work-up, no acute
indication for surgical intervention.
- Studies performed include:
MRI BRAIN
1. Study was prematurely aborted due to significant pain and
claustrophobia experienced by the patient.
2. Large expansile pituitary mass that erodes the sphenoid
sinuses anteriorly, suspicious for a probably hemorrhagic
invasive macroadenoma.
3. Additional 5.5 x 1.1 cm plaque-like lesion extending from
the prepontine cistern inferiorly to the foramen magnum is
likely a separate entity, may represent a meningioma.
4. MRI brain with contrast is required for further
characterization of both findings.
NCCTH
1. 3.5 x 1.3 cm hyperdense expansile mass in the sella eroding
through the roof of the sphenoid sinus, which may reflect a
pituitary mass. Dedicated MRI the sella is recommended for
further characterization.
2. No intracranial hemorrhage.
3. Paranasal sinus disease. Please correlate with clinical
findings.
CXR
INDINGS:
Cardiac silhouette size is moderately enlarged but similar
compared to the prior exam. The mediastinal and hilar contours
are not substantially changed in the interval. Mild pulmonary
vascular congestion is similar to the prior exam. There is no
focal consolidation, pleural effusion, or pneumothorax is
detected. There are no acute osseous abnormalities visualized.
IMPRESSION:
Similar mild pulmonary vascular congestion.
- Patient was given:
___ 12:44 PO/NG Phytonadione 5 mg
___ 14:57 PO Lorazepam 1 mg
___ 19:30 IV Phytonadione 5 mg
___ 19:30 IV Kcentra
___ 19:42 SC Insulin 8 Units
___ 20:05 IV Kcentra 4 Units
___ 21:45 IV LORazepam
___ 22:32 SC Insulin 5 Units
___ 22:32 PO Pravastatin 80 mg
___ 22:32 PO Omeprazole 20 mg
___ 23:04 IV Magnesium Sulfate
___ 00:07 IV Magnesium Sulfate 2 gm
- Vitals on transfer: 98.0 94 161/100 20 98% RA
Upon arrival to the floor, the patient is slow with his
responses. He is able to say ___ and eventually says
___ He says he is at the hospital because of
'low...something.' He denies any acute complaints. No headaches.
He does endorse chronic blurry vision in his L eye for the past
___. Patient says that he manages all of his medications by
himself, though is unable to name any of them. He is not sure
what dose of Coumadin he takes, but is sure that he has been
taking it. 10-point ROS is limited by patient
participation/mental status.
Past Medical History:
1. AFib s.p. three prior ___; amiodarone, coumadin.
2. DM (HbA1c 6.8% (1.16))
3. GERD
4. HTN
5. Gout
6. Obstructive sleep apnea, uses CPAP.
7. dCHF. History of tachy mediated CM, EF 30%->normalized.
Social History:
___
Family History:
Multiple family members died at early age from cardiac
complications. Mom died at ___ of CVA, Father died ___ with HTN,
MI, pancreatic cancer, Brother died at ___ of MI and CVA.
Physical Exam:
ADMISSION:
Vitals- 100.9 ___ 93 RA
GENERAL: AOx1, slow speech
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes. Oropharynx is clear.
NECK: No elevated JVP.
CARDIAC: Irregular rhythm, normal rate, no murmurs/rubs/gallops.
No JVP elevation.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: No spinous process tenderness. No CVAT.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 2+
bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy.
NEUROLOGIC: AOx1. CN2-12 intact. Peripheral visual fields full
b/l. ___ strength througout. Normal sensation. No dysmetria.
Gait deferred.
DISCHARGE:
VS: 97.9 112-147/69-100 88 21 97 RA
GENERAL: NAD
HEENT: anicteric sclera, pink conjunctiva
HEART: irregular, normal rate, S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: warm, no edema
NEURO: No gross motor deficits, ___ strength in UE, CN II-XII
grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 11:11AM BLOOD WBC-7.5 RBC-6.15* Hgb-15.9 Hct-48.4
MCV-79* MCH-25.9* MCHC-32.9 RDW-15.3 RDWSD-40.4 Plt ___
___ 11:11AM BLOOD Neuts-61.6 ___ Monos-11.8 Eos-1.2
Baso-0.9 NRBC-0.3* Im ___ AbsNeut-4.60 AbsLymp-1.81
AbsMono-0.88* AbsEos-0.09 AbsBaso-0.07
___ 11:11AM BLOOD ___ PTT-107.5* ___
___ 11:11AM BLOOD Glucose-359* UreaN-10 Creat-1.1 Na-141
K-3.6 Cl-100 HCO3-22 AnGap-19*
___ 06:44PM BLOOD Calcium-9.8 Phos-3.6 Mg-1.5*
___ 11:11AM BLOOD Prolact-7.7
___ 08:46AM BLOOD Cortsol-3.5 Testost-26*
___ 08:46AM BLOOD FSH-6.1 LH-3.3 TSH-2.0
INR:
___ 11:11AM BLOOD ___ PTT-107.5* ___
___ 06:44PM BLOOD ___ PTT-117.2* ___
___ 05:40AM BLOOD ___ PTT-33.6 ___
___ 08:10AM BLOOD ___ PTT-35.9 ___
___ 08:01AM BLOOD ___ PTT-36.2 ___
___ 06:10AM BLOOD ___ PTT-40.5* ___
___ 06:15AM BLOOD ___ PTT-47.9* ___
PERTINENT LABS
___ 08:46AM BLOOD FSH-6.1 LH-3.3 TSH-2.0
___ 11:11AM BLOOD Prolact-7.7
___ 08:46AM BLOOD Free T4-1.2
___ 08:46AM BLOOD Cortsol-3.5 Testost-26*
DISCHARGE LABS
___ 06:15AM BLOOD WBC-6.6 RBC-5.30 Hgb-13.9 Hct-42.1
MCV-79* MCH-26.2 MCHC-33.0 RDW-14.0 RDWSD-39.5 Plt ___
___ 06:15AM BLOOD Glucose-106* UreaN-17 Creat-1.0 Na-139
K-3.8 Cl-99 HCO3-27 AnGap-13
___ 06:15AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.8
IMAGING
___ CT head
1. 3.5 x 1.3 cm hyperdense expansile mass in the sella eroding
through the
roof of the sphenoid sinus. This may reflect a pituitary mass.
Dedicated MRI of the sella is recommended for further
characterization.
2. No intracranial hemorrhage.
3. Paranasal sinus disease. Please correlate with clinical
findings.
___ CTA head
1. Re-demonstration of the precontrast hyperdense pituitary
macroadenoma which shows fairly diffuse enhancement
postcontrast. No new enhancing lesions. No compromise of the
ICAs.
2. The macro adenoma extends into the sphenoid sinus below with
associated
mucosal thickening/air-fluid level in the left sphenoid sinus.
Please note that a CSF leak cannot be excluded, but this may
also be due to retained mucus in the sinus due to narrowing of
the left sign and ostium.
3. No significant stenosis by NASCET criteria of the imaged
carotid arteries.
MICROBIOLOGY
Urine culture negative ___
BCx negative ___
___ MRI w/ and w/o contrast
IMPRESSION:
1. Motion limited exam. 2. Large lobulated sellar mass invading
the medial portions of bilateral sphenoid sinuses, with mild
extension to the left cavernous sinus and abutment of the left
ICA without evidence for narrowing, and with mild retro clival
extension. Subacute blood products in the left superior sellar
component of the mass. 3. In addition to the mild retro clival
extension of the sellar mass, there is a larger retro clival
nonenhancing signal abnormality from the dorsum sellae to the
top of the dens, with small amount of layering subacute blood
products at the level of the craniocervical junction. Given the
presence of subacute blood products in the sellar mass, this may
represent a chronic hematoma. 4. While the retro clival
abnormality compatible with hematoma effaces the prepontine and
pre medullary cisterns, there is no compression of the brainstem
and no significant mass effect on the cervicomedullary junction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FLUoxetine 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 80 mg PO QPM
10. Vitamin D 400 UNIT PO DAILY
11. Furosemide 40 mg PO DAILY
12. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Lisinopril 10 mg PO DAILY
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Warfarin 2.5 mg PO 4X/WEEK (___)
18. Warfarin 5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Hydrocortisone 20 mg PO QAM
RX *hydrocortisone 20 mg 1 tablet(s) by mouth QAM Disp #*30
Tablet Refills:*0
2. Hydrocortisone 10 mg PO QPM
RX *hydrocortisone 10 mg 1 tablet(s) by mouth QPM Disp #*30
Tablet Refills:*0
3. Glargine 16 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Amiodarone 200 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. FLUoxetine 20 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Pravastatin 80 mg PO QPM
15. Spironolactone 50 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 400 UNIT PO DAILY
18. Warfarin 2.5 mg PO 4X/WEEK (___)
19. Warfarin 5 mg PO 3X/WEEK (___)
20. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until told by your primary care
physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
likely pituitary macroadenoma
Hypoglycemia
supratherapeutic INR
atrial fibrillation
type II diabetes
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with afib on warfarin and DM2 presenting with
pituitary mass and supratherapeutic INR// Please perform CTA with EEA protocol
to further characterize pituitary mass
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.0 s, 28.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
1,307.8 mGy-cm.
2) Spiral Acquisition 3.9 s, 30.5 cm; CTDIvol = 27.6 mGy (Head) DLP = 840.8
mGy-cm.
3) Spiral Acquisition 3.9 s, 30.8 cm; CTDIvol = 27.6 mGy (Head) DLP = 849.0
mGy-cm.
4) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 43.4 mGy (Head) DLP =
21.7 mGy-cm.
5) Stationary Acquisition 5.6 s, 0.5 cm; CTDIvol = 68.3 mGy (Head) DLP =
34.1 mGy-cm.
Total DLP (Head) = 3,053 mGy-cm.
COMPARISON: Prior CTA done ___ and MRI a done ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Re-demonstration of a hyperdense expansile avidly enhancing mass (2, 31) in
the sella invading through the region of the sphenoid sinus. No obvious focal
areas of non enhancement. There is mild thickening of the infundibulum.
Again demonstrated is mucosal thickening of the left sphenoid sinus +/-
fluid/mucous resulting in an air fluid level. The ostium of the left sphenoid
sinus is narrowed, which is likely related to expansion of the mass arising
from the sella. Mild suprasellar extension without contact with the optic
chiasm, was better seen on MRI performed ___. No involvement of the
internal carotid arteries.
There is no evidence of large territorial infarction, hemorrhage, or edema.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Bilateral periventricular, subcortical, and deep white matter
hypodensities are nonspecific but most likely represent sequelae of chronic
small vessel ischemic changes.
The visualized portion the bilateral mastoid air cells and middle ear cavities
are clear. The visualized portion the bilateral orbits are unremarkable.
The vessels of the circle of ___ and their principal intracranial branches
appear normal with no evidence of stenosis, occlusion, or aneurysm. The
basilar artery terminates as the superior cerebellar arteries. Bilateral
fetal origin of the PCAs. The dural venous sinuses are patent.
Significant dental disease, most extensive in posterior-most right maxillary
molar and posterior most right mandibular molar with osseous resorption
surrounding the ___ be from extensive periodontal disease or infection;
extension of periodontal disease is more likely. No surrounding rim enhancing
collection to suggest periodontal abscess. Consider dental consult.
IMPRESSION:
1. Re-demonstration of the precontrast hyperdense pituitary macroadenoma which
shows fairly diffuse enhancement postcontrast. No new enhancing lesions. No
compromise of the ICAs.
2. The macro adenoma extends into the sphenoid sinus below with associated
mucosal thickening/air-fluid level in the left sphenoid sinus. Please note
that a CSF leak cannot be excluded, but this may also be due to retained mucus
in the sinus due to narrowing of the left sign and ostium.
3. No significant stenosis by NASCET criteria of the imaged carotid arteries.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with insulin-dependent diabetes, atrial
fibrillation on Coumadin, presenting with headache and ear pain, found to have
a pituitary mass. Pituitary views to evaluate pituitary mass.
TECHNIQUE: Sagittal T1 weighted, and axial T1 weighted, T2 weighted, FLAIR,
gradient echo, and diffusion-weighted images of the brain were obtained.
Following intravenous gadolinium administration, axial T1 weighted images of
the brain and sagittal MPRAGE images of the brain with multiplanar
reformations were obtained.
COMPARISON: Incomplete pituitary MRI, ___.
CTA head and neck, ___.
Head CT, ___.
FINDINGS:
Postcontrast MP RAGE images are severely degraded by motion artifact despite 2
acquisition attempts. Multiple other sequences are mildly or moderately
limited by motion artifact.
There is no acute infarction. There is no edema, mass effect, or evidence for
blood products in the brain parenchyma. There are extensive confluent T2
hyperintensities in the subcortical, deep, and periventricular white matter of
the cerebral hemispheres, nonspecific but most likely sequela of chronic small
vessel ischemic disease given the patient's cardiovascular risk factors.
There is mild tumor global parenchymal volume loss with prominent ventricles
and sulci.
The previously seen pituitary mass is not optimally imaged in the absence of
dedicated high-resolution precontrast and postcontrast coronal and sagittal T1
weighted images through the sella, and given the severe motion degradation of
the postcontrast MP RAGE images. The ___ pituitary MRI is incomplete
as the patient could not tolerate postcontrast imaging. Again seen is a large
lobulated mass extending from the sella into the medial portions of bilateral
maxillary sinuses, which measures 2.7 cm AP x 1.7 cm craniocaudad on image
2:13 and 2.9 cm transverse on image 3:10. The mass demonstrates heterogenous
contrast enhancement. The left superior sellar component of the mass
demonstrates high signal on precontrast T1 weighted images with low signal on
T2 weighted and gradient echo images, as well as relative ___ on the
prior CT, compatible with subacute blood products. There is no mass effect on
the optic chiasm. Prior incomplete pituitary MRI better demonstrates that the
mass extends into the left cavernous sinus and abuts the cavernous left
internal carotid artery, without evidence for flow void narrowing.
In addition, there is an extra-axial retro clival abnormality extending from
the dorsum sellae to the top of the dens, which measures 5.7 cm craniocaudad
by 0.8 cm AP on sagittal image 02:13, and up to 2.2 cm transverse on image
14:8. Sagittal reformatted images of the ___ CT demonstrate linear
calcification along the upper dorsal margin of this abnormality. The superior
ventral portion of this abnormality, abutting the dorsum sellae and upper
clivus, demonstrates heterogenous high and low signal on T1 weighted images
with apparent contrast enhancement on postcontrast images, images 2:13, 12:89,
3:8, 10:8, as well as intermediate T2 signal on image 14:8, suggesting
retroclival extension of the sellar mass. The remainder of this abnormality
demonstrates low signal on T1 weighted images and high signal on T2 weighted
images, without evidence for significant contrast enhancement. In the
inferior aspect of this abnormality at the level of the craniocervical
junction, there is a small amount of layering T2 hypointensity and T1
hyperintensity with blooming artifact on gradient echo images (14:3, 3:3,
13:3), consistent with layering subacute blood products. While the prepontine
and pre medullary cisterns are effaced, there is no compression of the
brainstem or fourth ventricle. Ventral CSF space in the foramen magnum is
narrowed but not completely effaced. Dorsal CSF space in the foramen magnum
is preserved.
There is mild mucosal thickening in the ethmoid air cells and left greater
than right maxillary sinuses. In addition to invasion of the sphenoid sinuses
by the above-described sellar mass, there is also fluid in the left maxillary
sinus and mild mucosal thickening in bilateral maxillary sinuses.
IMPRESSION:
1. Motion limited exam.
2. Large lobulated sellar mass invading the medial portions of bilateral
sphenoid sinuses, with mild extension to the left cavernous sinus and abutment
of the left ICA without evidence for narrowing, and with mild retro clival
extension. Subacute blood products in the left superior sellar component of
the mass.
3. In addition to the mild retro clival extension of the sellar mass, there is
a larger retro clival nonenhancing signal abnormality from the dorsum sellae
to the top of the dens, with small amount of layering subacute blood products
at the level of the craniocervical junction. Given the presence of subacute
blood products in the sellar mass, this may represent a chronic hematoma.
4. While the retro clival abnormality compatible with hematoma effaces the
prepontine and pre medullary cisterns, there is no compression of the
brainstem and no significant mass effect on the cervicomedullary junction.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, R Ear pain
Diagnosed with Other specified disorders of brain
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 139.0
dbp: 88.0
level of pain: UTA
level of acuity: 3.0 | BRIEF SUMMARY
=============
Mr. ___ is a ___ with history of atrial fibrillation on
Coumadin (chads2 4), HFpEF (LVEF 63% ___, hypertension, and
T2DM who presented with weakness in setting of hypoglycemia,
subsequently found to have new pituitary mass concerning for a
pituitary macroadenoma.
# Expansile sellar mass concerning for pituitary macroadenoma:
Initially presented to ED with weakness and hypoglycemia. He was
noted to be lethargic upon presentation, and a CT head showed a
3.5x1.3 cm hyperdensity in the sella eroding into the sphenoid
sinus. Neurosurgery was consulted, and felt that there was no
need for inpatient surgical intervention, currently no focal
neurologic findings. ENT was consulted, and will coordinate with
neurosurgery for surgical management as an outpatient. He was
discharged to follow up as above.
# Supratherapeutic INR: INR >13 on admission, unclear etiology.
___ be due to inapprpropriate med administration in the setting
of confusion. He received vitamin K and Kcentra in the ED, with
normalization of his INR given concern for bleeding into the
suprasellar mass. His warfarin was held, and once cleared by
neurosurgery was transitioned to ___ to bridge and restarted
on warfarin. He was discharged on his prior dose of warfarin
with strict instructions to follow up for INR checks and with
his PCP.
# Hypocortisolemia:
# subacute confusion: Patient with a few weeks of new confusion,
may be related to neuroendocrine deficit secondary to mass.
Endocrine was consulted and recommended sending testing for the
HPA axis. He was found to have low testosterone and low AM
cortisol. IGF-1 and ACTH were normal. He was started on
hydrocortisone 20 mg QAM and 10 mg QPM with improvement in
mental status. Low testosterone level was not treated.
# Hypoglycemia: Patient with report of hypoglycemia when EMS
arrived. No hypoglycemia in house. His glargine initially at 16
units BID, then increased to 18 units BID but he had borderline
low blood sugars so this was reduced back to 16u BID at
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / niacin / Benadryl / donepezil / Exelon / Librax (with
clidinium)
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with HTN and DM who presented from her
assisted living facility with acute onset left leg and face
weakness with slurred speech at 12:00 noon today. She was
walking
with her rollator when she suddenly started dragging the left
leg
behind her and her speech sounded slurred. She was helped into
bed (required 2 aides, normally she is able to do this alone)
then slept for 1.5 hours. When she awoke, she continued to have
left leg weakness therefore she was sent to the ED. Upon
arrival,
BP elevated to 182/63 but came down without intervention. Her
daughter met her in the ED and at that time, symptoms had
resolved. She noticed some tremulousness of the hands and word
finding difficulties slightly worse than usual, but otherwise
appeared well with no clear weakness or numbness and without
slurred speech. CT/ CTA revealed hypodensity in the R basal
ganglia and no significant vascular abnormalities.
Toxic/metabolic/infectious workup was negative.
ROS: On neurologic review of systems, the patient denies
headache, lightheadedness. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies current focal muscle weakness, numbness,
parasthesia. Denies loss of sensation. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
DEMENTIA
DIABETES ___
HYPERTENSION
OSTEOARTHRITIS
DEPRESSION
HYPERLIPIDEMIA
PERIPHERAL NEUROPATHY
DIARRHEA
OSTEOPOROSIS
MACULAR DEGENERATION
THYROID NODULE
ANXIETY
PROTEINURIA
OBSESSIVE-COMPULSIVE DISORDER
CHRONIC KIDNEY DISEASE
VITAMIN D DEFICIENCY
GAIT DISTURBANCE
ORAL MASS
Social History:
Social History (Last Verified ___ by ___,
MD):
Marital status: Married
Children: Yes: 1 son 2 daughters
Lives with: Other: ___ ___
Lives in: Group Setting
Work: ___
Tobacco use: Former smoker
Year Quit: ___
Years Since ___
Quit:
Pack Years: 0
Alcohol use: Present
Alcohol use may have a drink on special occasions
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: at ___
Diet: Regular
Comments: Lives in memory unit. medications managed
through pharmacy and aides at ___
___. Uses a cane.
Family History:
Family History (Last Verified ___ by ___,
MD):
Relative Status Age Problem Onset Comments
Mother ___ DIABETES ___
STOMACH CANCER in her ___
Father ___ ALZHEIMER'S DISEASE
Sister ___ BREAST CANCER in her ___
Comments:
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.8 HR: 70 BP: 182/63; current 149/64 RR: 16
SaO2:99% RA
General: NAD
HEENT: Atraumatic/normocephalic, no oropharyngeal lesions, neck
supple
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 2. Able to state day
and month of birth but not year. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2.5. EOMI, no nystagmus. V1-V3
without
deficits to light touch bilaterally. No facial movement
asymmetry. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 3+ 2+ 2+
R 2+ 2+ 3+ 2+ 2+
Plantar response withdrawal bilaterally
- Sensory: No deficits to light touch. Unable to cooperate with
DSS
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Normal initiation. Kyphotic posture. Narrow base with
walker. Walks around examination room, pivoting, sitting and
standing from the bed with minimal assistance
DISCHARGE PHYSICAL EXAM
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, oriented to self. Not able to state year
or month, or where she is, which is baseline her daughter.
Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2.5. EOMI, no nystagmus. V1-V3
without
deficits to light touch bilaterally. No facial movement
asymmetry. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 4+ 5 5- 5 ___- 5 5- 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
deferred
- Sensory: No deficits to light touch. Unable to cooperate with
DSS
- Coordination: No dysmetria with finger to nose testing
bilaterally.
Pertinent Results:
___ 06:52AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.9* Hct-31.2*
MCV-95 MCH-30.2 MCHC-31.7* RDW-12.9 RDWSD-44.6 Plt ___
___ 06:52AM BLOOD ___ PTT-26.3 ___
___ 06:52AM BLOOD Glucose-100 UreaN-29* Creat-1.2* Na-143
K-4.8 Cl-107 HCO3-24 AnGap-12
___ 06:52AM BLOOD ALT-11 AST-14 LD(LDH)-197 CK(CPK)-52
AlkPhos-59 TotBili-0.2
___ 07:30PM BLOOD Lipase-23
___ 06:52AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:52AM BLOOD TotProt-6.0* Albumin-3.9 Globuln-2.1
Cholest-PND
___ 06:52AM BLOOD %HbA1c-5.5 eAG-111
___ 07:30PM BLOOD Triglyc-374* HDL-36* CHOL/HD-7.9
LDLcalc-173*
___ 06:52AM BLOOD TSH-PND
___ 06:52AM BLOOD CRP-3.9
MRI brain w/o contrast ___
"
FINDINGS:
Acute infarcts in the right putamen as well as body of the right
caudate
nucleus. No intracranial hemorrhage. No mass. Generalized
cerebral atrophy
with ex vacuo dilatation of the ventricular system. Mild
periventricular
white matter T2 and FLAIR hyperintense changes are most likely
sequela of
microangiopathy. Partially empty sella. The craniocervical
junction appears normal. Degenerative changes of the cervical
spine. The orbits appear normal. The major intracranial vessels
demonstrate normal T2 flow voids. Mild mucosal thickening
involving the paranasal sinuses.
IMPRESSION:
1. Acute infarcts in the right basal ganglia as described above.
"
CTA h/n ___ (preliminary read)
"Wet Read by ___ on FRI ___ 7:42 ___
Noncontrast head CT: No acute intracranial process.
CTA head and neck:
Patent intracranial cervical vasculature without dissection or
aneurysm
greater than 3 mm.
Final read pending 3D reconstruction. "
============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 173) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (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
]
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?
() 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? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Lisinopril 2.5 mg PO DAILY
5. Memantine 5 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. OLANZapine 5 mg PO DAILY
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
9. Aspirin 81 mg PO DAILY
10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. amLODIPine 5 mg PO DAILY
5. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
6. Escitalopram Oxalate 10 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lisinopril 2.5 mg PO DAILY
9. Memantine 5 mg PO DAILY
10. Mirtazapine 15 mg PO QHS
11. OLANZapine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
mild left sided weakness
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with 2 hours of left sided weakness now
resolved; hypodensity in R putamen on CTH// stroke eval
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Prior CT done ___
FINDINGS:
Focal areas of slow diffusion are consistent with acute infarcts in the right
putamen as well as body of the right caudate nucleus. There is no evidence of
mass effect or hemorrhagic transformation, generalized cerebral atrophy with
ex vacuo dilatation of the ventricular system. Mild periventricular white
matter T2 and FLAIR hyperintense changes are most likely sequela of
microangiopathy. Partially empty sella. The craniocervical junction appears
normal. Degenerative changes of the cervical spine. The orbits appear
normal. The major intracranial vessels demonstrate normal T2 flow voids.
Mild mucosal thickening involving the paranasal sinuses.
IMPRESSION:
1. Focal areas of slow diffusion consistent with acute infarcts in the right
putamen and body of the right caudate nucleus as described above.
2. T2/FLAIR hyperintensities in the subcortical white matter suggests chronic
microvascular ischemic changes.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 10:09 am, 10 minutes after discovery
of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Slurred speech
Diagnosed with Disorientation, unspecified, Hypokalemia, Altered mental status, unspecified
temperature: 97.7
heartrate: 74.0
resprate: 16.0
o2sat: 99.0
sbp: 182.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ woman with a history of HTN and DM presented with
acute onset left-sided weakness and slurred speech that lasted
for 2 hours before resolving spontaneously prior to presentation
to the hospital. She was admitted to the stroke service. CT head
showed hypodensity in the right basal ganglia. MRI brain w/o
contrast confirmed small acute infarct in the right putamen and
as well as the body of the right caudate nucleus. Her stroke was
most likely secondary to small vessel disease given the location
and her risk factors. We did consider this a failure of ASA. Her
home aspirin was stopped, and she was started on Plavix 75 mg
daily. She had mild weakness on the L side in an upper motor
neuron pattern distribution. ___ assessed and felt that she was
able to be discharged home with home ___. She passed her swallow
evaluation. TTE not done as this was felt to be small vessel
etiology.
Her stroke risk factors include the following:
1) DM: A1c 5.5%
2) intra and extra cranial calcifications noted on CTA
3) Hyperlipidemia: LDL 173, started on atoravastatin 80
#
CKD--Cr 1.4 on admission, 1.2 on discharge (baseline).
TRANSITIONAL ISSUES
stroke - follow up in stroke clinic in ___ months. Stopped
aspirin, started Plavix 75 mg daily this admission. Increased
atorvastatin to 80 mg qhs.
DM - continue glycemic control
HTN - continue blood pressure control
Consider outpatient Echo
Home ___
TSH pending at the time of discharge |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Open Right Hemicolectomy
History of Present Illness:
___ y/o M ___ with ___ duodenal ulcer in ___ (NSAID
induced per patient), s/p H. pylori eradication ___, p/w 3 days
of RLQ pain and BRBPR. No nausea, vomiting, hematemesis or
melena. No history of abdominal surgeries. Patient reports that
he had BRBPR and intermittent diarrhea and constipatino x 2
months. Presented to OSH 2 months ago, had KUB, and was given
stool softeners. Symptoms continued, and started having ___
diarrhea, so he had colonoscopy 3 weeks ago with Dr. ___
___ affiliate). He was told he has "cancer" of some kind, but
was supposed to discuss details with Dr. ___ ___. No
fevers/chills at home, currently ___ diarrhea/day. No sick
contacts at work or home, no recent travel.
Initial VS in the ED: 98 80 131/77 20 99%. Labs notable for Hct
34 on arrival, 32 on repeat. Patient was given 5mg IV morphine,
but continued to have pain and unable to tolerate PO CT
abdomen: 1. bowel wall thickening and edema and surrounding
inflammatory changes in the distal and terminal ileum,
inflammation at cecum at the level of the ileocecal valve. c/w
an enteritis, either inflammatory or infectious. Normal appendix
VS prior to transfer: 98.8 73 ___ 99%
Past Medical History:
vericose veins
duodenal ulcer
Social History:
___
Family History:
No history of GI bleeding or other GI disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5, 109/72, 72, 18, 98%RA
General: no acute distress, pleasant
HEENT: Sclera anicteric
Neck: supple
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, mild TTP in RLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
SKIN: no rash
NEURO: A+Ox3, CN ___ grossly intact
DISCHARGE PHYSICAL EXAM:
General: Ambulating inpatient floor without issue. Pain
controlled. Tolerating regular diet. Reports passing flatus.
VS: 97.8, 89, 106/63, 18, 97% RA
Neuro: A&OX3
Resp: no issues
Abd: midline incison closed with dermabond, no drainage or
errythema noted
Lower Extremities: No edema.
Pertinent Results:
ADMISSION LABS:
___ 09:48PM WBC-8.5 RBC-4.05* HGB-9.8* HCT-32.1* MCV-79*
MCH-24.2* MCHC-30.5* RDW-13.7
___ 02:06PM GLUCOSE-93 UREA N-6 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 02:06PM ALT(SGPT)-9 AST(SGOT)-16 ALK PHOS-76 TOT
BILI-0.3
___ 02:06PM LIPASE-19
___ 02:06PM WBC-8.8 RBC-4.37* HGB-10.5*# HCT-34.3*#
MCV-79*# MCH-24.1*# MCHC-30.7* RDW-13.9
___ 07:10AM BLOOD WBC-10.4 RBC-4.23* Hgb-10.2* Hct-33.5*
MCV-79* MCH-24.0* MCHC-30.4* RDW-14.2 Plt ___
___ 08:20PM BLOOD Hct-33.7*
___ 07:30AM BLOOD WBC-8.0 RBC-3.91* Hgb-9.8* Hct-30.9*
MCV-79* MCH-25.1* MCHC-31.8 RDW-13.8 Plt ___
___ 09:48PM BLOOD WBC-8.5 RBC-4.05* Hgb-9.8* Hct-32.1*
MCV-79* MCH-24.2* MCHC-30.5* RDW-13.7 Plt ___
___ 09:48PM BLOOD Neuts-74.2* Lymphs-17.8* Monos-6.5
Eos-1.3 Baso-0.2
___ 02:06PM BLOOD Neuts-80.4* Lymphs-12.7* Monos-6.0
Eos-0.7 Baso-0.2
___ 07:10AM BLOOD Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-36.7* ___
___ 09:48PM BLOOD Plt ___
___ 02:06PM BLOOD Plt ___
___ 02:06PM BLOOD ___ PTT-38.1* ___
___ 07:10AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-141 K-3.9
Cl-107 HCO3-24 AnGap-14
___ 08:20PM BLOOD Na-140 K-3.9 Cl-105
___ 07:30AM BLOOD Glucose-81 UreaN-9 Creat-0.8 Na-140 K-3.6
Cl-104 HCO3-26 AnGap-14
___ 07:10AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
___ 08:20PM BLOOD Mg-1.9
___ 07:30AM BLOOD CEA-21*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
do not take more than 3000mg of tylenol in ___ hrs or drink
alcohol while taking
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
ok to not take if loose stool develops
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN pain
Please take with food.
RX *ibuprofen [Advil] 200 mg ___ tablet(s) by mouth every eight
(8) hours Disp #*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink alcohol or drive a car while taking this
medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Sided Colon Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of peptic ulcer disease with right lower quadrant pain
and bright red blood per rectum for three days.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis after the administration of IV contrast only. Sagittal and coronal
reformatted images were obtained and reviewed.
FINDINGS:
LUNG BASES: There is dependent basilar atelectasis. The bases of the lungs
are otherwise clear. There are no nodules, consolidations or pleural
effusion. The base of the heart is normal. There is no pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There are no focal
hepatic lesions. The portal vein is patent. The gallbladder is normal in
appearance. There is no intra- or extra-hepatic biliary duct dilation. The
spleen, pancreas, adrenal glands, and kidneys are normal. There is no
evidence of pyelonephritis or hydronephrosis. The kidneys enhance and excrete
contrast symmetrically.
The stomach is mostly collapsed. The proximal small bowel is normal in course
and caliber. There is no evidence of obstruction. There is no free air. In
the distal ileum, extending into the terminal ileum, there is marked small
bowel wall thickening, surrounding stranding, and tracer associated ascites.
There is no stricturing or surrounding abscess. There is mild surrounding
inflammatory change around the cecum at the level of the ileo-cecal valve.
There is trace free fluid in the right pelvis.
There are enlarged scattered mesenteric lymph nodes, likely reactive. There
is no retroperitoneal lymphadenopathy. The pbdominal vasculature is normal in
course and caliber.
PELVIS: The rectum is unremarkable. The large bowel is normal in course and
caliber without focal inflammatory changes, other than the mild changes in the
cecum, as described above. The appendix is visualized and normal. The
bladder and prostate are normal. There is no pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. No fractures identified.
IMPRESSION:
1. Extensive bowel wall edema, surrounding inflammatory changes, and
associated trace acites in the distal and terminal ileum. Additionally, there
is some inflammatory changes in the cecum at the level of the ileocecal valve.
This is most consistent with an enteritis, either inflammatory or infectious.
2. Normal appendix.
Radiology Report
PA AND LATERAL CHEST ___
No prior studies for comparison.
FINDINGS: Heart size, mediastinal and hilar contours are normal. Lungs and
pleural surfaces are grossly clear. No pleural effusion or acute skeletal
finding.
IMPRESSION: No acute cardiopulmonary radiographic abnormality.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.0
heartrate: 80.0
resprate: 20.0
o2sat: 99.0
sbp: 131.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was initially admitted to the ___ medical service
from the emergency department:
___ y/o M with h/o remote duodenal ulcer, presents with abdominal
pain, BRBPR x2 months, CT showing cecal and terminal ileum
inflammation.
# Colon Mass: Presented with RLQ abdominal pain and BRBPR. Per
discussion with outpatient GI doctor, he has colonoscopic
evidence of a large apple-core mass in the ascending colon.
Biopsies were taken of this lesion, which were consistent with a
poorly-differentiated colon primary. CT showed evidence of
thickening and inflammation in this region. Colorectal surgery
recommended resection of this lesion, especially in the setting
of anemia.
# Anemia: Baseline Hct appears to be in the mid 40's as of ___, but on admission it was down to 32, and continued to drift
down during his time on medicine. Given the presence of a large
colon mass, this is the likely source of blood loss.
The patient was transferred to the colorectal surgery inpatient
surgery pre-operativly. His CEA was 21. Right open colectomy was
preformed on ___. The patient tolerated this
procedure well and recovered on ___ 5. Post-operative day
one, the patient was given intrvenous pain medications and
fluids. All post-operative laboratory values were stable. He
ambulated without issue with god pain control. Clear liquids
were tolerated well. The foley catheter was removed at midnight.
The patient was able to voisd without issue on post-operative
day two. In the late morning of ___ day two, the
patient reported passing flatus. His diet was advanced to
regular which was tolerated well. All pain medications were
transitioned to pills. The patient was requiring minimal
narcotic medications. On the morning of post-operative day
three, the patient was stable and tolerated breakfast. He
continued to pass flatus. He was meeting all discharge criteria
and was discharged home in the care of his supportive wife. All
follow-up instructions were given to the patient. The pateint
had access to a ___ inerpreter throughout his
hospitalization however, he understands ___ well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Reglan / Benadryl Decongestant / Phenergan / Prochlorperazine /
Depakote / vancomycin / Compazine
Attending: ___.
Chief Complaint:
abdominal pain, facial weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ G6P3 @ 10w2d by LMP (LMP ___ which makes
___ ___ although states she was given ___ of ___ with
h/o chronic abdominal pain, longstanding narcotic use, adrenal
insufficiency (per notes likely secondary to chronic narcotic
use) who presents to the ED with multiple complaints including
abdominal pain, nausea/vomiting and right facial numbness. Seen
by Neurology for evaluation of right facial numbness and
multiple
other neurologic complaints. Per their initial impression, most
c/w functional, have not yet recommended imaging. OBGYN
consulted
re: abdominal pain/nausea/vomiting in the setting of early
pregnancy.
Pt states she has had abdominal pain x 1 month, mostly
periumbilical, constant. Pain has become worse over the past
week, also associated with nausea and vomiting. Has had vomiting
since early pregnancy, was using ginger chews earlier in
pregnancy, no longer using, no other meds. Vomits 4 times per
day, usually bilious or yellow. No documented fever, chills. No
abnormal vaginal discharge, no bleeding.
Has been using narcotics x ___ years. Has been using fentanyl
patch
(changes every other day) and dilaudid 2mg every 4 hours,
although she hasn't been taking the dilaudid this week due to
her
nausea and vomiting.
Has not yet seen an OB. Unplanning pregnancy, but desired,
planning to continue.
Past Medical History:
POBhx: SAB x 2, SVD x 3 (full term, aged ___, 4)
PGynhx: h/o endometriosis diagnosed by laparoscopy, regular
periods, no STIs, denies abnl Paps
PMH:
- chronic abdominal pain s/p negative work-up
- chronic narcotic use: has been using x 7 days, states
prescribed by her PCP ___, currently on fentanyl patch and
PO dilaudid 2mg q4h, although has not taken dilaudid for approx
1
week, states she "thinks patch fell off today"
- adrenal insufficiency thought to be secondary to chronic
narcotic use, last saw in ___
- hyperprolactinemia
- H/o hyperprolactinemia
- Conversion disorder
- migraine
- Anxiety/Depression
- Iron deficiency anemia
- History of gastric ulcer
- Iron deficiency anemia
- Asthma
- Eczema
- pt reports h/o upper extremity DVT (although unable to find in
her record); pt states she received short course of
anticoagulation but unsure if it was a pill or injection
PSH: diagnostic laparoscopy, occipital nerve decrompression
surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VITALS:
Yest 19:19 94 120/70 18 100% RA
Yest ___ 114/62 10 99% RA
Yest 21:48 8 68 ___ 10 100% RA
Yest ___ 118/58 9 99% RA
Yest ___ 124/69 9 99% RA
Yest ___ 108/66 15 100% RA
Yest 23:46 8 98.4 79 109/61 12 100% RA
General: NARD, appears uncomfortable
Abdomen: Mildly tender diffusely but distractable, nondistended,
no rebound, no guarding
Back: No CVAT
SSE: No bleeding, posterior multiparous cervix
Bimanual: 10 week sized anteverted uterus, nontender, no CMT, no
adnexal masses or tenderness.
On discharge:
VSS
Gen: NAD
CV: RRR
Abd: soft, non-tender
Ext: non-tender
SVE: deferred
Pertinent Results:
LABORATORY
On admission:
___ 07:10PM BLOOD WBC-6.2 RBC-4.88 Hgb-13.0 Hct-39.9 MCV-82
MCH-26.6 MCHC-32.6 RDW-14.2 RDWSD-41.6 Plt ___
___ 07:10PM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-138
K-4.5 Cl-106 HCO3-15* AnGap-22*
___ 07:10PM BLOOD ALT-9 AST-23 AlkPhos-48 TotBili-0.4
___ 07:10PM BLOOD Albumin-4.2 UricAcd-3.1
___ 07:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Urine:
___ 01:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 01:55AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
F/U LABS:
RADIOLOGY:
PELVIC ULTRASOUND: An intrauterine gestational sac is seen and a
single living embryo is identified with a crown rump length of
33
mm representing a gestational age of 10 weeks 2 days. This
corresponds satisfactorily with the menstrual dates of
10 weeks 2 days. The uterus is normal. The ovaries are normal.
IMPRESSION: Single live intrauterine pregnancy with size equal
to
dates.
___ OB Ultrasound
- NT 1.2 mm (normal)
Medications on Admission:
colace, linzess, hydrocortisone 20 mg qAM and 10 mg qPM,
advair, singulair, spiriva, fentanyl patch, dilaudid 2mg q4h prn
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice daily
Refills:*2
2. doxylamine succinate 10 mg ORAL QPM
3. Fentanyl Patch 100 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour Place 1 patch on a large patch of skin
every 3 days Disp #*1 Patch Refills:*0
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*2
6. Prenatal Vitamins 1 TAB PO DAILY
7. Pyridoxine 25 mg PO TID
RX *pyridoxine 25 mg 1 tablet(s) by mouth three times daily Disp
#*40 Tablet Refills:*2
8. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN severe pain
9. Lorazepam 0.5 mg PO Q8H:PRN nausea
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 8 hours
Disp #*21 Tablet Refills:*0
10. Montelukast 10 mg PO DAILY
11. Hydrocortisone 20 mg PO QAM
12. Hydrocortisone 10 mg PO QPM
13. Solu-CORTEF (hydrocorTISone Sod Succinate) 100 mg
intramuscular ONCE
If feeling unwell, you can take one quarter of the injection. If
vomiting and unable to tolerate oral medication, take half of
solution
RX *hydrocortisone sod succinate [Solu-Cortef] 100 mg 0.25 mg IM
as needed Disp #*3 Vial Refills:*0
14. Syringe 3cc/21Gx1 (syringe with needle (disp)) 3 mL 21 x 1
miscellaneous ONCE
RX *syringe with needle (disp) [Syringe 3cc/21Gx1"] 21 gauge X
1" Use syringe for intramuscular injection once Disp #*10
Syringe Refills:*0
15. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet by mouth twice daily Disp
#*40 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and vomiting of pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with Ndobhoff placement // ? dobhoff placement
COMPARISON: Radiographs from ___
IMPRESSION:
There is a Dobbhoff tube which is too high, with the distal tip in the mid to
lower esophagus. This should be advanced at least 20-25 cm or removed.
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ year old woman with nausea, vomiting of pregnancy, f/u dobhoff
placement // dobhoff placement
COMPARISON: Radiographs from ___ at 18:00
IMPRESSION:
The Dobbhoff tube has been advanced with the distal tip well within the body
of the stomach, appropriately sited. Heart size is within normal limits.
There are no focal consolidations, pleural effusion, or pulmonary edema. There
are no pneumothoraces.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Numbness, Abd pain, Vomiting
Diagnosed with OTH CURR COND-ANTEPARTUM, CHEST PAIN NOS, SKIN SENSATION DISTURB
temperature: 98.4
heartrate: 118.0
resprate: 16.0
o2sat: 100.0
sbp: 118.0
dbp: 79.0
level of pain: 8
level of acuity: 1.0 | Patient is a ___ year old G6P3 who was admitted to the hospital
on ___ given persistent nausea in early pregnancy. Her
hospital course was notable for several other issues below:
1. Persistent nausea/abdominal pain: On admission patient had
reported a 10 pound weight loss over several weeks, as well as
vomiting at home. Initial diagnostic evaluation was negative for
concerning etiologies of nausea/pain. She had a negative
ultrasound for adnexal pathology, normal white blood count
making appendicitis or other infectious etiologies unlikely, and
a normal urinalysis making kidney stones or urinary tract
infection unlikely. Her nausea was felt to be consistent with a
combination of nausea of pregnancy and long-standing nausea. In
the hospital, she was initially managed with oral zofran and
fluids and intermittently was able to tolerate oral intake. Her
pain was managed with her normal doses of narcotics (see problem
below). By hospital day 4, however she was unable to tolerate
oral intake due to nausea and abdominal pain induced by nausea.
She requested IV ativan use in order to eat and received a few
doses of this with good ability to eat. Additional services were
consulted to evaluate alternative reasons for the patient's
persistent nausea. Endocrinology was consulted due to history of
adrenal insufficiency, and while her steroid dose was increased
to stress dosages, this did not improve her ability to take oral
intake. Psychiatry was also consulted, due to history of
somatization disorder, and her presentation was felt to be
consistent with this. There was no intrinsically medical reason
identified for persistent nausea. Because she was able to
tolerate some oral intake, she was switched to oral ativan which
she initially declined. She declined all other oral medications,
despite demonstrated ability to tolerate oral intake and
requested IV ativan in exchange for eating. This request was not
met, and patient unable to consistently provide herself with
nutrition for another 2 days, although she was able to take oral
ativan and dilaudid. Per recommendation from hospital
nutritionist, decision was made to proceed with enteral feeding
through a feeding tube. Thus, on hospital day 7 (___), a
Dobhoff tube was placed in a two step fashion in the patient's
stomach. Appropriate location was confirmed with a chest x-ray
and enteral feeding was started. The patient was able to
tolerate enteral feeding without any vomiting, and she was
passing gas and having bowel movements. Plan was made to proceed
with enteral feeding as an outpatient, however given patient's
insurance, outpatient tube feeding was not possible. On hospital
day 10, tube feedings were cycled overnight, which patient
tolerated well, and attempts were made for patient to eat and
drink around the tube. Patient did overall well with this on
hospital days ___. Tube feeding was decreased on hospital day
14, and plan was made to stop tube feeding on hospital day ___
(___) with plan for removal on ___. However, patient
reported being unable to eat and she had lost 3 kg over ___ days
by hospital day 16 (___) and thus tube feeding was
restarted. On hospital day 17, team decided that tube feeding
was counter-productive to goals of care for patient (to go
home). Since patient had demonstrated ability to eat, and tube
was felt to be limiting ability to eat, plan was made with
patient approval for trial of feeding without feeding tube. The
feeding tube was thus removed. On hospital day 17, patient able
to eat and drink and thus decision was made for trial of home
with close outpatient ___. Of note, she was discharged on
a week's worth of oral ativan (7 days x three times daily), as
well as zofran, doxylamine, pepcid, and vitamin b6 to optimize
ability to tolerate oral feeding. Of note, ativan is not a
standard anti-emetic in pregnancy, and thus this medication was
provided for initial optimization, but it was made clear to
patient this would not be a continuing medication provided by
obstetric service in pregnancy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
(Patient is non-verbal with severe dementia, all information is
from ___)
.
___ with history of severe vascular dementia (non-verbal at
baseline), lives in a nursing home who presents with 1 day of
nausea/vomiting. She vomited brown liquid today x3 with 2
episodes of diarrhea (per EMS report). Pt non-verbal and can not
communicate symptoms or story. In ED Labs notable for lactate
2.1, K 6.5, Na 147, Cr 3.6. Trop 0.03. WBC 21 with 92% neuts.
HCT 43, Plt 241. INR 1.0, PTT 25. EKG showed no peaked T waves.
Pt given 30 kayexelate but drank very little of it. CT abd
showed: dilated small bowel loops, 3.3cm, ___oncern for possible obstruction caused by internal hernia. No
evid of bowel ischemia. NGT placed. Pt given vanc and zosyn.
Power of attorney decided against surgical intervention and
ultimately decided to transition to comfort measures only.
.
Patient currently appears comfortable and is in no acute
distress.
.
REVIEW OF SYSTEMS:
can not obtain
Past Medical History:
vascular dementia
TIA
recurrent UTI
Osteoporois
benign breast lump
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM
VS - 97.4, HR 108, 158/90, RR 20
GENERAL - NAD, comfortable, non verbal, opens eyes to voice
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART- tachycardic
ABDOMEN - soft, nt, nd.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - non verbal, looks comfortable, currently with eyes
closed
.
DISCHARGE EXAM
GENERAL - NAD, comfortable, non verbal, opens eyes to voice
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART- tachycardic
ABDOMEN - soft, nt, nd.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - non verbal, looks comfortable, currently with eyes
closed
Pertinent Results:
ADMISSION LABS
___ 10:30PM BLOOD WBC-20.9* RBC-4.99 Hgb-14.1 Hct-43.5
MCV-87 MCH-28.3 MCHC-32.4 RDW-14.0 Plt ___
___ 10:30PM BLOOD Neuts-92.2* Lymphs-3.7* Monos-3.3 Eos-0.5
Baso-0.4
___ 10:30PM BLOOD ___ PTT-25.1 ___
___ 10:30PM BLOOD Glucose-150* UreaN-82* Creat-3.6* Na-147*
K-6.2* Cl-109* HCO3-25 AnGap-19
___ 03:50AM BLOOD Glucose-160* UreaN-82* Creat-3.4* Na-144
K-5.7* Cl-107 HCO3-21* AnGap-22*
___ 10:30PM BLOOD ALT-14 AST-20 AlkPhos-61 TotBili-0.4
___ 10:30PM BLOOD Lipase-75*
___ 10:30PM BLOOD cTropnT-0.03*
.
URINE
___ 02:45AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 02:45AM URINE RBC-1 WBC-10* Bacteri-MOD Yeast-NONE
Epi-<1
___ 02:45AM URINE CastHy-9*
.
MICROBIOLOGY
Blood culture pending x 1
.
IMAGING
CXR
IMPRESSION:
Right upper lobe mass with pleural tag, concerning for primary
lung
malignancy. Additional nodular opacity in left mid lung is
indeterminate.
A CT chest is recommended for further evaluation.
Bibasilar opacities may reflect aspiration, atelectasis or
infectious
pneumonia. These may be further evaluated at the time of CT.
.
CT ABDOMEN PELVIS
1. Small-bowel obstruction, with at least two transition points
in the
lower-to-mid abdomen, with creation of closed loop where the
bowel loop is
dilated up to 2.6 cm. No evidence of bowel ischemia on this
non-contrast CT study.
2. A 2.1-cm left adrenal and 1.2-cm right adrenal nodules, are
not
characterized in this study, may represent lipid poor adenomas
or metastatic disease. If clinically feasible, adrenal protocol
CT scan or an MRI can be obtained for further evaluation.
3. Pelvic free fluid, with minimal internal hemorrhage.
4. Sigmoid colonic diverticulosis without evidence of acute
diverticulitis. A
2.7-cm left adnexal cyst, given the postmenopausal status, a
pelvic ultrasound
is recommended for further evaluation.
5. Fecal impaction in the rectum.
.
Medications on Admission:
actonel 35mg
allopurinol ___
calcium antacid ___
citalopram 20mg
docusate 100mg
lasix 20mg
indomethacin 50mg
lisinopril 2.5mg
nystatin powder
olanzapine 2.5mg
senna
vit D 400
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Hyperkalemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with NG tube placement.
COMPARISON: Chest radiograph, ___,
CHEST/ABDOMEN RADIOGRAPHS: A nasogastric tube coils in the fundus of the
stomach with the tip terminating in the gastric body. Mildly dilated small
bowel loops are partially imaged in this study. A circumscribed 3.0 cm right
upper lobe opacity with a pleural tag, is concerning for a malignancy. Again
seen are multifocal pulmonary opacities in the left mid lung and possibly the
lung bases, reflective of multifocal infection.
IMPRESSION: Nasogastric tube coils in the fundus and terminates in the
gastric body.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V/D
Diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, DEHYDRATION, HYPERKALEMIA, ARTERIOSCLER DEMENT NOS, CEREBRAL ATHEROSCLEROSIS
temperature: 98.5
heartrate: 110.0
resprate: 18.0
o2sat: 92.0
sbp: 168.0
dbp: 87.0
level of pain: nonverbal
level of acuity: 2.0 | PRIMARY REASON FOR ADMISSION
___ F with severe dementia who presents with emesis with CT
showing SBO, pt is admitted for for medical management of SBO,
acute renal failure, hyperkalemia, leukocytosis. After
discussion with patient's power of attorney, pt was made comfort
measures only.
.
# Small bowel obstruction: Patient was admitted with emesis. CT
scan demonstrated SBO with at least 2 transition points likely
___ internal hernia with a closed loop. Initially NG tube was
placed and patient was evaluated by surgery regarding possible
intervention. In discussion with the patients HCP/power of
attorney the decision was made not to persue surgical
intervention. She was latter made comfort measurues only the
the NG tube was removed. She was symptomatically managed with
PRN morphine, zofran and ativan.
.
#Leukocytosis: Pt was notes to have a leukocytosis on admission
with a predominance of neutrophils. Differential includes:
urinary vs GI source. CXR also concerning for a possible
pneumonia. The patient was covered broadly for gram neg, gram
pos, anaerobes in ED with vanco and zosyn. Antibioitic were
discontinued when care was transitioned to comfort measures.
.
#Severe Sepsis: On admission met patient was tachycardic with a
leukocytosis, likely source being urinary or GI, meeting
criteria for sepsis. Lactate 2.1 (>2.0) suggesting severe
sepsis. MAP>60 therefore patient did not meet criteria for
septic shock. As above the patient was initially started on
antibiotics as well as IVF these were discontinued.
.
#Hypernatremia: Na 147, pt is 1.8 L free water deficit. Likely
from poor access to water.
.
# ARF: Initialy Cr 3.6. Likey pre-renal in setting of sepsis,
emesis, SBO, poor access to water and hydration. ATN also
considered, possibly preceeded by a pre-renal state. Given 3 L
in the ED. Acute renal failure likely explains hyperkalemia.
.
#Hyperkalemia: K 6.5, confirmed on green top. Likely from ARF.
EKG with no peaked T waves, narrow QRS, no EKG signs of
hyperkalemia right now. However, pt not able to take kayexelate
since she has SBO and not able to excrete K through bowel
movements. K will likely increase and cause arrtyhmias. Power of
attorney is aware, he wants patient to be CMO, he explained that
he does not want any dialysis.
.
# ? Lung mass: Patient noted to have possible RUL mass on CXR
concerning for malignancy. CT was recommended for further
evaluation. However this was not done given patients poor
prognosis from other active medical issues.
.
#Comfort Measures Only: Patient's power of attorney requests
that patient be CMO. Wants goal of care to focus on comfort
only. He does not want any surgeries, no tubes, no HD. Given
patients rising K, she is at risk for arrythmias. Also at risk
for hypotension in the setting of possible sepsis. Pt
unfortunately not able to verbalize any pain or discomfort. She
was given PRN morphine for pain. All vitals and lab draws were
held. In dsicussion with the power of attorny the decision was
made to transition her to hospice care at her home facility.
.
TRANSITIONAL ISSUES
- As above patient should be treated with comfort measures only
- Patient will receive hospice care at her home facility |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Dyspnea on exertion, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ with CLL, secondary ITP on Prednisone and
recently started on Rituxan, HTN, HL, carotid artery stenosis,
likely CAD s/p recent demand-type NSTEMI with TTE showing
regional WMAs c/w CAD and increased LVEDP, who presents with
dyspnea on exertion.
She was here a couple weeks ago for management of ITP in context
of admission for hypovolemia and demand-type NSTEMI in setting
of diarrhea due to Norovirus. She was discharged home and per
family has been doing very well. Her platelets continued to be
low, so she was started on Rituximab and had infusion on
___, which she tolerated fine. On ___, she felt some
fatigue. Then today she noticed dyspnea while going up the
stairs. No chest pain, leg swelling, cough or cold symptoms,
fevers, nor chills. She complained to her daughters, who around
the same time noticed increased dyspnea during conversation.
They brought her to an urgent care where her initial vitals
showed SpO2 of 84, so they brought her to the ED.
In the ED, she was mildly hypoxic and tachycardic. Vitals and
symptoms normalized with ___ supplemental oxygen. Labs showed
mild hyponatremia, chronic hemogram abnormalities, Tn of
0.13-->0.10 down from her prior values in our system. UA
negative. CXR showed pulmonary edema. CTA chest showed no PE but
confirmed infiltrates c/w pulmonary edema along with moderate
bilateral pleural effusions. Admission was requested for
possible CHF.
ROS is negative in 10 points except as noted
Past Medical History:
CLL, secondary ITP on Prednisone and recently started on Rituxan
HTN
HL
Carotid artery stenosis currently on aspirin, family reports
that she has 75-99% stenosis, followed by Dr. ___ at ___
___ CAD s/p recent demand-type NSTEMI with TTE showing
regional WMAs c/w CAD and increased LVEDP
Surgeries: Hysterectomy, wrist ORIF
Social History:
___
Family History:
Not relevant to current presentation
Physical Exam:
Admission Exam:
Vitals AVSS
Gen NAD, quite pleasant
Abd soft, NT, ND, bs+
CV RRR, no MRG
Lungs slightly diminished bilateral bases, scant bibasilar
crackles
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
Psych normal affect
Discharge exam:
AF, BP 100s-120s (most recent reading 144/75, HR 95-115, RR 18,
SaO2 96/RA
General: well-appearing woman in NAD, AO X 3
HEENT: MMM, OP clear
Neck: supple, JVP approx. 8 cm
Chest: bibasilar crackles
CV: RR tachy, no m/g/r
Abd: soft, NT/ND, NABS
Ext: 1+ pedal edema b/l mainly at ankles
Neuro (per Neurology consultant on ___:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L ___ 5
R ___ 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 2
R 2+ 2+ 2+ 3+ 2
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, +extinction to LT on the
left when testing both simultaneously
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
On re-examination several hours later, Ms. ___ had R gaze
deviation while she was sitting up in bed after waking up from a
nap where she was sleeping upright. Had paraphasias and unable
to name fingers ___ a pinking a "pee-wee," could not name
index finger, could name thumb). Unable to say how much money 7
quarters is (said 4 quarters is $1). Able to draw a clock but on
circling A's on a page, she only circled one A on the right side
of the page. VFF to finger wiggling, eyes unable to cross
midline. Not using her left arm as much, required quite a bit of
prompting. Did say that her left hand was her own. Exam improved
with lying her flat, eyes did cross midline and she started to
use her LUE more spontaneously.
Pertinent Results:
Labs on admission:
Heme
___ 04:00PM BLOOD WBC-24.3* RBC-3.21* Hgb-8.2* Hct-26.4*
MCV-82 MCH-25.5* MCHC-31.1* RDW-15.9* RDWSD-47.3* Plt Ct-54*#
___ 04:00PM BLOOD Neuts-47 Bands-0 ___ Monos-1* Eos-0
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-11.42* AbsLymp-12.64*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 04:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-1+ Polychr-NORMAL
___ 04:00PM BLOOD ___ PTT-23.8* ___
Chem
___ 04:00PM BLOOD Glucose-266* UreaN-20 Creat-0.8 Na-129*
K-3.6 Cl-94* HCO3-21* AnGap-18
___ 04:00PM BLOOD cTropnT-0.13*
___ 08:02PM BLOOD cTropnT-0.10*
Imaging on admission:
CXR
Increased interstitial prominence due to mild to moderate
pulmonary edema or potentially atypical infection. Small right
pleural effusion.
CTA chest
1. No evidence of pulmonary embolism to the segmental level or
aortic
abnormality.
2. Mild to moderate asymmetric pulmonary edema with bilateral
small to
moderate pleural effusions and moderate cardiomegaly.
3. Multiple prominent mediastinal lymph nodes, measuring up to
1.0 cm.
Suspected but not well assessed subcarinal nodes which are
likely enlarged.
EKG on admission: Sinus tachycardia NANI no acute ischemic
changes
Relevant prior studies:
TTE ___
Mild regional left ventricular dysfunction c/w CAD
(multivessel), with overall preseved systolic function. Elevated
left ventricular filling pressure. Normal right ventricular free
wall systolic function. Mild mitral regurgitation. Mild
pulmonary hypertension.
Labs over hospital course and on discharge:
Heme:
___ 07:25AM BLOOD WBC-18.9* RBC-3.20* Hgb-8.1* Hct-25.6*
MCV-80* MCH-25.3* MCHC-31.6* RDW-15.8* RDWSD-45.4 Plt Ct-75*
___ 07:55AM BLOOD WBC-29.9*# RBC-3.49* Hgb-8.7* Hct-28.0*
MCV-80* MCH-24.9* MCHC-31.1* RDW-15.8* RDWSD-45.6 Plt Ct-90*
Chem:
___ 07:55AM BLOOD UreaN-23* Creat-0.8 Na-135 K-3.5
___ 07:25AM BLOOD cTropnT-0.26*
___ 05:10PM BLOOD CK-MB-2 cTropnT-0.22*
___ 07:55AM BLOOD CK-MB-3 cTropnT-0.28*
___ 07:55AM BLOOD Triglyc-102 HDL-49 CHOL/HD-2.8 LDLcalc-70
___ 07:55AM BLOOD TSH-1.3
___ 07:55AM BLOOD %HbA1c-PND
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with hx of CLL, recent chemo infusion, no SOB. had hx of
pleural effusion from blood transfusion// effusion?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
There is prominence of interstitial lung markings, particularly in the
perihilar distribution, right greater than left. There is no pneumothorax or
left pleural effusion. Small right pleural effusion is suspected. The
cardiomediastinal silhouette and hilar contours appear stable.
IMPRESSION:
Increased interstitial prominence due to mild to moderate pulmonary edema or
potentially atypical infection. Small right pleural effusion.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with CLL, presented with SOB, xray shows mild pulm edema, and
possible infiltrates, doesn't explain her SOB and increase O2 requirement//
PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 156 mGy-cm.
COMPARISON: Chest radiograph from ___
FINDINGS:
HEART AND VASCULATURE: Of note, the study is suboptimal due to respiratory
motion artifact. Within these limitations, the 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.
AXILLA, HILA, AND MEDIASTINUM: There are multiple prominent appearing
mediastinal lymph nodes, measuring up to 1.0 cm (series 3: Image 72) in the
prevascular region. In the subcarinal region there is suggestion of
underlying adenopathy measuring 1.5 cm by 2.4 cm (2:53) though exact
measurements is difficult given similar attenuation of the adjacent pleural
effusion with this density. 8 mm lymph node seen adjacent to the upper
esophagus. No axillary or hilar lymphadenopathy is present. No mediastinal
mass.
PLEURAL SPACES: There are bilateral dependent, layering, nonhemorrhagic
pleural effusions, moderate on the right and small on the left. There is no
evidence of pneumothorax.
LUNGS/AIRWAYS: The diffuse ground-glass opacities in the bilateral lungs,
right-greater-than-left, which are concerning for asymmetric mild-to-moderate
pulmonary edema. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: Mild degenerative changes are seen in the thoracic spine. No
suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level or aortic
abnormality.
2. Mild to moderate asymmetric pulmonary edema with bilateral small to
moderate pleural effusions and moderate cardiomegaly.
3. Multiple prominent mediastinal lymph nodes, measuring up to 1.0 cm.
Suspected but not well assessed subcarinal nodes which are likely enlarged.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Hypoxemia
temperature: 98.1
heartrate: 110.0
resprate: 16.0
o2sat: 90.0
sbp: 132.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | This is a ___ with CLL, secondary ITP on prednisone and recently
started on Rituxan, HTN, HL, carotid artery stenosis, likely CAD
s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w
CAD and increased LVEDP, who presents with dyspnea on exertion
consistent with pulmonary edema. Course complicated by
acute-left sided weakness and neglect concerning for CVA vs.
TIA.
Active Problems -
# Dyspnea on exertion and
# Acute hypoxic respiratory failure, likely due to
# Pulmonary edema with bilateral pleural effusions, likely due
to
# Acute diastolic CHF: Her story is fairly consistent with acute
diastolic CHF, with recent admission where she received fluids
initially but also had NSTEMI and TTE showing some LV overload
(BNP at that time was quite elevated as well). She has history
of fluid overload requiring diuresis in context of platelet
transfusion. Last admission she was discharged only on home
HCTZ, which may have been inadequate to maintain euvolemia.
Prednisone also likely contributed to fluid retention, and
recently she received her Rituxan infusion ___, after which she
began developing shortness of breath. During her
hospitalization, she received a total of 100 mg IV Lasix (doses
of 40 mg, 40 mg, and finally 20 mg IV on ___ with improvement
in her symptoms. She is no longer requiring additional O2.
Goal is to continue gentle diuresis with aim of -500cc/24 hours.
Her oncologist is aware that she will likely need Lasix with
her next Rituximab infusion.
# Acute left-sided weakness and left gaze neglect - occurred the
morning of ___, along with noted dysarthria. Upon assessment
by the neurology team, her symptoms had resolved but upon
reassessment several hours later, her symptoms recurred (see
discharge exam) raising concern for a flow-limiting lesion,
especially in light of her carotid artery stenosis on the right.
Her symptoms resolved with laying flat and improvement of her
SBPs to the 140s (she has been otherwise in the 100s-120s).
Neurology recommends an MRI here along with vascular surgery
consult to discuss CEA, however patient and her family prefer to
transfer to the ___ as her vascular surgeon is there. Therefore
no studies were performed here prior to transfer, except for a
lipid profile (at goal), hemoglobin A1C (at goal), and TSH
(wnl). She was on ASA every other day due to her ITP; after
discussion with her oncologist, she was changed to daily
aspirin. She is on a statin.
# CLL, ITP - followed by Dr. ___. Recently
admitted in ___ with steroid-resistant ITP, so was started
on Rituximab for a planned 4 doses over 4 weeks. Her Rituximab
will be held this week per her oncologist given acute medical
issues. She will need Lasix with future infusions as noted
above. Her baseline WBC is in the low ___ platelets in
the ___ is good for her. She is on prednisone 20 mg daily for
her ITP.
# CAD, recent NSTEMI type 2 - during recent admission in ___,
she sustained a type II NSTEMI (no EKG changes, peak Troponin at
OSH 1.5) felt to be in the setting of hypotension from
dehydration due to norovirus. TTE showed WMA c/w underlying CAD
and preserved systolic function. Her troponins trended down and
then back up here to 0.28, likely from fluid overload. She had
no EKG changes or symptoms. She is on aspirin, BB, and ACE-I
(latter two which may need to be held to allow for permissive
hypertension given concern for CVA).
# Sinus tachycardia - HR in the ___ here, likely related to
hypoxia and volume overload. Improved to ___ prior to d/c with
improvement of hypovolemia.
# GERD - on PPI.
Patient is full code.
HCP: ___
Relationship: Daughter
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / linezolid / Heparin Analogues
Attending: ___.
Chief Complaint:
Fever, emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of multiple UTIs and neurogenic bladder, seizure
disorder, and chronic constipation on standing bowel regimen
presents from nursing home with 1 day of fever to 101.8 on
___. Of note, patient reported eating impressive ___
meal on ___ with eggs ___ and some dairy, and endorse
emesis thereafter associated with meal. She reprots since then
she has felt well, with no abdominal pain, chills, chest pain,
shortness of breath, or back pain or dysuria. Yesterday, she
felt a little warm, and temperature was 101.7. She was brought
to the ED given her history of recurrent UTIs, including history
VRE. Per patient, she spoke gibberish yesterday night, which
"usually happens with my UTI's".
In the ED, initial vitals were: 99.5 94 115/47 21 98.
CBC showed W 12.9 H/H 11.2/31.3 BUN/cr of 46:1.1
Her lactate was 1.4, and her initial U/A in ED showed > 182 WBC,
+ leuk, and was cloudy appearing.
She had urine and blood cultures drawn at 1 am.
She recieved. She recieved 1 gm of ceftriaxone at 200 am and 1
g vanc at 4 am. 1000 ml NS and 2.5 mg oxycodone at 2 am.
On the floor, patient reports no complaints save for feeling
hungry and wishing to eat. She reports standing consitpation,
and again denies any dysuria. She confirms that she does not
have a foley, and is straight cathed at rehab, and had straight
cath in ED for urine culture above. She self reprots feeling
better after abx in ED.
Past Medical History:
PAST MEDICAL HISTORY:
- Seizure disorder
- Neurogenic bladder with recurrent urinary tract infections
including VRE, though most recently Vancomycin sensitive
enterococcus
- Hypertension
- Anemia
- Hyperlipidemia
- Paroxysmal atrial fibrillation
- Gastroesophageal reflux disease
- Severe osteoarthritis of her left hip
- Small bowel obstruction s/p laparotomy in ___
- Lumbar discectomy in ___. T6-9 laminectomy done in ___ done due to residual fluid left in spinal canal. Sister
reports second cervical spine operation ___ at ___ and
not ambulatory and with neurogenic bladder since then.
- UGIB ___ duodenal ulcer ___
- History of HIT
Social History:
___
Family History:
Father deceased at age ___ from a heart virus. Her brother is
alive but had leukemia as well as complications of a brain bleed
and he also had coronary artery disease, status-post MI.
Physical Exam:
ON ADMISSION
Vitals: bp 137/54 T 98 HR 74 RR 18 97 % RA.
General: Alert, oriented, no acute distress. Lying in bed.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Slight frontal maxilary sinus tenderness. No rhinorrhea.
Oropharynx cl;ear without exudates.
Neck: Supple, JVP not elevated, no cervical LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally over anterior chest, no
wheezes, rales, rhonchi. Slight psoterior B/L bibasilar crackles
aucsulted on deep inspiration.
Abdomen: Soft, non tender, slightly distended.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Cotton inbetween toes B/L. Some evidence onchymycosis.
ON D/C
Vitals: T:97.___.6 BP: 101-136/46-71 P: 51-61 R: 18 O2:
98-99%RA
General: Alert, oriented, no acute distress, lying in bed,
sleeping. comfortable appearing with fewer covers
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No CVA tenderness, no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: EOMI, palate elevation symmetric, sensation grossly
intact, able to move all extremities
Pertinent Results:
ON ADMISSION
___ 01:15AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 01:15AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 01:15AM URINE RBC-14* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-2 TRANS EPI-5
___ 01:15AM URINE HYALINE-38*
___ 01:15AM URINE MUCOUS-MANY
___ 12:47AM LACTATE-1.7
___ 12:20AM GLUCOSE-126* UREA N-46* CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14
___ 12:20AM estGFR-Using this
___ 12:20AM ALT(SGPT)-8 AST(SGOT)-21 LD(LDH)-178 ALK
PHOS-75 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2
___ 12:20AM LIPASE-21
___ 12:20AM ALBUMIN-3.4*
___ 12:20AM WBC-12.9*# RBC-3.37* HGB-11.2* HCT-31.3*
MCV-93 MCH-33.2* MCHC-35.7*# RDW-13.8
___ 12:20AM NEUTS-88.3* LYMPHS-6.9* MONOS-4.0 EOS-0.7
BASOS-0.1
___ 12:20AM PLT SMR-LOW PLT COUNT-91*
CXR ___
FINDINGS:
Evaluation is somewhat limited by the patient's body habitus. At
the right
base, there is localized pleural and parenchymal scarring with
volume loss,
which appears similar to prior exams. No new consolidation is
identified.
There is no pulmonary edema, pleural effusion, or pneumothorax.
The
mediastinal contours are normal. The heart size is at the upper
limits of
normal.
IMPRESSION:
No definite pneumonia, though given the baseline abnormality in
the right lung
base, an acute process is difficult to exclude. If indicated,
short term
followup chest radiographs or CT could be obtained.
DISCHARGE LABS
___ 04:15AM BLOOD WBC-5.3 RBC-3.15* Hgb-10.4* Hct-29.5*
MCV-94 MCH-32.9* MCHC-35.1* RDW-13.7 Plt ___
___ 04:15AM BLOOD Glucose-74 UreaN-30* Creat-1.0 Na-142
K-4.3 Cl-114* HCO3-19* AnGap-13
___ 04:15AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
MICROBIOLOGY
__________________________________________________________
___ 1:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
__________________________________________________________
___ 12:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q8H:PRN nausea
2. Bisacodyl 10 mg PR QAM
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. Fleet Enema ___AILY:PRN no bm during day
5. Acetaminophen 650 mg PO Q4H:PRN pain
6. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN sob
7. RISperidone 0.5 mg PO BID:PRN agitation
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
10. Guaifenesin ___ mL PO Q4H:PRN nasal congestion
11. Senna 17.2 mg PO QHS
12. Calcium Carbonate 500 mg PO QHS
13. Ranitidine 150 mg PO QHS
14. Atorvastatin 10 mg PO QPM
15. Aspirin 81 mg PO DAILY
16. FoLIC Acid 1 mg PO DAILY
17. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
18. RISperidone 1 mg PO BID
19. Juven (arginine-glutamine-calcium Hmb) unknown oral Other
unkown
20. Gabapentin 100 mg PO BID
21. LACOSamide 100 mg PO BID
22. OxycoDONE (Immediate Release) 2.5 mg PO DAILY
23. OxycoDONE (Immediate Release) 2.5 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PR QAM
5. Calcium Carbonate 500 mg PO QHS
6. Fleet Enema ___AILY:PRN no bm during day
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 100 mg PO BID
9. Guaifenesin ___ mL PO Q4H:PRN nasal congestion
10. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN sob
11. LACOSamide 100 mg PO BID
12. Lorazepam 0.5 mg PO Q6H:PRN anxiety
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
15. OxycoDONE (Immediate Release) 2.5 mg PO DAILY
16. OxycoDONE (Immediate Release) 2.5 mg PO BID
17. Prochlorperazine 10 mg PO Q8H:PRN nausea
18. Ranitidine 150 mg PO QHS
19. RISperidone 0.5 mg PO BID:PRN agitation
20. RISperidone 1 mg PO BID
21. Senna 17.2 mg PO QHS
22. Ciprofloxacin HCl 250 mg PO Q12H Duration: 4 Days
D1 = ___, please finish on ___. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
24. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
25. Juven (arginine-glutamine-calcium Hmb) 0 unknown ORAL
Frequency is Unknown unkown
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Fever. Evaluate for pneumonia.
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: Chest radiograph from ___. Chest radiograph from ___.
FINDINGS:
Evaluation is somewhat limited by the patient's body habitus. At the right
base, there is localized pleural and parenchymal scarring with volume loss,
which appears similar to prior exams. No new consolidation is identified.
There is no pulmonary edema, pleural effusion, or pneumothorax. The
mediastinal contours are normal. The heart size is at the upper limits of
normal.
IMPRESSION:
No definite pneumonia, though given the baseline abnormality in the right lung
base, an acute process is difficult to exclude. If indicated, short term
followup chest radiographs or CT could be obtained.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.5
heartrate: 94.0
resprate: 21.0
o2sat: 98.0
sbp: 115.0
dbp: 47.0
level of pain: 13
level of acuity: 3.0 | Mrs. ___ is a ___ year old woman with neurogenic bladder
complicated by multiple urinary tract infections presenting with
fever, mental status change, increased urinary urgency with
leukocytes and white blood cells on urinalysis. Given patient's
history of chronic UTIs and the clinical presentation the most
likely diagnosis is UTI.
# UTI: Patient has a history of recurrent UTI's in setting of
neurogenic bladder, and comes in with fever, dysuria and grossly
positive U/A. On admission she was empirically started on
vancomycin and zosyn for UTI after review of her prior culture
date. Given microbiological history, and patients allergy to
linezolid, she was transitioned to daptomycin for gram positive
and meropenem for gram negative coverage ___. In house,
Ms ___ symptomatically improved. Urine culture taken before
abx administration on ___ showed fecal contamination, so
patient was empirically narrowed to ciprofloxacin based on her
prior urinary tract infection of Morganella morganii sensitive
to Ciprofloxacin. Patient was monitored for a an additional
48hrs on ciprofloxacin alone to assure she remained afebrile and
symptom free. On ciprofloxacin she continued to feel improved,
mentoring at baseline and was d/ced back to rehab on ___ with
plan to discontinue antibiotics on the evening of ___.
# Frontal maxillary sinus tenderness: Nasal exam unconcerning
for acute bacterial sinusitis (no purulent dischagre or focal
tenderness but rather B/L frontal sinus tenderness). Of note,
patient is on guaifenesine at nursing home for "nasal
congestion". It appears patient has been using afrin off and on,
making rebound congestion possbility. She was trialed on
fluticasone with good response.
# Constipation: home constipation regimen: bisacodyl pr, fleet
enema prn, milk of magnesium, senna. will continue. One time
episode emesis ___ concerning for possible obstruction though
patient passing gas. She had a BM ___ without issue.
# Hx HIT: No heparin products used in house. Use fondaparinoux. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
TBI, L frontal IPH, IVH, ___
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ year old female who presents to ___ on ___ with a mild TBI.
Mechanism of trauma:
Per the patient and her husband, the patient sustained a
mechanical fall at approximately noon on ___. They report
that they were exiting their home, walked down the back stairs,
and the patient slipped and fell on ice at the bottom portion of
the stairs. She was initially well, and without any complaint -
therefore they continued with their usual day's plans. Later on
in the evening, the patient's daughter felt that the patient was
"off" and called for an ambulance to take the patient to the ED
for evaluation. She was initially examined at ___
and underwent a ___ that revealed a large left frontal IPH
with edema, IVH, SDH.
Past Medical History:
Hypertension
Migraines
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on Admission
GCS at the scene: 14
GCS upon Neurosurgery Evaluation: 15
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[x]4 Opens eyes spontaneously
Verbal:
[x]5 Oriented
Motor:
[x]6 Obeys commands
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: ___ bilaterally
EOMs: Intact
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, 3 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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
===================
Discharge Exam:
===================
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right ___ Left ___
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
Right55___
Left5 5 5 5 5 5
[ ]Clonus [ ___ [x]Sensation intact to light touch
[x]Propioception intact
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Recent lab and imaging results:
Labs:
___ 04:50AM BLOOD WBC-9.5 RBC-3.81* Hgb-11.0* Hct-34.2
MCV-90 MCH-28.9 MCHC-32.2 RDW-13.7 RDWSD-44.5 Plt ___
___ 11:00PM BLOOD Neuts-90.4* Lymphs-4.3* Monos-4.4*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.84* AbsLymp-0.61*
AbsMono-0.63 AbsEos-0.00* AbsBaso-0.03
___ 04:50AM BLOOD ___ PTT-26.7 ___
___ 04:50AM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-12
___ 09:26AM BLOOD CK(CPK)-75
___ 09:26AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:50AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
___ 06:30AM BLOOD Osmolal-291
Imaging:
MR HEAD W & W/O CONTRAST Study Date of ___ 1:02 ___
IMPRESSION:
1. 5.9 cm left frontal intraparenchymal hematoma appears
slightly increased in size compared to 1 day ago. No definitive
underlying enhancing mass lesion is identified. Recommend
repeat examination after resolution of hematoma for better
evaluation of any underlying lesion.
2. Ventricular size similar. Rightward midline shift of the
left frontal lobe is also similar.
3. Additional findings as described above.
RECOMMENDATION(S): Consider follow-up imaging after resolution
of hematoma for better evaluation of any underlying lesion.
CHEST (PORTABLE AP) Study Date of ___ 4:10 ___
IMPRESSION:
No previous images. There are low lung volumes that accentuate
the prominence of the transverse diameter of the heart. The
minimal if any vascular congestion. No evidence of pleural
effusion or acute focal pneumonia.
CTA HEAD W&W/O C & RECONS Study Date of ___ 5:27 AM
IMPRESSION:
1. Unchanged findings of a large frontal intraparenchymal
hemorrhage with
surrounding edema, local mass effect, and rightward bowing of
the anterior
falx.
2. New, layering intraventricular hemorrhage within the
bilateral occipital horns.
3. Stable appearance of a small subdural hematoma along the
anterior left
temporal and frontal lobes.
4. No new or additional sites of acute intracranial hemorrhage.
No evidence for acute vascular territorial infarction by CT.
5. Patent intracranial vasculature without high-grade stenosis,
occlusion, or aneurysm greater than 3 mm.
6. Additional findings, as above.
Medications on Admission:
25mg atenolol daily
Imitrex ___ PRN: migraine
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. LevETIRAcetam 1000 mg PO Q12H Duration: 2 Days
For a total of 7 days from your injury
6. Metoprolol Tartrate 25 mg PO BID
___ transition back to home Atenolol 25mg daily as patient's BP
tolerates
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
intraparenchymal hemorrhage with surrounding edema
intraventricular hemorrhage
subdural hematoma
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: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old woman with large left IPH (? traumatic)// underlying
vascular abnormality
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 27.2 mGy (Head) DLP =
13.6 mGy-cm.
3) Spiral Acquisition 2.7 s, 21.2 cm; CTDIvol = 30.0 mGy (Head) DLP = 637.3
mGy-cm.
Total DLP (Head) = 1,454 mGy-cm.
COMPARISON: Outside hospital CT head ___.
FINDINGS:
CT HEAD:
Again seen is a large, left frontal intraparenchymal hematoma which appears
grossly unchanged from the previous examination, allowing for mild interval
evolution and differences in patient positioning.
Again, there is surrounding vasogenic edema with mass effect and partial
effacement of the anterior horn of the left lateral greater than right lateral
ventricles. Additionally, there is rightward bowing of the anterior falx by
approximately 5 mm, similar to the previous examination.
Layering intraventricular hemorrhage is noted within the bilateral occipital
horns. Additionally, there is a 5 mm thick focus of subdural hematoma along
the anterior left temporal lobe extending superiorly overlying the frontal
lobe, also similar from the previous examination. No new sites of acute
intracranial hemorrhage are identified. No evidence for acute vascular
territorial infarction.
The remainder of the ventricles and sulci are grossly unremarkable in
appearance. The basal cisterns are patent. There is no evidence for impending
downward herniation at this time.
The paranasal sinuses, middle ear cavities, and mastoid air cells are clear.
The orbits are grossly unremarkable bilaterally.
CTA HEAD:
There is a left sided dominant vertebrobasilar system, with the right V4
segment terminating in the ___, a normal variant. Allowing for this, the
visualized vertebral arteries are patent bilaterally. The basilar artery is
patent and unremarkable.
The visualized portions of the internal carotid arteries are patent
bilaterally. Mild right and moderate left calcifications are seen within the
cavernous segments of the ICAs. There are bilateral fetal origins of the
posterior cerebral arteries, also a normal variant.
No evidence for high-grade stenosis or vessel occlusion. No sites of aneurysm
formation greater than 3 mm. The anterior cerebral arteries are mildly
displaced towards the right secondary to the patient's large intraparenchymal
hematoma. No evidence for focal stenosis or occlusion. The dural venous
sinuses remain patent.
IMPRESSION:
1. Unchanged findings of a large frontal intraparenchymal hemorrhage with
surrounding edema, local mass effect, and rightward bowing of the anterior
falx.
2. New, layering intraventricular hemorrhage within the bilateral occipital
horns.
3. Stable appearance of a small subdural hematoma along the anterior left
temporal and frontal lobes.
4. No new or additional sites of acute intracranial hemorrhage. No evidence
for acute vascular territorial infarction by CT.
5. Patent intracranial vasculature without high-grade stenosis, occlusion, or
aneurysm greater than 3 mm.
6. Additional findings, as above.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with IPH, concern for tumor vs trauma// r/o
tumor
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA head ___
FINDINGS:
5.9 x 3.8 cm the left frontal intraparenchymal hemorrhage is again
demonstrated causing effacement of frontal horns of the lateral ventricles
bilaterally. The hemorrhage may have slightly increased in size from the CT
examination of 1 day prior. Postcontrast examination demonstrates mild
peripheral scattered curvilinear and rounded foci within the periphery of the
hematoma, likely reactive in nature without evidence of definitive underlying
mass. Hemorrhage product in the occipital horns of the lateral ventricles are
re-identified. The superimposed periventricular and subcortical mild T2/FLAIR
white matter hyperintensities are nonspecific, but compatible with chronic
microangiopathy in a patient of this age. The major intracranial flow voids
are preserved. No evidence for interval acute infarct. The dural venous
sinuses are patent. Mild mucosal thickening of the ethmoid air cells. The
remainder the paranasal sinuses are essentially clear. The orbits are
unremarkable. The mastoid air cells appear clear.
IMPRESSION:
1. 5.9 cm left frontal intraparenchymal hematoma appears slightly increased in
size compared to 1 day ago. No definitive underlying enhancing mass lesion is
identified. Recommend repeat examination after resolution of hematoma for
better evaluation of any underlying lesion.
2. Ventricular size similar. Rightward midline shift of the left frontal lobe
is also similar.
3. Additional findings as described above.
RECOMMENDATION(S): Consider follow-up imaging after resolution of hematoma
for better evaluation of any underlying lesion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with IPH, baseline CXR// baseline CXR
IMPRESSION:
No previous images. There are low lung volumes that accentuate the prominence
of the transverse diameter of the heart. The minimal if any vascular
congestion. No evidence of pleural effusion or acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, s/p Fall, Transfer
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall on same level due to ice and snow, initial encounter
temperature: 97.9
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | #IPH with cerebral edema
The patient was admitted from the emergency department to the
neuro intensive care unit where she was started on Mannitol
therapy. A bolus of Decadron was given but then shortly after
discontinued. She was started on Keppra for seizure prophylaxis.
A CTA was performed which demonstrated a stable large left
frontal intraparenchymal hemorrhage with edema. There was no
evidence of vascular abnormalities. An MRI was also ordered due
to concerns for an underlying lesion given the location, size,
and morphology of the bleed which was negative to underlying
lesion with recommendations to repeat in 6 weeks. She remained
stable and was transferred to ___ on ___ where the mannitol
was weaned to off. Neurology was consulted who recommended
follow-up in the stroke neurology clinic with repeat MRI to
re-evaluate for underlying lesion and follow-up in ___ clinic if
needed after discharge. Patient was evaluated by ___ and OT who
recommended rehab. She remained neurologically stable and was
transferred to the neuro floor. Her electrolytes were repleted
PRN and she was given a small fluid bolus for slightly elevated
BUN with improvement.
#Hypertension
Patient's home atenolol 25mg was switched to metoprolol tartrate
12.5mg BID. In order to maintain SBP goal <160 the dose was
increased to metoprolol tartrate 25mg BID. The patient tolerated
this well and blood pressure was maintained at goal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
Left ear fullness and headache s/p left posterior fossa
craniotomy for trigeminal neuralgia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old female with h/o migraines and left trigeminal
neuralgia who underwent a left posterior fossa craniotomy for
decompression on ___. The procedure was uncomplicated and
she was discharged home on POD#3 in stable condition after a
routine post-operative course. Decadron was tapered and
discontinued on ___. She was seen in outpatient clinic on
___ for suture removal with complaints of left ear fullness,
which has been persistent since that time. Also admits to
muffled hearing and a crackling sensation. Denies pulsating pain
or ringing in ears. No drainage from ear. No inner ear pain. She
does admit to left-sided facial pain since yesterday, different
from her pre-operative TGN pain, and headache since this
morning. Also complains of dizziness and a feeling of "leaning
to the left". Denies fever/chills, redness/drainage from her
surgical wound.
Past Medical History:
Trigeminal Neuralgia, s/p left posterior fossa craniotomy
for decompression
Migraine headaches
Social History:
___
Family History:
NC.
Physical Exam:
ADMISSION EXAM:
O: T 97.0 HR 81 BP 123/89 O2sat 99% on RA
Gen: Awake, alert. Appears uncomfortable.
HEENT: No significant perioribtal erythema or edema. No
significant erythema or edema surrounding left ear. No
tenderness with manipulation of outer ear. Canal clear without
drainage or blockage. TM easily visualized, good light reflex,
no significant erythema. No bulging of TM.
Incision well-healed with no significant surrounding erythema or
edema. Mild tenderness to palpation at the mastoid as well as
along the length of the incision. No fluctuance. No wound
dehiscience. Unable to express fluid upon palpation.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not assessed
II: Pupils equally round and reactive to light, to mm
bilaterally. No ptosis or proptosis.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric. Decreased
sensation to light touch in V1, V2, V3 on left.
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: Grossly intact to light touch throughout.
Coordination: No dysmetria as tested by finger-nose-finger
DISCHARGE EXAM:
Neurologically intact, with slightly decreased sensation in left
V1-V3 distributions.
Pertinent Results:
___ 08:10PM BLOOD WBC-8.8 RBC-3.89* Hgb-12.9 Hct-36.5
MCV-94 MCH-33.0* MCHC-35.2* RDW-14.6 Plt ___
___ 08:10PM BLOOD Neuts-58.2 ___ Monos-5.2 Eos-2.3
Baso-0.3
___ 08:10PM BLOOD ___ PTT-32.9 ___
___ 08:10PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-140
K-4.0 Cl-108 HCO3-21* AnGap-15
___ 08:10PM BLOOD CRP-11.2*
CT Head ___:
Post-operative changes s/p left suboccipital craniotomy, without
acute intracranial hemorrhage or edema. Fluid in the left
mastoid air cells possibly reflecting inflammation.
MRI HEAD W/ & W/O CONTRAST ___:
1. Posterior fossa craniectomy and cranioplasty with fluid
subjacent to the craniotomy site. This may represent
postoperative change although all
pseudomeningocele is not excluded.
2. Left mastoid effusion. The bony margins are better delineated
on prior CT dated ___ when there was no evidence of
focal dehiscence at the floor of the middle cranial fossa.
Medications on Admission:
Zomig 5 mg nasal spray as needed
Gabapentin 600 mg PO TID
Topiramate (Topamax) 100 mg PO DAILY
Venlafaxine 150 mg PO DAILY
Omeprazole 20mg QD
Discharge Medications:
Zomig 5 mg nasal spray as needed
Gabapentin 600 mg PO TID
Topiramate (Topamax) 100 mg PO DAILY
Venlafaxine 150 mg PO DAILY
Omeprazole 20mg QD
OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet ___
MEDrol (Pak) (methylPREDNISolone) 4 mg oral ASDIR
RX *methylprednisolone [Medrol (Pak)] 4 mg 1 tablets(s) by mouth
AS DIRECTED Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mastoid effusion
Migraine
TMJ
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old woman with s/p Left microvascular decompression //
Please evaluate for interval changes
TECHNIQUE: Axial images of the head were obtained without contrast with
sagittal and coronal reformats.
DOSE: DLP:8 ___ MGy-cm
CTDI: 5 6 mGy
COMPARISON: MRI ___.
FINDINGS:
There is no acute hemorrhage mass effect midline shift or hydrocephalus.
Gray-white matter differentiation is maintained. There is a coil pack in the
right paraclinoid region from prior aneurysm embolization. A small high
density area is seen adjacent to the left trigeminal nerve rootlet in the
neural vascular decompression. Posterior fossa craniotomy and cranioplasty are
visualized.
The visualized paranasal sinuses are clear. No skull fracture is seen.
IMPRESSION:
No acute intracranial abnormalities are identified. Changes from prior no
velocity compression are identified on the left side. Scratch previous
embolization is noted.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with recent L suboccipital crani p/w L ear
fullness, fluid in mastoid, ?CSF leak // Evaluate for CSF leak; please extend
through posterior fossa
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: CT head ___.
FINDINGS:
The examination is limited secondary to a artifact from patient motion.
There is no evidence of acute intracranial hemorrhage or mass effect. The
ventricles and basal cisterns appear normal. There are normal vascular flow
voids.
There is no evidence of acute infarct based on diffusion-weighted imaging.
There is minimal T2/FLAIR signal hyperintensity within the subcortical white
matter which is nonspecific though presumably on of chronic small vessel
ischemic disease.
There are postoperative changes of a root paraclinoid aneurysm embolization,
posterior fossa craniectomy, and cranioplasty. There is T2 signal
hyperintensity/ fluid subjacent to the cranioplasty site which may represent
postoperative change although pseudomeningocele is not excluded. The bony
margins are better delineated on prior CT dated ___ where there was
no evidence of focal dehiscence of the floor of the middle cranial fossa.
There is fluid within the bilateral mastoid air cells, left greater than
right. The orbits, skull base, and paranasal sinuses are unremarkable.
IMPRESSION:
1. Posterior fossa craniectomy and cranioplasty with fluid subjacent to the
craniotomy site. This may represent postoperative change although all
pseudomeningocele is not excluded.
2. Left mastoid effusion.The bony margins are better delineated on prior CT
dated ___ when there was no evidence of focal dehiscence at the floor
of the middle cranial fossa
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Headache, L Ear pain
Diagnosed with HEADACHE, TINNITUS NOS
temperature: 97.0
heartrate: 81.0
resprate: 16.0
o2sat: 99.0
sbp: 123.0
dbp: 89.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ was admitted to the Neurosurgical Service for further
evaluation of left ear fullness, headache, & dizziness on ___
s/p left posterior fossa craniotomy for TGN. The patient's pain
was well controlled with Tylenol and oxycodone. Head CT was
reported to show no acute intracranial findings, but was notable
for fluid in the mastoid. Her CRP on admission was 11.2. ENT
service was consulted for concern of possible CSF leak or
mastoiditis. Imaging was reviewed and felt to represent fluid in
the mastoid with no evidence of bony destruction or coalescent
mastoiditis. Recommendations were made to obtain MRI and pursue
treatment of other possible contributing factors including
migraines and TMJ. An MRI Head was performed on ___ which
showed postoperative changes s/p posterior fossa craniectomy and
left mastoid effusion.
The hospital course was otherwise remarkable. The patient
remained afebrile and neurologically intact. She continues to
have left sided head pressure and ear fullness with decreased
hearing on the left. Based on the imaging and overall clinical
picture, decision was made to discharge the patient home on a
steroid taper, with instructions to follow up closely with ENT
(Dr. ___ and neurosurgery (Dr. ___. A thorough
discussion was had with the patient regarding the expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient expressed readiness for discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / hydrochlorothiazide / Dilaudid
Attending: ___
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
Sigmoidoscopy (___)
History of Present Illness:
___ with history of HTN and vasovagal syncope as well as prior
constipation and N/V following prior non-abdominal surgeries who
presents with constipation, N/V, and abdominal pain following L
thumb surgery on ___. Pt fell in the setting of increasing
pain following surgery, but daughter was present and denies LOC.
Pt reoprts history of vasovagal syncope in past. Pt reports that
she has become constipated and not had BM since surgery 5 days
ago. During that time has developed nausea and frequent vomiting
(green color), with poor po intake. Has also developed abdominal
pain. She reports these symptoms are similar to her course
following knee surgeries last year (pt was in rehab at the
time), although did not have abdominal pain in the past. Per
daughter, pt's 'GI system completely shuts down' and may take
weeks to recover. At home, she has been on scopolamine patch and
zofran. Began taking vidocine after fall, and then tramadol. No
known recent antibiotics or sick contacts. Pt denies fevers,
SOB, cp.
She was seen at ___ where she was given an
enema for constipation and discharged. Daughter reports she was
leaking blood per rectum following enema.
In the ED, initial vital signs were: 99.4 98 149/79 14 99%. Labs
were notable for WBC 13, Cr 1.2. CT abd showing diffuse bowel
wall thickening throughout the colon with adjacent fat
stranding, consistent with pancolitis. Patient was given
ondansetron, lorazepam, and flagyl in ED, as well as 2L NS.
On Transfer Vitals were:97.4 105 171/97 18 96% RA
Past Medical History:
Past Medical History:
-Vasovagal syncope.
-Hypertension (dx ___
-Carotid stenosis: <40% bilaterally (6.12 u/s).
-Dilated ascending aorta: 3.6cm- TTE ___.
-Aortic regurgitation: 1+ ___.
-Post-op DVT after L TKR, 2.13, on warfarin from ___
Past Surgical History:
-L thumb surgery at ___ ___
-bilateral knee replacement in ___
-R hand surgery
Social History:
___
Family History:
Mother ___ ___ HYPERTENSION
Father ___ ___ STROKE
Sister ___ ___ BREAST CANCER
Brother ___ MELANOMA
Brother ___ ___ COMPLICATIONS OF OBESITY
Physical Exam:
On admission:
Vitals- 98.4 132/62 91 24 95%RA
General- Alert, oriented x3, no acute distress
HEENT- Sclera anicteric, mildly dry MM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present, tender to
palpation in lower mid abdomen, no rebound tenderness or
guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
On discharge:
Vitals- 98.1 119/50 78 18 96%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, mildly dry MM, oropharynx clear
Lungs- CTA bl
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present, mildly
tender to palpation diffusely, no rebound tenderness or guarding
GU- no foley
Ext- cast on L hand; 1+ ___ edema bilaterally
Pertinent Results:
==================
Labs:
==================
___ 11:25AM BLOOD WBC-13.3*# RBC-4.44 Hgb-13.9 Hct-41.9
MCV-95 MCH-31.4 MCHC-33.2 RDW-13.2 Plt ___
___ 07:45AM BLOOD WBC-7.4 RBC-3.84* Hgb-12.0 Hct-35.9*
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.8 Plt ___
___ 11:25AM BLOOD Neuts-82.1* Lymphs-10.1* Monos-7.1
Eos-0.2 Baso-0.5
___ 11:25AM BLOOD ___ PTT-23.8* ___
___ 07:45AM BLOOD ___ PTT-24.4* ___
___ 07:50AM BLOOD ESR-46*
___ 11:25AM BLOOD Glucose-124* UreaN-43* Creat-1.2* Na-132*
K-4.8 Cl-93* HCO3-23 AnGap-21*
___ 07:45AM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-133
K-3.5 Cl-98 HCO3-25 AnGap-14
___ 11:25AM BLOOD ALT-12 AST-20 AlkPhos-60 TotBili-0.7
___ 11:25AM BLOOD Lipase-12
___ 11:25AM BLOOD Albumin-3.7
___ 07:50AM BLOOD Calcium-7.3* Phos-2.2* Mg-2.3
___ 07:45AM BLOOD Calcium-7.9* Phos-2.2* Mg-2.2
___ 11:25AM BLOOD CRP-281.3*
___ 12:55PM BLOOD Lactate-1.2
___ 11:54AM BLOOD Lactate-1.0
==================
Micro:
==================
___ 7:04 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
==================
Imaging/Procedures:
==================
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:53 ___
IMPRESSION:
1. Diffuse bowel wall thickening throughout the colon with
adjacent fat
stranding, with sparing of the distal sigmoid colon and rectum,
consistent with pancolitis, either infectious or inflammatory in
etiology.
2. Small amount of ascites in the abdomen and pelvis.
Sigmoidoscopy Report
___
Findings:
Mucosa: Segmental discontinuous severe ulceration with
exudates, friability, erythema and congestion without
spontaneous bleeding were noted in the splenic flexure and
transverse colon. Findings were at times asymmetric within the
bowel. There was evidence of reperfusion injury with dilated
blood vessel within the mucosal wall. These findings are
compatible with ischemic colitis. Cold forceps biopsies were
performed for histology. Normal mucosa was noted in the rectum
and sigmoid colon.
Protruding Lesions Internal & external hemorrhoids were noted.
Excavated Lesions Several diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be of mild severity.
Impression:
Internal & external hemorrhoids
Normal mucosa in the rectum and sigmoid colon
Diverticulosis of the sigmoid colon
Ulceration, friability, erythema and congestion in the splenic
flexure and transverse colon compatible with ischemic colitis
(biopsy)
Otherwise normal sigmoidoscopy to transverse
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Oxybutynin 5 mg PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Vitamin D 1000 UNIT PO DAILY
9. Glucosamine (glucosamine sulfate) 3000 mg oral unknown
10. Caltrate-600 + D Vit D3 (800) (calcium carbonate-vitamin D3)
600 mg(1,500mg) -800 unit oral unknown
11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg oral unknown
Discharge Medications:
1. Caltrate-600 + D Vit D3 (800) (calcium carbonate-vitamin D3)
600 mg(1,500mg) -800 unit oral unknown
2. Glucosamine (glucosamine sulfate) 3000 mg oral unknown
3. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg oral unknown
4. Oxybutynin 5 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Pravastatin 10 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 100 mg by mouth twice daily Disp #*60
Capsule Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17 g by mouth once daily
Disp #*30 Packet Refills:*0
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 4
hours Disp #*21 Tablet Refills:*0
13. Lorazepam 0.5 mg PO Q4H:PRN severe nausea not responding to
ondansetron/zofran
RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 4 hours Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ischemic colitis
___, likely pre-renal
HTN
HLD
Overactive bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain post wrist surgery.
TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast
was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT abdomen and pelvis from ___.
FINDINGS:
ABDOMEN: There is mild bibasilar atelectasis. There is a 9-mm hypodensity
in the right lobe of the liver near the dome that is too small to
characterize, but which is unchanged from prior exam and likely represents a
hepatic cyst. The liver is otherwise homogeneous with no focal lesions.
There is no biliary ductal dilatation. The gallbladder is normal. The
spleen, pancreas, and adrenal glands are normal. The kidneys are
unremarkable. The stomach, duodenum, and intra-abdominal loops of small bowel
are normal in caliber and unremarkable. There is diffuse bowel wall
thickening throughout the colon with adjacent fat stranding, with sparing of
the distal sigmoid colon and rectum, consistent with pancolitis. The
intra-abdominal aorta demonstrates atherosclerotic disease but is otherwise
normal in appearance. A small amount of ascites is seen in the perihepatic
region and pelvis. No free air is present. No pathologically enlarged
mesenteric or retroperitoneal lymph nodes are seen.
PELVIS: The rectum is normal in appearance. The distal ureters and bladder
are normal. Small amount of ascites is noted in the pelvis. Prostate is
unremarkable.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. Superior endplate scalloping of L2 is new
from the prior exam. Mild grade 1 L4 on L5 anterolisthesis is unchanged.
IMPRESSION:
1. Diffuse bowel wall thickening throughout the colon with adjacent fat
stranding, with sparing of the distal sigmoid colon and rectum, consistent
with pancolitis, either infectious or inflammatory in etiology.
2. Small amount of ascites in the abdomen and pelvis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, Weakness
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, UNSPECIFIED CONSTIPATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.4
heartrate: 98.0
resprate: 14.0
o2sat: 99.0
sbp: 149.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | ___ with history of HTN and vasovagal syncope as well as prior
constipation and N/V following prior non-abdominal surgeries who
presents with constipation, N/V, and abdominal pain following L
thumb surgery on ___, found to have pancolitis on CT and
findings consistent with ischemic colitis on sigmoidoscopy.
#Ischemic colitis: Pt with symptoms of N/V, constipation,
abdominal pain, and poor po. Pt was given 1 dose metronidazole
in ED. CT shows pancolitis with sparing of distal colon and
sigmoid. Inflammatory markers elevated. Underwent sigmoidoscopy
with findings consistent with ischemic colitis; with biopsies
taken. Possibly due to hypotension during recent surgery. Pt
symptoms improved during admission, and leukocytosis resolved.
Pain was treated with tylenol; opiates avoided due to potential
to slow bowel transit. Pt was treated with bowel regimen for
constipation; per GI stimulating laxatives were avoided. Pt was
placed on low residue diet and was tolerating po prior to
discharge. Amlodipine was discontinued given desire to avoid
further hypotension, with goal SBP>120. Pt to avoid NSAIDs,
continue low residue diet, use colace and miralax prn
constipation; po hydration encouraged. Will follow up with GI in
___ week for full colonoscopy.
#HTN: Given ischemic colitis, goal SBP >120. Amlodipine was
discontinued. Home lisinopril and metoprolol were continued.
Also remained on asprin 325mg.
___, likely pre-renal: Recent baseline creatinine 0.8-1.0.
Creatinine elevated at 1.2 on admission. Likely prerenal in
setting of poor po, BUN:cr >20. Creatinine returned to baseline
after IV fluids.
#Hyponatremia: Possibly hypovolemic hyponatremia in setting of
poor po intake. Improved following IVF.
#HLD: Continued on pravastatin.
#Overactive bladder: Home oxybutynin was held during admission
given potential effect on constipation; was restarted at
discharge. |
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:
Coronary angiography ___ with placement of bare metal stent
to OM1
History of Present Illness:
___ year old man with h/o hyperlipidemia, bipolar disorder, and
hypothyroidism who presents with chest pain.
Patient reports acute onset of substernal chest pain waking him
from sleep at 2 AM the morning of presentation. Pain felt like a
constant pressure rated ___ in severity. It radiated down
both arms Right>Left and to his jaw. Pain was associated with
diaphoresis. He denied nausea or shortness of breath. At 545 am
he called his nephew to bring him to the ED.
Initially upon questioning, patient denied prior episodes of
chest pain; however, on further reflection, he says at times he
has fleeting pain associated with shortness of breath on
exertion. He reportedly had chest pain before in ___ that
occurred while walking and associated with some shortness of
breath and diaphoresis. At that time, he underwent a nuclear
stress (exercised 7 mins on modified ___, ___ METS) with no
anginal symptoms, no ECG changes, and normal perfusion imaging.
In the ED, initial vitals were T 98 HR 70 BP 182/84 RR 18 SaO2
100%. He was given ASA 324 mg and SL nitro. ECG showed normal
sinus rhytm with ST depressions in V2-V4. Troponin was 0.10. CXR
showed no acute process. He was started on a heparin drip and
taken directly to the catheterization laboratory due to concern
for a posterior STEMI. In the cath lab, he was also loaded with
prasugrel and received a bare metal stent to OM1. He was also
noted to have left main disease, felt not to be clinically
significant currently. ECG after PCI showed resolution of ST
depressions.
On arrival to the floor, patient was chest pain free. He was
requesting food.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies current myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Bipolar disorder
Colon polyps
Crohn's disease
Diverticulitis
Hypercholesterolemia
Hypothyroidism
Osteoarthritis
Parkinsonism
Status post tonsillectomy
Status post anal fistulectomy
Social History:
___
Family History:
Father died from MI at ___.
Brother with MI at ___, later CABG, died at ___.
Mother with CVA in ___.
Nephew with colon cancer.
Sister with hypothyroid.
No other family history of arrhythmia, cardiomyopathies.
Physical Exam:
On Admission:
GENERAL: WDWN elderly Caucasian man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T: 97.3 BP: 107/58 HR: 60 RR: 20 O2 sat: 99% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, OP clear.
NECK: Supple without elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs or gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS. Soft, NTND
EXTREMITIES: No clubbing, cyanosis or edema. Right groin without
hematoma or bruit.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
NEURO: A&Ox3. CN II-XII grossly intact. Strength ___ in upper
and lower extemities. Resting tremor noted on Right.
Prior to discharge:
T 97.9 BP 131/80 HR 55 RR 18 SaO2 97% on RA
EXTREMITIES: No clubbing, cyanosis or edema. Groin cath site
clean, dressing intact. No hematoma or bruit.
PULSES:
Right: Femoral 2+ DP 2+ ___ 2+
Left: Femoral 2+ DP 2+ ___ 2+
Pertinent Results:
Admission Labs:
___ 07:30AM BLOOD WBC-11.7* RBC-4.43* Hgb-14.0 Hct-40.9
MCV-92 MCH-31.5 MCHC-34.1 RDW-13.2 Plt ___
___ 07:30AM BLOOD ___ PTT-27.0 ___
___ 07:30AM BLOOD Glucose-119* UreaN-9 Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-26 AnGap-14
___ 07:30AM BLOOD cTropnT-0.10*
Cardiac Enzymes:
___ 07:30AM BLOOD cTropnT-0.10*
___ 03:40PM BLOOD CK-MB-89* cTropnT-2.00*
___ 06:20AM BLOOD CK-MB-34* MB Indx-6.1* cTropnT-1.09*
Discharge Labs:
___ 06:15AM BLOOD WBC-8.8 RBC-3.96* Hgb-12.8* Hct-36.7*
MCV-93 MCH-32.2* MCHC-34.8 RDW-13.2 Plt ___
___ 06:15AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-142
K-4.4 Cl-104 HCO3-35* AnGap-7*
___ 06:15AM BLOOD CK-MB-7 cTropnT-0.80*
ECG ___ 7:19:42 AM
Sinus rhythm with ventricular premature beats. ST segment
depression in the anterolateral leads. Compared to the previous
tracing of ___ ventricular ectopy and ST segment depression
are new and may be due to myocardial ischemia.
ECG ___ 8:56:26 AM
Normal sinus with one ventricular premature complex.
Non-specific anterolateral T wave inversions and non-specific ST
segment abnormalities in the inferior leads. Abnormal tracing.
Compared to the previous tracing of ___ there is no
significant change.
Cardiac catheterization ___
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA had 40% stenosis in
the distal vessel segment. The LAD had adjacent ostial and
proximal 70-80% stenoses. The LCX had diffuse disease proximally
followed by total occlusion of a large OM1. There was an
additional 80% ostial lesion of a large branch coming off the
proximal OM1. The dominant RCA had minimal luminal
irregularities throughout.
2. Limited resting hemodynamics revealed normal systemic
arterial pressures with a measured central aortic pressure of
120/62/86.
3. Successful PTCA and stenting of the upper pole of the first
major obtuse marginal branch with a 2.25 x 18 mm Integrity BMS
(see ___ comments).
4. Successful RFA AngioSeal (see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Acute posterior MI.
3. Successful PCI of the upper pole of the major obtuse marginal
branch with a 2.25 x 18 mm Integrity BMS.
4. Successful RFA AngioSeal.
Echocardiogram ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the inferolateral and
anterolateral segments. The remaining segments contract normally
(LVEF = 50 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size. Mildly reduced left ventricular systolic
function with regional wall motion abnormalities as described
above. No clinically significant valvular disease. Normal
pulmonary artery systolic pressure.
Medications on Admission:
Divalproex ER 750 mg po qhs
Levothyroxine 75 mcg po daily
Lovastatin 20 mg po daily
Quetiapine 25 mg po qhs
Discharge Medications:
1. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30
Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30
Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. valproic acid Oral
7. divalproex ___ mg Tablet Extended Release 24 hr Sig: Three
(3) Tablet Extended Release 24 hr PO QHS (once a day (at
bedtime)).
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- ST Elevation Myocardial Infarction, posterior
Secondary:
- Coronary artery disease
- Hyperlipidemia
- Hypothyroidism
- Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: Radiograph available from ___.
FRONTAL CHEST RADIOGRAPH: The heart size is top normal. The hilar and
mediastinal contours are within normal limits and unchanged since ___ when taking into account differences in technique. There is no
pneumothorax, focal consolidation, or pleural effusion. No bony abnormalities
are seen.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CP/ARM PAIN
Diagnosed with INTERMED CORONARY SYND
temperature: 98.0
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 182.0
dbp: 84.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ is a ___ yo M with a history of hyperlipidemia, but no
known history of CAD who presented with ongoing substernal chest
pain found to have elevated cardiac biomarkers and ECG showing
ST depressions in V2-V4 concerning for posterior STEMI (vs.
anterior ischemia), now s/p coronary angiography with bare metal
stent deployment in OM1.
# STEMI/CAD: Patient presented with posterior STEMI (peak CKMB
89) found to have occlusion in OM branch now s/p BMS placement.
Patient also found to have 2 vessel CAD that was not intervened
on. ___ had 40% stenosis in distal segment, and LAD had
adjacent ostial and proximal 70-80% stenosis. Patient's risk
factors for CAD include hyperlipidemia and family history.
Echocardiogram showed some focal areas of hypokinesis but
overall EF relatively preserved at 50-55% with no clinical
evidence of heart failure.
- Patient should have an Imaging Stress Test in ___ weeks as
outpatient to evaluate if the residual LAD disease is
significant and warrants further intervention. He was scheduled
to follow-up with ___ in cardiology at ___.
- Started on prasugrel for at least one month (ideal 12 months)
- Started ASA 325 mg
- Changed home lovastatin to atorvastatin 80 mg
- Started Metoprolol Succinate 25 mg Daily for post-MI secondary
prophylaxis
- Started Lisinopril 2.5mg, this can be uptitrated as an
outpatient as BP tolerates
- Patient was given information and contact numbers for cardiac
rehabilitation programs near him. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Incarcerated incisional hernia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ M w/ PMH cholangiocarcinoma s/p R
hepatectomy,
extraehaptic bile duct rsxn w/ RNY HJ ___ for
cholanagiocarcinoma p/w incisional hernia, pain, nausea and
obstipation x 12 hrs. He reports that he saw Dr. ___ in clinic
___ and had begun to develop obstipation, nausea the day
prior to clinic visit that self-resolved. Planned for elective
incisional hernia repair, and was going to hear from surgical
services this week re: timing of surgery. By ___ was
feeling great. ___ am, however, he developed abdominal pain
at his hernia, the hernia was "popping out" and he also
developed nausea, burping, obstipation. He had no emesis yet.
In ED,
received IVF, antiemetic and pain control and is now feeling
better, but hernia still bothering him and is "stuck out." No
other complaints on ROS.
Past Medical History:
1. Hyperlipidemia.
2. Benign prostatic hypertrophy.
3. Diverticulosis.
4. Hemorrhoids.
5. History of left shoulder surgery for traumatic dislocation.
6. Status post right inguinal hernia repair.
7. History of guaiac-positive stools with colonoscopy showing
diverticulosis and EGD showing mild gastritis.
8. Cholangiocarcinoma, s/p resection and chemotherapy
Social History:
Has two siblings, two grown children and five grandchildren. He
is not married, but has a partner, ___.
He is not working presently, but for many years worked in a
small ___ and had a lot of exposure to various
solvents.
He drinks alcohol approximately once a week. Smoked from age of
___.
Physical Exam:
On admission:
Vitals: 96.7 56 127/63 15 100%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, mildly distended, tender around ventral hernia, no
rebound or guarding, normoactive bowel sounds, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 02:30AM BLOOD WBC-8.6 RBC-3.65* Hgb-10.6* Hct-33.3*
MCV-91 MCH-29.0 MCHC-31.8* RDW-15.3 RDWSD-51.0* Plt ___
___ 02:30AM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-139
K-4.1 Cl-106 HCO3-22 AnGap-15
___ 02:30AM BLOOD ALT-32 AST-45* AlkPhos-167* TotBili-0.7
___ 02:30AM BLOOD Albumin-3.0*
___ ABDOMINAL US:
IMPRESSION:
1. Small volume ascites. No evidence of varices.
2. A small amount of pneumobilia is consistent with prior
hepaticojejunostomy.
3. Splenomegaly is mild.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Finasteride 5 mg PO QHS
5. Lidocaine-Prilocaine 1 Appl TP PRN pain
6. Nadolol 20 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. promethazine 6.25 mg/5 mL oral DAILY:PRN nausea
9. Furosemide 40 mg PO BID:PRN leg swelling
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Finasteride 5 mg PO QHS
3. Furosemide 40 mg PO BID:PRN leg swelling
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. promethazine 6.25 mg/5 mL oral DAILY:PRN nausea
8. Cyanocobalamin 500 mcg PO DAILY
9. Lidocaine-Prilocaine 1 Appl TP PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated incisional hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ s/p R hepatectomy, extraehaptic bile duct rsxn w/ RNY HJ
___ for cholanagiocarcinoma p/w incisional hernia (also h/o portal
hypertensive gastropathy and GAVE) // assess ascites and varices
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT ___, ultrasound ___.
FINDINGS:
LIVER: The patient is status post right partial hepatectomy and resection of
the common hepatic and common bile duct. A small amount of pneumobilia is
again seen consistent with prior hepaticojejunostomy. There is no focal liver
mass. The main portal vein is patent with hepatopetal flow. There is small
volume ascites.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 13.7 cm.
IMPRESSION:
1. Small volume ascites. No evidence of varices.
2. A small amount of pneumobilia is consistent with prior
hepaticojejunostomy.
3. Splenomegaly is mild.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene
temperature: 96.7
heartrate: 56.0
resprate: 15.0
o2sat: 100.0
sbp: 121.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | The patient with history of incisional hernia was admitted to
the General Surgical Service for evaluation of severe abdominal
pain. In ED patient was found to have incarcerated hernia,
which was manually reduced. After patient's hernia was reduced,
patient's diet was advanced to regular and was well tolerated.
On HD 2, patient underwent abdominal US as part of pre-operative
evaluation. Ultrasound revealed small volume ascites without
evidence of varices. Patient continue to tolerated regular diet,
he was able to move his bowels, and he denied abdominal pain.
Patient was discharged home in stable condition. Prior his
discharge, he was scheduled to see his Hepatologis for pre-op
evaluation.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |