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Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM
sent in from ___ on ___ for increased confusion
and altered mental status, worse this AM. She was admitted to
___ on ___ with depression and agitation. She was
started on lithium a week prior to admission and had a level
checked on ___ which was 1.3. Her Cr prior to admission was
0.8. After a week on lithium, she was noted to be "slowed down"
per nursing staff. A level was checked on ___ which was She
was found to have a lithium level of 2.4 on ___. Last FSBG was
70. She also complains of decreased appetite and a hand tremor
that began today.
In the ED, initial vitals were: T:96.8 HR 67 BP: 96/65 RR 16
O2sat 100%. Labs were notable for an eosinophilia of 17%, Na 132
and Cr 1.3. Tox screen was negative. VBG was 7.36/47/39/28.
On the floor, VS were 98.6, 94/82, 64, 18, 95%. Pt was awake,
alert, oriented x3, tearful. Interviewed with help of ___
interpreter, speech was slurred.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
PSYCHIATRIC HISTORY:
No known consistent outpatient treaters. States that she was
last seen at ___. Notes struggling with periods of
low mood throughout her life. Has past history of several
suicide attempts - notes pill overdose several months ago before
meeting her boyfriend, and past attempt in ___. Reports using
street drugs to manage periods of depression or thoughts of
suicide. No previous treatments for substance abuse.
PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Asthma
Type II diabetes
Rpeorted history of past DVT and left pulmonary embolus, past
treatmetn with coumadin
Seen regularly by Dr. ___ in ___ for pain
management. Apparently has history of back pain and shoulder
pain for which she has gotten steroid injections and been
perscribed percocet for pain control.
ALLERGIES: Levofloxacin
Social History:
___
Family History:
Per patient:
- Daughter has heart disease and bipolar disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6, 94/82, 64, 18, 95%RA
General: Well-appearing older female, tremor evident in both
upper extremities, R>L, tearful
HEENT: PERRL, EOMI, tongue protrudes midline, MMM
Neck: supple
CV: RRR, nml S1/S2, no m/r/g
Lungs: CTAB, crackles at bases, otherwise clear
Abdomen: BS+, obese, nontender
GU: No Foley
Ext: wwp, no edema
Neuro: A&O x3, CN II-XII intact, strength ___ in upper
extremities and lower extremities, 2+ reflexes biceps,
brachioradialis, patellar
Skin: no rashes or lesions
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6, 98.3, 63-64, 94-109/68-82, ___, 96%RA
General: Well-appearing older female, tremor evident in both
upper extremities, R>L
HEENT: PERRL, EOMI, tongue protrudes midline, MMM
Neck: supple
CV: RRR, nml S1/S2, no m/r/g
Lungs: CTAB, crackles at bases, otherwise clear
Abdomen: BS+, obese, nontender
GU: No Foley
Ext: wwp, no edema
Neuro: A&O x2, CN II-XII intact, strength ___ in upper
extremities and lower extremities, 2+ reflexes biceps,
brachioradialis, patellar
Skin: no rashes or lesions
Pertinent Results:
ADMISSION LABS:
==============
___ 09:44PM URINE OSMOLAL-621
___ 09:44PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-4* PH-7.0 LEUK-SM
___ 09:44PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 09:44PM URINE HYALINE-6*
___ 11:51AM ___ PO2-39* PCO2-47* PH-7.36 TOTAL
CO2-28 BASE XS-0 INTUBATED-NOT INTUBA
___ 11:51AM O2 SAT-68
___ 11:40AM GLUCOSE-104* UREA N-27* CREAT-1.3*
SODIUM-132* POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16
___ 11:40AM estGFR-Using this
___ 11:40AM cTropnT-0.01
___ 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:40AM WBC-11.0 RBC-4.78 HGB-14.6 HCT-44.0 MCV-92
MCH-30.6 MCHC-33.2 RDW-13.4
___ 11:40AM NEUTS-69.5 LYMPHS-8.3* MONOS-4.8 EOS-17.0*
BASOS-0.4
___ 11:40AM PLT COUNT-184
DISCHARGE LABS:
===============
___ 07:40AM BLOOD Lithium-1.3
___ 07:40AM BLOOD Calcium-9.4 Phos-2.4* Mg-1.6
___ 07:40AM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-137
K-3.7 Cl-109* HCO3-20* AnGap-12
LITHIUM:
========
___ 11:40AM LITHIUM-2.8*
___ 04:55PM LITHIUM-2.3*
___ 07:55AM BLOOD Lithium-1.9*
CREATININE:
===========
___ 04:55PM GLUCOSE-78 UREA N-22* CREAT-1.0 SODIUM-136
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12
___ 09:44PM URINE HOURS-RANDOM CREAT-132 SODIUM-83
POTASSIUM-39 CHLORIDE-62
___ 07:55AM BLOOD Glucose-82 UreaN-16 Creat-0.8 Na-138
K-3.8 Cl-109* HCO3-19* AnGap-14
IMAGING:
========
___ CXR
IMPRESSION:
Opacity in the superior segment of the right lower lobe could
reflect
atelectasis particularly given low lung volumes, however
infection should be considered in the appropriate clinical
setting. Consider repeat evaluation with improved inspiration
when patient is able.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
2. Tiotropium Bromide 1 CAP IH DAILY
3. Amlodipine 5 mg PO DAILY
Hold for SBP<90, HR<60
4. Lisinopril 10 mg PO DAILY
Hold for SBP <90
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Haloperidol 5 mg PO TID
7. OLANZapine 15 mg PO HS
8. Lithium Carbonate 300 mg PO DAILY
9. Lithium Carbonate 600 mg PO QHS
10. Aspirin 81 mg PO DAILY
11. Lorazepam 1 mg PO Q6H:PRN anxiety
12. TraZODone 50 mg PO HS:PRN insomnia
13. Mylanta *NF* 1 tablet Oral daily prn gas
14. Ibuprofen 400 mg PO Q6H:PRN pain
15. Haloperidol 5 mg PO TID:PRN agitation
16. DiphenhydrAMINE 50 mg PO Q6H:PRN agitation, axiety
17. Guaifenesin ___ mL PO Q6H:PRN cough
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Guaifenesin ___ mL PO Q6H:PRN cough
4. Mylanta *NF* 1 tablet Oral daily prn gas
5. Tiotropium Bromide 1 CAP IH DAILY
6. Amlodipine 5 mg PO DAILY
7. Ibuprofen 400 mg PO Q6H:PRN pain
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. Lorazepam 1 mg PO Q6H:PRN anxiety
10. OLANZapine 15 mg PO HS
11. TraZODone 50 mg PO HS:PRN insomnia
12. Haloperidol 5 mg PO TID:PRN agitation
13. Haloperidol 5 mg PO TID
14. Docusate Sodium 100 mg PO BID
15. Senna 1 TAB PO BID:PRN constipation
16. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Lithium toxicity
Secondary diagnoses: bipolar disorder, diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cough and lethargy with lithium toxicity.
COMPARISON: ___.
FINDINGS:
AP upright and lateral chest radiographs were obtained. The lungs are low in
volume with an opacity in the superior segment of the right lower lobe. There
is no pleural effusion or pneumothorax. The heart is normal in size with
normal cardiomediastinal contours.
IMPRESSION:
Opacity in the superior segment of the right lower lobe could reflect
atelectasis particularly given low lung volumes, however infection should be
considered in the appropriate clinical setting. Consider repeat evaluation
with improved inspiration when patient is able.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE, RENAL & URETERAL DIS NOS, ADV EFF PSYCHOTROPIC NEC
temperature: 96.8
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 96.0
dbp: 65.0
level of pain: 0
level of acuity: 1.0 | ___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM
sent in from ___ on ___ for increased confusion
and altered mental status, worse this AM. She was found to have
a lithium level of 2.4 on ___.
EKG showed sinus bradycardia with a rate of 60, LAD w/ ?LBBB,
LVH and T wave inversions
# Lithium toxicity: Likely increased level in setting of ___,
particularly in a patient on lisinopril with questionable PO
intake. She was aggressively hydrated with normal saline and her
lithium level trended down, as did her creatinine. ___ was 1.3 on
discharge. She was monitored on telemetry and with q4 neuro
checks.
# Non anion-gap metabolic acidosis: Likely due to increased NS.
Stable at discharge, fluids were changed to LR.
# Hyponatremia: Na 132 initially, increased to 136. Patient
looks euvolemic to hypovolemic on exam. Improvement with fluids
suggests hypovolemic hyponatremia as in ___ the sodium would
decrease with IVF. Sodium was 137 on discharge.
# Hypertension: Amlodipine was held in the setting of
hypotension. Blood pressures remained stable and her amlodipine
was continued on discharge. It is important that the patient
remain well hydrated at all times with antihypertensives and
lithium on board.
# Diabetes: Hold glucophage in setting of renal dysfunction. She
was maintained on insulin sliding scale while in the hospital.
# COPD: continued triotropium, advair, albuterol |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
LHC with PCI
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of HTN and HLD who
presented with chest pain and presyncope this morning and was
found to have STEMI.
Ms. ___ was in her usual state of health until this morning
when she developed substernal chest pain at rest according to
notes from the emergency room. Unfortunately, Ms. ___ does not
remember any events from this morning except for feeling unwell
and going outside her ___ to get help. According to her son,
the patient's daughter-in-law stopped by this morning to drop
off
food. The patient did not answer the door which was surprising
to
the daughter-in-law. The daughter-in-law then opened the door
with an extra key and found the patient on the kitchen floor.
EMS was called, and she received 500 cc NS and a full dose
aspirin.
She does note that she has been very healthy and takes no
medications. She denies any history of chest pain either at rest
or with exertion. She is a never smoker and drinks alcohol
occasionally.
She normally receives care at ___ in ___.
In the ED:
- Initial VS: T 97.7, HR 70, BP 142/94, RR 18, O2 100% RA
- Labs notable for:
- WBC 9.7, Hgb 12.1, Plt 268
- Na 133, K 10.0, Bicarb 18, Cr 1.2 (grossly hemolyzed)
- Na 138, K 4.4, Bicarb 17, Cr 1.2 (not hemolyzed)
- EKG notable for: Supraventricular bigeminy, ventricular rate
72, STE in II, III, aVF, TWI in V1-V2 and V4-V5, STD and TWI in
1
and aVL.
- Patient was taken emergently to the cath lab. Coronary
angiogram was performed via right radial access. He was noted to
have 100% occlusion of the ___ RCA and 70% of the mid RCA, felt
to the culprit. He received DESx2 to the ___ and mid RCA. He
received atropine due to low HR. Given the increased amount of
contrast required, he was ordered for post-procedure IVF. He was
loaded with ticagrelor 180 mg.
On the floor, the patient confirms the above history. She denies
active chest pain or dyspnea. She reports feeling well.
Patient indicates she would like to be DNR/DNI but is ok with
her
code status being Full Code in the ___ period
(___).
Past Medical History:
- Hypertension
- Hyperlipidemia
- Osteoarthritis
Social History:
___
Family History:
Father with HTN and HLD. Both mother and father are deceased.
Physical Exam:
ADMISSION EXAM:
=================
VITALS: BP 101 / 70, HR 97, RR 16, O2 96 RA
GENERAL: Appears younger than stated age. Lying in bed. Alert
and
oriented x 3.
HEENT: NCAT. Sclera anicteric. PERRL
NECK: Supple with JVD
CARDIAC: RRR, normal s1 and s2
LUNGS: Clear to auscultation, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No lower extremity edema.
PULSES: Warm. Distal pulses palpable and symmetric
DISCHARGE EXAM:
==================
___ 0720 Temp: 98.0 PO BP: 118/79 HR: 130 RR: 20 O2 sat:
96%
O2 delivery: 2L
___ Total Intake: 1440ml PO Amt: 1440ml
___ Total Output: 450ml Urine Amt: 450ml
GENERAL: Sitting up on bed AOx3
NECK: JVP at clavicle at 45 degrees
CARDIAC: tachycardic s1 and s2, irregularly irregular rythm
LUNGS: Clear to auscultation b/l, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. L forearm with large ecchymosis from IV
infiltrate (blood).
SKIN: No lower extremity edema.
PULSES: Warm. Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
==============
___ 09:17PM POTASSIUM-4.5
___ 09:17PM cTropnT-6.84*
___ 09:17PM PLT COUNT-272
___ 01:00PM GLUCOSE-161* UREA N-19 CREAT-1.2* SODIUM-138
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-17* ANION GAP-17
___ 01:00PM TSH-2.6
___ 01:00PM FREE T4-1.6
___ 12:19PM GLUCOSE-175* UREA N-18 CREAT-1.2* SODIUM-133*
POTASSIUM-10.0* CHLORIDE-101 TOTAL CO2-18* ANION GAP-14
___ 12:19PM estGFR-Using this
___ 12:19PM WBC-9.7 RBC-4.84 HGB-12.1 HCT-41.1 MCV-85
MCH-25.0* MCHC-29.4* RDW-15.1 RDWSD-46.1
___ 12:19PM NEUTS-82.0* LYMPHS-8.4* MONOS-8.0 EOS-0.2*
BASOS-0.7 IM ___ AbsNeut-7.97* AbsLymp-0.82* AbsMono-0.78
AbsEos-0.02* AbsBaso-0.07
___ 12:19PM PLT COUNT-268
DISCHARGE LABS:
===============
___ 06:25AM BLOOD WBC-7.8 RBC-3.59* Hgb-9.3* Hct-31.4*
MCV-88 MCH-25.9* MCHC-29.6* RDW-17.9* RDWSD-55.9* Plt ___
___ 06:25AM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-143
K-4.3 Cl-105 HCO3-24 AnGap-14
IMAGING:
========
___
IMPRESSIONS:
- Mucosa suggestive of ___ esophagus
- Erosions in the antrum and hiatial hernia
- Erosions in the duodenal bulb
- There was no evidence of blood or recent bleeding and no
high-risk stigmata on her erosions and ulcers
- Esophageal hiatial hernia
- Tortuous esophagus
RECOMMENDATIONS:
- High dose PO BID PPI for at least ___ wks
- Recommend repeat EGD in ___ wks to evaluate for healing of
the lower esophageal ulcers surrounded by ___ esophagus,
if the benefits of a repeat EGD to rule out cancer out weigh the
risks in the context of her overall health
- Close monitoring of CBC and stool output
- If brisk bleeding continues, consider, CTA. If slower bleeding
continues despite PPI, will need to reassess for small bowel or
colonic source
___ ABD & PELVIS W/O CON
IMPRESSION: 1. No evidence of retroperitoneal hemorrhage.
___ Echo Report
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/ color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral walls (see schematic) and preserved/normal
contractility of the remaining segments. Quantitative biplane
left ventricular ejection fraction is 47 %. There is no resting
left ventricular outflow tract gradient. Dilated right
ventricular cavity with moderate global free wall hypokinesis.
The aortic sinus is mildly dilated with mildly dilated ascending
aorta. The aortic arch diameter is normal with a normal
descending aorta diameter. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
a centrally directed jet of mild [1+] aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is moderate mitral annular calcification. There
is trivial mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is mild [1+] tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional hypokinesis c/w CAD (RCA/LCx distribution).
DIlated right ventricle with mild-moderate free wall
hypokinesis. MIldly dilated thoracic aorta with mild aortic
regurgitation. Mild tricuspid regurgitation.
___ Cath-Endovascular
Single severe vessel CAD (RCA 100% and 70%) wihtout collaterals
which was hard to open, s/p PCI with 2 DES and good result. Mild
LAD disease (30%) distal.
LM: The Left Main, arising from the left cusp, is a large
caliber
vessel. This vessel bifurcates into the Left Anterior Descending
and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 30% stenosis in the
proximal segment. The Diagonal, arising from the proximal
segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. The ___ Obtuse Marginal, arising from the
proximal segment, is a medium caliber vessel. The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a
large caliber vessel. There is a 100% stenosis in the proximal
segment. There is a 70% stenosis in the proximal segment.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment,
is a medium caliber vessel.
___
Supraventricular bigeminy, ventricular
rate 72, STE in II, III, aVF, TWI in V1-V2 and V4-V5, STD and
TWI
in 1 and aVL.
MICROBIOLOGY:
=============
None
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with recent h.o. STEMI s/p stent x 2. Now w/
Afib RVR and increasing O2 reqs.// Acute change Acute change
IMPRESSION:
Prior chest radiographs available.
Heterogeneous opacification in the left lower lung is new. Most likely this
is atelectasis but close follow-up is recommended for the possibility of
aspiration and potential subsequent pneumonia.
Upper lungs clear. Heart size normal. No mediastinal widening. No
pneumothorax or pleural effusion.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ y/o female who presented with chest pain and presyncope this
morning and was found to have STEMI s/p PCI DES ___ with R fem access with
Hgb now 8.3// eval for retroperitoneal bleed after fem access on ___ with
decreasing Hgb
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 12.6 s, 43.3 cm; CTDIvol = 16.2 mGy (Body) DLP =
677.5 mGy-cm.
Total DLP (Body) = 689 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild bronchiectases seen in lower lobes. Dependent
atelectasis is seen in lung bases.
ABDOMEN:
HEPATOBILIARY: Multiple hepatic cysts are seen largest in the left hepatic
lobe measuring 1.7 cm there is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: Foci of calcifications are seen in the pancreas likely due to prior
episodes of pancreatitis. Otherwise 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. There are calcified granuloma in the
spleen. There is a small accessory spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: the kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small to moderate size hiatal hernia. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Diverticulosis of the colon is noted, without evidence of wall
thickening and fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not seen.
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 a Schmorl's nodes in superior endplate of L1. No suspicious
osseous lesion noted
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, STEMI
Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is a ___ y/o female who presented with chest pain and
presyncope and was found to have STEMI. Course complicated by
anemia and GI bleed with ulcerations in the esophagus, now
stabilized. Patient also developed Afib/Atrial flutter now rate
controlled with Digoxin and Metoprolol.
# CORONARIES: DES x2 to RCA, 30% ___ LAD
# PUMP: EF 47%
# RHYTHM: Afib/Aflutter |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / Zithromax Z-Pak
Attending: ___.
Chief Complaint:
Decreased PO intake, Hypotension, Dysphagia
Major Surgical or Invasive Procedure:
PEG Tube (___)
History of Present Illness:
___ with h/o RSD (reflex sympathetic dystrophy), HTN, GERD, IBS,
asthma, PE with acute cor pulmonale and pulmonary fibrosis on 4
L
of oxygen at home with chronic pain requiring a brain stimulator
with recent bulbar symptoms causing her to become severely
dysphasic requiring an outpatient eval for G-tube who presents
for inability to tolerate p.o. for several days and was found to
be hypotensive at her PCPs office. She states that she has had
difficulty with swallowing for "awhile" now and was previously
on
a soft/pureed diet. Over the last week it has become
increasingly
difficult for her to swallow solids or liquids and as a result
she has been unable to take many of her medications. She was
recently seen by her pain doctor who was recommending a G-tube
be
placed so that she would be able to take enteral
nutrition/medications again. The plan was initially to try and
hold off until after ___ to have her come into the
hospital but today in her PCPs office she was noted to be
hypotensive and was sent to the ED. Patient notes that this
morning she felt weak and "not like [herself]". She attributes
this to not eating or drinking more than a intermittent sips for
the past few days. Patient also notes that she had a fall
recently due to lower extremity weakness which has exacerbated
her chronic back pain.
In the ED, initial vitals were:
HR:90 BP:75/41 RR:16 95% 3L NC
- Exam:
Con: alert, oriented and in no acute distress
HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI.
No erythema or exudate in posterior pharynx; uvula midline; MMM.
Neck: neck veins flat with full ROM
LAD: no cervical LAD
Resp: Breathing comfortably on 4L NC. No incr WOB, CTAB with no
crackles or wheezes.
CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral.
Abd: Soft, Nontender, Nondistended with no organomegaly; no
rebound tenderness or guarding.
MSK: ___ without edema bilaterally
Skin: No rash, Warm and dry, No petechiae
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
- Labs:
INR: 1.2
Cr: 1.3
WBC: 7.4
lactate: 1.0
- Imaging:
CXR: Multiple devices and wires project over the chest.
Bibasilar atelectasis.
- Micro:
UA: leuk (lg) WBC (49) Bact (few)
- Consults:
none
- Patient was given:
3L NS
1gm ceftriaxone
Upon arrival to the floor, patient reports that she has her
chronic nausea and back pain but is otherwise feeling well. She
notes that she is open to having a G-tube and is willing to do
whatever we suggest in terms of food/medications.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
HYPERTENSION
MIGRAINE HEADACHES
PAIN
CRPS
HAND PAIN
BACK PAIN
RLE PAIN
SLEEP DISORDER
NAUSEA
ARM PAIN
THORACIC OUTLET SYNDROME
PULMONARY EMBOLISM
Social History:
___
Family History:
Mother: cardiac stents
Father: heart disease
Sister: small cell lung cancer
SisterL shydrager syndrome (multisystem atrophy)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.0 PO, BP 120/61, HR 74, RR 18, ___
___: Weight: 220
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. OP Clear
EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus.
NECK: No cervical lymphadenopathy. No JVD, no carotid bruit.
LUNG: Absent breath sounds posterior lung fields, normal breath
sounds anterior fields, no accessory muscle use
HEART: RRR, Normal S1/S2, No M/R/G
BACK: No CVA tenderness.
ABD: Soft, non-tender, non-distended; nl bowel sounds; no
rebound
or guarding, no organomegaly
GU: Not examined
EXTRM: Extremities warm, trace edema, no cyanosis, positive
___ pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities with
purpose
PSYC: Mood and affect appropriate
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 912)
Temp: 97.8 (Tm 98.0), BP: 101/72 (90-114/59-74), HR: 81
(74-88), RR: 18 (___), O2 sat: 95% (92-98), O2 delivery: 4L,
Wt: 232.14 lb/105.3 kg
GENERAL: NAD, but significant stuttering with speech.
HEENT: AT/NC, anicteric sclera, MMM PERRLA
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, but with small breath volumes
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, and oriented. Speech coherent but with stuttering
repeating the end of sentences x3-4 times. CN II-XII intact but
requires some encouragement to keep eyes closed and to keep
shoulders shrugged. Normal tone. No tongue fasciculations.
Strength appears ___ bilaterally with encouragement but then
gives way after ___ seconds.
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 04:29PM BLOOD WBC-7.4 RBC-4.18 Hgb-10.7* Hct-34.5
MCV-83 MCH-25.6* MCHC-31.0* RDW-16.4* RDWSD-49.4* Plt ___
___ 04:31PM BLOOD ___ PTT-33.9 ___
___ 04:29PM BLOOD Glucose-132* UreaN-31* Creat-1.3* Na-144
K-4.7 Cl-106 HCO3-24 AnGap-14
___ 06:54AM BLOOD cTropnT-<0.01
___ 05:05PM BLOOD cTropnT-<0.01
___ 04:29PM BLOOD Lipase-21
___ 04:29PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.9 Mg-2.0
RELEVANT LABS:
==============
___ 04:34PM BLOOD Lactate-1.0
___ 06:59AM BLOOD calTIBC-235* Ferritn-122 TRF-181*
___ 06:59AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.8 Mg-1.9
Iron-69
Test Result Reference
Range/Units
ZINC 110 60-130 mcg/dL
MICROBIOLOGY:
=============
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
=======
CXR ___:
Multiple devices and wires project over the chest. Bibasilar
atelectasis.
PEG ___:
There is a percutaneous gastrostomy tube projecting over the
left upper
quadrant of the abdomen. There are no abnormally dilated loops
of small or large bowel. No free intraperitoneal air is
identified. No suspicious
radiopaque calculi are visualized. The osseous structures are
unremarkable. Spinal cord stimulator leads are noted in the
lower thoracic and upper lumbar spine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Pregabalin 300 mg PO BID
3. Mirtazapine 45 mg PO QHS
4. erenumab-aooe 70 mg/mL subcutaneous Monthly
5. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Tizanidine 8 mg PO TID
8. amLODIPine 7.5 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. ketamine (bulk) 100 % miscellaneous TID:PRN
11. Furosemide 20 mg PO DAILY
12. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN Pain - Moderate
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QAM
14. Promethazine 12.5 mg PO BID:PRN nausea
15. Sumatriptan Succinate 6 mg SC ONCE:PRN migraine
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*3 Capsule 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. erenumab-aooe 70 mg/mL subcutaneous Monthly
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QAM
7. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN Pain - Moderate
8. ketamine (bulk) 100 % miscellaneous TID:PRN
9. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain
10. Mirtazapine 45 mg PO QHS
11. Pregabalin 300 mg PO BID
12. Promethazine 12.5 mg PO BID:PRN nausea
13. Sumatriptan Succinate 6 mg SC ONCE:PRN migraine
14. Tizanidine 8 mg PO TID
15. HELD- amLODIPine 7.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until you see your primary care doctor
16. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you see your primary care doctor
17. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Oral pharyngeal and esophageal dysphasia
Acute kidney injury
hypotension
SECONDARY DIAGNOSIS
=====================
Urinary tract infection
Chronic regional pain syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with weakness// acute process?
COMPARISON: Prior CT of the chest from ___
FINDINGS:
AP portable upright view of the chest. Spinal cord stimulator projects over
the cervical spine. Electrodes representing neural stimulators project over
the right hemithorax and right side of the neck. There is bibasilar
atelectasis without convincing evidence for pneumonia. Please note the
implanted device within the left chest wall obscures the underlying portion of
the heart and lung. No large effusion or pneumothorax is seen. Overall
cardiomediastinal silhouette appears grossly unremarkable. Imaged bony
structures are intact.
IMPRESSION:
Multiple devices and wires project over the chest. Bibasilar atelectasis.
Radiology Report
EXAMINATION: Chest radiographs, two AP upright portable views.
INDICATION: Dobhoff tube placement. Oro pharyngeal dysmotility.
COMPARISON: Prior study from ___.
FINDINGS:
Second of two views shows a Dobhoff tube partly coiled in the stomach. Lung
volumes are very low. Cardiac, mediastinal and hilar contours appear stable.
Atelectasis at each lung base is improved. There is no pneumothorax or
pleural effusion. Spinal catheters appear unchanged.
IMPRESSION:
Dobhoff terminating in the stomach. Mostly resolved atelectasis at each lung
base.
Radiology Report
INDICATION: ___ year old woman with recent dobhoff placement and reporting
chest tightness.// PTX?
COMPARISON: Radiographs from ___
IMPRESSION:
There is a Dobhoff tube with distal tip in the fundus of the stomach. There
are markedly low lung volumes. Atelectasis at the lung bases. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with oropharyngeal dysphagia with dobhoff
placement. Concern for movement of tube?// interval change in tube placement?
interval change in tube placement?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___ through
___.
Transesophageal feeding tube coiled appropriately in the upper stomach.
Multiple indwelling stimulator leads unchanged in their respective positions.
Lung volumes remain exceedingly small, exaggerating mild cardiomegaly. No
definite pulmonary abnormality. Pleural effusions small if any. No
pneumothorax.
Radiology Report
INDICATION: ___ year old woman with history of oropharyngeal and esophageal
dysphagia and concern for diaphragmatic weakness potentially secondary to CRPS
who presented with hypotension iso poor PO intake. Failed s/s and needs long
term enteral access for nutrition.// PEG placement
COMPARISON: Chest x-ray dated ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g of Ancef
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 11.3 minutes, 76 mGy
PROCEDURE: 1. Placement of a Ponsky pull-through gastrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance a 19 gauge needle was introduced under
fluoroscopic guidance and position confirmed using an injection of dilute
contrast. A ___ wire was introduced into the stomach. A small skin
incision was made along the needle and the needle was removed, and a 5 ___
vascular sheath was placed. A short Kumpe catheter was advanced over the
wire. The ___ wire was exchanged for a Glidewire. The Glidewire was
advanced into the esophagus in the Kumpe catheter followed up to the level of
the midesophagus. The Glidewire was exchanged for ___ wire. The Kumpe
catheter was removed
The snare was attached to the gastric end of the ___ wire. Under
continuous fluoroscopic guidance, the ___ wire was advanced into the oral
cavity. A hemostat was used to secure the ___ wire. Under continuous
fluoroscopic guidance, the snare device was pulled through the stomach into
the esophagus and out of the oral cavity. The snare was released, the ___
wire was removed and the Ponsky tube was attached to the snare and secured.
Under continuous fluoroscopic guidance, the Ponsky tube was then pulled
through the oral cavity into the esophagus and finally the stomach. The
Ponsky tube was cut and an overlying disc, lock and adapter were placed.
Contrast was injected through the Ponsky tube to confirm appropriate
placement. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a Ponsky gastrostomy tube.
IMPRESSION:
Successful placement of a 20 ___ Ponsky gastrostomy tube via pull
technique.
Radiology Report
INDICATION: ___ year old woman s/p PEG placement w/ worsening abdominal pain//
R/o free air, s/p PEG placement
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There is a percutaneous gastrostomy tube projecting over the left upper
quadrant of the abdomen. There are no abnormally dilated loops of small or
large bowel. No free intraperitoneal air is identified. No suspicious
radiopaque calculi are visualized. The osseous structures are unremarkable.
Spinal cord stimulator leads are noted in the lower thoracic and upper lumbar
spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Failure to thrive, Hypotension
Diagnosed with Hypotension, unspecified
temperature: nan
heartrate: 90.0
resprate: 16.0
o2sat: 95.0
sbp: 75.0
dbp: 41.0
level of pain: 0
level of acuity: 1.0 | BRIEF HOSPITAL COURSE
=====================
___ with h/o thoracic outlet syndrome s/p rib resections in
___,
subsequent chronic regional pain syndrome, HTN, GERD, IBS,
asthma, PE with acute cor pulmonale on 4 L at home with chronic
pain requiring a brain stimulator with recent bulbar symptoms
leading to oral pharyngeal and esophageal dysphasia. The patient
was noted to be hypotensive by ___ likely in the setting of poor
p.o. intake over the last several weeks and was admitted to
___ for further workup. The patient could not tolerate a
dobhoff so PEG was placed for supplemental enteral feeding.
==============
Active Issues
==============
#Decreased PO Intake
#Oropharyngeal and esophageal dysphagia
#Stuttering
#Hypotension
Patient had a recent admission to ___ for oropharyngeal and
esophageal dysphasia and worsening shortness of breath in the
setting of possible diaphragmatic weakness. Her symptoms were
developing over the last several months and had been evaluated
by her outpatient neurologist and workup has so far included
normal CK, TSK, myositis panel, alpha glucosidase activity.
During the admission to ___, her workup included an EMG which
showed decreased recruitment in genioglossus and VSS study
showing oropharyngeal and esophageal dysmotility with silent
aspiration. Etiology of these symptoms was not determined, there
was a concern for functional component. She was discharged with
follow-up with the neuromuscular specialist. Her motor cortex
stimulator was turned off in the last 3 weeks, but this does not
appear to significantly improve her symptoms. Over the last few
weeks her dysphasia continued to worsen and she was unable to
tolerate p.o. intake. She has close follow-up with ___ and
speech therapy as an outpatient and was noticed to be
hypotensive which resulted in her admission to ___
___. ___ was fluid resuscitated which improved her ___ and
hypotension. Her hypotension was likely caused by poor p.o.
intake given no signs for infection, cardiogenic or obstructive
cause. Her antihypertensives were held: Lisinopril 40mg daily,
Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine 7.5mg
daily. Neurology was consulted and felt that her CRPS may be
contributing to her dysphagia. Dobbhoff was placed and tube
feeds were started to supplement nutrition, but the patient
could not tolerate the tube d/t gagging sensation particularly
with medications. A PEG was placed on ___ and we were working
on scheduling with outpatient follow up with neurology with
continued outpatient ___ and Speech therapy.
#Hypoxia
#Restrictive lung disease likely ___ diaphragmatic paralysis
#History of unprovoked pulmonary embolism
Patient w/ known PE and bronchiectasis and concern for
diaphragmatic paralysis. Currently uses ___ O2 at home but was
discharged on 1L NC from ___ 1 month ago. Currently feels her
breathing is at her baseline. She was on Xarelto at home for
anticoagulation. She was started on heparin drip while inpatient
given lack of enteral access and after Dobbhoff was placed was
started on apixaban twice daily given possibility of Dobbhoff
migrating into the jejunum which would limit absorption of
rivaroxaban. A PEG was ultimately placed and she continued on
apixaban 5mg BID. She was continued on Advair daily.
#Anemia
Hgb 10.7 in ED with recent baseline around ___ per ___
records. No active signs of bleeding. Her hemoglobin was stable
during admission.
#UTI
UA in ED concerning for infection w/ large leuk esterase, 49
WBCs, few bacteria. Urine culture grew pansensitive E. coli. She
was started on ceftriaxone in the ED and was narrowed to
nitrofurantoin with sensitivities. She completed a 5-day course
of antibiotics.
___
Presented with Cr of 1.3 from last known 0.7 in ___. Received
4L IVF and improved
to 0.6. Likely in the setting of dehydration and poor p.o.
intake.
==============
Chronic Issues
==============
#Hypertension
-Her home antihypertensives were held initially lisinopril 40mg
daily, Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine
7.5mg daily. She remained normotensive during admission and was
restarted on metoprolol succ 25mg XL at discharge.
#Reflex Sympathetic Dystrophy
#Chronic Pain
Patient w/ significant chronic pain. Follows with Dr. ___
in Pain ___ here. He was initially started on IV Dilaudid
given lack of enteral access and was transitioned to her home
regimen of Dilaudid p.o. ___ mg 4 times daily as needed.
-Continue Lyrica 300mg BID
-Holding ketamine lozenges while inpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Sulfa (Sulfonamide Antibiotics) / vancomycin /
Coreg / metoprolol / atorvastatin
Attending: ___
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history notable for uncontrolled DM, HTN, pyoderma of right hip,
recurrent necrotizing fasciitis of abdomen/groin s/p multiple
debridements and now wound vac, who presents from her SNF with
concerns for her care there.
Per patient and OMR, she has had a recently prolonged
hospitalization of 2 months for the necrotizing fasciitis
(please
see d/c summary ___ - her course was complicated by wound
infection, gastroparesis requiring GJ tube, depression,
hypotension, uncontrolled diabetes, UTI, and bacteremia. She
was
ultimately discharged to ___ for rehab and was there until
1 week ago, when she was transferred to ___. While
there, she was concerned re: suboptimal care in terms of wound
management and management of her diabetes - she reports multiple
episodes of hyperglycemia while there. No other new symptoms -
no f/c/s, chest pain, shortness of breath, dizziness,
lightheadedness, n/v/abd pain, constipation, ___ edema.
+baseline
chronic diarrhea of ___ BMs per day (loose). No rashes. No
changes in mood.
She came into our ED for the above reason and was here for the
past 1.5 days; she was admitted to the medical service for
optimization of her DM and rehab placement. Per patient, she
was
seen by ___ in the ED and surgery, who replaced her wound vac
today.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
DM 2, uncontrolled
Graves' disease s/p RAI
pyoderma of right hip
HTN
HL
LBBB
necrotizing fasciitis of lower abdomen and b/l groins, s/p
multiple debridements and wound vac closures
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate,
mucous membranes moist
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. GJ tube c/d/I; pressure ulcer proximal to this
site with significant depth and some drainage, no erythema or
foul odor. +wound vac of the lower abdomen, wound not fully
examined due to vac
GU: No suprapubic fullness or tenderness to palpation, +catheter
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate,
mucous membranes moist
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. GJ tube c/d/I; pressure ulcer proximal to this
site with significant depth and some drainage, no erythema or
foul odor. +wound vac of the lower abdomen, wound not fully
examined due to vac
GU: No suprapubic fullness or tenderness to palpation, +catheter
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-9.1 RBC-3.35* Hgb-9.2* Hct-29.5*
MCV-88 MCH-27.5 MCHC-31.2* RDW-17.1* RDWSD-54.2* Plt ___
___ 01:30PM BLOOD Neuts-70.2 Lymphs-17.2* Monos-6.6 Eos-5.0
Baso-0.6 Im ___ AbsNeut-6.36* AbsLymp-1.56 AbsMono-0.60
AbsEos-0.45 AbsBaso-0.05
___ 01:30PM BLOOD Glucose-176* UreaN-26* Creat-0.8 Na-136
K-7.2* Cl-97 HCO3-26 AnGap-13
___ 01:30PM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
DISCHARGE LABS:
___ 05:54AM BLOOD WBC-7.4 RBC-3.15* Hgb-8.7* Hct-27.7*
MCV-88 MCH-27.6 MCHC-31.4* RDW-17.0* RDWSD-54.0* Plt ___
___ 05:54AM BLOOD Glucose-208* UreaN-30* Creat-0.8 Na-139
K-4.8 Cl-96 HCO3-25 AnGap-18
___ 05:54AM BLOOD ALT-10 AST-10 AlkPhos-166* TotBili-<0.2
___ 05:54AM BLOOD Albumin-2.9* Calcium-9.1 Phos-4.8* Mg-1.6
GI/G-tube check ___:
Percutaneous gastrojejunostomy catheter is looped in the stomach
with tip in the region of the pylorus, as seen on the prior CT
exam. No extraluminal oral contrast material seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 17.2 mg PO DAILY:PRN constipation
2. Heparin 5000 UNIT SC BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Moexipril 3.75 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Dronabinol 10 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
10. Mirtazapine 15 mg PO QHS
11. Famotidine 20 mg PO Q12H
12. Ferrous Sulfate 325 mg PO DAILY
13. melatonin 5 mg oral QHS
14. Multivitamins 1 TAB PO DAILY
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Escitalopram Oxalate 10 mg PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Glargine 30 Units Bedtime
NPH 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. LORazepam 0.5 mg PO Q8H:PRN anxiety
The Preadmission Medication list is accurate and complete.
1. Senna 17.2 mg PO DAILY:PRN constipation
2. Heparin 5000 UNIT SC BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Moexipril 3.75 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Dronabinol 10 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
10. Mirtazapine 15 mg PO QHS
11. Famotidine 20 mg PO Q12H
12. Ferrous Sulfate 325 mg PO DAILY
13. melatonin 5 mg oral QHS
14. Multivitamins 1 TAB PO DAILY
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Escitalopram Oxalate 10 mg PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Glargine 30 Units Bedtime
NPH 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. LORazepam 0.5 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Glargine 25 Units Bedtime
Regular 7 Units Lunch
Regular 7 Units Dinner
Regular 7 Units at 0000
Insulin SC Sliding Scale using REG Insulin
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
4. Dronabinol 10 mg PO TID
5. Escitalopram Oxalate 10 mg PO DAILY
6. Famotidine 20 mg PO Q12H
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Heparin 5000 UNIT SC BID
10. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
11. Levothyroxine Sodium 150 mcg PO DAILY
12. LORazepam 0.5 mg PO Q8H:PRN anxiety
13. melatonin 5 mg oral QHS
14. Mirtazapine 15 mg PO QHS
15. Moexipril 3.75 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Senna 17.2 mg PO DAILY:PRN constipation
19. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyperglycemia
Recurrent necrotizing fasciitis
Sacral uclers
Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with GJ tube// Correct placement?
TECHNIQUE: Supine scout AP view of the abdomen was obtained. Subsequently,
20 cc of Gastrografin oral contrast material was injected through the
patient's GJ tube and subsequent supine AP view of the abdomen was obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Percutaneous gastrojejunostomy catheter seen which is looped within the
stomach and tip terminating in the region of the pylorus. Contrast injected
through this catheter opacifies the stomach and proximal duodenum. No
extraluminal oral contrast material seen. Bowel gas pattern is unremarkable.
Multiple soft tissue anchors project over the right iliac bone. No acute
osseous abnormality.
IMPRESSION:
Percutaneous gastrojejunostomy catheter is looped in the stomach with tip in
the region of the pylorus, as seen on the prior CT exam. No extraluminal oral
contrast material seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Failure to thrive
Diagnosed with Diarrhea, unspecified
temperature: 98.9
heartrate: 109.0
resprate: 20.0
o2sat: 98.0
sbp: 112.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ female with poorly controlled DM2,
HTN, pyoderma of R hip, recurrent necrotizing fasciitis of
abdomen/groins/p multiple debridement presenting from rehab with
hyperglycemia and awaiting insurance auth to be
transferred to a different facility.
# Hyperglycemia, uncontrolled DM - baseline HgB 11% and has been
affected by her recent infections and hospitalizations. She was
restarted on glargine and regular insulin 7U (at 1200, 1800, and
0000) with TF's and ISS with regular insulin. FSBG's were in
the high 100's to 200's.
# Gastroparesis with TF dependence: pt continued on Glucerna |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ man with complicated medical
comorbidities including CAD status post three-vessel CABG, along
with systolic CHF with EF around 30%, with recent finding of
kidney mass suspicious of RCC presenting for sudden onset
dyspnea.
Patient reports that he was home yesterday morning developed
sudden onset dyspnea after breakfast. No chest pain or
palpitations. Dyspnea worse with exertion. Rested for several
hours but dyspnea persisted.
Of note, he has a history of significant systolic CHF with an
ejection fraction estimated around 30% or so, maintained on
torsemide diuretic along with beta blockade and ___ therapy. He
underwent a nuclear stress test with nuclear imaging on ___
which revealed left ventricular dilation at rest and during
stress, with a global ejection fraction of ___ with diffuse
hypokinesis with akinesis in the interventricular septum,
inferior infarct without ischemia. An echo on ___ revealed
LV enlargement with moderate systolic dysfunction with an EF of
35%, 2+ mitral insufficiency, 2+ tricuspid insufficiency, severe
pulmonary hypertension and right ventricular systolic pressures
of 60-65.
In the ED, initial vitals were:
Labs were significant for BNP of 3190, trop x1 negative,
creatinine of 1.3 and UA negative for infection.
Imaging significant for :
EKG - sinus rhythm
CXR - pulmonary edema
Patient was given:
___ 21:50 IV Furosemide 80 mg
___ 22:25 IV Ondansetron 4 mg
___ 22:25 IV LORazepam 1 mg
___ 22:35 PO Potassium Chloride 40 mEq
On the floor, patient reports improvement in his breathing. He
reports his daughter came back from ___ on ___ and has
been throwing up and having loose stools. He reports as of
yesterday, he has been having nausea, abdominal pain and
throwing up as well. He feels over the weekend, he has noticed
his ankles swell up more and has had some weight gain. He was
walking around watering his plants when he experienced sudden
onset dyspnea (which is moderate exertion for him). He has been
exercising every other day to lose weight for a scheduled
?partial nephrectomy for newly diagnosed renal mass in the near
future. He reports he has not felt anything like this before.
Denies any chest pain at the time. Reports he did experience
some orthopnea. He has been taking his medication as prescribed
and did notice an improvement in his breathing after he received
the IV Lasix in the ED.
Review of systems:
(+) Per HPI
Past Medical History:
1. CAD status post three-vessel CABG in ___ after a stress
test.
2. Systolic CHF with ejection fraction 30%
3. Hypertension.
4. Non-insulin-dependent diabetes.
5. Morbid obesity.
6. GERD.
7. Obstructive sleep apnea, on CPAP.
8. Episodic atrial fibrillation, status post cardioversion one
year ago.
9. Renal mass, c/f renal cell carcinoma
SURGICAL HISTORY:
1. CABG x 3, ___.
2. Elective cardioversion, ___ for AFib.
3. Right rotator cuff.
Social History:
___
Family History:
Mother had myasthenia ___, deceased. Father had CAD,
deceased.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VITAL SIGNS: T98 BP 147/87 HR 96 RR 22 Sats 95 on 4L
GENERAL: Well-appearing and obese. NAD
HEENT: Anicteric sclerae. Mucous membranes are moist and pink.
NECK: Difficult to assess with body habitus
LUNGS: Bilateral crackles up to mid zones of lungs
HEART: Normal rate, regular rhythm. Soft ___ systolic ejection
murmur, heard throughout the precordium.
ABDOMEN: Obese, soft, nontender, nondistended. No palpable
masses.
EXT: 2+ pitting edema bilaterally up to knees
NEURO: A and O x3. No asterixis. Normal gait. Power ___ in all
four extremities. CnII-XII intact
LABS: see below
DISCHARGE PHYSICAL EXAM:
========================
VITAL SIGNS: Tm 98.0 104-122/44-57 ___ 18 99/CPAP
Weight: 125.5 <- 125.5 <- 124.6 <- 124.0 <- 125.8 <- 126.6 <-
127 <- 131.6 <- 132.2 <- 133.8
I/Os:
8 ___
24 ___
GENERAL: Well-appearing and obese. NAD
HEENT: NCAT
NECK: no JVD
LUNGS: CTABL
HEART: Normal rate, regular rhythm. Soft ___ systolic ejection
murmur, heard throughout the precordium.
ABDOMEN: Obese, soft, nontender, nondistended.
EXT: trace edema bilaterally up to knees
NEURO: grossly non-focal
Pertinent Results:
ADMISSION
=========
___ 09:00PM BLOOD WBC-10.9*# RBC-4.22* Hgb-11.7* Hct-36.8*
MCV-87 MCH-27.7 MCHC-31.8* RDW-15.4 RDWSD-48.2* Plt ___
___ 09:00PM BLOOD Neuts-86.8* Lymphs-5.8* Monos-6.5
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.49*# AbsLymp-0.63*
AbsMono-0.71 AbsEos-0.02* AbsBaso-0.03
___ 09:00PM BLOOD ___ PTT-36.4 ___
___ 09:00PM BLOOD Glucose-147* UreaN-17 Creat-1.3* Na-140
K-3.2* Cl-100 HCO3-28 AnGap-15
___ 07:00AM BLOOD ALT-16 AST-18 AlkPhos-144* TotBili-1.4
___ 07:00AM BLOOD Lipase-42
___ 09:00PM BLOOD proBNP-3190*
___ 09:00PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-2 cTropnT-0.01
___ 07:00AM BLOOD Albumin-4.1 Calcium-8.8 Phos-4.5 Mg-1.9
___ 04:55PM BLOOD Lactate-1.9
PERTINENT
=========
___ 03:20PM BLOOD Glucose-135* UreaN-31* Creat-1.8* Na-140
K-3.5 Cl-103 HCO3-25 AnGap-16
___ 06:32AM BLOOD Glucose-109* UreaN-21* Creat-1.4* Na-139
K-3.6 Cl-101 HCO3-24 AnGap-18
___ 03:00PM BLOOD UreaN-24* Creat-1.8* Na-140 K-3.9 Cl-100
HCO3-26 AnGap-18
___ 03:05PM BLOOD UreaN-38* Creat-2.5* Na-135 K-4.4 Cl-100
HCO3-24 AnGap-15
DISHCARGE
=========
___ 07:10AM BLOOD WBC-5.7 RBC-4.21* Hgb-11.6* Hct-37.2*
MCV-88 MCH-27.6 MCHC-31.2* RDW-16.1* RDWSD-51.5* Plt ___
___ 06:30AM BLOOD ___ PTT-32.9 ___
___ 07:10AM BLOOD Glucose-106* UreaN-33* Creat-1.6* Na-137
K-4.5 Cl-101 HCO3-26 AnGap-15
___ 07:10AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.2
___ 09:07PM BLOOD Lactate-1.1
MICROBIOLOGY:
==============
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
=======
- Nuclear Stress ___
IMPRESSION: 1. Normal myocardial perfusion. 2. Severely enlarged
left
ventricular cavityL. 3. Reduced left ventricular ejection
fraction calculated to
be 32 percent.
-TTE ___
The left atrium is moderately dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is at
least 15 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the mid to distal inferior wall and a
dyskinetic septum. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is markedly dilated with moderate global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened, but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severely dilated,
moderately hypokinetic left ventricle with regional wall motion
abnormalities consistent with coronary artery disease. Dilated,
hypokinetic right ventricle. Mildly dilated aortic root and
ascending aorta. Mild to moderate mitral regurgitation. Severe
pulmonary artery systolic hypertension.
-EKG - sinus rhythm - no ST changes
-CXR ___: pulmonary edema
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Torsemide 20 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Atorvastatin 40 mg PO QPM
3. Losartan Potassium 100 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
Start: ___, First Dose: Next Routine Administration Time
7. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*90 Tablet Refills:*0
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
9. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
10. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*0
11. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
======
Acute on Chronic Systolic CHF
Cardiogenic Shock
SECONDARY
========
___ on CKD
CAD s/p CABG
Renal Mass
GERD
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with dyspnea and lower extremity edema.
Evaluate for pneumonia and pleural effusions.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: CT chest ___.
FINDINGS:
Moderately severe pulmonary edema is accompanied by a small right pleural
effusion. There is no consolidation, large pleural effusion or pneumothorax.
Cardiomegaly is severe. Sternal wire disruption and displacement are
consistent with known sternal dehiscence,unchanged since ___. There
is a large air-fluid level in the stomach.
IMPRESSION:
Cardiomegaly and moderate pulmonary edema consistent with congestive heart
failure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Abd pain
Diagnosed with Heart failure, unspecified
temperature: 98.9
heartrate: 95.0
resprate: 16.0
o2sat: 95.0
sbp: 166.0
dbp: 96.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ man with complicated medical
comorbidities including CAD status post three-vessel CABG, along
with systolic CHF with EF around 30%, with recent finding of
kidney mass suspicious of RCC presenting for sudden onset
dyspnea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
1. IVC filter placement
History of Present Illness:
___ woman, factor V leiden carrier not on
anticoagulation, who had a syncopal event with headstrike
earlier
on ___. She reports she felt unwell upon awakening, having
noted
chest heaviness, plus left ankle and calf soreness. While at the
bank, she felt diaphoretic and dizzy, and subsequently lost
consciousness, striking her head on the fall.
She awoke in the ambulance and was alert and aware of her
surroundings. She denies any prior syncopal episodes or prior
clots or taking anticoagulation.
She was taken to an OSH where she received dilt x1 for AF (this
is the first time she's been diagnosed with AF).
Past Medical History:
PAST MEDICAL HISTORY
HTN
Hyperlipidemia
factor V leiden carrier
Social History:
___
Family History:
FAMILY HISTORY:
Daughter - Factor V ___ homozygote, SLE
Son - UC
Other daughter - healthy
Father - Died age ___ of Lung cancer
Mother - Died age ___ of CHF and COPD
Physical Exam:
Discharge Physical Exam:
VS: T 98.5HR 56 BP 105/56 RR 18 SpO297%RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable. LLE edema and
tenderness. Compression stockings in place.
Pertinent Results:
___ 01:10PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-Test
___ 01:10PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test
___ 01:49AM BLOOD CA ___ -Test
___ 01:49AM BLOOD CEA-0.3
___ 01:10PM BLOOD Lupus-POS
___ 06:00PM BLOOD WBC-11.2* RBC-3.82* Hgb-12.2 Hct-36.2
MCV-95 MCH-31.9 MCHC-33.7 RDW-12.8 RDWSD-44.3 Plt ___
___ 04:28AM BLOOD WBC-9.7 RBC-3.39* Hgb-10.5* Hct-32.4*
MCV-96 MCH-31.0 MCHC-32.4 RDW-12.7 RDWSD-43.9 Plt ___
___ 06:00PM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-22 AnGap-18
___ 04:28AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-138 K-4.8
Cl-103 HCO3-23 AnGap-17
___ 04:28AM BLOOD ___ PTT-67.0* ___
___ 05:00AM BLOOD ___ PTT-70.3* ___
___ 09:15AM BLOOD ___
Medications on Admission:
Hydrochlorithiazide 25 QD
Lisinopril 7.5 QD
Calcium with vit D
Multivit
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amiodarone 400 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 25 mg PO TID
Hold for HR<55 or SBP <90
5. Senna 8.6 mg PO BID:PRN constipation
6. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. bilateral pulmonary emboli
2. subarachnoid hemorrhage
3. left DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with bilateral subsegmental PEs, ___ edema, also with
subdurals and difficult risk/benefit calculation on treatment for venous
thrombi // Evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is loss of normal compressibility, flow, and augmentation of the left
common femoral, femoral, and duplicated popliteal veins with echogenic
material noted within the veins, compatible with DVT. The thrombus extends
into the left posterior tibial and peroneal veins, with loss of normal color
flow and compressibility. Of note, the proximal extent of the thrombus is not
seen.
There is normal respiratory variation in the common femoral vein on the right.
There is loss of normal respiratory variation in the common femoral vein on
the left.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Extensive thrombus is noted within the left common femoral vein and
extends into the superficial femoral, duplicated popliteal veins, posterior
tibial, and peroneal veins. Of note, the proximal extent of the clot is not
seen and could extend into the pelvis.
2. No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST
INDICATION: ___ year old woman with SAH, bilateral PEs, and LLE DVT that
extends at least into Lt CFV. // please evaluate extent of DVT found by
ultrasound in left CFV. Please protocol study for venous phase
TECHNIQUE: Pre and post contrast with split bolus: MDCT axial images were
acquired through the abdomen and pelvis prior to and following intravenous
contrast administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 6.5 mGy (Body) DLP = 335.0
mGy-cm.
2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 20.6 mGy (Body) DLP =
1,063.9 mGy-cm.
Total DLP (Body) = 1,399 mGy-cm.
COMPARISON: Lower extremity ultrasound from ___
FINDINGS:
LOWER CHEST: There is mild bilateral dependent subsegmental atelectasis. There
is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout. Several cystic
lesions are seen in the tail of the pancreas, the largest measuring 2.2 cm
(image 3:45). There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout. A 4 mm
hypodensity is seen, too small to be characterize (image 3:39).
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: A small hiatal hernia is noted. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. There
is moderate sigmoid diverticulosis without diverticulitis The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: A 2.3 cm left adnexal cyst is noted.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted. There is compression of the left common iliac vein by the
right common iliac artery at the bifurcation, with the vein measuring 6 mm in
AP diameter (image 3:99). There is complete occlusive thrombus of the left
common iliac vein, extending down into the left femoral vein.
BONES: An 8 mm sclerotic focus is seen in the right iliac bone (image 3:125)
and likely represents a benign bone island.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Compression of the left common iliac vein by the right common iliac artery
with complete thrombosis of the left common iliac vein extending down into the
left femoral vein.
2. Incidental findings of cystic lesions within the tail of the pancreas as
well as a 2.3 cm left adnexal cyst.
RECOMMENDATION(S): Non urgent MRCP is recommend for further evaluation of the
pancreatic tail lesions.
Non urgent pelvic ultrasound is recommend for further evaluation of the left
adnexal cyst.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:09AM, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with subarachnoid hemorrhage. Assess for
evolution.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 15.2 cm; CTDIvol = 46.4 mGy (Head) DLP =
702.4 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside head CT performed on ___ at 23:22.
FINDINGS:
A globular focus of subarachnoid blood in a left medial frontal sulcus is
unchanged. Small left parafalcine subdural hematoma is also stable. There is
no mass effect on the brain parenchyma. No new hemorrhage is identified.
There is no evidence for parenchymal edema or loss of gray/ white matter
differentiation. The ventricles and sulci are age-appropriate.
No fracture is identified. There is minimal mucosal thickening in the
frontoethmoidal recesses. Middle ear cavities, pneumatized petrous apices,
and the visualized mastoid air cells are well aerated.
IMPRESSION:
1. Stable globular focus of subarachnoid hemorrhage in a left medial frontal
sulcus.
2. Stable small left parafalcine subdural hematoma without mass effect on the
brain parenchyma.
Radiology Report
INDICATION: IVC filter placement confirmation
TECHNIQUE: Fluoroscopic abdominal radiograph.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
Intraoperative insertion of an IVC filter. An IVC filter is in a vertical
orientation with its feet at approximately the level of T10.
Visualized osseous structures are unremarkable.
Radiology Report
Study carotid series complete
Reason syncope
Findings. Duplex evaluation was performed of both carotid arteries. No
plaque is identified.
On the right velocities are 88/20, 75/20, 57 in the ICA, CCA, ECA
respectively. The ratio is 1.2. This is consistent with no stenosis.
On the left velocities are 76/13, 71/23, 60 in the ICA, CCA, ECA respectively.
The ratio is 1.1. This is consistent with no stenosis.
There is antegrade flow in both vertebral arteries.
Impression no evidence of stenosis in either carotid artery
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ female status post fall with parafalcine subdural
hematoma and subarachnoid hemorrhage. Evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
Total DLP (Head) = 757 mGy-cm.
COMPARISON: NECT ___.
FINDINGS:
No significant change in the left frontal parafalcine subdural hematoma and
focus of subarachnoid hemorrhage in the left medial frontal sulcus . There is
no mass effect or midline shift. The basal cisterns appear patent. There is
no CT evidence of new hemorrhage or infarct. There is mild global cerebral
volume loss with appropriate ventricular size.
There is no evidence of 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. Stable focus of subarachnoid hemorrhage in the left medial frontal sulcus.
2. Stable left parafalcine subdural hematoma.
3. No evidence of mass effect or midline shift, new hemorrhage or acute
infarct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ female status post fall with traumatic subarachnoid
hemorrhage 5 days prior study now on therapeutic anticoagulation. Evaluate
for interval change in subarachnoid hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
Stable left medial frontal sulcus parafalcine subarachnoid hemorrhage. Stable
small left parafalcine subdural hematoma. No new hemorrhage identified. No
mass effect or midline shift. The ventricles and sulci are normal in size and
configuration.
There is no evidence of 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. Stable left medial frontal sulcus parafalcine subarachnoid hemorrhage.
2. Stable small left parafalcine subdural hematoma.
3. No evidence of mass effect or midline shift, new hemorrhage or acute
infarct.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, SDH, PE
Diagnosed with Syncope and collapse
temperature: 98.7
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___- A Fib with RVR (asymptomatic), given dilt 10mg x1. CT head
- stable SAH. CT abd/pelvis - thrombus extends to just ___ to
confluence of iliac veins. Went to OR and had IVC filter placed.
Occasionally goes back into a-fib with RVR. Started on dilt gtt.
BP remains stable despite RVR. Mentates well.
___- PO dilt started 45 Q6, dilt gtt weaned, then recurrent a
fib RVR, back on dilt gtt, increased PO 45->60 Q6; carotid US
done; EKG shows persistent prolonged QTc (489); SQH BID started
per NSGY
___- added metoprolol 12.5mg po BID to wean dilt gtt. Plan for
anticoagulation tomorrow agreed upon by ACS and NSGY: baseline
CT head in AM -> heparin gtt (target PTT 60-80) -> repeat CT
head when therapeutic; start Coumadin.
___- Started on heparin. Pre and post heparin CT head stable.
Heparin at goal PTT.
___- Transfer to SICU for sustained afib w RVR. On arrival,
tried metop 5 IV x2 with spontaneous break into sinus,
nonsustained. Dilt 15 mg IV x1 given with rate control. Continue
PO regimen, converted to metop TID, continued dilt PO 60 q6h,
___ consult for IPMN, 2 brief runs of afib w rvr to 140s
spontaneously resolved
___- intermittent a fib RVR, self-limited, BP always stable;
in AM, PO dilt increased to 90 QID. Cardiology consulted.
Recommended amiodarone load (200 TID x 2 weeks) and diltiazem
decreased to 60 QID. Metoprolol left at 25 TID.
___: O/n, HR variability worse since decreasing PO dilt and
stopping IV dilt. Amio increased to 400 BID, dilt ___ q6h per
cards, recs (should get dilt x2 doses ___ then d/c in ___. Home
HCTZ held for low BPs in the setting of other anti-HTN meds.
Given warfarin 2.5mg. Diltiazem 30 held once in ___ for
hypotension.
___: 5mg warfarin
FLOOR COURSE: The patient was transferred to the floor and did
well. She was bridged from a heparin drip to warfarin, and her
heparin drip was discontinued on ___ once her INR became
therapeutic>2. She was also continued on metoprolol and
amiodarone for her atrial fibrillation and remained rate
controlled throughout the remainder of her stay.
Of note, the pancreas surgery service was consulted for an
incidentally found cystic lesion of her pancreas, likely an
IPMN. She will follow up with Dr. ___ in pancreatic surgery
clinic in the next few weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ drainage of abscess
History of Present Illness:
Mr. ___ is a ___ gentleman with Crohn's disease
(complicated by fistulas & abscess in the past) s/p colectomy,
as well as DVT on Warfarin for the past 2 months who presented
to the ED due to 2 weeks of abdominal pain, fever today and
outpt MRI today demonstrating intra-abdominal abscess.
.
At his baseline he is very functional, maintaining a demanding
job, with plans to travel to ___ next week for business. But
for the last 2 weeks he has felt stabbing pain to the right of
his belly button. At first he thought it was muscle strain from
weightlifting. The pain started out mild but is now severe,
___. He has felt a hard lump in the area as well. On the day
of presentation, he went to an outpatient GI appointment, where
he was refferred for U/S. It was felt that this might represent
a spigelian hernia or hematoma in the setting of Warfarin use,
but he was also referred for MRI to r/o abscess. The MRI showed
51mm x 60mm x 68mm RLQ abdominal abscess and possible fistulous
tract, so he was referred to the ED.
.
In the ED, initial VS were: pain ___, T 101.1, HR 76, BP
146/73, RR 16, POx 100%RA. Labs were notable for WBC 15.7, ESR
44, CRP 33.1, and INR 4.0. GI consult suggested PPI, Zosyn, and
continuing ___ at his current dose. It was felt that the
abscess may be amenable to ___ drainage. He received Zosyn
4.5g IV. Also received Tylenol ___ PO and Dilaudid 2mg IV for
pain. Was given Vitamin K 10mg IV, Protonix 40g IV, and 1L
normal saline. Dr. ___ GI) was called from the
ED and requested Medicine admission.
On the floor, he feels fine because he just received pain
medication. The pain becomes very severe between doses of pain
meds.
REVIEW OF SYSTEMS:
(+)
-easy bleeding since starting Warfarin
-bloody ostomy output since starting Warfarin
-abdominal hernia seems the same as usual
(-)
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
nausea, vomiting, diarrhea, constipation, tarry output from
ostomy, dysuria, hematuria.
Past Medical History:
Crohns Disease
-history of remote pneumocolonic fistula and pelvic abscesses
Nephrolithiasis s/p L ureteropscopy, laser litho on ___
Urethral strictures.
Rosacea.
Anxiety and depression.
Lactose intolerant.
___ Ex-lap/LOA, take down of enterocutaneous fistula w
ileocolonic anastomosis
___ I&D of intraabdominal abscess; Abdominal wound exploration;
excision of abdominal wall abscess secondary to infected suture;
SBR for enterocutaneous fistula
___ Exploratory laparotomy with takedown of fistula
___ Exploratory laparotomy, lysis of adhesion, jejunal
stricturoplasty
___ Total proctectomy with end transverse colostomy
Social History:
___
Family History:
Patient is adopted.
Physical Exam:
ADMISSION EXAM
VS - Temp 98.7F, BP 128/81, HR 85, R 18, O2-sat 97% RA
GENERAL - Alert, interactive, well-appearing gentleman in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP non-elevated, no carotid
bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - nondistended; ventral hernia present (easily
reducible); right abdomen with palpable grapefruit-sized mass;
tender to palpation left abdomen but no rebound or guarding; no
hepatomegaly
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, steady gait
.
DISCHARGE EXAM
VS - T 98.1 BP 97/64 (97/64-123/76), HR 61, R 18, O2-sat 99% RA
drain 5 mL over 24 hours
GENERAL - Alert, interactive, well-appearing gentleman in NAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - nondistended; mild TTP at the the drain site
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 10:19AM BLOOD WBC-15.7*# RBC-5.42 Hgb-14.3 Hct-45.5
MCV-84 MCH-26.3* MCHC-31.4 RDW-14.4 Plt ___
___ 10:19AM BLOOD Neuts-86.5* Lymphs-7.7* Monos-4.3 Eos-1.2
Baso-0.2
___ 10:19AM BLOOD ESR-44*
___ 10:19AM BLOOD UreaN-16 Creat-1.1 Na-141 K-3.5 Cl-102
HCO3-31 AnGap-12
___ 10:19AM BLOOD ALT-36 AST-23 CK(CPK)-85 AlkPhos-58
Amylase-134* TotBili-0.4 DirBili-0.1 IndBili-0.3
___ 10:19AM BLOOD Albumin-3.5 Calcium-8.4 Iron-24*
___ 08:00PM BLOOD CRP-33.1*
___ 10:19AM BLOOD calTIBC-415 VitB12-GREATER TH
Folate-GREATER TH Ferritn-104 TRF-319
___ 08:18PM BLOOD Lactate-1.7
.
DISCHARGE LABS
___ 06:25AM BLOOD WBC-6.0 RBC-5.12 Hgb-13.1* Hct-43.4
MCV-85 MCH-25.5* MCHC-30.1* RDW-14.5 Plt ___
___ 06:25AM BLOOD ___ PTT-31.0 ___
___ 06:25AM BLOOD Glucose-80 UreaN-8 Creat-1.2 Na-139 K-4.3
Cl-99 HCO3-32 AnGap-12
___ 06:25AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
.
URINE STUDIES
___ 10:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:30AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 10:30AM URINE RBC-66* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:30AM URINE CaOxalX-OCC
___ 10:30AM URINE Mucous-RARE
.
MICROBIOLOGY
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. SPARSE GROWTH ___ STRAIN.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
.
STUDIES
US ___
IMPRESSION: Bilobed-shaped intra/ extra abdominal cystic lesion
at the level of the lateral border of the right rectus abdominis
muscle. This could represent a resolving hematoma/ abscess or a
spigelian hernia containing fluid. Given the acuity of onset and
skin discoloration reported by the patient, a hematoma is
favored. However, the intra-abdominal communication is less
typical of a hematoma and abscess or hernia is not excluded.
Correlate with MRE performed the same day.
.
MRE ___
1. Walled off abscess is identified in the right lower quadrant.
The abscess extends into the right abdominal wall.
2. Thickened ileal loops with mucosal hyperenhancement on
arterial phase are seen in proximity to the abscess, consistent
with active Crohn's disease.
3. Cholelithiasis without signs of cholecystitis.
.
___
CT Abdomen Pelvis
1. The previously described abscess in the right lower quadrant
has
significantly resolved when compared to prior imaging and now
measures 1.4 x 2.5 x 3.2 cm with a catheter noted in good
position. No fistulous
communication is demonstrated between this collection and the
adjacent small or large bowel. There is no evidence for
recurrent Crohn's disease in the small bowel.
2. Cholelithiasis.
Medications on Admission:
mercaptopurine 50 mg daily
warfarin 2.5mg ___ (since 2 months ago; plans for 6 month
treatment)
Fish Oil 300 mg-500 mg daily
cyanocobalamin 1,000 mcg/mL injection once or twice monthly
Multi-Vitamin HP/Minerals daily
Folic Acid 1 mg daily
fluticasone 50 mcg/actuation Nasal Spray daily
Discharge Medications:
1. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fish Oil 300-500 mg Capsule Sig: One (1) Capsule PO once a
day.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
4. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*28 syringe * Refills:*0*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 14 days: do not drink while taking this
medication.
Disp:*42 Tablet(s)* Refills:*0*
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14
days.
Disp:*28 Tablet(s)* Refills:*0*
10. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain: do not drive while taking this
medication as it can make you tired .
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Abscess
Crohns Disease
Microscopic hematuria
Secondary Diagnosis
Nephrolithiasis
Urethral strictures.
Rosacea.
Anxiety
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ patient with history of
Crohn's disease that involves the large and small bowel. The patient is
status post multiple resections of the terminal ileum and resection of the
rectum. The patient has left colostomy.
The patient is now presenting with right-sided pain. The request is to rule
out fistula.
COMPARISON: Ultrasound examination from ___. CT of the abdomen
from ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5
Tesla magnet including dynamic 3D imaging obtained prior to, during, and after
the intravenous administration of 8 cc of Gadovist.
900 cc of barium sulfate was given orally.
In addition, 1 mg of IM glucagon was administered to reduce bowel motion.
FINDINGS: A fluid filled multiloculated collection is seen in the right lower
quadrant. The collection measures 51 x 60 (12, 28) x 68 mm (1001, 68). The
collection extends into the right abdominal wall (12, 16) and shows persistent
rim enhancement. The collection is surrounded by multiple thickened ileal
loops that shows mucosal hyperenhancement (12, 59 and 12, 57 and 1001, 66).
No discrete fistula is seen between the bowel loops and the collection;
however, in some regions there is no fat plane between the bowel loops and the
collection (1001, 16). Mild-to-moderate fat stranding is seen in proximity to
the collection (1002, 61).
The patient is status post multiple resections of the terminal ileum and
resection of the rectum. Susceptibility artifacts are seen along the proximal
colon. Left-sided colostomy is seen.
The rest of the small and large bowel shows no mucosal hyperenhancement or
thickening of the wall that suggest inflammation.
Bilobed structure is seen in segment VI of the liver. The lesion shows high
signal intensity on T2-weighted images and shows no enhancement. The lesion
measures 9 x 50 mm (11, 23) and is most consistent with simple liver cyst.
Otherwise, the liver is normal. There is no intra- or extra-hepatic biliary
duct dilatation.
Cholelithiasis is seen without signs of cholecystitis. The spleen is within
normal limits.
Note is made of a small splenule.
The pancreas shows normal signal and is within normal limits.
The adrenals are unremarkable.
Multiple lesions are seen within the kidneys.
The lesions show high signal intensity on T2-weighted images and no
enhancement post-contrast, consistent with simple cysts.
No free fluid or lymphadenopathy are detected.
The aorta and its branches are patent and of normal caliber.
The portal vein and its branches and the splenic vein are patent and of normal
caliber.
Normal bone marrow signal is seen.
IMPRESSION:
1. Walled off abscess is identified in the right lower quadrant. The abscess
extends into the right abdominal wall.
2. Thickened ileal loops with mucosal hyperenhancement on arterial phase are
seen in proximity to the abscess, consistent with active Crohn's disease.
3. Cholelithiasis without signs of cholecystitis.
These findings were discussed by Dr. ___ Dr. ___ by
phone at 4 p.m. ___.
Radiology Report
STUDY: FOCUSED RIGHT LOWER QUADRANT ABDOMINAL SONOGRAM.
INDICATION: Patient with questionable hematoma due to Coumadin in the
abdominal wall.
COMPARISON: No recent studies are available for comparison.
TECHNIQUE: Focus sonographic evaluation of the lower quadrant of the abdomen
was performed and reviewed.
FINDINGS: In the region of the patient's palpable abnormality and tenderness,
there is a 6.8 x 5.9 x 5.1 cm hypoechoic lesion with posterior acoustic
enhancement which appears to extend into the subcutaneous muscle plane as well
as into the abdominal cavity. There is a dehisence in the anterior abdominal
wall seen lateral to the lateral margin of the right rectus abdominis muscle.
There are few foci of increased echogenicity within this lesion. There is no
definite communication with bowel identified nor was there peristalsis with
this lesion.
IMPRESSION: Bilobed-shaped intra/ extra abdominal cystic lesion at the level
of the lateral border of the right rectus abdominis muscle. This could
represent a resolving hematoma/ abscess or a spigelian hernia containing
fluid. Given the acuity of onset and skin discoloration reported by the
patient, a hematoma is favored. However, the intra-abdominal communication is
less typical of a hematoma and abscess or hernia is not excluded. Correlate
with MRE performed the same day.
Findings were discussed with Dr ___ by Radiology ___ over telephone on
___ at 4: 15 p.m
Radiology Report
STUDY: CT-guided percutaneous drainage of right lower quadrant abdominal
fluid collection.
INDICATION: ___ male with history of Crohn's disease complicated by
multiple previous fistulas and abscesses, status post colectomy, two weeks of
abdominal pain and fever, recent MRI demonstrating intra-abdominal abscess.
Request percutaneous drainage.
COMPARISON: Previous MR enterography dated ___ and ultrasound
abdomen dated ___.
OPERATORS: Dr. ___ Dr. ___. Dr. ___ was present for the
entire duration of the procedure and personally supervised it.
PROCEDURE: After explaining the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The
patient was brought to the CT suite and was placed supine on the CT table. A
preprocedure timeout was performed using three unique patient identifiers as
per standard ___ protocol.
Limited preprocedure CT images were obtained through the lower abdomen, which
demonstrated irregular 7.2 x 3.7 cm fluid collection in the right lower
abdomen. An appropriate skin entry site overlying this fluid collection was
marked and the skin was prepped and draped in the usual sterile fashion. 1%
lidocaine solution was used to anesthetize the skin, subcutaneous soft tissues
and the anterior abdominal wall musculature.
Under CT fluoroscopic guidance, ___ needle was advanced into the fluid
collection via an anterior approach. There was immediate return of purulent
fluid. A floppy-tipped ___ wire was advanced through the ___ needle
into the abscess cavity. The ___ needle was then exchanged for an 8
___ pigtail drainage catheter. After confirming appropriate positioning,
the loop of the pigtail drainage catheter was formed within the abscess
cavity. We immediately drained about 75 mL of purulent fluid. Following
this, about 35 mL of diluted intravenous contrast was injected through the
pigtail drainage catheter into the abscess cavity. There was no communication
with the surrounding loops of small bowel. The injected contrast was aspirated
back. The drainage catheter was secured to the anterior abdominal wall and
was attached to a large suction bulb.
The patient tolerated the procedure well without any immediate ___
complications.
Moderate sedation was provided by administering divided doses of Versed (1.5
mg) and Fentanyl (150 mcg) throughout the total intraservice time of 30
minutes during which the patient's hemodynamic parameters were continuously
monitored.
IMPRESSION: Successful CT-guided percutaneous drainage catheter placement
into right lower quadrant intra-abdominal abscess. Sample of the aspirate
sent for microbiological analysis. Sinogram shows no communication with bowel.
Radiology Report
CT ABDOMEN AND PELVIS
INDICATION: Status post ___ drainage of abdominal abscess. History of Crohn's
disease.
COMPARISON: MR enterography ___, CT abdomen ___ and
CT interventional procedure ___.
TECHNIQUE: MDCT axial acquired images from the lung bases to pubic symphysis
displayed with 5mm slice thickness withwith oral and IV contrast. Multiplanar
2D and 3D reformations have been provided.
FINDINGS: Atelectatic changes noted in the right lower lobe without pleural
or pericardial effusion. Normal hepatic contour with a simple hepatic cyst
identified within segment VII of the liver measuring 13 mm (series 2a, image
20). The hepatic and portal venous vasculature is patent. There is no intra-
or extra-hepatic biliary dilatation and a single gallstone is evident within
the gallbladder (series 2a, image 27).
Spleen is normal in size with an incidental splenule noted in the left upper
quadrant (series 2a, image 23). Pancreas enhances homogeneously. Both
adrenal glands are unremarkable. Both kidneys are normal apart from simple
renal cysts identified bilaterally. There are no retroperitoneal masses or
adenopathy.
No abnormally dilated or thickened small or large bowel loop in the visualized
upper abdomen. There is no evidence for active Crohn's disease. A neoterminal
ileum is noted in the right lower quadrant. Adjacent to this is a pigtail
catheter inside a collection which now measures 1.4 x 2.5 x 3.2 cm (previously
5.1 x 6.5 x 7.9 cm) (series 2a, image 63) which is entirely decompressed when
compared to prior MR enterography from ___ and the catheter is in
good position. There is no fistulous communication demonstrated between this
collection and the small or large bowel in the vicinity which are completely
opacified with oral contrast. No oral contrast is identified within the
collection.
CT PELVIS: No pelvic adenopathy or free fluid. Visualized portions of the
bladder and prostate gland were unremarkable. There has been a previous
proctectomy. There is no free fluid.
CT OSSEOUS SKELETON: No osseous destructive lesion.
IMPRESSION:
1. The previously described abscess in the right lower quadrant has
significantly resolved when compared to prior imaging and now measures 1.4 x
2.5 x 3.2 cm with a catheter noted in good position. No fistulous
communication is demonstrated between this collection and the adjacent small
or large bowel. There is no evidence for recurrent Crohn's disease in the
small bowel.
2. Cholelithiasis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD ABSCESS
Diagnosed with PERITONEAL ABSCESS
temperature: 101.1
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 146.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | PRIMARY REASON FOR ADMISSION
Mr. ___ is a ___ gentleman with Crohn's disease
(complicated by fistulas & abscess in the past) s/p colectomy,
as well as 2 month h/o DVT (currently supratherapeutic on
Warfarin) who presents with abdominal pain, fevers, and elevated
inflammatory markers in the setting of intra-abdominal abscess.
.
#. Abdominal pain, R side: The patient was noted to have an
abscess in the RLQ extending to the abdominal wall. There was no
evidence of fistula or active crohn's disease on MRE. The
patient was started on broad spectrum antibiotics with zosyn. A
drain was placed by ___ and drained serosanguinous fluid. Culture
of the fluid grew 2 species of pan sensitive E. Coli. The
patients antibiotics were narrowed to oral cipro/flagyl. The
patient was also continued on his home ___. Pain improved and
the patient was slowly advanced to a low residue diet. At the
time of discharge the patient had been afebrile x 48 hrs and WBC
had normalized. Repeat CT demonstrated the abscess had greatly
reduced in size and had decompressed. Drain output decreased to
the point that GI and ___ were comfortable removing the drain,
and the drain was removed. The patient was discharged home. He
will follow-up with Dr. ___ at which time his antibiotic
course will be determined. He will eventually need a repeat CT
Scan to document resolution of the abscess.
.
#. LLE DVT: The patient was diagnosed with a DVT 2 months prior
to admission. He has been anti-coagulated with warfarin. INR on
admission was supratherapeutic at 4.0. He was given 10 mg of IV
vitamin K prior to placement of drain. Following the procedure
he was started on a heparin gtt and transitioned to lovenox. In
discussion with his PCP the decision was made not to restart his
warfarin, but continue on Lovenox alone. The patient will
follow-up with his PCP regarding his ___.
.
# CKD: Cr at baseline throughout admission. He was pre-hydrated
prior to CT.
.
TRANSITIONAL ISSUES
- full code
- final fluid cultures and blood cultures were pending at the
time of discharge
- Patient will follow-up with his gastroenterologist Dr ___
in addition to his PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
colonoscopy (___)
History of Present Illness:
___ history of atrial fibrillation on Eliquis and hypertension
who presents as transfer from ___ with melena.
Patient underwent colonoscopy on ___ which was notable
for
polypectomy x3, 1 site requiring clipping due to oozing. He was
then discharged home restarted his Eliquis ___. His bowel
movement on ___ was brown but required some straining.
His bowel movement on ___ noted was brown-black in color.
Since then, he has continued to have dark stools, becoming more
black and tarry in nature. He also noted one BM that was very
dark with a streak of red in the toilet. Other than the change
in
color of his stools, he was completely asymptomatic at home. He
denies any dizziness, lightheadedness, palpitations, chest pain,
shortness of breath, abdominal pain, n/v, or hematemesis. Given
the ongoing nature of his dark stools, he called the o/c GI
physician at ___ who recommended he present to the ED. He went
to ___ and was transferred to ___ for further
evaluation. Of note, initial lab work at ___ was notable for
Hgb
of 14.
Of note, the patient reports 30lbs unintentional weight loss
over
the past year.
In the ED:
The patient arrived late on ___. His initial hemoglobin was
13.1. KUB was unremarkable. GI was consulted, and the patient
was started on IV PPI and bowel prep was initiated for scope on
___. Repeat colonoscopy was notable for cecal site with
adherent clot, which was thought to be the source of bleeding.
The patient received 3 endoclips to the site and was admitted
for
further monitoring.
Initial vital signs were notable for:
Temperature 96.5 heart rate 80 blood pressure 112/70 respiratory
rate 16 satting 96% on room air
Exam notable for:
Gen: well developed male, NAD, talkative
HEENT: NC/AT
CV: Irregular rhythm, normal rate. No appreciable murmurs.
Pulm: CTAB. Nonlabored respirations.
Abd: soft, nondistended, nontender to palpation.
Rectal: no frank blood. guaiac positive.
Ext: no lower extremity edema
Labs were notable for:
Hemoglobin 13.1 INR 1.4
Studies performed include:
-Chest x-ray did not reveal free air
-Colonoscopy with cecal site with adherent clot, received clip
x3
Patient was given:
Moviprep
Colchicine
metoprolol succinate 25mg
lorazepam 0.25 mg PO
Zofran 4mg IV
febuxostat 80mg PO
Consults:
GI
Upon arrival to the floor, the patient is hungry but feels well.
His last bloody BM was while taking prep, which he notes at that
time was a very deep blackish red. He has not had any BMs since
the colonoscopy. He denies any fevers, chills, abdominal pain,
lightheadedness, dizziness, palpitations.
REVIEW OF SYSTEMS:
Notable for 30 lbs unintentional weight loss over past year.
Other per HPI. Otherwise negative.
Past Medical History:
-COLON POLYP
-HYPERTENSION
-DIVERTICULOSIS
-ATRIAL FIBRILLATION
-ADHD
-CHOLECYSTECTOMY
-HERNIA REPAIR
Social History:
___
Family History:
No family history of colon cancer or GI malignancy that he is
aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Irregular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill wnl. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 2322)
Temp: 98.4 (Tm 98.4), BP: 102/69 (102-120/67-85), HR: 67
(67-72), RR: 18, O2 sat: 98% (97-100), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRLA, MMM.
CARDIAC: irregularly irregular. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill wnl. No rash.
NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 11:45PM BLOOD WBC-4.8 RBC-3.86* Hgb-13.1* Hct-39.7*
MCV-103* MCH-33.9* MCHC-33.0 RDW-14.3 RDWSD-54.4* Plt ___
___ 11:45PM BLOOD Neuts-61.8 Lymphs-17.1* Monos-9.8
Eos-9.8* Baso-1.3* Im ___ AbsNeut-2.97 AbsLymp-0.82*
AbsMono-0.47 AbsEos-0.47 AbsBaso-0.06
___ 11:45PM BLOOD ___ PTT-29.6 ___
___ 11:45PM BLOOD Glucose-94 UreaN-29* Creat-1.2 Na-142
K-4.8 Cl-100 HCO3-29 AnGap-13
___ 06:50AM BLOOD Calcium-10.4* Phos-3.7 Mg-2.5
EGD REPORT (___)
====================
Impressions:
-Cecal EMR site was identified which had a large adherent clot
suggestive of recent bleeding. No active bleeding was seen.
(Injection, Endoclip).
-Ascending colon polypectomy site was visualized with no signs
of active bleeding. There was a visible post polypectomy ulcer.
(Endoclip).
-Moderate diverticulosis of the descending colon and sigmoid
colon.
-No other sources of bleeding identified.
Recommendations:
-Cecal EMR site is the most likely source of bleeding. No active
bleeding, s/p successful application of 3 hemoclips.
-Recommend repeat colonoscopy in 6 months to assess EMR site and
polypectomy of previously seen small left sided polyps.
-Recommend observation inpatient overnight. If no signs of any
more bleeding, may discharge home.
-Continue to hold anticoagulation for 48 hours after which it
may be resumed.
IMAGING:
========
CXR (___)
The lungs are well inflated and clear. No focal consolidations.
No pulmonary edema. 7 mm nodule projecting over the left lower
lung, which should be followed up with a chest CT on a
nonemergent basis. Unchanged enlargement of cardiac silhouette.
No pleural effusion. No pneumothorax. No pneumoperitoneum.
IMPRESSION:
1. No pneumoperitoneum.
2. Cardiomegaly.
3. 7 mm nodule projecting over the left lower lung, which should
be followed
up with a chest CT on a nonemergent basis.
DISCHARGE LABS:
===============
___ 05:35AM BLOOD WBC-4.3 RBC-3.43* Hgb-11.4* Hct-35.5*
MCV-104* MCH-33.2* MCHC-32.1 RDW-14.0 RDWSD-53.8* Plt ___
___ 05:10AM BLOOD ___ PTT-26.3 ___
___ 05:35AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-8*
___ 05:10AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Colchicine 0.6 mg PO DAILY
4. Famotidine 20 mg PO BID:PRN heartburn
5. Furosemide 40 mg PO QAM
6. Furosemide 20 mg PO QPM
7. LORazepam 0.25 mg PO BID:PRN anxiety
8. Losartan Potassium 100 mg PO QHS
9. MethylPHENIDATE (Ritalin) 10 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Colchicine 0.6 mg PO DAILY
4. Famotidine 20 mg PO BID:PRN heartburn
5. Furosemide 20 mg PO QPM
6. Furosemide 40 mg PO QAM
7. LORazepam 0.25 mg PO BID:PRN anxiety
8. Losartan Potassium 100 mg PO QHS
9. MethylPHENIDATE (Ritalin) 10 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until the morning of ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
post-polypectomy lower gastrointestinal bleed
SECONDARY DIAGNOSES:
====================
atrial fibrillation
hypertension
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 ongoing melena after recent colonoscopy with
biopsies. Needs eval to exclude perforation.// eval of free air under
diaphragm
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are well inflated and clear. No focal consolidations. No pulmonary
edema. 7 mm nodule projecting over the left lower lung, which should be
followed up with a chest CT on a nonemergent basis. Unchanged enlargement of
cardiac silhouette. No pleural effusion. No pneumothorax. No
pneumoperitoneum.
IMPRESSION:
1. No pneumoperitoneum.
2. Cardiomegaly.
3. 7 mm nodule projecting over the left lower lung, which should be followed
up with a chest CT on a nonemergent basis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Melena, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 96.5
heartrate: 80.0
resprate: 16.0
o2sat: 96.0
sbp: 112.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT:
==================
___ history of atrial fibrillation on Eliquis and hypertension
s/p recent polypectomy on ___ who presents as transfer from
___ with melena, now s/p colonoscopy on ___ with 3
clips to cecal EMR site and ascending colon polypectomy site. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p bicycle accident
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation, right olecranon
using tension band.Irrigation and debridement including skin,
subcutaneoustissue, muscle and bone, excisional debridement of
hematoma, right elbow.
___: Open reduction, internal fixation of right anterior
column acetabular fracture with intercolumnar screws and
supra-acetabular screws with minimal invasive exposure
History of Present Illness:
___ year female with no PMH presenting to the ED s/p bike
accident. Per family, she was riding her bike and hit a stick in
the road and fell off her bike, + LOC, no helmet. Per the
family, when they went back to see her she was unresponsive at
the scene, whole body tremors and "foaming" at the mouth, this
episode lasted for approximately 30 seconds, - incontinence.
After episode, was confused and within ___ minutes was
oriented but drowsy. + nausea, + headache. She complains of
right hip and right elbow pain in the trauma bay.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
VS - 98.2 79 104/53 19 100% RA
General: alert, in mild discomfort
HEENT: R forehead abrasion and hematoma, PERRL, EOMI, Oropharynx
WNL
Neck: supple. C-collar.
CV: RRR, no murmur
Lungs: CTAB, normal work of breathing
Abdomen: soft, NT, ND
GU: +foley
Ext: splint to RUE, ttp over R hip
Neuro: alert and oriented to self, year, place. CN ___ intact.
Moving all extremities.
Skin: no rash
Discharge Physical Exam:
VS: 97.9 F, 62, 107/60, 18, 98% RA
N: A&Ox3. PERRL. follows commands. Moves all extremities. Right
arm full ROM strength not assessed r/t non weight bearing.
CV: RRR, no murmur
Lungs: CTAB
Abdomen: soft, non-tender, non-distended
Ext: warm and dry. no edema
Skin: grossly intact. abrasion to right side of face. sutures to
right elbow. two sites with single suture to right anterior
pelvis.
Pertinent Results:
___ 05:25AM BLOOD WBC-5.1 RBC-3.29* Hgb-9.7* Hct-29.1*
MCV-88 MCH-29.5 MCHC-33.3 RDW-11.9 RDWSD-38.6 Plt ___
___ 04:55AM BLOOD WBC-5.0 RBC-3.21* Hgb-9.5* Hct-28.8*
MCV-90 MCH-29.6 MCHC-33.0 RDW-12.1 RDWSD-39.7 Plt ___
___ 04:30AM BLOOD WBC-5.9 RBC-3.05* Hgb-8.9* Hct-27.4*
MCV-90 MCH-29.2 MCHC-32.5 RDW-12.2 RDWSD-39.6 Plt ___
___ 08:42PM BLOOD WBC-8.0# RBC-3.10* Hgb-9.2* Hct-27.9*
MCV-90 MCH-29.7 MCHC-33.0 RDW-12.3 RDWSD-40.1 Plt Ct-88*
___ 04:53PM BLOOD WBC-5.1# RBC-3.10* Hgb-9.1* Hct-28.1*
MCV-91 MCH-29.4 MCHC-32.4 RDW-12.3 RDWSD-40.4 Plt Ct-81*
___ 11:38PM BLOOD WBC-13.2* RBC-3.58* Hgb-10.5* Hct-31.8*
MCV-89 MCH-29.3 MCHC-33.0 RDW-12.1 RDWSD-39.7 Plt ___
___ 03:45PM BLOOD WBC-10.7* RBC-4.19 Hgb-12.5 Hct-37.2
MCV-89 MCH-29.8 MCHC-33.6 RDW-12.1 RDWSD-38.8 Plt ___
___ 08:42PM BLOOD Glucose-109* UreaN-8 Creat-0.6 Na-138
K-3.4 Cl-103 HCO3-26 AnGap-12
___ 04:53PM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-137 K-3.8
Cl-103 HCO3-22 AnGap-16
___ 06:37AM BLOOD Glucose-108* UreaN-9 Creat-0.5 Na-135
K-3.7 Cl-103 HCO3-23 AnGap-13
___ 11:38PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-137
K-3.7 Cl-103 HCO3-23 AnGap-15
___ 12:43AM BLOOD Lactate-1.0
___ 03:58PM BLOOD Glucose-125* Lactate-3.8* Na-138 K-3.3
Cl-100
Radiology:
___ pelvis: Several fluoroscopic images from the operating
room demonstrate placement of 2 screws in the right hemipelvis.
Single screw is seen within the right iliac bone and a second
screw is seen through the superior pubic rami along the
iliopectineal line. This is fixating a minimally displaced
acetabular fracture. No hardware related complications are seen.
___ right knee: Small effusion. No acute fracture is seen
___ R Shoulder XRAY: No fracture or dislocation in the right
upper humerus, imaged right scapula and distal clavicle and
adjacent ribs
___ R Forearm Xray: Acute open displaced fracture of the right
olecranon
___ CT C Spine: No cervical spine fracture or malalignment
___ CT Torso: No acute soft tissue or organ injury within the
torso. 2. Small amount of free fluid in the pelvis, nonspecific
and can be physiologic but correlation with physical exam is
suggested. 3. Minimally displaced fracture of the right
acetabulum involving the anterior and medial walls with fracture
line extending to the right iliac wing. 4. Minimally displaced
fracture of the parasymphyseal right pubic bone at the pubic
symphysis. 5. 4.9 cm well-circumscribed fat containing lesion at
the left adnexa, compatible with a dermoid.
___ Pelvis XRAY: Full extent of the nondisplaced fracture
involving the right acetabulum, superior pubic or a mass, and
extend into the right iliac wing are shown to better advantage
by
the torso CT and oblique views of the pelvis obtained
today.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Milk of Magnesia 30 mL PO Q6H:PRN constipation
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*60 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC at bedtime Disp #*14
Syringe Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Anterior column acetabular fracture, right side
Right open olecranon fracture
Left subarachnoid 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
INDICATION: Trauma.
TECHNIQUE: Single supine view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no focal consolidation. No evidence of
pneumothorax on this supine film. The cardiomediastinal silhouette is within
normal limits. No visualized fractures.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with +head strike +LOC off bike // acute IC
process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is artifact from motion and beam hardening centered at the skullbase.
Noting this, there is hyperdensity in the region of the left sylvian fissure.
It is uncertain if this is artifactual or due to subarachnoid hemorrhage
(2:11, 12).
There is no mass, midline shift, or acute major vascular territorial infarct.
No other evidence of hemorrhage. Gray-white matter differentiation is
preserved. Ventricles and sulci and unremarkable. Basilar cisterns are
patent.
Included paranasal sinuses and mastoids are essentially clear besides partial
opacification of the right posterior ethmoids. There is right forehead scalp
swelling without underlying fracture. Skull and extracranial soft tissues are
otherwise unremarkable.
IMPRESSION:
Hyperdensity in the region of the left sylvian fissure, potentially
artifactual although subarachnoid hemorrhage cannot be excluded. Repeat exam
is suggested. No other evidence of acute intracranial hemorrhage.
Right frontal scalp swelling without underlying fracture.
NOTIFICATION: Findings discussed by Dr. ___ with Dr. ___ at 24:30 on
___ in person at time of discovery.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old woman with +head strike +LOC off bike // acute
fx/malalign
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 732 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.There is no significant
canal or foraminal narrowing.There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
INDICATION: ___ year old woman with fall off bike, evaluate for acute process,
difficulty moving legs
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 433 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. There is no mediastinal hematoma. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the cul-de-sac.
REPRODUCTIVE ORGANS: The uterus is unremarkable. At the left adnexa, there is
a 4.9 x 4.9 cm well circumscribed predominantly fat containing lesion with
some internal soft tissue and calcifications.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
No atherosclerotic disease is noted.
BONES: There is a minimally displaced fracture of the right acetabulum
involving the anterior and medial walls extending to the right iliac wing.
There is also a minimally displaced fracture of the parasymphyseal right pubic
bone. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute soft tissue or organ injury within the torso.
2. Small amount of free fluid in the pelvis, nonspecific and can be
physiologic but correlation with physical exam is suggested.
3. Minimally displaced fracture of the right acetabulum involving the anterior
and medial walls with fracture line extending to the right iliac wing.
4. Minimally displaced fracture of the parasymphyseal right pubic bone at the
pubic symphysis.
5. 4.9 cm well-circumscribed fat containing lesion at the left adnexa,
compatible with a dermoid.
NOTIFICATION: Findings discussed with Dr. ___ the trauma team in
person, at 16:30 on ___, 2 minutes following discovery. Finding
of free fluid was subsequently discussed by Dr. ___ with Dr. ___ the
phone.
Radiology Report
INDICATION: b24F with right elbow pain and laceration after fall from bicycle
// eval for fracture/dislocation
TECHNIQUE: Three views of the right elbow.
COMPARISON: None.
FINDINGS:
There is an acute displaced fracture through the olecranon process. The
proximal fracture fragment is displaced approximately by 2.8 cm. There is no
definite other fracture noting suboptimal views due to patient's injury.
There is subcutaneous gas and apparent gas within the joint space as well.
IMPRESSION:
Acute open displaced fracture of the right olecranon.
Radiology Report
EXAMINATION: PELVIS (AP ONLY) PORT
INDICATION: ___ year old woman with s/p bicycle accident, acetabular fracture
on CT in the ED // eval acetabular fracture eval acetabular fracture
TECHNIQUE: Frontal view of the pelvis.
COMPARISON: Torso CT ___.
IMPRESSION:
Full extent of the nondisplaced fracture involving the right acetabulum,
superior pubic or a mass, and extend into the right iliac wing are shown to
better advantage by the torso CT and oblique views of the pelvis obtained
today.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman status post bike accident with possible
subarachnoid hemorrhage on imaging. Evaluate for interval change. Please
perform at 22:00 on ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal, sagittal thin-section bone algorithm images were obtained.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___ at 16:06.
FINDINGS:
Small amount of subarachnoid hemorrhage along the left temporal lobe is seen
(series 2: Image 13). Otherwise, no new intracranial hemorrhage, territorial
infarct, mass or edema is seen. The ventricles and sulci are normal in size
and configuration. There is no evidence of fracture. Moderate amount of
fluid is seen in the right maxillary sinus. The visualized portion of the
other paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable. Right parietal
subgaleal hematoma/swelling is minimally more prominent when compared to prior
exam. No skull fractures.
IMPRESSION:
Interval evolution of left temporal subarachnoid hemorrhage along the sylvian
fissure. No definitive new intracranial hemorrhage or infarction.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS IN O.R. RIGHT
INDICATION: I D ORIF RIGHT OLECRANON FRACTURE
TECHNIQUE: Screening provided in the operating room without a radiologist
present.
COMPARISON: ___
FINDINGS:
Total fluoroscopy time 49.5 seconds. Images demonstrate fixation of olecranon
fracture. With pins and cerclage wires. For details of procedure, please
consult the procedure report.
IMPRESSION:
Screening for procedure guidance.
Radiology Report
EXAMINATION: SHOULDER 1 VIEW RIGHT
INDICATION: ORIF RIGHT OLECRANON FX
TECHNIQUE: One AP One view of the right shoulder.
COMPARISON: Torso CT ___.
IMPRESSION:
No fracture or dislocation in the right upper humerus, imaged right scapula
and distal clavicle and adjacent ribs.
Radiology Report
EXAMINATION: PELVIS W/JUDET VIEWS (3V)
INDICATION: R/O FRACTURE
TECHNIQUE: 2 oblique views of the hips.
COMPARISON: 2 oblique views of the pelvis are obtained
IMPRESSION:
Right acetabular fracture extends into the right iliac wing posteriorly to the
upper margin of the RPO view. Both femurs are intact.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old woman s/p MVC accident with right knee pain // acute
fractures? acute fractures?
TECHNIQUE: Three views of the left knee
COMPARISON: None available.
FINDINGS:
Tricompartmental joint spaces are preserved. No acute fracture is seen. No
concerning bone lesion. No chondrocalcinosis. No erosion. There is a small
effusion.
IMPRESSION:
Small effusion. No acute fracture is seen.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with Right knee pain // ?fracture
?fracture
TECHNIQUE: Three views of the right knee.
COMPARISON: None available
FINDINGS:
No acute fracture is seen. No concerning bone lesion. Joint spaces are
preserved. There is a small effusion. Small soft tissue calcification medial
subcutaneous tissues. No embedded radiopaque foreign body is seen.
IMPRESSION:
Small effusion. No acute fracture is seen.
Radiology Report
INDICATION:
Acetabular fracture. ORIF.
COMPARISON: Radiographs from ___
IMPRESSION:
Several fluoroscopic images from the operating room demonstrate placement of 2
screws in the right hemipelvis. Single screw is seen within the right iliac
bone and a second screw is seen through the superior pubic rami along the
iliopectineal line. This is fixating a minimally displaced acetabular
fracture. No hardware related complications are seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK/HEAD INJURY
Diagnosed with Disp fx of olecran pro w/o intartic extn right ulna, init, Unsp fracture of right acetabulum, init for clos fx, Traum subrac hem w LOC of 30 minutes or less, init, Pedl cyc driver inj pick-up truck, pk-up/van in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 10
level of acuity: nan | Ms. ___ is a ___ yo F who was admitted to the Acute Care
Trauma Surgery service on ___ after a fall from her bike.
Her CT images showed a small SAH, a right acetabular fracture,
and right elbow/olecranon fracture with overlying open wound.
Neurosurgery was consulted for the SAH and recommended a repeat
head CT and Keppra for seizure prophylaxis. The repeat head CT
was stable, the patient was alert and oriented and
neurologically intact with no evidence of seizure activity.
Orthopedic surgery was consulted for the acetabular fracture and
right elbow/olecranon fractures and recommended surgical repair.
Given concern for the SAH the patient was admitted to the Trauma
Surgical ICU for close neurological monitoring. The patient was
hemodynamically stable. She was kept NPO with maintenance IV
fluids. On HD2 informed consent was obtained and the patient was
taken to the operating room with orthopedic surgery for an open
reduction, internal fixation of the right olecranon and an
irrigation and debridement of the right elbow. She tolerated
the procedure well. Please see operative report for details. She
was advanced on a regular diet. She remained hemodynamically
stable and neurologically intact and was transferred to the
floor for further management. She was kept NPO at midnight with
maintenance IV fluid. On HD3 informed consent was obtained and
she was taken to the operating room with orthopedic surgery for
an open reduction, internal fixation of the right anterior
column acetabular fracture. She tolerated the procedure well.
Please see operative report for details. Given her negative
C-spine and physical exam, her cervical collar removed. Her pain
was initially controlled with IV morphine and then transitioned
to PO oxycodone and IV dilaudid for breakthrough once tolerating
a regular diet. On HD4 she was tolerating a regular diet and
fioricet was started for headache with good pain control. Her
foley catheter was removed and she voided without difficulty.
She was evaluated by physical therapy for mobility assessment
and teaching and occupational therapy for a right arm splint. On
HD5 lovenox SQ daily was started per orthopedic surgery for DVT
prophylaxis.
She remained hemodynamically stable and continued to work with
physical therapy and occupational therapy, who recommended
discharge to home with services at a wheelchair level given her
weight bearing status. During this hospitalization, the patient
was adherent with respiratory toilet and incentive spirometry,
and actively participated in the plan of care. The patient
initially received subcutaneous heparin and then started on
lovenox subcutaneously on HD 5 after her orthopedic surgeries.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, independently mobilizing, voiding without assistance, and
pain was well controlled. The patient was discharged home with
___ and ___ services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled with orthopedic surgery. She was advised to follow up
with cognitive therapy as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
HA/fever/body aches
Major Surgical or Invasive Procedure:
TEE (___)
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 0200
_
________________________________________________________________
PCP: Dr. ___.
_
________________________________________________________________
HPI:
___ with h/o tobacco use, HTN, COPD, discoid lupus, presents
with fevers, lethargy thrombocytopenia. Patient received reclast
5 days ago and corticosteroid injections to LLF and RRF flexor
trigger finger on ___. Developed fevers to 100.7 5 days ago
after the reclast injection. She also had sx c/w Raynaud's as
well. Complains of severe headache, neck pain, back pain, and
myalgias for 5 days- worse with walking. Also reports cough with
white sputum. Decreased appetite at home but reports no weight
loss ? ___ lbs.Denies urinary sympotoms, chest pain, N/V.
Conjunctivae became injected with increased drainage in the past
week. No sick contacts.
HV CXR read: New patchy right perihilar density most consistent
with an acute inflammatory and/or infectious infiltrate but
follow-up is recommended.
In ER: (Triage Vitals:0 98.2 86 148/74 18 99% )
Meds Given:
Morphine Sulfate (Syringe) 4mg Syringe [class 2] ___ ___,
___
___ 18:20 &&Cefepime [___] ___ ___
___ 20:30 Vancomycin 1g Frozen Bag ___ ___
___ 20:32 Morphine Sulfate (Syringe) 4mg Syringe [class 2] 1
___
___ 20:47 Dexamethasone Sod Phosphate 10mg/mL Vial 4
___
___ 21:08 Acyclovir 500 mg in 5% Dextrose 1 from Pharmacy
Diagnosis:
PNA and ? mennigits
[x]CXR: done at ___
[x]speak with hematolgy ___: transfuse platelets, decadron
40mg IV QD x4 days
[X]CT abdomen- negative
[x]CT head: no ICH
While in the ED desated to 90% while sleeping and placed on 2L.
Pt being admitted for multiple issues.
1) thrombocytopenia: got transfused, decadron per hematology
recs. likely ITP
2) CXR suggest infection, also has syx concerning for
meningitis. Will treat for both. Cannot tap ___ platelets
Disposition/Pending: admit to medicine, hematology will see in
the am
Admission Vitals: sleeping 98.5 87 120/76 20 96% on ? 2L
.
Upon arrival to the floor the above history from the ED is
confirmed.
PAIN SCALE: ___ neck pain
________________________________________________________________
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
[] All Normal
[ ] Blurred vision [ -] Loss of vision [] Diplopia [ ]
Photophobia
+ erythematous injected conjunctivae
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [- ] Sore
throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[+? ] Shortness of breath- she denies but her sister has noticed
some increased sob [ ] Dyspnea on exertion [ ] Can't walk 2
flights [+ ] baseline Cough without clear change but it hurt
to cough[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis
[+]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ?] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ -]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[-] Nausea [-] Vomiting [+] Abd pain- b/l with palpation
when she arrived in the ED [] Abdominal swelling [ +] Diarrhea-
light brown, no blood, not black [ ] Constipation [ ]
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: [] All Normal
[ -] Rash [ ] Pruritus
MS: [] All Normal
[+ ] Joint pain - per HPI [ ] Jt swelling [ ] Back pain [ ]
Bony pain
NEURO: [] All Normal
[+ ] Headache [- ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities [-] dysarthria
[ ] 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:
ALLERGY:
[- ]Medication allergies [ ] Seasonal allergies
[]all other systems negative except as noted above
Past Medical History:
LUNG DISEASE, CHRONIC OBSTRUCTIVE
Hypertension
Thyroid nodule
BENIGN NEOPLASM - PANCREAS- s/p pancreatectomy and splenectomy
??DECLINED - COPD (NOT DX, FOR PROB LIST ONLY)
GOITER - NONTOXIC MULTINODULAR
TOBACCO DEPENDENCE
OSTEOPOROSIS
HEARING LOSS, SENSORINEURAL
DISCOID LUPUS
SCREENING FOR ___ CANCER
Lumbar Spinal Stenosis
Social History:
___
Family History:
She is ___ of 6 siblings and only she and her sister are left.
Brother ___ Cancer- ___ lung cancer
Father ___ and died of metastatic prostate cancer with
asbestos exposure.
Mother ___ and asbestos exposure secondary to husband- died
at age ___.
Sister died of ALS but also had breast and bladder cancer
Oldest sister with rheumatoid arthritis and lung cancer.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE ___. VS T 98.7 P 93 BP 154/84 RR O2Sat on __100% RA__
Gen: Thin female laying bed, NAD. Sister at bedside.
Nourishment: Thin, she appears frail, pale and ? chronic vs
acute illness
Grooming: OK
Mentation: alert, speaks in full sentences, looks exhausted.
2. Eyes: [] WNL
Injected erythematous conjunctivae b/l
3. ENT [] WNL
[+] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [+] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
Decreased BS throughout out. Occasional soft wheezes.
She does look as though her breathing is a little labored.
6. Gastrointestinal [ X] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [x] WNL
[ ] Tone WNL [X ]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [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
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant
Pertinent Results:
___ 09:05PM PLT COUNT-48*#
___ 06:12PM COMMENTS-GREEN
___ 06:12PM LACTATE-0.9
___ 04:37PM GLUCOSE-144* UREA N-48* CREAT-1.0 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-23 ANION GAP-13
___ 04:37PM estGFR-Using this
___ 04:37PM ALT(SGPT)-33 AST(SGOT)-39 ALK PHOS-149* TOT
BILI-0.7
___ 04:37PM LIPASE-50
___ 04:37PM ALBUMIN-3.6
___ 04:37PM URINE HOURS-RANDOM
___ 04:37PM URINE GR HOLD-HOLD
___ 04:37PM WBC-9.0 RBC-4.47 HGB-15.6 HCT-45.0 MCV-101*
MCH-34.9* MCHC-34.7 RDW-13.7
___ 04:37PM NEUTS-85* BANDS-2 LYMPHS-7* MONOS-4 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 04:37PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL
BURR-OCCASIONAL HOW-JOL-OCCASIONAL
___ 04:37PM PLT SMR-RARE PLT COUNT-6*
___ 04:37PM ___ PTT-31.1 ___
___ 04:37PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:37PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:37PM URINE HYALINE-3*
___ 04:37PM URINE MUCOUS-RARE
------------------
Admission Abdominal CT:
No clear CT explanation for patient's abdominal pain.
-No bowel obstruction or inflammation
-Appendix not visualized though no secondary signs of acute
appendicitis
-Indeterminate right renal hypodensity - likely a hyperdense
cyst. Consider
non-emergent renal ultrasound
-Severe degenerative changes of the lumbar spine
Head CT: no acute intracranial process.
ECG: Rate = 91 bpm, incomplete RBBB, TWI in leads V1- V3.
.
.
.
TTE (___):
No echocardiographic evidence of endocarditis in a high quality
study. Normal regional and global biventricular systolic
function. Moderate pulmonary hypertension. Mildly dilated right
ventricle with preserved systolic function.
.
TEE (___):
Mild aortic and mitral leaflet thickening without discrete
valvular pathology or pathologic valvular regurgitation. No
evidence of endocarditis. Extensive suimple atheroma in thoracic
aorta.
.
PCXR (___):
Right PICC in standard position with distal tip in the mid SVC.
No pneumothorax. Previously identified right perihilar opacity
is less dense on this study and may represent interval
improvement.
.
.
Discharge Labs:
___ 06:32AM BLOOD WBC-16.2* RBC-3.55* Hgb-11.8* Hct-34.6*
MCV-97 MCH-33.2* MCHC-34.1 RDW-14.3 Plt ___
___ 06:32AM BLOOD Glucose-159* UreaN-16 Creat-0.5 Na-134
K-4.5 Cl-98 HCO3-32 AnGap-9
___ 06:32AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
.
.
Microbiology
Blood Cx (___)
Blood Culture, Routine (Final ___:
STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS. FINAL
SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = <=0.12 MCG/ML. CEFTRIAXONE = 0.125
MCG/ML = S.
CEFTRIAXONE Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS GALLOLYTICUS SSP
PASTEURIANUS
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Surveillance Blood Cx's: ___ - no growth. ___ - no
growth to date, final pending.
.
.
Medications on Admission:
Zoledronic Acid-Mannitol&Water (RECLAST) 5 mg/100 mL
Intravenous Solution reclast 5mg/100ml infuse as directed
Losartan 50 mg Oral tablet Take 1 tablet daily
Clobetasol 0.05 % Topical Cream APPLY TO ITCHY RED SPOTS ON
THE BODY.NEVER FOR USE ON THE FACE
Desonide 0.05 % Topical Cream APPLY AS DIRECTED once to twice
daily AS NEEDED
Triamcinolone Acetonide 0.1 % Topical Cream apply 2x/day to
body rash as needed for itch&redness for up to 2wks.not on face,
neck,under arms or breasts or in groin
Hydrochlorothiazide 50 mg Oral Tablet take one tablet daily
Fluticasone-Salmeterol (ADVAIR DISKUS) 100-50 mcg/dose
Inhalation Disk with Device INHALE 1 PUFF TWICE DAILY
Potassium Chloride 10 mEq Oral Tablet Extended Release TAKE 4
TABLETS TWICE DAILY
Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA
Aerosol Inhaler ___ puffs every ___ hours as needed; dispense
ProAir if generic inhaler is not available
Hydrocortisone Valerate 0.2 % Topical Cream APPLY TWICE DAILY
AS DIRECTED TO THE FACE FOR ITCHY RED FLARES
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION use 1
ampule EVERY FOUR TO SIX HOURS AS NEEDED for asthma symptoms
FISH OIL 1,000 MG CAP (OMEGA-3 FATTY ACIDS/VITAMIN E) daily
VITAMIN D-3 400 UNIT TAB (CHOLECALCIFEROL) 1 by mouth once
daily
B COMPLEX ___ TAB (VITAMIN B COMPLEX) 1 by mouth once daily
VITAMIN C 500 MG TAB (ASCORBIC ACID) 1 by mouth once daily
MAGNESIUM OXIDE 250 MG TAB 1 by mouth once daily
SELENIMIN 200 MCG TAB (SELENIUM) 1 by mouth once daily
LYSINE 500 MG TAB 1 by mouth once daily
COENZYME Q10 100 MG CAP (UBIDECARENONE) 1 by mouth once daily
PRIMROSE OIL 1,000 MG CAP (EVE PRIM/LINOLEIC/GAMOLENIC AC)
taking 1300mg daily
ASTRAGALUS ROOT 250 MG CAP taking 500mg/day
MILK THISTLE 140 MG CAP taking 70mg/day
MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 TABLET DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q 12H
please continue until ___ for a total of a 2 week course
___ - ___
RX *ceftriaxone 2 gram 2 grams IV every twelve (12) hours Disp
#*16 Bag Refills:*0
2. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Ascorbic Acid ___ mg PO BID
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES HS:PRN dry
eyes
RX *dextran 70-hypromellose [Artificial Tears] ___ drops in
each eye at bedtime Disp #*1 Bottle Refills:*0
7. Calcium Carbonate 500 mg PO QID:PRN heart burn
RX *calcium carbonate 200 mg calcium (500 mg) 1 tablet(s) by
mouth four times a day Disp #*120 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
10. Reclast *NF* (zoledronic acid-mannitol&water) 5 mg/100 mL
Injection q ___ year
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Strep Bovis pneumonia, meningitis and bacteremia
hyponatremia
hypocalcemia
thromobocytopenia
Sjogrens sydrome
hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ female with platelet count of 3, fevers and headache.
Abdominal pain.
TECHNIQUE: Contiguous axial images were obtained from skull base to vertex
without intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: None listed.
FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift, or territorial infarct. The ventricles and sulci are symmetric
and unremarkable. The gray-white matter differentiation is preserved.
Mucous retention cyst is seen in the left maxillary sinus. There is also
partial opacification of the bilateral ethmoid air cells and mucosal
thickening in the sphenoid sinuses. Mastoid air cells are clear. Skull and
extracranial soft tissues are unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: ___ female with fevers, thrombocytopenia, and diffuse
abdominal pain
COMPARISON: None available
TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. Intravenous contrast was
administered. Coronal and sagittal reformations were prepared.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal bibasilar atelectasis.
No pleural effusion is identified. The imaged cardiac apex is within normal
limits.
There are multiple too small to characterize hypodensities throughout the
liver (2:9, 11, 18, 26), likely small cysts or biliary hamartomas. No
suspicious hepatic lesion is identified. The hepatic veins and portal venous
system are grossly patent. No intra- or extra-hepatic biliary ductal
dilatation is identified. The gallbladder is mildly distended, though without
pericholecystic fluid or wall thickening. The spleen is not visualized,
likely secondary to prior surgical resection. The pancreatic head, neck, and
proximal body appear normal. Surgical clips are seen in the region of the
pancreatic tail, likely due to prior distal pancreatectomy (2:20). No
pancreatic ductal dilatation is noted. The adrenal glands are symmetric
without focal lesion. There is symmetric enhancement and excretion of both
kidneys without suspicious focal lesion or hydronephrosis. A 1.3 x 1.6 cm
hypodense lesion is identified within the interpolar region of the right
kidney with indeterminate attenuation values, likely a hyperdense cyst (2:23).
Non-emergent renal ultrasound could be performed for further evaluation.
There is no abdominal free fluid or free air. The abdominal aorta and its
branch vessels demonstrate moderate atherosclerotic calcifications, though are
non-aneurysmal and grossly patent. Stomach and small bowel loops are normal
in caliber and configuration without evidence of obstruction or inflammation.
The appendix is normal.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum and colon are normal in
caliber and configuration without evidence of obstruction or inflammation.
The bladder is distended and appears normal. The uterus and adnexa appear
unremarkable. No pelvic free fluid is identified.
OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is
identified. There is mild S-shaped scoliosis of the lumbar spine with loss of
vertebral body height at multiple levels, most severe at L1 and L2.
IMPRESSION:
1. Small subcentimeter hypodensities throughout the liver, likely small
cysts, though too small to characterize.
2. 1.6-cm hypodense lesion in the interpolar region of the right kidney,
likely a hyperdense parapelvic cyst. Non-emergent renal ultrasound is
recommended for further evaluation.
3. Severe degenerative changes of the lumbar spine with loss of height at
multiple levels, though no malalignment.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Right perihilar density, mild thrombocytopenia, evaluation for
developing pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the right perihilar opacity
is almost unchanged in extent and appearance. The opacity is rounded and
adjacent to the minor fissure. The opacity also cannot completely be
differentiated against a structure of the right hilus.
The differential diagnosis should not only include pneumonia, but also the
possibility of a part solid neoplasm, potentially associated with right hilar
adenopathy. This finding should best be confirmed or excluded by CT.
At the right lung base, mild peribronchial thickening persists. The left lung
is normal. Bilateral apical thickening is symmetrical. The presence of
bilateral dorsal minimal pleural effusions cannot be excluded. Borderline
size of the cardiac silhouette without evidence of pulmonary edema.
Radiology Report
INDICATION: New PICC placement.
COMPARISON: Comparison is made to radiographs of the chest from ___ and ___.
FINDINGS: Frontal radiograph of the chest demonstrates a right subclavian
line in standard position with distal tip terminating in the mid SVC. The
previously seen right perihilar opacity is less dense on this study and may be
resolving, however, it is difficult to compare the current portable AP view
with the prior PA and lateral views for subtle changes of this finding.
Further imaging of this area with either conventional radiographs or CT is
recommended if clinically justified. The cardiomediastinal silhouette is
unremarkable. There is no evidence of new focal consolidation, pleural
effusion or pulmonary edema.
CONCLUSION: Right PICC in standard position with distal tip in the mid SVC.
No pneumothorax. Previously identified right perihilar opacity is less dense
on this study and may represent interval improvement.
The above findings were communicated to IV nurse, ___, via telephone by Dr.
___ at 12:30, at the time of discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, THROMBOCYTOPENIA NOS
temperature: 98.2
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 148.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | .
The patient is a ___ year old female with h/o HTN, osteoporosis,
COPD who presents with headache, fevers and back pain s/p
trigger finger injections and a reclast injection also found to
have PTL = 6K on presentation with a CXR also demonstrates PNA.
.
# Community acquired PNA/ Mennigits:
The patient is asplenic and this likely contributing to the
patient having Strep Bovis infection, although the original
source is unclear. Due to her delayed presentation, the patient
likely became bacteremic and developed meningitis from this.
Upon her presentation from ___ clinic, the patient was
empirically started on vanco/CTX and dexamethasone. LP was
deferred in the ED due to low platelets. The patient was
followed by ID in-house, and no CSF sample was acquired as it
was unclear how it would changed management. She had a PICC
line placed and she will be sent home on 14 days of CTX at
2grams IV twice daily, end date is ___. Rheumatologic
causes of her symptoms where also considered and the
rheumatology team was consulted. They thought that her
meningeal signs were less likely due to systemic lupus and more
likely due to acute infectious issues. She did have some
leukocytosis on discharge with a WBC# of 16K, but was afebrile
and without any new or concerning localizing symptoms.
.
# Strep Bovis bacteremia
The patient had blood cultures positive for Strep Bovis on
presentation. TTE was checked which was negative for
vegatations, as was a TEE. Subsequent blood cultures cleared.
The patient had a picc line placed and sensitivities returned
with pan-sensitive Strep Bovis, so the patients coverage was
narrow down to CTX 2gm IV BID for a 2 week course ___ -
___. She will be followed in ___ at ___ and will
also need to have an outpt colonoscopy to further evaluate her
Strep Bovis bacteremia and r/o underlying occult malignancy in
her lower GI tract.
.
# Thrombocytopenia
This was likely due to her acute infection, but ITP was also
considered in the diagnosis. Hematology was following the
patient and she was placed on dexamethasone for 3 days. The
patient smear showed megakaryocytes and did not show signs of
MAHA. With this treatment and treatment of her infectious
issues, her platelets count improved. She showed no signs of
active bleeding (other then microscopic hematuria) and her Hgb
was stable. The patient should have a repeat CBC 1 week after
d/c and should follow with ___ Hematology Dr. ___.
By day of discharge (___), her plt count had returned to
normal levels, with a count of 250K, with a nadir of 6K on day
of presentation to ED (___).
.
# Hyponatremia:
This was likely due to dehydration from acute illness. The
patient was also found to be taking in fairly large amounts of
free water in house. As a result, the patient was free water
restricted and and her HCTZ was also held. With these
interventions her sodium improved and was stable at 134 on day
of discharge.
#Hypocalcemia:
The etiology of this was unclear but vitamin d deficiency,
autoimmune hypoparathyroidism and rheumatologic phenomenon where
considered (see below). The patient was repleted in house
mostly because she was experiencing facial twitching which was
thought to be due to low calcium. The patients PTH was found to
be within the normal range. Her vitamin d level was also
checked and it was low at 20. She should f/u with her outpt
Endocrinologist for further management.
.
# Sjogrens syndrome
The Rheumatology team accessed the patient in house and though
that systemic lupus was unlikely but that the patient should
start treatment with artifical tears and artificial salvia for
sjogrens syndrome. Furthermore, they also recommended treatment
for oral ___, the patient was started on nystatin. The
patient should follow with Rheumatology as an outpatient.
.
# microscopic hematuria
Pt was noted to have microscopic hematuria x 2 on UA. She had
no urinary symptoms, and it is possible that she had some
bleeding in the setting of low plt count. However, once her plt
count responds, she will need a repeat UA in the outpt setting
to assess for resolution of her hematuria. If it persists, she
will need further w/u for hematuria.
.
#Transitional Issues
[] repeat CBC in 1 week and fax to PCP/Hematology, will need to
assess her plt # and her WBC #, given thrombocytopenia during
the hospitalization and also leukocytosis of unknown etiology on
discharge.
[] follow up with Hematology, Rheumatology, ID clinic and PCP
[] follow up any pending blood cultures (surveillance blood cx's
from ___, no growth to date)
[] complete course of antibiotics with IV Ceftriaxone 2gm IV BID
x 2 weeks, f/u with ID
[] outpt colonoscopy to further w/u her Strep Bovis bacteremia
[] electrolyte check as an outpt to check her sodium levels for
stability
[] repeat UA as outpt to assess for microscopic hematuria
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Ace Inhibitors / lisinopril
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ year old female with nausea, vomiting, abdominal pain for
three four days. Symptoms triggered only after eating; patient
essentially asymptomatic when not eating. Abdominal pain sharp,
epigastric/RUQ, and radiating to back. No fevers or chills. No
diarrhea. No chest pain or dyspnea. Seen in local ED two days
ago, complaining of back pain, given cyclobenzeprine.
Yesterday, during hemodialysis, looked unwell, brought back to
local ED with SBP 84 mmHg. Given history, concern for biliary
pathology. Labs obtained, T. bili, alkaline phosphatase, and
INR elevated. Ultrasound suggestive of common bile duct
obstruction. The patient has penicillin allergy, was given
levofloxacin (per report, no documentation), vitamin K (per
report, no documentation), gentle IV fluid bolus, and
transferred to ___ for ERCP.
.
___ ED Course (labs, imaging, interventions, consults):
- Initial Vitals: 99.4 78 90/43 18 95% 4L Nasal Cannula
- guaiac negative
.
Upon tranfer from ED:
Mental Status: alert and oriented x 3, very pleasant
Lines & Drains: #22g IV in left DH-after multiple attemps, very
poor access.
Fluids: NS 500 cc bolus
Drips: Received flagyl 500mg IV, and 2 units of FFP
Precautions:Universal
Belongings: with patient
Most Recent Vitals: 98.3 79 92/44 23 99%RA
.
Upon arrival to floor, patient felt well. Denied abdominal pain,
no nausea. No other complaints.
.
12 point ROS as noted above, otherwise negative.
Past Medical History:
-Renal Failure on Dialysis for over ___ years (___)
-Type II DM
-HTN
-protein C deficiency, homosyteinanemia, spontan DVT s/p IVC
filter about ___ years ago
-AV fistula placement
Social History:
___
Family History:
No family history of biliary pathology.
Physical Exam:
VS: 98.4 104/75 HR 80 16 95% 2 liters nasal cannula
General: pleaseant female, appears tired, no distress
HEENT: mild scleral icterus
Cardiac: RRR, normal S1, S2. II/VI SEM at ___ without
radiation. No thrills or rubs.
Pulm: bibasilar rales
Abdomen: obese, soft, non-distended, non-tender
Ext: 2+ radial and DP pulses. AV fistula in RUE; failed grafts
in LUE. trace bilateral ___ edema
Neuro: CNs intact. Strength and sensation grossly intact.
Pertinent Results:
Abdominal ultrasound (pre-liminary)
CBD dilated to 1.4 cm. No intrahepatic bile duct dilatation.
Pancreas obscured by overlyign bowel gas. Cholelithiasis without
cholecystitis. Numerous shadowing right renal stones.
Labs:
blood cultures ___ pending
WBC-16.1* RBC-3.47* HGB-11.6* HCT-36.2 MCV-105* MCH-33.4*
MCHC-31.9 RDW-15.0
NEUTS-89.2* LYMPHS-8.5* MONOS-2.0 EOS-0.2 BASOS-0.1
PLT COUNT-160
LACTATE-2.6*
GLUCOSE-148* UREA N-31* CREAT-7.9* SODIUM-132* POTASSIUM-4.8
CHLORIDE-90* TOTAL CO2-25 ANION GAP-22*
ALT(SGPT)-66* AST(SGOT)-138* ALK PHOS-251* TOT BILI-7.0*
LIPASE-13
ALBUMIN-2.9*
___ PTT-70.5* ___
Medications on Admission:
- Coumadin
- nifedipine ER 30 mg tablet,24 hr extended release Oral 1
tablet extended release 24hr(s) Once Daily
- Lipitor 20 mg tablet Oral 1 tablet(s) Once Daily
- pentoxifylline ER 400 mg tablet,extended release Oral 1 tablet
extended release(s) Three times daily
- allopurinol ___ mg tablet Oral 1 tablet(s) Twice Daily
- Humulin N 100 unit/mL Susp, Sub-Q Inj Subcutaneous 1
Suspension(s) unknown times daily
- trazodone 50 mg tablet Oral 1 tablet(s) Once Daily, at bedtime
- Diovan 80 mg tablet Oral 1 tablet(s) Twice Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q24H
RX *Cipro 500 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet
Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
4. NIFEdipine *NF* 30 mg Oral daily
extended release
5. Pentoxifylline 400 mg PO DAILY
extended release
6. Valsartan 80 mg PO BID
7. Allopurinol ___ mg PO EVERY OTHER DAY
8. Atorvastatin 20 mg PO DAILY
9. Glargine 25 Units Bedtime
10. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
choledocholithiasis
esrd
protein c deficincy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of cholangitis, ERCP, pre-operative chest x-ray.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Borderline size of the cardiac
silhouette with no evidence of overt pulmonary edema. No pleural effusions,
no pneumonia. Normal appearance of the hilar and mediastinal structures.
Radiology Report
STUDY: MR of the abdomen.
INDICATION: ___ female with end-stage renal disease, on hemodialysis,
presenting with cholangitis from choledocholithiasis status post ERCP, now
with increasing total bilirubin, question choledocholithiasis.
COMPARISON: No previous MR examination is available for comparison.
Correlation is made to ultrasound abdomen dated ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5
Tesla magnet. IV contrast was not administered for the examination. 2.5 mL
of Gadavist was mixed with 75 mL of water and was administered as enteric
contrast.
FINDINGS: The lung bases are clear.
In the liver, there is ill-defined, poorly characterized lesion in segment ___
of the liver measuring 1.6 x 1.3 cm in size, which is hypointense on T1
sequences (series 15, image 13) and hyperintense on the T2 sequences (series
16, image 6). There is no intrahepatic biliary ductal dilatation. Again
noted is dilatation of the middle aspect of the common hepatic duct measuring
up to 12 mm in size (series 3, image 10). There is anatomic variant with low
and medial insertion of the cystic duct (series 3, image 11). There is a
large gallstone within the fundus of the gallbladder measuring 1 cm in size.
No filling defects are seen in the extrahepatic biliary tree to suggest
choledocholithiasis. Evaluation for cholangitis is limited due to lack of IV
contrast administration.
The adrenal glands and spleen appear within normal limits. In the pancreatic
neck, note is made of an 11 x 4 mm T2 hyperintense lesion (series 9, image 18)
which likely represents a side branch IPMN versus a pancreatic cyst.
Additional smaller similar lesions measuring less than 5 mm in size are seen
in the uncinate process (series 9, image 22) and tail of the pancreas (series
9, image 14). The pancreatic duct is nondilated. There are no inflammatory
changes about the pancreas.
The kidneys appear atrophic and there are multiple small T2 hyperintense
lesions in the left kidney, most suggestive of acquired renal cysts.
Nonspecific fluid signal intensity is seen around the kidneys bilaterally.
There is no upper abdominal lymphadenopathy. No obvious abnormalities are
seen in the bowel. Bone marrow signal is within normal limits.
IMPRESSION:
1. No MRCP evidence of choledocholithiasis.
2. Low and medial insertion of the cystic duct, anatomic variant.
3. Incompletely characterized focal lesion in segment ___ of the liver,
slightly hyperintense on T2-weighted images, and not well evaluated without
contrast. Dedicated hepatic imaging or comparison with prior studies
suggested for further characterization. Given ESRD/hemodialysis,
consideration could be made for multiphasic CT with IV contrast, and
coordination with dialysis schedule.
4. Multiple cystic lesions in the pancreas, the largest of which measures
about 11 mm in size in the pancreatic neck. A followup MRI could be
considered in six months (as clinically indicated) to ensure stability, or
comparison to prior studies.
MRCP findings were discussed with Dr. ___ by Radiology ___ over phone on
___ at 3:15 p.m.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CBD OBSTRUCTION/ERCP
Diagnosed with CHOLELITH/CHOLEDOCHOLITH, NO CHOLECYS, NO OBS, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 99.4
heartrate: 78.0
resprate: 18.0
o2sat: 95.0
sbp: 90.0
dbp: 43.0
level of pain: 0
level of acuity: 3.0 | ___ year old female with history of IDDM, HTN, ESRD on HD,
protein C deficiency complicated by DVT s/p IVC filter presented
with nausea, vomiting, and abdominal pain with labs and imaging
suggestive of choledocholithiasis/cholangitis without evidence
of pancreatic involvement. IV Ciprofloxacin and Flagyl were
started. She met severe sepsis criteria based on source of
infection and leukocytosis, hypotension, and elevated lactate.
She was kept NPO and an ERCP was performed demonstrating a
moderate diffuse dilation at the main duct with the CBD
measuring 14 mm. A large filling defect was suggestive of stone
in the lower third of the common bile duct. Sphincterotomy was
performed. Pus was seen flowing through the ampulla after the
sphincterotomy. Multiple dark stones matted together, large
amount of sludge and pus were extracted successfully using a 12
mm balloon. Cipro and Flagyl were continued. Blood cultures from
___ were negative. Blood cultuers from ___ and ___ were
unfinalized.
She remained afebrile. LFTs remained elevated with bilirubin in
mid 7 range. MRCP was done noting the following per MRCP report:
low and medial insertion of the cystic duct (anatomic variant),
incompletely characterized focal lesion in segment ___ of the
liver, slightly hyperintense on T2-weighted images, and not well
evaluated without contrast was noted. Dedicated hepatic imaging
or comparison with prior studies was suggested for further
characterization. Multiple cystic lesions in the pancreas, the
largest of which measures about 11 mm in size in the pancreatic
neck.
She was tentatively scheduled for cholecystectomy pending the
MRCP and repeat LFTs. LFTs remained elevated. OR was cancelled
and a repeat ERCP was done on ___ noting 1 cm narrowing in the
distal common bile duct. This was likely due to
post-sphincterotomy edema vs neoplasia. Brushings were performed
from the narrowing and sent for cytology. Balloon sweep
retrieved some sludge. A 5cm by ___ double pig tail biliary
stent was placed successfully. Post procedure, she was stable.
T.bili decreased slightly. Amylase and lipase were 58 and 156
respectively. Clear diet was advanced the next day without
nausea, vomiting or abdominal pain. Blood sugars were managed
with sliding scale insulin. Lantus was added once regular diet
was taken on ___.
Hemodialysis was performed on ___ without incident. Home meds
___, CCB and statin) were resumed on ___. She felt well enough
to go home on ___ and was discharged to home. Of note, given
MRCP finding of segment ___ lesion, tumor markers were sent (CA
___, CEA and AFP). Results were pending at time of discharge.
IV cipro and flagyl were switched to po form. She was instructed
to continue these antibiotics for 5 more days upon discharge
from hospital.
Coumadin had been on hold given procedures and possible OR.
Coumadin was resumed on ___ using home dose of 3mg per day.
Coumadin management was to be done by her outpatient
nephrologist at ___ in ___.
She was discharged to home in stable condition with f/u
appointment with Dr. ___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Plaquenil
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of CAD with previous MI, HTN, and ESRD
on peritoneal dialysis presents with 1 day of sharp, right-sided
chest pain. Patient reports that pain began last night after she
ate watermelon. As she was finishing eating, she developed ___
pain in the Right side of her chest and throughout her abdomen.
She notes that she felt gurgling in her stomach and was
belching. She had a single episode of diarrhea. Afterward, the
pain in her chest persisted. She describes the pain as radiating
to her back. No associated Left-sided CP, SOB, jaw pain,
diaphoresis. Pain cannot be reproduced with palpation of chest
wall. Pain was not relived by BMs or belching. Pain persisted
until today, and she called EMS to bring her to the ED. Of note,
patient has had a cough over the past few days. Denies fever,
chills.
Of note, patient did go on a long car ride to and from ___ in ___, but did not notice any leg swelling in that
setting. While in ___, she did not some increased ___ leg
swelling/pain. No erythema.
In the ED, initial vitals were: 98.0; 75; 162/84; 16; 95% RA
Labs notable for:
7.8>12.3/37.2<275
K: 5.6
BUN/Cr: 41/7.1
Trop 0.04
UA w/3 WBCs and >600 prot.
D-dimer 2571
Imaging notable for:
B/L LENIS:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left
lower extremity veins.
CXR
IMPRESSION:
Bibasilar atelectasis.
Patient was given 4mg IV morphine
Vitals prior to transfer: 98.1; 73; 147/77; 17; 99% RA
On the floor, patient reports continued pain in her chest.
Otherwise, she reported feeling well.
Past Medical History:
H/o myocardial infarction (___)
H/o stroke (___)
DM (diabetes mellitus), type 2, uncontrolled
ESRD - Left UE AVG placed on ___, first HD session on
___
Obesity
Hypothyroidism
Depression
Hypertension, essential
Hepatitis
Anemia
Hypercholesterolemia
Gout
?SLE
Social History:
___
Family History:
Mother died at age ___, and had history of COPD, emphysema, DM,
HTN, stroke, hx of MI.
Father is deceased, but patient does not know about the cause of
his death or any family history on that side.
Patient has 4 children.
Physical Exam:
ON ADMISSION:
Vital Signs: 97.7; 171/84; 73; 20; 95 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, midly-distended, bowel sounds
present, no organomegaly, no rebound or guarding. Post CCY scar
on RUQ.
GU: No foley
Ext: Warm, well perfused, 1+ pulses, no clubbing, TTP, warmth,
erythema, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
ON DISCHARGE:
Vitals- 98.7 155/77 84 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. chest wall tender on palpation
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, midly-distended, bowel sounds
present, no organomegaly, no rebound or guarding. Catheter in
place for PD
GU: No foley
Ext: Warm, well perfused, 2+ peripheral pulses, no clubbing, or
edema. Neuro: CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
Pertinent Results:
ON ADMISSION:
___ 05:28PM GLUCOSE-125* UREA N-41* CREAT-7.1*#
SODIUM-135 POTASSIUM-5.6* CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
___ 05:28PM CK(CPK)-205*
___ 05:28PM cTropnT-0.04*
___ 05:28PM CK-MB-2
___ 05:28PM D-DIMER-2571*
___ 05:28PM WBC-7.8 RBC-3.71* HGB-12.3 HCT-37.2 MCV-100*
MCH-33.2* MCHC-33.1 RDW-13.7 RDWSD-50.0*
___ 05:28PM NEUTS-62.4 ___ MONOS-11.1 EOS-4.4
BASOS-0.8 IM ___ AbsNeut-4.84 AbsLymp-1.64 AbsMono-0.86*
AbsEos-0.34 AbsBaso-0.06
___ 05:28PM PLT COUNT-275
___ 05:18PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:18PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
___ 05:28PM BLOOD cTropnT-0.04*
___ 12:10AM BLOOD cTropnT-0.03*
ON DISCHARGE:
___ 07:35AM BLOOD WBC-7.5 RBC-3.57* Hgb-11.8 Hct-35.9
MCV-101* MCH-33.1* MCHC-32.9 RDW-13.3 RDWSD-49.1* Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-230* UreaN-41* Creat-6.9* Na-135
K-3.9 Cl-95* HCO3-24 AnGap-20
IMAGING:
Chest X-ray (___): Bibasilar atelectasis.
Bilateral Lower extremity duplex (___): No evidence of deep
venous thrombosis in the right or left lower extremity veins.
V/Q scan (___): Low likelihood ratio for acute pulmonary
thromboembolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Amitriptyline 10 mg PO QHS
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Glargine 20 Units Breakfast
5. Nephrocaps 1 CAP PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Allopurinol ___ mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Levothyroxine Sodium 175 mcg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Vitamin D 4000 UNIT PO DAILY
13. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. Glargine 20 Units Breakfast
3. Allopurinol ___ mg PO DAILY
4. Amitriptyline 10 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Vitamin D 4000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Musculoskeletal chest pain
SECONDARY:
End Stage Renal Disease
Diabetes Mellitus
Hypothyroidism
Depression
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Mild to moderate enlargement the cardiac silhouette is unchanged. The
mediastinal and hilar contours are within limits. The pulmonary vasculature
is not engorged. Streaky and linear opacities in both lung bases likely
reflect areas of atelectasis. No pleural effusion, focal consolidation or
pneumothorax is present. No acute osseous abnormalities detected.
IMPRESSION:
Bibasilar atelectasis.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with chest pain, d dimer 2571. // ? 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: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.0
heartrate: 75.0
resprate: 16.0
o2sat: 95.0
sbp: 162.0
dbp: 84.0
level of pain: 8
level of acuity: 2.0 | ___ yo F w/ ___ CAD w/ previous MI, HTN, ESRD on peritoneal
dialysis presents with sharp right sided chest pain. EKG
revealing normal sinus rhythm, V/Q scan low probability, CXR
clear, trops negative x2, and therefore unlikely to be ACS, PE,
pneumothorax, or pneumonia. Pain was reproducible on palpation
on exam and therefore suspect patient has a musculoskeletal
chest pain such as costochondritis. Patient received peritoneal
dialysis overnight while hospitalized and her electrolytes were
wnl on discharge.
#Musculoskeletal Chest Pain
Pain was reproducible on palpation on exam and therefore
suspect patient has a musculoskeletal chest pain such as
costochondritis. EKG revealing normal sinus rhythm, V/Q scan low
probability, CXR clear, trops negative x2, and therefore
unlikely to be ACS, PE, pneumothorax, or pneumonia. Patient's
pain was improved with tylenol and she was stable for discharge
#End stage renal disease
Patient with hyperkalemia in the setting of ESRD. No EKG
changes. Patient received peritoneal dialysis while
hospitalized. Patient was continued on nephrocaps
#Hypertension
Patient's BP goal <170 per renal team, which was at goal during
hospitalization. Patient was continued on home lisinopril,
isosorbide mononitrate
#CAD
Stable. Patient was continued on home atorvastatin, metoprolol,
lisinopril, and aspirin
#Diabetes Mellitus
Stable. Patient continued on home glargine and insulin sliding
scale
#GERD.
Patient was continued on home PPI
#Hypothyroidism/Neuropathy/Gout
Stable. Continued home amitriptyline, levothyroxine, and
allopurinol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Egg / Flecainide / Synthroid
Attending: ___.
Chief Complaint:
Abdominal distension, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with a history of hypothyroidism,
hypertension, atrial fibrillation on Coumadin presenting with 24
hours of abdominal discomfort, diarrhea. Patient reports
yesterday morning she began having diarrhea, no bowel movement
for 6 hours and then had almost one episode of diarrhea every
hour even throughout the night until today. She notes that she
may have had around 20 BM in that entire period. Patient reports
the diarrhea is watery with no tenesmus, blood or mucus. Patient
feels bloated with multiple lot of gas in her abdomen and
nauseous as well last night. She attributes these symptoms to a
salad that she ate at ___ one day prior to initiation of
symptoms. She has had no recent sick contacts. There is no
fever, chills, vomiting, flank pain, dysuria or vaginal
discharge
or bleeding.
Pertinent ED course:
ED EXAM
VS: 98.9, 58, 178/77, 19, 100% on RA.
GEN: ___, no apparent distress
ENT: Mucous membranes are moist
GI: Abdomen is soft, nondistended, nontender to palpation, no
flank tenderness.
ED LABS:
___ 06:34AM BLOOD WBC:5.4 RBC:3.81* Hgb:11.3 Hct:35.1
MCV:92
MCH:29.7 MCHC:32.2 RDW:12.7 RDWSD:43.0 Plt Ct:161
___ 06:34AM BLOOD Glucose:110* UreaN:26* Creat:1.0 Na:141
K:3.9 Cl:106 HCO3:19* AnGap:16
___ 06:34AM BLOOD ALT:61* AST:45* AlkPhos:208* TotBili:0.9
___ 06:34AM BLOOD Lipase:44
___ 06:34AM BLOOD Albumin:4.4
ED MICROBIOLOGY:
___ C. Diff PCR: Negative
___ UCx: PENDING
ED RADIOLOGY:
CT A/P w Contrat
1. ___ small and large bowel without wall thickening or
dilatation, which could represent gastroenteritis in appropriate
clinical setting. No evidence of colitis or bowel obstruction.
2. Substantial interval growth of a segment VIII hemangioma
measuring 12.5 x 12.3 cm causing intrahepatic biliary ductal
dilatation, more severe in the right lobe.
3. Additional hepatic hemangiomas are minimally changed in the
interval.
4. 1.4 x 1.2 cm indeterminate lesion in the interpolar region of
the left kidney, for which dedicated renal ultrasound on a non
urgent basis is recommended.
ED TREATMENT
___ 06:51 IVF NS Started
___ 07:04 IV Ondansetron 4 mg
___ 08:30 IVF NS 1 mL Stopped (1h ___
___ 08:30 IVF NS Started 150 mL/hr
___ 11:02 IVF NS Confirmed No Change in Rate, rate
continued at 150 mL/hr
___ 15:21 IVF NS Stopped (6h ___
___ 15:21 IVF NS Started 250 mL/hr
___ 19:35 IVF NS Stopped (4h ___
___ 19:41 PO/NG Warfarin 3.75 mg
Upon arrival to the floor, the patient reports that she is
feeling "much better." She notes that her diarrhea has
decreased
in frequency, with the last BM at 1300 earlier today. It was
watery, without blood. She has been able to eat some ___
crackers and drink water since that point without issue.
Currently is not experiencing headache, dizziness, chest pains,
or shortness of breath.
Past Medical History:
AFIB
HEPATIC ANGIOMA
MULTINODULAR GOITER
HYPOTHYROIDISM ___ ___'S
PRIMARY HYPERPARATHYROIDISM S/P RESECTION OF LLPT ADENOMA ___
VITAMIN D DEFICIENCY
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Exam:
=======================
VITALS: 97.9F, 88, 178/82, 16, 98% on RA.
GENERAL: Woman laying in bed in NAD, wearing own clothing.
EYES: PERRLA, sclera anicteric, EOMI.
ENT: Neck supple, oropharynx nonerythematous, MMM.
CV: RRR, no m/g/r
RESP: CTAB in Anterior and posterior fields with no w/c/r
GI: Abdomen soft, ___ with no palpable
masses. Gurgling active bowel sounds auscultated.
GU: No foley
MSK: Moving all four extremities spontaneously, no ___ edema.
SKIN: No evidence of excoriations, sores, or wounds.
NEURO: AAOx3
Discharge Exam:
=======================
VITALS:
GENERAL: Woman sitting in bed in NAD, wearing own clothing.
EYES: PERRLA, sclera anicteric, EOMI.
ENT: Neck supple, oropharynx nonerythematous, MMM.
CV: RRR, no m/g/r
RESP: CTAB
GI: Abdomen soft, ___
MSK: Moving all four extremities spontaneously, no ___ edema.
SKIN: No evidence of excoriations, sores, or wounds.
NEURO: AAOx3
Pertinent Results:
Admission Labs:
=========================
___ 06:34AM BLOOD ___
___ Plt ___
___ 06:34AM BLOOD ___
___ Im ___
___
___ 06:34AM BLOOD Plt ___
___ 06:34AM BLOOD ___
___
___ 06:34AM BLOOD ___
___ 06:34AM BLOOD ___
Discharge Labs:
===========================
___ 06:20AM BLOOD ___
___ Plt ___
___ 10:35AM BLOOD ___ ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___
___
___ 06:20AM BLOOD ___ LD(LDH)-162 ___
___
___ 06:20AM BLOOD ___
Microbiology:
=============================
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference ___.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
=========================
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 8:59 AM
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A right hepatic lobe dominant 12.5 x 12.3 cm
hypoattenuating
lesion with peripheral puddling of contrast is consistent with
an hemangioma
(Series 2, image 28), which appears to have grown from the
previous CT when
the hemangioma was visualized in segment VIII and measured
approximately 2.3 x
1.9 cm. Adjacent to the dominant hemangioma are 2 similar
appearing but
smaller hemangiomas, one measuring 4.3 x 3.0 cm in hepatic
segment VI (series
2, image 31) and the other one measuring 4.6 x 2.5 cm near the
dome of the
liver in hepatic segment VIII (Series 2, image 15). When
compared to ___, the segment VI hemangioma has decreased in size and the
segment VIII
hemangioma near the dome of the liver has increased in size.
The dominant
hemangioma causes compression the central intrahepatic bile
ducts mild
intrahepatic biliary ductal dilatation, more severe in the right
lobe. The
hepatic parenchyma is otherwise homogeneous. The gallbladder is
unremarkable.
No extrahepatic biliary ductal dilatation.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is a simple cyst arising from the lower pole of the left
kidney
measuring 2.4 x 2.2 cm (series 2, image 34). Peripelvic cyst
measuring 2.5 x
1.5 cm immediately medially is also noted. A 1.4 x 1.2 cm
hypoattenuating
lesion superior to the 2 cysts at the interpolar region of the
left kidney
(series 601, image 37) is indeterminate with attenuation values
up to 65 ___.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Fluid filled
small and large
bowel loops are demonstrated without wall thickening or abnormal
dilatation.
No obstruction. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus contains 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. Mild
atherosclerotic disease
is noted. Portal and hepatic veins appear patent. Hepatic
arteries are
patent.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
There are mild degenerative changes of the thoracolumbar spine.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
1.
RECOMMENDATION(S): Dedicated renal ultrasound on a nonemergent
basis.
Radiology Report
INDICATION: ___ female with abdominal pain, diarrhea, ongoing//rule out
colitis or other abdominal pathology
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 10.7 mGy (Body) DLP = 583.1
mGy-cm.
Total DLP (Body) = 593 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___ and ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A right hepatic lobe dominant 12.5 x 12.3 cm hypoattenuating
lesion with peripheral puddling of contrast is consistent with an hemangioma
(Series 2, image 28), which appears to have grown from the previous CT when
the hemangioma was visualized in segment VIII and measured approximately 2.3 x
1.9 cm. Adjacent to the dominant hemangioma are 2 similar appearing but
smaller hemangiomas, one measuring 4.3 x 3.0 cm in hepatic segment VI (series
2, image 31) and the other one measuring 4.6 x 2.5 cm near the dome of the
liver in hepatic segment VIII (Series 2, image 15). When compared to ___, the segment VI hemangioma has decreased in size and the segment VIII
hemangioma near the dome of the liver has increased in size. The dominant
hemangioma causes compression the central intrahepatic bile ducts mild
intrahepatic biliary ductal dilatation, more severe in the right lobe. The
hepatic parenchyma is otherwise homogeneous. The gallbladder is unremarkable.
No extrahepatic biliary ductal dilatation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a simple cyst arising from the lower pole of the left kidney
measuring 2.4 x 2.2 cm (series 2, image 34). Peripelvic cyst measuring 2.5 x
1.5 cm immediately medially is also noted. A 1.4 x 1.2 cm hypoattenuating
lesion superior to the 2 cysts at the interpolar region of the left kidney
(series 601, image 37) is indeterminate with attenuation values up to 65 ___.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Fluid filled small and large
bowel loops are demonstrated without wall thickening or abnormal dilatation.
No obstruction. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus contains 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. Mild atherosclerotic disease
is noted. Portal and hepatic veins appear patent. Hepatic arteries are
patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are mild degenerative changes of the thoracolumbar spine.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
1.
RECOMMENDATION(S): Dedicated renal ultrasound on a nonemergent basis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Lower abdominal pain
Diagnosed with Other specified noninfective gastroenteritis and colitis
temperature: 98.9
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 178.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | ___ with PMH of afib on Coumadin who presented with 24 hours of
diarrhea likely ___ viral gastroenteritis who improved after
receiving 2L of NS in the ED and was able to tolerate po well
without significant diarrhea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with PMH of laryngeal cancer s/p tracheostomy,
DM II, minimal change disease on chronic prednisone and
discharge from ___ yesterday for coag-negative staph UTI and
bacteremia presenting from home with fevers up to 102 and
diffuse weakness. He presented on ___ with 1 week of urinary
retention and weakness, was admitted to ___ for septic shock,
required vasopressors and stress dose steroids, was on
ceftriaxone, cefepime and then vancomycin and nafcillin. ID was
consulted and he was discharged on 6 week course of Vancomycin
via ___ line for presumed endocarditis, TTE was negative and he
was high risk for TEE given his tracheostomy. He reports
feeling well when he left, developed loose stools starting last
night, had 3 episodes of loose stools that he reports are soft
but not watery. His ___ saw him today and he had a fever of
102, felt weak and unable to ambulate normally. ___ was
concerned for bleeding and possible erythema at ___ site. Sent
to ___ ED, temp 100.6, CXR was initially read as concerning
for RLL consolidation, he was given cefepime and continued on
vancomycin and admitted.
He says he feels weak currently. Has been urinating frequently
with small amounts. He reports having back pain over the last
few months that is unchanged, had an MRI of lumber spine on
___ showing new L2-L3 disc herniation with central canal
stenosis and mass effect on the conus medullaris. Denies
headache, SOB, cough, CP, abdominal pain, n/v, dysuria, rash,
easy bruising or bleeding.
Ten point review of systems otherwise negative.
Past Medical History:
- Cancer of the larynx s/p tracheostomy
- Type II Diabetes with opthalmic complication
- Minimal change disease with a relapsing course, usually
steroid-responsive, on chronic prednisone.
- Essential Benign Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Pulmonary nodule
- Gynecomastia
- Hematuria
- Low back pain, facet arthropathy
- Insomnia
- Urinary retention
- Spinal stenosis, unspecified site
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
He denies a family history of kidney disease. His mother had
diabetes. His brother had prostate cancer. No family history of
CAD and HTN.
Physical Exam:
Admission Physical Exam:
VS: T 98.5 HR 65 BP 133/70 RR 18 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear, tracheostomy with speech
valve
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e, PICC line site with small amount of blood but
without erythema, tenderness or drainage
Neuro: CN II-XII intact, ___ strength throughout
Back: No spinal or paraspinal tenderness
discharge:
Vitals: 98.9 125/76 p74 RR18 98%ra
General: Alert and oriented x 3. NAD.
Lungs: CTAB, moving air well and symmetrically
HEENT: Laryngectomy site c/d/i, able to speak. PEERL. EOMI
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
EXT: No edema or cyanosis
PICC site RUE without swelling erythema or induration. dressing
c/d/i
Pertinent Results:
___ 09:40AM GLUCOSE-144* UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 09:40AM ALT(SGPT)-64* AST(SGOT)-33 LD(LDH)-284* ALK
PHOS-69 TOT BILI-0.6
___ 09:40AM WBC-7.4# RBC-4.29* HGB-11.2* HCT-36.0* MCV-84
MCH-26.1* MCHC-31.2 RDW-15.8*
___ 09:40AM PLT COUNT-167
___ 10:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:15AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
CXR PA & L ___:
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 05:59AM BLOOD WBC-4.7 RBC-3.90* Hgb-10.2* Hct-32.4*
MCV-83 MCH-26.2* MCHC-31.6 RDW-15.0 Plt ___
___ 05:59AM BLOOD Neuts-62.5 ___ Monos-9.7 Eos-1.2
Baso-0.4
___ 05:59AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-104 HCO3-27 AnGap-12
___ 05:59AM BLOOD ALT-41* AST-21 AlkPhos-53
___ 11:21PM BLOOD HBsAg-NEGATIVE
___ 11:21PM BLOOD HIV Ab-NEGATIVE
___ 05:59AM BLOOD Vanco-14.1
___ 11:21PM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin 1000 mg IV Q 12H
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
8. PredniSONE 10 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Vitamin D 1000 UNIT PO DAILY
12. Finasteride 5 mg PO DAILY
13. diclofenac sodium 0.1 % OPHTHALMIC TID
14. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
9. PredniSONE 10 mg PO DAILY
10. Rosuvastatin Calcium 10 mg PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 750 mg 1500 mg iv every twelve (12) hours Disp
#*126 Vial Refills:*0
13. Vitamin D 1000 UNIT PO DAILY
14. diclofenac sodium 0.1 % OPHTHALMIC TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fever
Secondary
Staph epidermis bacteremia
Diabetes Mellitus
Minimal change disease
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 recent urinary infection, with fever // eval
pna eval pna
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
Lungs are hyperinflated. There is a hazy opacity at the right lung base which
appears similar to findings seen on CXR from ___ and likely
represents a prominent fat pad as opposed to an area of early pneumonia. A
right-sided PICC line terminates at the mid to lower SVC. Calcifications are
noted of the aortic arch. The cardiomediastinal and hilar contours are within
normal limits. There is no pleural effusion or pneumothorax. Posterior
fixation hardware in the lumbar spine is partially visualized.
IMPRESSION:
No acute cardiopulmonary process.
NOTIFICATION: Final report discussed with Dr. ___ by NSR via phone on
___ at 3:35 ___.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 99.9
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | ___ year old male with PMH of laryngeal cancer s/p tracheostomy,
DM II, minimal change disease on chronic prednisone and
discharge from ___ ___ for coag-negative staph UTI and
bacteremia presenting from home with fevers up to 102 and
diffuse weakness.
#ID: Coag-negative staph UTI and bacteremia with presumed
endocarditis on 6 week course of vancomycin via ___ line.
Febrile to 102 but without focal symptoms. Had some loose stools
but not diarrhea. No cough or other URI symproms with an
unremarkable chest xray. No voiding symptoms. Urine No signs of
pneumonia or other localizing signs of infection. Urine Cx
negative and Blood cx with no growth by discharge. His vanc
trough was 10.1 prior to discharge and so appropraite dose
increases were made. He was afebrile throughout his hospital
stay with no new symptoms. His Vancomycin trough was 14.1 prior
to discharge and vancomycin increased to 1500mg q12 hours. Next
trough to be checked by ___ and faxed to Dr. ___. He will
complete a ___s previously planned, with ID follow
up.
#GU: Hx of BPH. Negative urine culture
Continued flomax and finasteride
#Renal: Minimal change disease on chronic prednisone, creatinine
at baseline.
Continued prednisone 10 mg daily
#CV: HTN, HL: continued amlodipine, lisinopril and aspirin
#DM II: Continued lantus and lispro sliding scale |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, suicidal ideation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH severe depression NPH s/p shunt placement in ___,
myasthenia ___, hypothyroidism, HTN, esophageal cancer in
remission, who presents to the emergency department with
suicidal
ideation and altered mental status.
Per nursing home, patient has been noted to have increased
agitation over the past month since he joined the nursing home.
He has become more resistant to care and restless. For instance,
he has developed skin lesions on his elbows because of continue
rubbing of his elbow onto the wheelchair arm rest. He has been
restrained more frequently due to his gait becoming more ataxic
and multiple falls throughout this month. Patient was scheduled
for ECT today but did not pursue as per psych recommendations.
Patient complains of left sided abdominal pain. He is unable to
point to the exact location or give further history. Patient
also
reports dysuria and that he has become more depressed lately. He
frequently makes comments alluding to his wanting to "give up".
He endorses SI to both nursing staff, police officer and to ED
staff. He is unable to clarify any further but states he wants
to
hurt himself. Denies any homicidal ideation. He attests to
experiencing auditory hallucinations in the past though not
recently. He is alert and oriented to self, thinks that he is in
"rehab" and believes that the date is ___, though he
could name the current president. Otherwise, patient has not
experienced any fevers or chills. No chest pain or shortness of
breath.
Per his HCP (niece), his change in mental status started in
___ months after he had been diagnosed with Myasthenia ___ and
put on Prednisone to which he takes to date. On ___, he got a
VP
shunt placed at ___ due to his normal pressure hydrocephalus,
and
his HCP said he got better. However, he regressed and became
fully incontinent again and having frequent falls. He had his VP
shunt adjusted and in ___ he joined the nursing home he
currently resides in.
Per nursing home, on ___, recent medication changes include:
Trazadone PRN 25 mg Q8 to 50 mg Q6, Klonipin from once daily to
twice a day (held on ___ for scheduled ECT today), and
Ritalin
held. His prednisone was tapered in early ___ from 40 mg to
30 mg daily. Nursing home is unsure when patient's prednisone
should be tapered off. In addition, patient got a CXR at OSH for
concerning cough and was unremarkable, per home nurse.
Based on discussion with the ED, it is unclear whether this AMS
is just related to his underlying psych issue or if he has a
true
medical issue.
In the ED, initial VS were: 97.8 151/82 85 20 100/RA
Labs showed:
- WBC 12 CBC otherwise WNL
- serum, urine tox negative
- LFTs WNL
- K 4.5 -> 7.3 (hemolyzed) -> 5.6
- Cr 1.4
- coags WNL
- UA w/o e/o UTI
- Lactate 1.7
Imaging showed:
-CT head:
1. Left frontal convexity mixed density subdural hematoma
measuring 4 mm. No midline shift. No other intracranial
hemorrhage.
2. Right posterior approach ventriculostomy catheter terminates
near midline in frontal horn of left lateral ventricle. No
definite findings to suggest hydrocephalus although no priors
for
direct comparison.
3. Hypodensity involving the left caudate head may represent
chronic small vessel ischemic change. MRI would be more
sensitive
to assess for acute infarct.
- CT shunt series: Right-sided VP shunt without radiographic
evidence of discontinuity or kink.
- CXR: No evidence of pneumonia
Patient received:
___ 13:44 IM LORazepam 2 mg ___
___ 21:29 PO LamoTRIgine 50 mg ___
___ 21:29 PO/NG Mirtazapine 45 mg ___
___ 21:29 PO Pyridostigmine Bromide 60 mg ___
___ 23:01 PO LevETIRAcetam 1000 mg ___
___ 23:01 IVF NS ___ Started
___ 00:30 IVF NS 1000 mL ___ Stopped (1h ___
Psychiatry was consulted:
Diagnostically this patient certainly has severe depression and
likely will need ECT treatment in the future, however; his
current picture is most concerning for a delirium of unknown
cause. Recommend ongoing medical workup for cause of his
delirium
with medical admission, consulting psych CL for management of
his
psychiatric condition. A safety assessment cannot be made at
this
time due to his mental status. Please contact psychiatry in the
event that he wishes to leave AMA or is being discharged.
Neurosurgery was consulted:
Patient seen and examined. He is altered and a poor historian.
He
is oriented to self, 'rehab', and says ___. He is
otherwise nonfocal. He follows commands and has full strength
throughout. NCHCT shows left sided SDH with no mass effect.
Discussed case with Attending Dr. ___. SDH is likely not the
cause of altered mental status. With these facts in mind,
neurosurgery recommends consider Medicine workup for other
etiologies of altered mental status
Transfer VS were: 138/65 72 16 97/RA
Past Medical History:
Depression
Normal pressure hydrocephalus S/P VP shunt
Hernia repair
hypothyroidism
hypertension
BPH
esophageal cancer ___ now in remission
Social History:
___
Family History:
Positive for depression.
Physical Exam:
ADMISSION EXAM
===============
VS: 97.6 ___ 18 93 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD; bony prominence at left clavicle;
bony prominence near thyroid gland
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, oriented to self, thinks he is in "rehab", and
believes the month and year is ___, CN's ___ grossly
intact, finger to nose to finger, heel to shin, follows commands
though unable to follow two commands at once, 4+/5 strength UE
and 4+/5 strength in ___
SKIN: warm and well perfused, traumatic ulcers on flexor
surfaces
of lower legs bilaterally
DISCHARGE EXAM
===============
VITALS: 97.9 115/73 63 99%Ra
GENERAL: NAD, sleeping comfortably and arouses to voice
HEENT: MMM.
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes, crackles
ABDOMEN: soft, nondistended, nontender, normoactive BS
EXTREMITIES: no lower extremity edema
NEURO: Says "at rehab" and ___. CN II-XII grossly
intact. Moves all four extremities.
SKIN: warm and well perfused, lots of ecchymoses, dry.
ulcerations on LEs covered with gauze
PSYCH: Flat affect. Denies SI.
Pertinent Results:
===============
Admission labs
===============
___ 03:22PM BLOOD WBC-12.0* RBC-4.07* Hgb-14.2 Hct-43.6
MCV-107* MCH-34.9* MCHC-32.6 RDW-15.4 RDWSD-60.9* Plt ___
___ 03:22PM BLOOD Neuts-93* Bands-1 Lymphs-1* Monos-3*
Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-11.28*
AbsLymp-0.12* AbsMono-0.36 AbsEos-0.00* AbsBaso-0.00*
___ 09:18PM BLOOD ___ PTT-26.7 ___
___ 03:22PM BLOOD Glucose-114* UreaN-30* Creat-1.4* Na-143
K-4.5 Cl-102 HCO3-28 AnGap-13
___ 03:22PM BLOOD ALT-25 AST-28 AlkPhos-62 TotBili-0.8
___ 03:22PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-2.1
===============
Pertinent labs
===============
___ 08:36AM BLOOD VitB12-652
___ 08:36AM BLOOD TSH-5.1*
___ 08:36AM BLOOD T4-5.7
___ 03:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:41PM BLOOD Lactate-1.7
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
===============
Discharge labs
===============
___ 08:10AM BLOOD WBC-7.7 RBC-4.10* Hgb-14.8 Hct-44.4
MCV-108* MCH-36.1* MCHC-33.3 RDW-16.2* RDWSD-64.7* Plt ___
___ 08:10AM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-139
K-5.0 Cl-99 HCO3-28 AnGap-12
___ 08:10AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
===============
Studies
===============
CXR (___): IMPRESSION:
No acute cardiopulmonary abnormality. Left clavicle fracture is
better assessed on the prior dedicated study.
EEG (___): IMPRESSION: This is an abnormal awake EEG because
of slow posterior dominant rhythm and mild diffuse slowing
suggesting a mild encephalopathy. This is a nonspecific finding
but can be seen with toxic/metabolic derangements, anoxia, and
medication effect. There are no epileptiform features or
electrographic seizures.
CT head without contrast (___): IMPRESSION:
1. Unchanged small left subdural hematoma, measuring 4 mm. No
new or
increasing hemorrhage. 2. Unchanged ventricular catheter
position. Stable ventricular size.
Shoulder x-ray (___): IMPRESSION: Fracture of the mid clavicle
of indeterminate age
CT head w/o contrast (___): IMPRESSION:
1. Left frontal convexity mixed density subdural hematoma
measuring 4 mm. No
midline shift. No other intracranial hemorrhage.
2. Right posterior approach ventriculostomy catheter terminates
near midline
in frontal horn of left lateral ventricle. No definite findings
to suggest
hydrocephalus although no priors for direct comparison.
3. Hypodensity involving the left caudate head may represent
chronic small
vessel ischemic change. MRI would be more sensitive to assess
for acute
infarct.
Shunt series (___): IMPRESSION: Right-sided VP shunt without
radiographic evidence of discontinuity or kink.
CXR (___): IMPRESSION: No evidence of pneumonia
===============
Microbiology
===============
Urine culture (___): NEGATIVE
Blood cultures (___): NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 50 mg PO BID
2. Mirtazapine 45 mg PO QHS
3. TraZODone 100 mg PO QHS
4. ClonazePAM 0.5 mg PO BID
5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY
6. DULoxetine 60 mg PO DAILY
7. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID
8. Juven (arginine-glutamine-calcium bmb) ___ gram oral BID
9. Levofloxacin 750 mg PO Q24H
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Liothyronine Sodium 5 mcg PO DAILY
12. GuaiFENesin ER 600 mg PO Q12H
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. PredniSONE 30 mg PO DAILY
16. Pyridostigmine Bromide 60 mg PO Q8H
17. Senna 17.2 mg PO BID
18. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
19. Thiamine 100 mg PO DAILY
20. AzaTHIOprine 150 mg PO DAILY
21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
22. Vitamin D ___ UNIT PO 1X/WEEK (___)
23. Milk of Magnesia Dose is Unknown PO DAILY
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. CloNIDine 0.1 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Ramelteon 8 mg PO QHS
6. ClonazePAM 0.125 mg PO QAM
7. DULoxetine 40 mg PO DAILY
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Liothyronine Sodium 5 mcg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. AzaTHIOprine 150 mg PO DAILY
14. LamoTRIgine 50 mg PO BID
15. Mirtazapine 45 mg PO QHS
16. Omeprazole 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. PredniSONE 30 mg PO DAILY
19. Pyridostigmine Bromide 60 mg PO Q8H
20. Senna 17.2 mg PO BID
21. Thiamine 100 mg PO DAILY
22. HELD- Acidophilus (Lactobacillus acidophilus) 1 cap oral BID
This medication was held. Do not restart Acidophilus until you
see your primary care provider
23. HELD- GuaiFENesin ER 600 mg PO Q12H This medication was
held. Do not restart GuaiFENesin ER until you see your primary
care provider
24. HELD- Juven (arginine-glutamine-calcium bmb) ___ gram
oral BID This medication was held. Do not restart Juven until
you see your primary care provider
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Toxic metabolic encephalopathy
Delirium
SECONDARY
=========
Depression with suicidal ideations
Normal pressure hydrocephalus status-post VP shunt
Subdural hematoma
Hypothyroidism
Hypertension
Benign prostatic hypertrophy
Left clavicular fracture
Myasthenia ___
GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with AMS// eval for PNA
TECHNIQUE: Chest AP
COMPARISON: Shunt series from ___ at 19:15
FINDINGS:
Lungs are moderately well expanded and essentially clear. Linear opacity in
the left lower lobe suggests scarring or atelectasis. The cardiomediastinal
silhouette and hila are unremarkable. Partially visualized right
ventriculoperitoneal shunt noted without kink or discontinuity. No
pneumothorax or pleural effusion.
IMPRESSION:
No evidence of pneumonia
Radiology Report
INDICATION: ___ year old man with AMS, increased agitation// eval for shunt
malfunctioning
TECHNIQUE: Shunt series: AP and lateral views of the head and neck, frontal
view of the chest and frontal view of the abdomen
COMPARISON: None.
FINDINGS:
Right ventriculoperitoneal shunt from a posterior approach is seen coursing
along the right neck, right chest, and coursing into the abdomen to terminate
in the left lower quadrant. No shunt discontinuity or kinking is identified.
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac mediastinal silhouettes unremarkable.
There is a nonobstructive bowel gas pattern.
IMPRESSION:
Right-sided VP shunt without radiographic evidence of discontinuity or kink.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with AMS, shunt placement in ___// eval for
worsening hydrocephalus
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 19.2 cm; CTDIvol = 47.1 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None available in PACs.
FINDINGS:
Right posterior approach ventriculostomy catheter terminates near midline the
frontal horn of the left lateral ventricle. The ventricles and sulci are
normal in size and configuration for age. No priors are available for direct
comparison. Periventricular white matter hypodensities are nonspecific may
suggest chronic small vessel ischemic changes. Hypodensity involving the left
caudate head may be related to chronic small vessel ischemic changes (02:20).
Left frontal convexity extra-axial fluid collection with hyperdensity is
suggestive of subdural hemorrhage in measures 4 mm maximally. There is
evidence of midline shift. The basal cisterns are patent. No other
intracranial hemorrhages seen.
No acute fracture seen. The paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Left frontal convexity mixed density subdural hematoma measuring 4 mm. No
midline shift. No other intracranial hemorrhage.
2. Right posterior approach ventriculostomy catheter terminates near midline
in frontal horn of left lateral ventricle. No definite findings to suggest
hydrocephalus although no priors for direct comparison.
3. Hypodensity involving the left caudate head may represent chronic small
vessel ischemic change. MRI would be more sensitive to assess for acute
infarct.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:05 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with subdural hematoma. Evaluation for interval
change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Noncontrast head CT from ___.
FINDINGS:
The right parietal approach VP shunt catheter terminates in the frontal horn
of left lateral ventricle near the septum pellucidum, unchanged. Streak
artifact from the related hardware in the scalp slightly limits evaluation of
the right posterior fossa and occipital region. The ventricles are stable in
size. The small left convexity mixed-density subdural hematoma appears
unchanged from prior study, measuring 4 mm in greatest dimension. There is no
significant sulcal effacement or shift of midline structures. Basal cisterns
are preserved.
There is no evidence of new intracranial hemorrhage or acute major vascular
infarction. Periventricular, deep, and subcortical white matter hypodensities
are grossly unchanged, nonspecific but likely the sequela of chronic small
vessel ischemic disease. A small chronic infarct is again seen in the right
caudate head..
Mild partial bilateral mastoid air cell opacification is likely secondary to
prolonged supine positioning in the inpatient setting.
IMPRESSION:
1. Stable small left convexity subdural hematoma, measuring 4 mm. No new
hemorrhage.
2. Stable VP shunt catheter position. Stable ventricular size.
Radiology Report
EXAMINATION: SHOULDER 1 VIEW LEFT
INDICATION: ___ year old man with AMS// LEFT SHOULDER XRAY- dislocation?
please do portable if possible as pt is agitated and delirious
COMPARISON: None
FINDINGS:
There is no gross evidence of dislocation involving the shoulder on the
solitary frontal view.
There is a fracture of the midclavicle with approximately 1.5 cm of overlap,
age indeterminate. This was likely present on a prior chest x-ray from ___. No older studies are available for comparison. There is no
radiopaque foreign body.
IMPRESSION:
Fracture of the mid clavicle of indeterminate age.
NOTIFICATION: The findings were discussed with ___. by ___
___, M.D. on the telephone on ___ at 6:15 pm, within 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CLAVICLE LEFT
INDICATION: ___ year old man with mid-clavicular fracture// left clavicle xray
TECHNIQUE: Left clavicle two views
COMPARISON: Portable supine left clavicle radiograph from ___
FINDINGS:
Again seen is the fracture through the mid left clavicle,. On today's exam,
the edges appear corticated. There is full shaft-width inferior displacement
of the lateral fragment and approximately 21 mm of overriding.
The AC joint remains congruent, with mild degenerative change.
Limited assessment of the left shoulder suggests mild glenohumeral joint
degenerative change. No widening of the coracoclavicular interval. Probable
diffuse osteopenia.
At the edge of these films, tubing extending vertically across the right chest
is thought to represent a ventriculoperitoneal shunt.
IMPRESSION:
Fracture of the mid left clavicle again noted, with full shaft width
displacement and overriding. Edges appear corticated, suggesting a nonacute
injury. No convincing bony bridging identified..
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p fall// Eval for trauma, hematoma
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 7.2 s, 18.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 1.6 s, 4.1 cm; CTDIvol = 49.6 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Hyperdense extra-axial fluid collection overlying the left cerebral convexity
measures up to 4 mm, and is unchanged in comparison with 12 hours prior.
There is no significant shift of the normally midline structures. No new or
increasing hemorrhage. No evidence of acute infarct. A right posterior
approach ventricular catheter terminates in the frontal horn of the left
lateral ventricle near the septum pellucidum, unchanged in position.
There is no evidence of 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 with the exception of bilateral lens
replacements.
IMPRESSION:
1. Unchanged small left subdural hematoma, measuring 4 mm. No new or
increasing hemorrhage.
2. Unchanged ventricular catheter position. Stable ventricular size.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with depression, NPH, and myasthenia ___ with
worsening delirium// evaluate for consolidations concerning for PNA
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
FINDINGS:
VP shunt catheter is partially visualized. Heart size is top-normal. There
is mild unfolding of the thoracic aorta with mild knob calcifications. Hilar
contours are preserved. Lungs are clear. Pleural surfaces are clear without
effusion pneumothorax. Left clavicle fracture is better assessed on the
recent dedicated study..
IMPRESSION:
No acute cardiopulmonary abnormality. Left clavicle fracture is better
assessed on the prior dedicated study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SI
Diagnosed with Altered mental status, unspecified
temperature: 97.8
heartrate: 85.0
resprate: 20.0
o2sat: 100.0
sbp: 151.0
dbp: 82.0
level of pain: ua
level of acuity: 2.0 | SUMMARY: Mr. ___ is a ___ with past medical history of
severe depression (receiving ECT), normal pressure hydrocephalus
s/p shunt placement in ___, myasthenia ___, hypothyroidism,
and hypertension who presents to the emergency department with
suicidal ideation and altered mental status.
======================
ACUTE MEDICAL PROBLEMS
======================
# Toxic Metabolic Encephalopathy
Patient presented with agitation and confusion. Was recently
hospitalized elsewhere and had negative workup done, although MS
improved temporarily after shunt adjustment. Workup for
reversible causes ruled out infections, worsening of subdural
hematoma, untreated hypothyroidism, neurosyphilis, B12
deficiency, and seizures as cause. Neurosurgery consulted and
felt no issues with shunt or change in ventriculomegaly. Likely
medication-induced in setting of possible underlying cognitive
decline or dementia. Initially required antipsychotics for
agitation, but improved with frequent re-orientation and
downtitration of psychitatric medications with guidance of
Psychiatry.
[] Continue clonazepam 0.125 mg qAM with plan to stop on ___
[] Started clonidine 0.1mg qhs to help with restlessness
[] Started Ramelteon 8 mg qhs to help maintain sleep-wake cycle
[] Continue home thiamine 100 mg PO daily
[] If patient becomes altered, get repeat head imaging to
evaluate for worsening subdural hematoma or normal pressure
hydrocephalus
[] Refer back to Geriatrics at ___ for further workup of
possible cognitive decline
[] Continue ___
#Depression with suicidal ideation
Evaluated by psychiatry in ED who issued ___ to ongoing
safety assessment for suicidal ideation. Per family members,
this change in his mental status was not consistent with his
typical depression episodes. Psychiatry was consulted who
recommended medication changes as below. Decision was made to
hold off on ECT due to ongoing delirum. Patient had intermittent
SI during hospitalization but without plan or intent.
[] Continued mirtazipine 45 mg PO qhs
[] Continued lamotrigine 50 mg PO BID
[] Decreased duloxetine to 40 mg PO daily
[] Stopped methylphenidate
[] Stopped trazadone
[] If mental status improves, consider restarting ECT
[] Ensure psychiatry ___
[] Ensure patient does not have access to items available to
harm himself
#Goals of Care
Long discussion with case management and Niece who is HCP. Plan
is still DNR/DNI and plan to still readmit to hospital if rehab
cannot handle symptomatic management of any acute conditions. A
decision on weather to escalate care or transition to comfort
measures will be made with each hospitalization.
====================
CHRONIC/STABLE ISSUES
====================
#Normal pressure hydrocephalus s/p VP shunt placement
Adjusted at recent hospitalization with some improved mental
status (reprogrammed from 15 to 13). This admission, shunt
series performed with no concern for kink or obstruction
(ventricles stable size). Neurosurgery held off on adjustment.
[] If urinary retention worsens or mental status worsens, would
re-image shunt
#Myasthenia ___
Patient with diagnosed severe ___ after recurrent
pneumonias in ___. Has been on pyridostigmine, azathioprine,
and a prednisone taper. Initial concern for prednisone
contributing to AMS however given severe MG, neurology believed
the prednisone taper should be continued to avoid precipitating
MG crisis. Paraneoplastic workup negative at ___.
[] Continued Azathioprine 150 mg PO daily, prednisone 30 mg PO
daily, and pyridostigmine 60 mg PO q8h
[] Continue Bactrim DS tab ___ and calcium/vitamin D while on
steroids
# Subdural hematoma:
Likely ___ to recent multiple falls. Non-contrast head CT shows
left sided SDH with no mass effect. Evaluated by neurosurgery
who believed SDH is likely not the cause of altered mental
status. However, can definitely be contributing to the patient's
overall decompensation. Completed Keppra 1000mg BID x 7 days as
per neurosurgery for ppx.
[] Consider head imaging if mental status worsens
# Left clavicular fracture
Exam notable for bulging clavicle. Per HCP, was chronic.
Shoulder xray with likely chronic fracture.
[] Per Orthopedics, nonsurgical management with sling
[] Tylenol prn
#Acute kidney injury
Patient with Cr 1.4 with reported baseline around 1.1.-1.2.
Likely prerenal in setting of poor PO intake. Resolved with IV
fluids.
#Hypernatremia
Patient with mild hypernatremia in setting of poor PO intake
which resolved on its own.
# Hypothyroidism
TSH slightly elevated at 5.1
[] Increased levothyroxine to 125 mcg PO daily
[] Continue liothyronine 5 mg PO daily
[] Repeat TSH as outpatient
# Hypertension
SBPs were controlled without medications
[] Goal SBP <160 for subdural hematoma.
# Benign prostatic hypertrophy
Had some urinary incontinence. No urinary tract infection
present.
#?GERD
Continued home omeprazole 20 mg PO daily.
[] Discuss need for PPI
#Poor PO intake
Per family, had poor PO intake at home. Albumin 3.5
[] Diet: ground solid and thin liquid diet, with aspiration
precautions
[] MVI with nutrients
TRANSITIONAL ISSUES
===================
Follow up
----------
[] Refer back to Geriatrics at ___
[] PCP ___ for medication changes. Discuss need for PPI
[] Outpatient psychiatry ___ --> consider ECT if mental
status improving
[] Follow up with Orthopedics with x-rays within 2 weeks of
discharge
[] Follow up neurosurgery for VP shunt monitoring and subdural
hematoma
[] ___ with Neurology for myasthenia ___
[] Repeat ___
Management
-----------
[] Ensure SBP <160 due to subdural hematoma
[] If patient with any neurologic deficits, repeat head CT
immediately and called Neurosurgery
[] Diet: GROUND SOLIDS and THIN LIQUIDS
[] Medications: WHOLE WITH WATER
[] Aspiration Precautions
-1:1 supervision for meals
-alert and attentive for meals
-encourage PO intake
-Frequent oral care (TID)
[] Continue to work with ___ and OT
[] Continue Bactrim DS 3x/week, calcium, and vitamin D while on
steroids for ___
[] Sling for management of clavicular fracture
[] Ensure patient does not have access to items available to
harm himself
[] Stop clonazepam on ___
ADVANCED CARE PLANNING
=======================
#CODE: DNR/DNI, MOLST form filled out
#CONTACT: ___ (niece), phone: ___- HCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nuts / indomethacin
Attending: ___
___ Complaint:
Transfer from ___ for leg color change, concern for
phlegmasia cerulea dolens
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o cervical cancer s/p treatment, HTN, HLD, bipolar, recent
diagnosis of unprovoked LLE DVT treated with hep gtt, and
discharged ___ on xarelto, presents as a transfer from ___
___ for concern for phlegmasia cerulea dolens.
Patient reports when her clot was first diagnosed she had
soreness in her left leg. This gradually improved with treatment
and while she was at home for 1 week. She regularly kept her leg
elevated and wrapped. She took the xarelto without issue. She
was able to ambulate without cp or SOB. No fevers, chills,
n/v/d. She was waiting for stockings to arrive.
Day prior to arrival she evaluated her left leg, she noticed a
purplish color change as well as swelling. On further
questioning she thinks it had been getting more sore over the
past two days as well. No numbness or tingling. She went to ___
___ for eval and then was sent here as no vascular surgery
there over the weekend.
In the ED, initial vitals were: 99.0 61 144/71 16 99% RA
Exam notable for extensive petechial erythema to the left left
lower extremity
Labs notable for wbc 10.3, h/h normal with MCV 102, bicarb 20
Vascular was consulted and recommended: hep gtt, stop xarelto,
no clot retrieval/TPA lysis given age, comorbidities, and clot
>10d. Plan to continue to follow. Decision was made to admit for
further management.
Vitals prior to transfer: 98.6 70 139/78 18 99% RA
On the floor, patient denies focal symptoms beyond described
above. Leg remains somewhat sore. She is concerned about how her
leg will develop without intervention.
Past Medical History:
h/o cervical cancer, HTN, HLD, reflux
hysterectomy, finger surgery, breast biopsy
bipolar disorder with depression
Social History:
___
Family History:
No known family history of blood clots,
hypercoagulable disorders, or vascular disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.1 151 / 77 61 18 95 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, bilateral pulses 2+, LLE edematous
compared to right, with erythema and non-blanching petechiae
from shin towards groin. Distal pulse intact without cyanosis or
mottling. Distal sensation to light touch intact.
Neuro: Grossly intact
Access: PIV
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.1F, 122-148/ 68-74, 55-71, 18, 94-96RA, ___
GENERAL: Cheerful and talkative. NAD
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, good dentition. Oropharynx is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Dry non productive cough. Coarse crackles left upper
field. Appropriate breath sounds appreciated in all fields. No
wheezes, rhonchi or rales. Resonant to percussion.
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. 3+ edema LLE, no sign of
atrophy/hypertrophy. Pulses Radial 2+ bilaterally, DP 2+ Right,
1+ left.
SKIN: No evidence of ulcers or lesions suspicious for
malignancy. Erythematous non blanching petechiae and purpura
along LLE from ankle to hip. Distal sensation diminished LLE but
intact.
NEUROLOGIC: AOx3 CN2-12 intact. ___ strength throughout. ROM LLE
decreased w/ swelling. Normal sensation. Ataxia, dysmetria,
disdiadochokinesia, Gait deferred. 3+ reflexes bl Biceps. 2+
brachioradialis, triceps, patellar.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:15AM PLT COUNT-227#
___ 12:15AM NEUTS-66.3 ___ MONOS-6.2 EOS-6.1
BASOS-1.1* IM ___ AbsNeut-6.85* AbsLymp-2.03 AbsMono-0.64
AbsEos-0.63* AbsBaso-0.11*
___ 12:15AM WBC-10.3* RBC-3.81* HGB-12.0 HCT-38.7
MCV-102*# MCH-31.5 MCHC-31.0* RDW-14.0 RDWSD-51.9*
___ 12:15AM estGFR-Using this
___ 12:15AM GLUCOSE-108* UREA N-19 CREAT-1.0 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-20* ANION GAP-20
___ 07:40AM ___
___ 07:40AM PLT COUNT-265
___ 07:40AM WBC-9.3 RBC-3.84* HGB-12.4 HCT-37.6 MCV-98
MCH-32.3* MCHC-33.0 RDW-14.4 RDWSD-50.4*
___ 07:40AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.3
___ 07:40AM GLUCOSE-104* UREA N-17 CREAT-1.0 SODIUM-144
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-20
___ 10:43AM ___ PTT-150* ___
DISCHARGE LABS:
===============
___ 08:25AM BLOOD WBC-8.6 RBC-4.23 Hgb-13.4 Hct-41.5 MCV-98
MCH-31.7 MCHC-32.3 RDW-14.4 RDWSD-51.1* Plt ___
___ 08:25AM BLOOD Glucose-101* UreaN-13 Creat-0.9 Na-144
K-3.6 Cl-105 HCO3-26 AnGap-17
___ 08:25AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.3
IMAGING:
========
CTA ABD PELV (___):
Extensive filling defect involving the left common iliac vein,
external iliac vein down to the left common femoral, deep
femoral and superficial femoral veins, with extensive left
inguinal and left thigh soft tissue stranding and subcutaneous
edema, consistent with deep venous thrombosis. There is also
thrombosis of the left internal iliac vein. There is no filling
defect seen within the inferior vena cava, right common iliac
vein or its principal branches.
CXR (___):
Lungs are hyperinflated, suggesting COPD. Heart size is at the
upper limits of normal or slightly enlarged. No CHF. Minimal
subsegmental atelectasis and/or scarring seen at the left lung
base. No focal infiltrate or ___ effusion identified. No
pneumothorax detected.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 15 mg PO BID
2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
3. Calcium Carbonate 600 mg PO BID
4. Clozapine 37.5 mg PO QHS
5. Docusate Sodium 100 mg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Latuda (lurasidone) 80 mg oral QHS
9. Lithium Carbonate CR (Eskalith) 450 mg PO QHS
10. Omeprazole 20 mg PO BID
11. Simvastatin 20 mg PO QPM
12. Vitamin D 800 UNIT PO BID
13. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
14. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY
15. Acetaminophen 1000 mg PO TID
16. T.E.D. Anti-Embolism Stocking (comp
stocking,knee,regular,sml) 2 stockings miscellaneous DAILY
Discharge Medications:
1. T.E.D. Anti-Embolism Stocking (comp
stocking,knee,regular,sml) 2 stockings miscellaneous DAILY
2. Acetaminophen 1000 mg PO TID
3. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
4. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
5. Calcium Carbonate 600 mg PO BID
6. Clozapine 37.5 mg PO QHS
7. Docusate Sodium 100 mg PO DAILY
8. Escitalopram Oxalate 20 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY
11. Latuda (lurasidone) 80 mg oral QHS
12. Lithium Carbonate CR (Eskalith) 450 mg PO QHS
Eskalith CR
13. Omeprazole 20 mg PO BID
14. Rivaroxaban 15 mg PO BID
15. Simvastatin 20 mg PO QPM
16. Vitamin D 800 UNIT PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Left lower extremity DVT
Secondary DIAGNOSES:
====================
Hypertension
GERD
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 woman with cough and swelling in legs // Evaluate
for pulmonary edema and pneumonia
COMPARISON: None.
FINDINGS:
Lungs are hyperinflated, suggesting COPD. Heart size is at the upper limits
of normal or slightly enlarged. No CHF. Minimal subsegmental atelectasis
and/or scarring seen at the left lung base. No focal infiltrate or gross
effusion identified. No pneumothorax detected.
IMPRESSION:
No CHF, focal infiltrate or gross effusion.
Probable background COPD. Heart size borderline enlarged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg swelling, Transfer
Diagnosed with Acute embolism and thrombosis of deep vein of l low extrem
temperature: 99.0
heartrate: 61.0
resprate: 16.0
o2sat: 99.0
sbp: 144.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ woman with past history of
hypertension, dyslipidemia, bipolar disorder, and a recent
diagnosis of unprovoked left lower extremity DVT started on
xarelto on ___, who presented for two days of worsening
left lower extremity soreness, swelling, and purpulish
discoloration with initial concern for phlegmasia.
# Left Lower Extremity DVT:
Initially seen at ___ but was transferred to ___ for
concern for phlegmasia cerulea dolens for a vascular surgery
evaluation. PAtient had worsening leg erythema, swelling, and
pain despite anticoagulation. After arrival to ___, the
patient was seen and evaluated by the vascular surgery to given
the concern for worsening thrombosis. They deferred any
additional intervention as the patient did not have evidence of
total vascular flow compromise. Patient was initially switched
to a heparin drip, but was subsequently restarted on Xarelto 1
day prior to discharge. Her pain and swelling improved with
compression and elevation. Plan is for continued compression
(thigh high stockings) and elevation ___ at home with
follow-up with vascular surgery. We strongly urged the patient
to continue the rivaroxaban for at least ___ year and perhaps
lifelong given the extent of thrombus. We also recommended that
she follow up with an outpatient hematologist/oncologist and an
apt was made for ___ 10:00a with Dr. ___. The
vascular surgery team plans to contact her for follow up as
well.
# Psychiatric history - Severe Depression and Bipolar prior
history of ECT therapy.
- Continued home Lexapro 20 mg po qd
- Continued home Xanax 0.5 mg po qhs
- Continued home clozapine 37.5 mg po qd
- Continued home Latuda 80mg qd
- Continued home Lithium ER 450 QHS
# HTN
- Continued HCTZ
# HLD:
- Continued simvastatin
# GERD:
- Continued PPI
# Vitamin deficiency/macrocytosis:
- Held home Cerefolin & B12 as non-formulary.
- Continued Calcium, vitamin D. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with a recent dx of insulin dependent DM in ___ and
severe esophagitis, who presents from his ___ clinic for
vomiting and blood sugar control.
Patient was at clinic for followup for his recent diagnosis of
diabetes and per the physician there he was somnolent and was
subsequently sent to this facility for further management.
Patient reports that since ___ he has been increasingly weak
and has had ___ episodes of vomiting per day since that time. He
does state that the vomit has bright red streaks at times, as
well as some bilious material. He does endorse mild diffuse
abdominal pain that has been constant since that time as well as
decrease in PO intake. He denies fevers, chills, diarrhea,
cough, chest pain, dysuria, flank pain. He does admit to
stopping his sliding-scale insulin on ___ because of how he
felt. He has been taking his lantus but has stopped all other
medications. He also endorses subjective fevers and chills, and
substernal burning chest pain consistent his known esophagitis
pain. Hasn't tried anything for the pain. Abdominal pain
described as sharp and stabbing without radiation, currently a
___ in severity.
In the ED, initial vital signs were: T97.8 ___ BP131/86 RR18
95%. Labs were notable for a Na of 127, glucose 388 (corrected
Na 134). Glucose down to 324 after getting 2L NS. Hct was at
33. Received 6 units of humalog at 7 pm. ABG was 7.52/40/70.
No AG on Chem7. Urine with Tr Ketones and 1000 glucose. Also
received 40 iv pantoprazole and zofran. Received 3rd liter of
NS.
On the floor, pt endorses above history, and current ___
abdominal pain and nausea.
Past Medical History:
DM with neuropathy
Personality disorder: avoidant?
Esophageal reflux
Diabetic neuropathy
CKD stage 1, microalbuminuria
Complaints of total body pain
HTN (hypertension)
Vomiting- thought ___ gastroparesis
Gastric polyp
Myopia
Constipation
Hearing deficit
Elevated LFTs
Lung nodule
Social History:
___
Family History:
negative for diabetes
Physical Exam:
ADMISSION EXAM:
=================
Vitals- T 97.9, BP 143/79, HR 96, 98/RA
General: Somnolent, NAD
HEENT: NCAT
Neck: supple
CV: RRR, no m/r/g
Lungs:CTAB
Abdomen: Soft, non-tender, + BS
GU: no foley
Ext: no c/c/e
Neuro: MAE, grossly wnl
Skin: no rash
MSK: chest pain reproducible on palpation
DISCHARGE EXAM:
=================
Vitals- 98.6, 135/68 (121-140/68-79), 88 (88-100), 16, 98/RA
CBGs: 107->131->153(1H)->249(60L/2H)->125
General: awake, interactive, NAD
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: Soft, mild tenderness periumbilical, non-distended,
normoactive BS
Ext: no c/c/e
Pertinent Results:
ADMISSION LABS:
=================
___ 02:50PM BLOOD WBC-10.4 RBC-4.03* Hgb-11.1* Hct-33.3*
MCV-83 MCH-27.7 MCHC-33.5 RDW-15.4 Plt ___
___ 02:50PM BLOOD Glucose-388* UreaN-29* Creat-1.0 Na-127*
K-3.5 Cl-83* HCO3-31 AnGap-17
___ 02:50PM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Calcium-9.6 Phos-3.8 Mg-2.3
___ 06:55PM BLOOD %HbA1c-7.2* eAG-160*
___ 02:55PM BLOOD pO2-70* pCO2-40 pH-7.52* calTCO2-34* Base
XS-8
___ 06:55PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS:
=================
___ 06:00AM BLOOD WBC-6.3 RBC-3.39* Hgb-9.6* Hct-28.5*
MCV-84 MCH-28.4 MCHC-33.8 RDW-16.6* Plt ___
___ 06:00AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-133
K-3.8 Cl-97 HCO3-29 AnGap-11
STUDIES:
=================
___ KUB: IMPRESSION: Moderate fecal loading. No evidence of
obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Sucralfate 1 gm PO TID
3. Metoclopramide 5 mg PO QIDACHS
4. Pregabalin 150 mg PO QID
5. Carbamazepine (Extended-Release) 200 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Amitriptyline 100 mg PO HS
8. Glargine 60 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin 81 mg PO DAILY
10. Glucagon 1 mg IM ONCE prn:hypoglycemia
11. Ranitidine 150 mg PO DAILY
12. Omeprazole 40 mg PO BID
Discharge Medications:
1. Amitriptyline 100 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Carbamazepine (Extended-Release) 200 mg PO BID
4. Glucagon 1 mg IM ONCE prn:hypoglycemia
5. Glargine 60 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Metoclopramide 5 mg PO QIDACHS
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Pregabalin 150 mg PO QID
10. Ranitidine 150 mg PO DAILY
11. Sucralfate 1 gm PO TID
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*2
14. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyperglycemia
Hyponatremia
Abdominal Pain
Secondary:
Diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Vomiting and hematemesis.
COMPARISONS: None.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is no pleural effusion or pneumothorax.
There is mild elevation of the right hemidiaphragm. Streaky opacities in the
right lower lung, probably referring mostly to the right middle lobe, suggest
minor scarring. Otherwise, the lungs appear clear. Bony structures are
unremarkable.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Radiology Report
INDICATION: Abdominal pain, vomiting, and constipation. Evaluate for
obstruction or fecal loading.
COMPARISON: None.
FINDINGS:
There is a moderate quantity of stool throughout the colon. There are no
air-filled dilated loops of small bowel or colon. No free air is seen in the
abdomen. Mild linear right lower lung atelectasis.
IMPRESSION:
Moderate fecal loading. No evidence of obstruction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Hyperglycemia
Diagnosed with VOMITING
temperature: 97.8
heartrate: 106.0
resprate: 18.0
o2sat: 95.0
sbp: 131.0
dbp: 86.0
level of pain: 10
level of acuity: 2.0 | ___ with a recent dx of insulin dependent DM and severe
esophagitis, who presents from his ___ clinic for vomiting and
blood sugar control.
# Abdominal/Substernal pain: ___ have been a viral gastritis or
an exacerbation of diabetic gastroparesis. No obstruction on
KUB. Patient was unable to take his home gastritis/esophagitis
meds given pain with swallowing and N/V. Nausea improved with
IVF and IV ondansetron. Tolerated po intake without emesis prior
to discharge. Continued symptomatic management with omeprazole,
ranitidine, metoclopramide, sucralfate.
# Diabetes/hyperglycemia: His glucose returned to normal with 3L
NS. He had no anion gap, but his UA did show trace ketones. Pt
reports having stopped his insulin given vomiting/abd pain.
glucose now well controlled, back on home regimen. A1c 7.2.
# Hyponatremia: Resolved. A component of pseudohyponatremia
given hyperglycemia, however dehydration was likely playing a
role in hypovolemic hyponatremia. Also BUN/Cr ratio >20
supporting this diagnosis.
# Hypertension: His antihypertensive regimen was changed from
chlorthalidone to lisinopril, given his history of diabetes and
hypokalemia. He will be discharged on lisinopril 5mg daily,
which should be uptitrated as outpatient.
# Chronic pain: continued lyrica and amytriptiline
# Constipation: started docusate and senna. |
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, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male with recently diagnosed CLL and warm
autoimmune hemolytic anemia presenting from ___ with chest
pain, fevers, and anemia.
He reports that ___ he was feeling his regular self until he
developed diarrhea, nonbloody. He had several episodes ___
and into ___, no sick contacts, no travel, no recent
antibiotics, no exotic food. He tried to sleep it off, but
___ night he woke with sharp chest pain. It was non
radiating, no nausea, no shortness of breath. The pain was
constant, prompting him to go to ___.
There, he was febrile to 102, HR 111, BP 95/70 satting 97% on
2L. Trop and EKG were negative, hct was 22 down from baseline of
36, Cr 3.0. Tbili was 2.5. Cdiff and flu negative. Peripheral
phenyephrine was started, he was given 4L NS, and given
ceftriaxone and vanc prior to transfer. He contineud to have
chest pain.
On arrival to the ED, initial vitals were T 99.1 HR 111 BP
109/70 RR 16 O2 97% 3LNC. Labs were notable for
18.5>5.4/15.4<289, K 2.6, HCO3 13, BUN 37 Cr 1.7. LDH 314,
direct bili 0.6. INR 1.5. He was complaining of chest pain, EKG
was without ischemia. He spiked a fever 103.1 and was given
tylenol and unasyn. He received 2 units of emergency release
PRBC's and crit bumped to 23.4. BMT evaluated him and he was
given prednisone 80mg and transferred to the FICU with another
unit of blood running.
On arrival to the ICU, he continues to have chest pain, now
migrated to the right side and worse with palpation. He feels
short of breath and had hiccups that have resolved. He has no
abd pain, no nausea. He reports no rash, no joint pains.
Past Medical History:
Warm antibody autoimmune hemolytic anemia
Chronic Lymphocytic Leukemia
Hypertension
Social History:
___
Family History:
Mother, Brother, Sister: HTN
3 Children (daughters): all healthy
No family history of leukemia or blood disorders
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 99.4 BP 125/82 HR 100 RR 30 O2 88%RA
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Poor air movement, scattered ronchi, no wheezes
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
DISCHARGE PHYSICAL EXAM
=======================
Vitals- 98.0-98.5, 122-134/68-90, 88-102, ___, 98-100% on RA.
General: Patient laying in bed comfortably in NAD.
HEENT: No oropharyngeal lesions.
Lungs: Poor inspiratory effort, but clear to auscultation with
no wheezes, rales, or rhonchi.
CV: Regular rate, regular rhythm, S1 and S2 present, no murmurs.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding. Normoactive bowel sounds.
Ext: No lower extremity swelling.
Lines: Temporary IJ removed, site currently dressed, clean, dry,
intact.
Pertinent Results:
ADMISSION LABS
==============
___ 06:58AM BLOOD WBC-18.5*# RBC-1.81*# Hgb-5.4*#
Hct-15.4*# MCV-85 MCH-29.8 MCHC-34.9 RDW-16.0* Plt ___
___ 06:58AM BLOOD Neuts-77.2* ___ Monos-2.8 Eos-0.9
Baso-0.3
___ 06:58AM BLOOD ___ PTT-34.9 ___
___ 01:01PM BLOOD Ret Aut-2.0
___ 06:58AM BLOOD Glucose-82 UreaN-37* Creat-1.7* Na-140
K-2.6* Cl-115* HCO3-13* AnGap-15
___ 06:58AM BLOOD ALT-15 AST-16 LD(LDH)-314* AlkPhos-53
TotBili-1.4 DirBili-0.6* IndBili-0.8
___ 06:58AM BLOOD Albumin-2.3* Calcium-6.1* Phos-2.4*#
Mg-1.6
___ 07:04AM BLOOD Lactate-0.7
___ 06:58AM BLOOD Hapto-153
HEMOLYSIS LABS
==============
___ 01:01PM BLOOD Ret Aut-2.0
___ 07:25PM BLOOD Ret Aut-1.7
___ 04:00PM BLOOD Ret Aut-3.1
___ 03:16AM BLOOD Ret Aut-3.4*
___ 05:50AM BLOOD Ret Aut-4.9*
___ 12:52AM BLOOD Ret Aut-5.7*
___ 12:08AM BLOOD Ret Aut-8.9*
___:04AM BLOOD Ret Man-17.8*
___ 12:00AM BLOOD Ret Man-18.6*
___ 12:02AM BLOOD Ret Man-32.0*
___ 12:27AM BLOOD Ret Man-31.2*
___ 12:05AM BLOOD Ret Aut-23.9*
___ 12:04AM BLOOD Ret Man-22.0*
___ 12:01AM BLOOD Ret Man-20.1*
G6PD
====
QG6PD-25.8
DISCHARGE LABS
==============
___ 12:01AM BLOOD WBC-10.8 RBC-1.97* Hgb-7.3* Hct-23.1*
MCV-117* MCH-36.9* MCHC-31.5 RDW-23.2* Plt ___
___ 12:01AM BLOOD Neuts-70.5* ___ Monos-2.5 Eos-0.1
Baso-0.4
___ 12:01AM BLOOD ___ PTT-35.2 ___
___ 12:01AM BLOOD Glucose-139* UreaN-21* Creat-1.0 Na-140
K-4.3 Cl-105 HCO3-22 AnGap-17
___ 12:01AM BLOOD ALT-41* AST-18 LD(LDH)-670* AlkPhos-58
TotBili-0.7 DirBili-0.2 IndBili-0.5
___ 12:01AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2
IMAGING
=======
___: CHEST (PORTABLE AP)
Compared to the prior study, there is a new right internal
jugular central venous line, the tip of which terminates at the
cavoatrial junction. There is no evidence of pneumothorax. The
lungs are clear but underinflated, accentuating the
cardiomediastinal contour. No pleural effusion.
___: BILATERAL LOWER EXTREMITY VEINS
FINDINGS:
There is normal compressibility, flow and augmentation of the
bilateral common femoral, superficial femoral, and popliteal
veins. Normal color flow and compressibility are demonstrated in
the posterior tibial and peroneal veins. There is normal
respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Inguinal
lymph nodes are not enlarged.
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower extremity veins.
___: CTA CHEST WITH AND WITHOUT CONTRAST
IMPRESSION:
1. Low lung volumes with trace bilateral pleural effusions.
2. Two right upper lobe nodules, the largest which measures 4 x
7mm. This was not seen previously and could be inflammatory or
a true nodule and followup chest CT in 3 months is recommended.
3. Prominent bi-axillary nodes as well as right paratracheal
node, minimally changed in size when compared to prior
examination dated ___ likely secondary to known CLL.
4. No pulmonary embolism.
___: ABDOMINAL SUPINE AND LATERAL DECUBITUS PORTABLE
FINDINGS:
Minimally dilated loops of small bowel in the right abdomen,
measuring up to 3.0 cm in diameter. There are no abnormally
dilated loops of large bowel to suggest megacolon. The apparent
sigmoid colonic wall thickening is probably due to colonic
under-distension. The left lateral decubitus view does not show
any evidence of intraperitoneal free air.
IMPRESSION:
1. No abnormally dilated loops of colon to suggest megacolon.
2. No pneumoperitoneum.
3. Minimally dilated small bowel loops, measuring up to 3.0cm in
diameter.
___: CHEST X-RAY PA AND LATERAL
FINDINGS:
Cardiac size normal. Mediastinal lymph nodes are better seen in
prior CT. The upper lungs are clear. There is no pneumothorax or
right pleural effusion. Small left effusion and atelectasis has
minimally increased. Right IJ catheter tip is in the lower SVC.
The osseous structures are unremarkable
IMPRESSION:
Minimal increase in size of small left effusion and adjacent
atelectasis
MICROBIOLOGY
============
___ 12:40 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference
Range-Negative).
___ 12:01 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
VIRAL CULTURE ADD-ON PER ___ ___ ___ 1228.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B, Parainfluenza
type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza
A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further information.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
**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.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B, Parainfluenza
type 1,2 & 3, and Respiratory Syncytial Virus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
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. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. PredniSONE 80 mg PO DAILY
RX *prednisone 20 mg 4 tablet(s) by mouth daily Disp #*32 Tablet
Refills:*0
5. Amlodipine 10 mg PO DAILY
6. FoLIC Acid 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
WARM AUTOIMMUNE HEMOLYTIC ANEMIA
CHRONIC LYMPHOCYTIC LEUKEMIA
DIARRHEA
SECONDARY DIAGNOSIS
===================
HYPERTENSION
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 central venous line
TECHNIQUE: Portable supine chest radiograph
COMPARISON: Outside hospital chest radiograph from earlier on the same date
FINDINGS:
Compared to the prior study, there is a new right internal jugular central
venous line, the tip of which terminates at the cavoatrial junction. There is
no evidence of pneumothorax. The lungs are clear but underinflated,
accentuating the cardiomediastinal contour. No pleural effusion.
IMPRESSION:
Satisfactory position of right internal jugular central venous line, with the
tip at the superior cavoatrial junction. No pneumothorax.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with chest pain, tachycardia, hypotension, and
hypoxia. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, 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.
Inguinal lymph nodes are not enlarged.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
INDICATION: ___ male with tachycardia, hypoxia, and tachypnea.
TECHNIQUE: Axial multidetector CT scan from the upper chest to the diaphragm
was performed following the administration of intravenous contrast.
Multiplanar reformatted images in coronal and sagittal axis were generated.
Oblique maximum intensity projection images were prepared and reviewed.
Dose 307 mGy-cm.
COMPARISON: Chest CT dated ___.
FINDINGS:
CT Thorax: The thyroid gland is unremarkable. There are prominent bilateral
axillary nodes, previously present and overall unchanged. There is a 1.2 cm
right paratracheal lymph node again noted (4:23), previously 1 cm. There is no
hilar adenopathy identified. The airways are patent to the subsegmental level.
The heart, pericardium and great vessels are within normal limits. There is
no pericardial effusion. No esophageal abnormality is identified.
Lung windows demonstrate low lung volumes is thought to account for diffuse
subtle increase in density throughout both lung fields. Trace bibasilar
pleural effusions are noted. Within the right upper lobe, there is a 4 x 7 mm
nodule identified (5:61) and inferiorly a 2 mm nodule along the fissure of the
middle lobe. Both were not definitively seen on the prior examination.
CTA Thorax: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without evidence of
dissection or aneurysmal dilatation. The pulmonary arteries are evaluated to
the segmental level. There is no filling defect to suggest pulmonary
embolism.
Osseous structures: No suspicious lytic or blastic lesions are identified.
The study is not tailored for intra-abdominal examination, the visualized
viscera are unremarkable.
IMPRESSION:
1. Low lung volumes with trace bilateral pleural effusions.
2. Two right upper lobe nodules, the largest which measures 4 x 7mm. This
was not seen previously and could be inflammatory or a true nodule and
followup chest CT in 3 months is recommended.
3. Prominent bi-axillary nodes as well as right paratracheal node, minimally
changed in size when compared to prior examination dated ___ likely
secondary to known CLL.
4. No pulmonary embolism.
NOTIFICATION: Findings and recommendations were discussed with ___,
house staff caring for the patient, by Dr. ___ telephone at 11:21, on
___.
Radiology Report
EXAMINATION: Abdominal radiograph
INDICATION: ___ year old man with CLL, leukocytosis, diarrhea, treating
empirically for c diff // ?Megacolon, perforation
TECHNIQUE: Portable abdominal radiograph
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Minimally dilated loops of small bowel in the right abdomen, measuring up to
3.0 cm in diameter. There are no abnormally dilated loops of large bowel to
suggest megacolon. The apparent sigmoid colonic wall thickening is probably
due to colonic under-distension. The left lateral decubitus view does not show
any evidence of intraperitoneal free air.
IMPRESSION:
1. No abnormally dilated loops of colon to suggest megacolon.
2. No pneumoperitoneum.
3. Minimally dilated small bowel loops, measuring up to 3.0cm in diameter.
NOTIFICATION: Final results were telephoned to Dr. ___ By Dr. ___ on
___ at 3:29PM.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with CLL and autoimmune hemolytic anemia with
decreased breath sounds on examination. // Question of bilateral pleural
effusions.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiac size normal. Mediastinal lymph nodes are better seen in prior CT. The
upper lungs are clear. There is no pneumothorax or right pleural effusion.
Small left effusion and atelectasis has minimally increased. Right IJ catheter
tip is in the lower SVC. The osseous structures are unremarkable
IMPRESSION:
Minimal increase in size of small left effusion and adjacent atelectasis
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Transfer, Hypotension
Diagnosed with HYPOTENSION NOS, CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, ACQ HEMOLYTIC ANEMIA NOS
temperature: 99.1
heartrate: 111.0
resprate: 16.0
o2sat: 97.0
sbp: 109.0
dbp: 70.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with CLL and autoimmune
hemolytic anemia who presents with fever, hypotension, anemia,
and chest pain.
# AUTOIMMUNE HEMOLYTIC ANEMIA: Patient has known direct Coombs
positive warm antibody autoimmune, often triggered by acute
illness. This presentation was likely in the setting of an acute
diarrheal illness. On admission, his Hct was 15 and labs were
consistent with hemolytic anemia. Patient was started on high
dose steroids and high dose folic acid. He was transfused a
total of 9 units pRBC in the ICU over the course of four days.
Hct improved to 20 on transfer to the floor. On the floor he was
continued on 40 mg IV methylprednisolone. He required an
additional four units of packed red blood cells on the ___
service. While remaining on the 40 milligrams IV
methylprednisolone Q12H, he did undergo rituximab infusion on
___ and ___. At the time of discharge
his H/H was 7.3/23.1. He did not require any blood transfusions
in the six days prior to discharge. He was transitioned to
prednisone 80 milligrams PO daily and was discharged on this
medication regimen. He was continued on folic acid 5 mg PO
daily. He was also discharged on acyclovir and bactrim given the
chronic steroid use.
Of note: PND labs were negative. G6PD was 25.8.
# LEUKOCYTOSIS/FEVER: WBC on admission was 32 with a neutrophil
predominance, though it uptrended to 104.5. Although patient
has known CLL, neutrophil predominance suggested a possible
infectious process vs. steroid-induced leukocytosis. Patient
was started on vancomycin, cefepime, and azithromycin initially
given CLL/functional neutropenia. Infectious work-up, including
C diff and stool studies, respiratory panel, and urine culture
was negative. CXR was notable for atelectasis without evidence
of pneumonia. Blood cultures remained negative. Antibiotics
were discontinued and his WBC continued to trend down. At the
time of discharge his WBC count was 10.8.
# CHRONIC LYMPHOCYTIC LEUKEMIA: Confirmed by flow cytometry and
FISH ___, no bothersome LAD or B symptoms so currently no
plan for treatment in the near future. CT of Chest ___:
showed severe adenopathy in the axillae, milder in the
mediastinum. CT of Abdomen and Pelvis: Mild splenomegaly of 15.7
x 9.2 cm; moderate retroperitoneal lymphadenopathy. Patient
underwent rituximab infusion as noted above.
# TACHYCARDIA: Patient became persistently tachycardic with HRs
to 140s on hospital day 2. Telemetry and EKG were notable for
sinus tachycardia, most likely secondary to anemia given acute
hematocrit coinciding with the tachycardia. CTA on admission
was negative for pulmonary embolism. When arriving on the floor
his tachycardia did improve. Heart rate remained around 100 bpm.
Patient remained asymptomatic with this tachycardia and was
hemodynamically stable while on the bone marrow transplant
floor.
# HYPOTENSION: Patient was hypotensive on admission and
briefly required pressors. Initial concern was for septic shock
given ___ SIRS criteria, though no infectious source could be
identified. Blood pressure improved after blood transfusions,
suggesting hypovolemic shock. After transfer to the ___ floor,
his blood pressures were stable. His lisinopril and
hydrochlorothiazide were stopped as his blood pressure was well
controlled without these medications.
# DIARRHEA: Stool culture from the outside hospital grew
pseudomonas, though GI did not believe that this was the cause
of his diarrhea. Repeat stool studies here, including C diff,
were negative. CMV negative. Given decreased oxygen-carrying
capacity in the setting of hemolytic anemia, ischemic colitis is
possible, though additional work-up was deferred. Patient
remained on antibiotics as noted above-vancomycin, cefepime,
azithromycin. Diarrhea decreased throughout hospitalization and
resolved at the time of discharge.
# CHEST PAIN: Patient had chest pain on admission that
responded to morphine and did not recur. EKG was unchanged and
cardiac enzymes were negative. CTA was negative for pulmonary
embolism. Chest pain was likely in the setting of anemia.
TRANSITIONAL ISSUES
===================
#PULMONARY NODULES: A CTA of the chest revealed "two right upper
lobe nodules the largest measuring 4mm x 7mm." Recommendation is
for follow-up CT of the chest in 3 months.
#FOLLOW-UP H/H: Patient has a follow-up H/H scheduled for
___.
#RITUXIMAB THERAPY: Patient underwent rituximab therapy on ___
and ___. Based on this schedule he is set to undergo his third
infusion of rituximab on ___.
#PREDNISONE TAPER: Discharged on prednisone 80 milligrams PO
daily. He was given a prescription for 7 days. Please address
tapering of prednisone as an outpatient.
#CONTACT: ___ ___
#CODE STATUS: FULL CODE. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lactose / morphine / onions
Attending: ___
Chief Complaint:
abdominal pain/SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with history of alcoholic cirrhosis, alcohol
abuse
complicated by withdrawal seizures, asthma with multiple
intubations in the
past presenting with abdominal pain and SOB.
Pt states his symptoms began ___ days ago with abdominal pain
and SOB. Abdominal pain radiates to his back and bilateral,
associated with nausea and "dry heaves". Also with subjective
fevers and chills. No hematemesis, melena, or hematochezia.
Unclear if pain worsened with food but pt has only been taking
in liquids recently. Uncertain if this feels like prior
episodes of pancreatitis. Pt states he also began drinking
again several days ago.
Pt additionally reports SOB over this time as well with
associated dry cough and wheezing. Has not missed any doses of
meds but does report not getting methadone for last few days d/t
DOE.
In the ED,
VS: Temp: 99.5 HR: 110 BP: 131/92 Resp: 20 O(2)Sat: ___id not appear to be actively w/d'ing on initial exam. Pulm
exam notable for wheezing
Labs: AST: 136, ALT: 37, Alk Phos: 982, Tbili: 2.3 (mildly
hemolyzed specimen)
CXR negative, CT a/p negative for pancreatitis, did show know
cirrhosis with splenomegaly and esophageal varices.
___ given several duonebs, methylpred, 1L NS, Zofran,
hydromorphone and admitted for management of abdominal pain,
EtOH w/d, and asthma exacerbaton
ROS:
GEN: positive for fevers, chills, negative for weight loss
HEENT: denies vision changes, headache
CV: denies chest pain, palpitations
RESP: see above HPI
GI: see above HPI
EXT: denies edema
NEURO: reports tremors, denies numbness/weakness
Rest of 10 point review of systems otherwise negative.
Past Medical History:
-Immunodeficiency/CMV gastritis
-Esophageal candidiasis
-Asthma with h/o intubation and difficult extubation
-Substance abuse: etoh with h/o withdrawal and DTs
-ETOH cirrhosis
-Pancreatitis
-Adjustment Disorder with Depressed Mood
-Gastritis without bleeding due to alcohol and CMV (CMV seen on
path report from gastric biopsy ___
-Atopic Dermatitis
-Allergic Rhinitis
Social History:
___
Family History:
Uncle died of EtOH cirrhosis. Multiple family members with
asthma including mother and sister. No other known ailments on
maternal side, does not know about father's side.
Physical Exam:
GEN: laying in bed, appears to be in discomfort
HEENT: no scleral icterus, no tongue fasciculations
CV: RRR, no m/r/g, no JVD
RESP: Diffuse wheezing throughout with decreased air movement,
no respiratory distress
GI: Soft, TTP in RUQ and LUQ, no rebound, mildly distended
EXT: no edema, WWP
SKIN: No rashes, no jaundice
NEURO: AAOx3, conversing normally, mild bilateral hand tremor,
no asterixis
PSYCH: Normal mood and affect, no e/o visual or auditory
hallucinations
Pertinent Results:
___ 01:40AM BLOOD WBC-8.3 RBC-4.33* Hgb-12.2* Hct-39.1*
MCV-90# MCH-28.2 MCHC-31.2* RDW-16.0* RDWSD-52.0* Plt ___
___ 01:40AM BLOOD Neuts-66.8 Lymphs-18.0* Monos-11.3
Eos-2.9 Baso-0.5 Im ___ AbsNeut-5.55# AbsLymp-1.49
AbsMono-0.94* AbsEos-0.24 AbsBaso-0.04
___ 02:12AM BLOOD ___ PTT-35.3 ___
___ 01:40AM BLOOD Glucose-86 UreaN-7 Creat-0.4* Na-137
K-4.1 Cl-102 HCO3-23 AnGap-16
___ 01:40AM BLOOD ALT-37 AST-136* AlkPhos-982* TotBili-2.3*
___ 01:40AM BLOOD Lipase-86*
___ 01:40AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.8 Mg-1.7
EXAMINATION: Chest radiograph. (___)
INDICATION: ___ w/wheeze and cough and tactile fevers, please
eval for PNA
// ___ w/wheeze and cough and tactile fevers, please eval for
PNA
TECHNIQUE: Single AP view.
COMPARISON: CTA chest ___.
FINDINGS:
Lung volumes are low. Bibasal areas of atelectasis are
extensive, in
particular in the right lung base Heart size is within normal
limits. Lung
fields are clear. There is no pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
EXAMINATION: CT abdomen pelvis. (___)
INDICATION: NO_PO contrast; ___ w/cirrhosis, abdominal pain,
immunosuppressed
with fevers, please eval for intraabdominal abscessNO_PO
contrast // ___
w/cirrhosis, abdominal pain, immunosuppressed with fevers,
please eval for
intraabdominal abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy
(Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 16.8 mGy
(Body) DLP = 914.7
mGy-cm.
Total DLP (Body) = 930 mGy-cm.
COMPARISON: CT ___ and MRCP ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver has a cirrhotic morphology. There is
no evidence of
focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: Mild splenomegaly is unchanged. The attenuation of the
spleen is
within normal limits.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted. Esophageal, splenic and periportal varices are
unchanged.
BONES: Mild to moderate compression deformities of the T7 and T9
vertebral
bodies are unchanged. No evidence of osseous malignancy or
infection.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No acute intra-abdominal abnormality.
2. Cirrhotic liver morphology with re-demonstrated mild
splenomegaly and
varices. No focal hepatic lesions seen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acamprosate 666 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sertraline 100 mg PO DAILY
10. Spironolactone 50 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
15. melatonin 3 mg oral QHS
16. Symbicort (budesonide-formoterol) ___ inhalation INHALATION
BID
Discharge Medications:
1. Azithromycin 500 mg PO Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Duration: 2 Days
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 6
hours as needed for pain Disp #*8 Tablet Refills:*0
3. PredniSONE 50 mg PO DAILY Duration: 1 Day
RX *prednisone 50 mg 1 tablet(s) by mouth daily Disp #*1 Tablet
Refills:*0
4. Acamprosate 666 mg PO TID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. melatonin 3 mg oral QHS
11. Methadone 80 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Sertraline 100 mg PO DAILY
16. Spironolactone 50 mg PO DAILY
17. Thiamine 100 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Alcohol withdrawal
Asthma exacerbation
Opiate dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ w/wheeze and cough and tactile fevers, please eval for PNA
// ___ w/wheeze and cough and tactile fevers, please eval for PNA
TECHNIQUE: Single AP view.
COMPARISON: CTA chest ___.
FINDINGS:
Lung volumes are low. Bibasal areas of atelectasis are extensive, in
particular in the right lung base Heart size is within normal limits. Lung
fields are clear. There is no pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT abdomen pelvis.
INDICATION: NO_PO contrast; ___ w/cirrhosis, abdominal pain, immunosuppressed
with fevers, please eval for intraabdominal abscessNO_PO contrast // ___
w/cirrhosis, abdominal pain, immunosuppressed with fevers, please eval for
intraabdominal abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 16.8 mGy (Body) DLP = 914.7
mGy-cm.
Total DLP (Body) = 930 mGy-cm.
COMPARISON: CT ___ and MRCP ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver has a cirrhotic morphology. There is no evidence of
focal lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Mild splenomegaly is unchanged. The attenuation of the spleen is
within normal limits.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Esophageal, splenic and periportal varices are unchanged.
BONES: Mild to moderate compression deformities of the T7 and T9 vertebral
bodies are unchanged. No evidence of osseous malignancy or infection.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal abnormality.
2. Cirrhotic liver morphology with re-demonstrated mild splenomegaly and
varices. No focal hepatic lesions seen.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified asthma with (acute) exacerbation, Unspecified abdominal pain
temperature: 99.5
heartrate: 110.0
resprate: 20.0
o2sat: 96.0
sbp: 131.0
dbp: 92.0
level of pain: 10
level of acuity: 3.0 | ASSESSMENT/PLAN:
___ male with PMHx alcoholic cirrhosis, alcohol abuse
complicated by withdrawal seizures, asthma with multiple
intubations in the past, and chronic pain on methadone
presenting with abdominal pain and SOB.
# Abdominal pain-- Pt reports mid-epigastric pain on
presentation radiating to back and flanks. CT a/p performed in
ED negative for any acute processes or signs of acute
pancreatitis. Very mild elevation in lipase. This was felt to
be more likely alcoholic gastritis rather than acute on chronic
pancreatitis. It was managed conservatively with bowel rest and
initially IV dilaudid which was transitioned to PO after pt
tolerating diet. PO dilaudid was also subsequently tapered and
pt was discharged with a 2 day supply for any ongoing
breakthrough pain.
# EtOH w/d-- ___ was monitored on CIWA and initially required
several doses of 4mg PO ativan which was tapered to 2 mg, 1 mg
and subsequently off as pt was no longer showing signs of
withdrawal.
# SOB/Asthma exacerbation-- Pt presents with SOB and is very
wheezy on exam with poor air movement. Unclear trigger for
asthma exacerbation but suspect possible ?aspiration event in
s/o recent ETOH intake. ___ reports medication compliance but
this may have also been a precipitating factor. He was started
on a prednisone burst, azithromycin, and given duonebs with
improvement.
# Opiate dependence-- Per reports, pt with long history of
hydromorphone use/abuse with issues in the past with getting
discharged from methadone clinics. Currently, he is at Habit
OPCO and was continued on 80mg methadone. Pt expressed
significant discontent with his pain medication regimen while
inpatient. However, it was felt to be unsafe to escalate
regimen more than 0.5mg IV dilaudid q4H initially as he was also
getting his outpatient methadone in addition to Ativan. Staff
also found him to be frequently somnolent despite reports that
his pain was poorly controlled.
# Elevated Transaminases-- Mildly elevated AST, Alk phos in
900's. Alk phos has been significantly elevated in 800's in the
past. MRCP was done last admission in ___ and this did not
show an intra- or exta-hepatic biliary duct dilatation or
masses. Alk phos remained elevated throughout his stay but his
AST/ALT downtrended.
# Cirrhosis-- home lasix and spironolactone were held initially
as pt had poor PO intake. He remained euvolemic despite holding
these medications and they will be resumed upon discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Throat pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of emergency repair acute Type A dissection
___ at ___ (30mm Gelveave graft from STJ -
innominate artery) who presents with chest pain and concern for
new dissection or aortic clot on CT scan.
Patient was in his USOH until ___ when he developed a
senstation that his throat was 'bruised' during inspiration. He
then developed intermittent left sided chest, axilla, and back
pain on ___ at rest. The pain would come and go, and could
get up to ___. He notes the chest pain more when laying on his
right side and the throat sensation more when he is lying on his
back. Due to his symptoms, his PCP told him to proceed to ___,
and he went to ___ on ___. There, a CTA showed concern
for a Type A aortic dissection of indeterminate age, but no
active extravasation. There was also some concern for an aortic
clot at some point, although not mentioned in the read. He was
then transferred to ___ for further evaluation.
In the ___ intial vitals were pain 4, T 98.5, HR 106, BP 123/84,
RR 18, O2 92% RA. Initial labs were notabele for WBC 11.1, INR
1.2, and trops negative x1. Remainder of CBC and chem10 were
wnl. Cardiac surgery was consulted who felt that this was not an
acute issue, but recommended repeat imaging in 48-72 hours. They
also recommended against any anticoagulation. Patient was then
transferred to cardiology for further management. Vitals on
transfer were pain 0, T 97.7, HR 98, BP 130/77, RR 15, O2 94%RA.
On the floor patient notes only mild throat discomfort, and
denies dysphagia or difficulty breathing. He also notes he will
have some chest pain as above when he rolls on his left side.
Both of these are significantly improved from earlier in the
week. He denies recent fevers or chills. No SOB or cough. No
palpitations. No nausea, vomiting or diarrhea. No recent travel
and no pain or swelling in his legs. He does note he started
taking tiotropium inhaler and atorvastatin on ___ preceeding
these symptoms. ROS is otherwise unremarkable.
Past Medical History:
1. Type A aortic dissection status post emergent repair at ___
___ in ___ with a 30 mm Gelweave graft from
the sinotubular junction to takeoff of the innominate artery.
2. Dyslipidemia.
3. Hypertension.
4. PFO and atrial septal aneurysm with apparent small stroke by
brain MRI.
5. Reported history of cluster headaches, also with complaint of
visual auras in the absence of headache.
6. Tobacco use.
7. ?CODP
Social History:
___
Family History:
-Maternal aunt, ___ who has an ascending aortic aneurysm and
is being evaluated at ___ without as
yet a clear genetic diagnosis.
-Cousin, (son of ___ also had an ascending aortic aneurysm
and has been seen at ___.
-Father with PE at ___
Physical Exam:
ON ADMISSION
VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA
General: Well appearing pleasant man in NAD
HEENT: Anicteric sclerae, PERLL, OP clear
Neck: No LAD, JVD not elevated
CV: RRR, no MRG
Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL
Abdomen: Soft, NT, nondistended. No HSM
Ext: No unilateral swelling or erythema. No edema
Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all
extremities equally.
ON DISCHARGE
VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA
General: Well appearing pleasant man in NAD
HEENT: Anicteric sclerae, PERLL, OP clear
Neck: No LAD, JVD not elevated
CV: RRR, no MRG
Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL
Abdomen: Soft, NT, nondistended. No HSM
Ext: No unilateral swelling or erythema. No edema
Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all
extremities equally.
Pertinent Results:
ON ADMISSION
___ 06:30PM BLOOD WBC-11.1* RBC-5.27 Hgb-14.1 Hct-42.7
MCV-81* MCH-26.7* MCHC-33.0 RDW-13.1 Plt ___
___ 06:30PM BLOOD Neuts-62.6 ___ Monos-8.5 Eos-1.5
Baso-0.8
___ 06:30PM BLOOD ___ PTT-28.9 ___
___ 06:30PM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-133 K-3.5
Cl-101 HCO3-23 AnGap-13
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
ON DISCHARGE
___ 07:05AM BLOOD WBC-10.4 RBC-4.84 Hgb-13.3* Hct-39.9*
MCV-83 MCH-27.5 MCHC-33.3 RDW-12.9 Plt ___
___ 07:05AM BLOOD Neuts-54.5 ___ Monos-5.6 Eos-3.0
Baso-0.5
___ 07:05AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-138
K-4.4 Cl-104 HCO3-26 AnGap-12
___ 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
___ 07:10AM BLOOD TSH-3.0
___ 07:10AM BLOOD T4-8.3
STUDIES:
CTA TORSO (___)
1. Apparent discontinuity of the ascending aorta with
communication to an
adjacent hematoma/fluid collection. Hyperdense areas adjacent
to this site
raise concern for extravasation of contrast into a contained
rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA
to assess for
active extravasation of contrast into the adjacent mediastinal
collections.
Comparison with any prior post-operative chest CTs would also be
helpful to
determine chronicity of findings.
2. 2-cm partially thrombosed aneurysm of the left gastric
artery
3. Nonspecific mediastinal and hilar adenopathy which is stable
since ___
suggesting a benign etiology.
4. Borderline pelvic lymph nodes of uncertain etiology and
chronicity.
5. Stable 3-cm left adrenal adenoma.
6. Ectasia of the right common iliac artery measuring 1.7 cm.
7. Diverticulosis
CT NECK (___)
1. No abnormal fluid collection or lymphadenopathy in the neck.
2. Mediastinal fluid collection and aortic dissection remain
unchanged since
prior study on ___.
CTA CHEST (___)
Probable thrombosed traumatic pseudoaneurysm medial to the
ascending aortic graft. The chronicity of these findings is
uncertain, though given probable surrounding granulation tissue,
findings are at least subacute or chronic. No acute active
extravasation is identified. Comparison with prior
post-operative CT examinations would be helpful. Recommend
short interval followup CT (~3 months) to assess for stability
and to guide any potential further interventional management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Throat pain
Hypoxia
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with history of type A aortic dissection, status
post emergent surgical repair in ___ with a 30-mm Gelweave graft from
STJ-innominate artery. Patient now presenting with chest and back pain
acutely. Assess for interval change.
COMPARISON: CTA of the chest from outside hospital performed on ___ and CTA of the chest and abdomen from outside hospital performed on
___.
TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained
with intravenous contrast. Images were acquired in an arterial phase.
Coronal and sagittal reformations were prepared. Additionally, 3D
reformations were created on a separate workstation and reviewed on the PACS.
CT CHEST WITH INTRAVENOUS CONTRAST: The thyroid gland is homogeneous without
focal nodule. No supraclavicular or axillary lymphadenopathy is identified.
Numerous mediastinal lymph nodes overall appear unchanged compared to most
recent prior examination from two days prior and many were present on
preoperative chest CT from ___. An anterior mediastinal lymph
node at the level of the great vessel takeoff measures 11 x 13 mm as compared
to 11 x 10 mm previously (2:38). A probable conglomerate of right hilar lymph
nodes measures 17 x 20 mm as compared to 16 x 22 mm on prior examination from
___ (2:56). The etiology is uncertain, though stability over ___ years
suggests a non-neoplastic etiology. The heart size is normal, and there is no
pericardial effusion. The central pulmonary arteries are patent.
The tracheobronchial tree is patent to subsegmental levels without bronchial
wall thickening or bronchiectasis. There is extensive centrilobular and
paraseptal emphysema predominantly within the lung apices. No suspicious
pulmonary nodule or mass is identified. Linear atelectatic scarring is
identified within the bilateral lung bases. There is no pleural effusion.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver demonstrates homogeneous
parenchymal enhancement without suspicious focal lesion. Subcentimeter
hypodensities within segment ___ and VI are unchanged compared to prior
examination and remain too small to characterize, though may represent small
cysts or biliary hamartomas. A simple cyst within segment IVb of the liver
measuring 1.8 x 1.4 cm is slightly increased in size since ___. Hepatic
veins and portal venous system are grossly patent. No intra- or extra-hepatic
biliary ductal dilatation is identified. The gallbladder, spleen, pancreas,
and right adrenal gland are normal. A 2.5 x 3.0 cm hypodense lesion within
the left adrenal gland is stable compared to prior examination of ___ and had
prior attenuation characteristics consistent with an adenoma. The kidneys
enhance symmetrically without suspicious focal lesion. There is no
hydronephrosis. Incidental note is made of a splenule. Stomach and small
bowel loops are normal in caliber and configuration without evidence of
obstruction or inflammation. There is no abdominal free fluid or free air.
No suspicious mesenteric or retroperitoneal lymphadenopathy is identified.
CT PELVIS WITH INTRAVENOUS CONTRAST: There is colonic diverticulosis without
signs of acute inflammation or obstruction. The bladder is distended and
appears normal. Prostate and seminal vesicles are unremarkable.
Subcentimeter pelvic lymph nodes are identified which are of uncertain
etiology. A left external iliac lymph node measures 8 x 20 mm (2:236) and a
right external iliac lymph node measures 8 x 10 mm (2:239). The stability of
these nodes cannot be determined as no prior pelvic imaging is available for
comparison. No suspicious inguinal adenopathy is identified.
CTA: The patient is status post emergent repair of a type A aortic dissection
in ___. The postoperative appearance of the ascending aorta appears
similar to recent examination from ___ from outside hospital.
The ascending aorta measures 5.2 x 5.2 cm at its maximum diameter, and this is
unchanged compared to recent prior examination. However, there appears to be
focal discontinuity of the medial aortic wall (2:52) and communication with an
adjacent hematoma/fluid collection. Hyperdense material is also identified
adjacent to this collection (2:49-54) which raises concern for extravasation
of contrast into a pseudoaneurysm. The adjacent collection measures 2.4 x 3.5
cm and is similar in size compared to CT from 2 days prior, though this
stability could just reflect a subacute contained rupture. The collection
described above appears to be in continuity with a second more superior
anterior mediastinal collection (2:43). This collection has a hyperdense rim
and is stable in size compared to CT from 2 days prior. Given the clinical
history, findings are concerning for subacute contained aortic rupture.
Comparison with prior post-operative chest CTs would be helpful to determine
the acuity of findings. Recommend follow-up multiphase chest CT to determine
if active extravasation is present. A focal dissection flap is seen at the
level of the aortic arch with extension into the proximal descending thoracic
aorta.
The descending thoracic aorta is normal in caliber and widely patent without
significant atherosclerotic plaque. The abdominal aorta and branch vessels
are non-aneurysmal and grossly patent. No focal dissection is identified.
There is minimal atherosclerotic plaque involving the infrarenal abdominal
aorta just proximal to the common iliac bifurcation. The right common iliac
artery is mildly ectatic measuring 1.7 x 1.4 cm (2:202). Distal flow to the
internal-external iliac arteries is preserved. There is variant anatomy at
the celiac axis. The common celiac trunk gives rise to the left gastric
artery and the splenic artery, and the common hepatic artery arises directly
from the aorta (2:133). There is an aneurysm of the left gastric artery
arising 2.7 cm from the origin of the aorta. The aneurysm measures 1.2 x 1.3
x 2.2 cm (2:122 and 602B:42). The more inferior portions of the aneurysm are
partially thrombosed. There is also a replaced left hepatic artery arising
from the left gastric artery. The SMA origin is widely patent. The two right
renal and one left renal arteries are widely patent. The ___ is also
widely patent.
BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is
identified.
IMPRESSION:
1. Apparent discontinuity of the ascending aorta with communication to an
adjacent hematoma/fluid collection. Hyperdense areas adjacent to this site
raise concern for extravasation of contrast into a contained
rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA to assess for
active extravasation of contrast into the adjacent mediastinal collections.
Comparison with any prior post-operative chest CTs would also be helpful to
determine chronicity of findings.
2. 2-cm partially thrombosed aneurysm of the left gastric artery
3. Nonspecific mediastinal and hilar adenopathy which is stable since ___
suggesting a benign etiology.
4. Borderline pelvic lymph nodes of uncertain etiology and chronicity.
5. Stable 3-cm left adrenal adenoma.
6. Ectasia of the right common iliac artery measuring 1.7 cm.
7. Diverticulosis
Dr. ___ communicated the above findings and recommendations (#1)
to Dr. ___ at 4:45 pm on ___ by telephone ___ minutes after
discovery.
DLP: 1253.56 mGy-cm
Radiology Report
HISTORY: Patient with throat pain, rule out abscess.
COMPARISON: CT chest from ___.
TECHNIQUE: Contiguous axial images were obtained through the neck following
administration of oral and 50 cc of Omnipaque. Coronal and sagittal reformats
were also submitted for review.
CTDIvol: 42.44mGy
CLP: 629.32 mGy-cm.
FINDINGS:
There is no abnormal fluid collection in the neck. The mediastinal fluid
collection and aortic dissection remain unchanged since ___.
Evaluation of the aerodigestive tract demonstrate no exophytic mucosal mass,
nor areas of focal mass effect. Evaluation of the cervical lymph chains
demonstrate no pathologic lymphadenopathy by imaging criteria. Thyroid gland
is normal. The salivary glands are unremarkable in appearance. Neck vessels
enhance bilaterally without significant stenosis.
IMPRESSION:
1. No abnormal fluid collection or lymphadenopathy in the neck.
2. Mediastinal fluid collection and aortic dissection remain unchanged since
prior study on ___.
Radiology Report
HISTORY: ___ male with history of type A aortic dissection status
post emergent surgical repair in ___ with 30 mm Gelweave graft from
STJ-innominate artery. Patient now admitted with throat and back pain.
Concern on recent CT for aortic pseudoaneurysm adjacent to the graft site.
Assess for active extravasation.
COMPARISON: CTA of the chest from ___ and CTA of the chest from
outside hospital performed on ___.
TECHNIQUE: MDCT axial images of the thoracic aorta were obtained with and
without intravenous contrast. Initial axial images were acquired in a
non-contrast phase followed by arterial, portal venous, and delayed phase
imaging. Coronal and sagittal reformations were prepared.
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: A limited scan field of view
focused on the ascending aorta, aortic arch, and proximal descending aorta was
performed to assess for active extravasation into a mediastinal fluid
collection adjacent to a surgically repaired ascending aorta. A previously
described fluid collection adjacent to the ascending aortic graft just to the
left of midline appears stable in size compared to multiple recent prior
examinations. Additionally, the collection is mildly hyperattenuating on
non-contrast images and does not demonstrate significant appreciable
enhancement (2:38 and 11:38). There are linear septations between the
ascending aortic graft and the above described collection, however, there
still appears to be a direct communication between the aortic graft and this
collection. The slow progressive enhancement of the septations over time is
consistent with granulation tissue/fibrinous tissue. No contrast fills the
collection on post-contrast images to suggest active extravasation. A
slightly more superior anterior mediastinal collection demonstrates
progressive rim enhancement, though does not centrally enhance. The stability
over time, and lack significant contrast enhancement of these collections,
suggests that the process is subacute or chronic. The patient likely had a
subacute rupture of the graft at some point and has now developed a contained
thrombosed pseudoaneurysm surrounded by granulation tissue. Comparison with
prior postoperative CTs would be helpful for further assessment. Scattered
mediastinal lymph nodes remain borderline in size and are unchanged compared
to most recent prior examination. Central pulmonary arteries are patent.
Severe paraseptal and centrilobular emphysema is noted. No bone destructive
lesion or acute fracture is identified. Imaged median sternotomy wires appear
intact.
IMPRESSION:
Probable thrombosed traumatic pseudoaneurysm medial to the ascending aortic
graft. The chronicity of these findings is uncertain, though given probable
surrounding granulation tissue, findings are at least subacute or chronic. No
acute active extravasation is identified. Comparison with prior
post-operative CT examinations would be helpful. Recommend short interval
followup CT (~3 months) to assess for stability and to guide any potential
further interventional management.
Dr. ___ communicated the above results and recommendations to Dr.
___ at 4:30 pm on ___ by telephone.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with THORACIC AORTIC EMBOLISM
temperature: 98.5
heartrate: 106.0
resprate: 18.0
o2sat: 92.0
sbp: 123.0
dbp: 84.0
level of pain: 4
level of acuity: 2.0 | ___ with history of emergency repair acute Type A dissection
___ at ___ (30mm Gelveave graft from STJ -
innominate artery) who presents with throat pain.
# Throat pain:
Due to the patient's history of type A dissection, there was
concern for aortic dissection. CTA from the outside hospital
showed evidence of dissection, but this was thought to represent
a chronic flap from his previous dissection. Cardiac surgery was
consulted, who recommended repeat CTA in 48 hours to evaluate
for progression. Repeat CTA on ___ showed extravasation of
contrast into a contained rupture/pseudoaneurysm. Radiology
recommended repeat multiphase CTA to assess for active
extravasation. Repeat CTA on ___ was negative for acute/active
extravasation, however the patient likely had a leak in the
past, given the presence of granulation tissue. Radiology
recommended repeat CTA in 3 months to evaluate for progression.
We were unable to obtain films from ___, where
the patient was diagnosed with his dissection. However a
post-operative CTA report did not note any leak. The patient
remained hemodynamically stable. Blood pressure and pulses were
equal in both arms. His losartan dose was increased to 50mg. The
patient's throat pain resolved during hospitalization, and the
etiology was thought to be due to a viral infection.
# COPD:
The patient denied any shortness of breath. CT chest with
extensive centrilobular and paraseptal emphysema. He was also
found to be slightly hypoxic (SpO2 89-91% with ambulation). The
patient was continued on spiriva. Smoking cessation was
encouraged.
# HTN: Currently normotensive. His dose of losartan was
increased to 50mg daily as losartan as it has been shown to be
beneficial in patients with cystic medial necrosis.
# Leukocytosis:
Noted on admission labs. Differential was within normal limits.
Baseline unknown. The patient was afebrile and without
infectious symptoms besides throat pain. WBC trended down during
hospitalization.
# HLD: Continued atorvastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Bactrim / Beta-Blockers (Beta-Adrenergic
Blocking Agts) / propranolol
Attending: ___
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old lady with H/O IDDM, hypertension, CAD s/p MI in
___, seizures, SLE, CKD, and recent discharge for syncope on
___ thought secondary to a seizure presents with chest
discomfort, dyspnea on exertion and fatigue today of sudden
onset while exerting herself. She denied palpitations but did
state that her heart felt like it had slowed down dramatically
when this occurred. She states she has never had symptoms like
this before, but has had substernal chest pain previously upon
awakening in the morning that was relieved with eating a meal.
Due to these new symptoms, she went to the ED where she was felt
to have sinus bradycardia to the ___ and hypertension. She was
recently started on propranolol 10 mg BID by her PCP for
essential tremor on ___. Her chest pain resolved by the time
she reached the ED, and over the ED course, it was noted that
she went from presumed sinus bradycardia to regular rhythm with
rates in the ___ but with a prolonged PR interval of ~300
msec. Cardiology was consulted in the ED who felt that her
bradycardia was secondary to her newly started propranolol, and
recommended admission to ___ for observation. After arrival to
the cardiology floor, she has no complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Insulin dependent diabetes (Dr. ___
- CAD (s/p MI ___
- Hypertension
- Hypercholesterolemia
- SLE (Dr. ___
- ___ arthritis
- Osteoporosis
- Cervical dysplasia
- Bell palsy
- Syphilis s/p penicillin Rx
- Fibular Fx and Tibial Fx s/p ORIF, ___
Social History:
___
Family History:
Mother - DM, CVA. Daughter - DM
Physical ___:
Admission Physical Exam:
General: Elderly ___ woman, alert, oriented, no
acute distress, hard of hearing
Vitals: T 98.0 BP 190/61 HR 78 RR 18 SaO2 94% on RA
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~10 cm, no LAD
Lungs: Bilateral bibasilar rales ___ up
CV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace pedal and pretibial edema.
Discharge Physical Exam:
General: Alert, oriented, no acute distress, hard of hearing
Vitals: T 98.4, BP 154/69, HR 53, RR 16, SaO2 95% on RA
HEENT: NC/AT. Sclera anicteric
Lungs: Minimal rales in the Right base. No wheezes, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at LUSB and RUSB; no rubs or gallops
Abdomen: soft, non-tender, non-distended, normo-active bowel
sounds present
Ext: Warm, well perfused, no edema.
Pertinent Results:
___ 07:16PM BLOOD WBC-8.8 RBC-3.57* Hgb-10.8* Hct-32.7*
MCV-91 MCH-30.2 MCHC-33.0 RDW-14.2 Plt ___
___ 07:16PM BLOOD Neuts-58.3 ___ Monos-8.5 Eos-2.5
Baso-0.3
___ 07:16PM BLOOD ___ PTT-31.1 ___
___ 07:16PM BLOOD Glucose-180* UreaN-40* Creat-1.7* Na-130*
K-5.1 Cl-99 HCO3-23 AnGap-13
___ 07:16PM BLOOD proBNP-1618*
___ 07:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
___ 07:00AM BLOOD TSH-1.0
DISCHARGE LABS (from day prior to discharge)
___ 07:00AM BLOOD WBC-7.2 RBC-3.63* Hgb-11.1* Hct-32.9*
MCV-91 MCH-30.6 MCHC-33.8 RDW-16.4* Plt ___
___ 06:43AM BLOOD Glucose-72 UreaN-32* Creat-1.2* Na-141
K-5.0 Cl-107 HCO3-29 AnGap-10
___ 07:16PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00AM BLOOD CK(CPK)-88
URINE STUDIES
___ 11:22PM URINE Color-Straw Appear-Clear Sp ___
___ 11:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 11:22PM URINE RBC-0 WBC-2 Bacteri-MOD Yeast-NONE Epi-1
TransE-<1
___ 11:22PM URINE CastHy-15*
___ 12:50AM URINE Hours-RANDOM UreaN-333 Creat-79 Na-12
K-30 Cl-11
___ 12:50AM URINE Osmolal-223
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
EKG ___
Ectopic atrial rhythm at a very slow rate. Left ventricular
hypertrophy with associated ST-T wave changes, although ischemia
or infarction cannot be excluded. Compared to the previous
tracing the rate is much slower.
___
___
EKG ___
Ectopic atrial rhythm at a normal rate with P-R interval
prolongation. Left ventricular hypertrophy with strain pattern.
Lateral T wave inversions. Non-specific ST segment flattening in
the inferolateral leads and non-specific J point elevation in
the right precordial leads. Compared to the previous tracing of
the prior date the rate is faster and now normal, although still
with leftward P wave axis. Left anterior fascicular block and
left ventricular hypertrophy with strain and/or ischemia are
unchanged. Non-specific repolarization abnormalities are
similar.
___
___
CXR PA/LAT ___
The heart size is at the upper limits of normal, likely
exaggerated by AP technique. The mediastinal contours
demonstrate a mildly tortuous aorta with calcified
atherosclerotic disease of the aortic knob. The lungs again
demonstrate a prominent reticular pattern particulary at the
bases without clear evidence of new consolidation. There is no
large pleural effusion or pneumothorax.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. DimenhyDRINATE 50 mg PO Q8H:PRN nausea
5. Docusate Sodium 100 mg PO BID
6. Enalapril Maleate 20 mg PO BID
7. LeVETiracetam 750 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
9. PredniSONE 5 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Furosemide 20 mg PO DAYS (___)
13. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily
alternating with 2 tablets daily.
14. NPH 15 Units Breakfast; NPH 5 Units Dinner
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enalapril Maleate 20 mg PO BID
6. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily
alternating with 2 tablets daily.
7. NPH 15 Units Breakfast; NPH 5 Units Dinner
8. LeVETiracetam 750 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
10. PredniSONE 5 mg PO DAILY
11. Simvastatin 10 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. DimenhyDRINATE 50 mg PO Q8H:PRN nausea
14. Furosemide 20 mg PO 3X/WEEK (___)
15. Doxazosin 2 mg PO HS
RX *doxazosin [Cardura] 2 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
16. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ectopioc atrial bradycardia, due to
Beta blocker toxicity
Chest pain
Coronary artery disease
Hypertension
Shortness of breath
Acute on chronic left ventricular diastolic heart failure
Acute kidney injury
Gastroesophageal reflux disease
Tremor
Diabetes mellitus
Hypothyroidism
Systemic lupus erythematosis
Rheumatoid arthritis
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with dyspnea and chest pain.
STUDY: AP upright and lateral chest radiographs.
COMPARISON: Chest CT from ___ and multiple chest radiographs from ___ to ___.
FINDINGS: The heart size is at the upper limits of normal, likely exaggerated
by AP technique. The mediastinal contours demonstrate a mildly tortuous aorta
with calcified atherosclerotic disease of the aortic knob. The lungs again
demonstrate a prominent reticular pattern particulary at the bases without
clear evidence of new consolidation. There is no large pleural effusion or
pneumothorax.
IMPRESSION: Chronic interstitial lung disease, but no definite evidence of
pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS
temperature: 98.5
heartrate: 97.0
resprate: 18.0
o2sat: 94.0
sbp: 132.0
dbp: 54.0
level of pain: 10
level of acuity: 2.0 | ___ year old lady with history of IDDM, hypertension, CAD s/p MI
in ___, seizures, SLE, CKD, and syncope who presented with
substernal chest pain, dyspnea on exertion and subjective
feeling of her heart slowing, found to have non-sinus
bradycardia and shortness of breath. Her bradycardia was felt
secondary to recently starting propanolol. She was monitored in
the hospital for propanolol washout, and her bradycardia
resolved (as such, she did not require a pacemaker). She should
avoid beta blockers in the future (now listed as an allergy).
>> Active Issues:
# Bradycardia: Following initiation of a nodal blocking agent,
Ms. ___ presented with a symptomatic ectopic atrial
bradycardic rhythm. Her propanolol was stopped, and her
bradycardia resolved. She also had first-degree AV block.
Hypothyroidism was less likely as a cause (TSH was wnl). Acute
MI was also unlikely as she had negative troponins and no
obvious ischemic ECG changes from baseline. Her chest discomfort
was likely due to new bradyarrhythmia.
- She was discharged in sinus rhythm and heart rate consistently
between 60-70.
- She should avoid all nodal blocking agents in the future.
# Shortness of breath: On admission, she was mildly volume
overloaded with JVD, rales, mild room air hypoxia, likely an
exacerbation of her chronic diastolic CHF. She responded well to
gentle diuresis with furosemide 20 mg IV.
# Acute Kidney Injury: Cr of 1.7 on admission, improved to 1.2
on discharge. FENa was less than 1%, so more likely pre-renal.
She endorsed poor PO intake prior to admission. ___ could also
be secondary to poor renal perfusion due to decreased cardiac
output when bradycardic, as well as diastolic heart failure.
# Hypertension: She was hypertensive on admission, which may
have caused exacerbation of diastolic heart failure. She was
started on doxazosin every evening to maintain control of BP
throughout the day. She was continued on her amlodipine and
ACE-I.
# CAD: Stable on this admission. Her chest pain today was in the
setting of bradycardia, and dyspnea suggestive of exacerbation
of diastolic CHF. Her more chronic symptom of morning
sub-sternal pain which is relieved with food and worsened by
lying down seems more related to dyspepsia or GERD than ischemic
in origin. She had no evidence of MI with serial normal
troponins, and was continued on her aspirin dihydropyridine
calcium channel blocker, and statin.
# Epigastric pain: Given the association with lying down and
eating, likely dyspepsia or GERD. She was started on omeprazole
for this.
>> Chronic issues
# History of seizures: Continued levetiracetam.
# SLE: Continued prednisone, hydroxychloroquine.
# DM, type 2: In house, she was managed with Humalog ISS and NPH
___.
>> TRANSITIONAL ISSUES
- CODE: Full.
- Contact: daughter is also HCP, ___ ___
- The patient reports that she actually takes hydroxychloroquine
twice daily, as opposed to alternating with lower dose.
- She should avoid nodal blocking agents in the future. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vertebral artery dissection and basilar thrombus
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The patient is a ___ year-old right-handed man without
significant
past medical history who presents with right ear ringing and
profound dizziness with nausea and vomiting. Patient was in his
usual state of health yesterday evening doing his regular gym
routine which included weight lifting and elliptical work he
felt
at his baseline state of health after his workout and went to
sleep. He woke up this morning with severe right sided tinnitus
profound nausea and vomiting and extreme dizziness without
visual
changes. He called ___ he was taken to an OSH, where he had CTA
which revealed left-sided vertebral artery dissection with
basilar thrombus. He was started on a heparin GTT with bolus
and
transferred to ___ for further care.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness,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:
No significant past medical history
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
========================
Physical Exam:
Vitals: reviewed in ED dashboard
General: Awake, cooperative, in severe distress due to
dizziness.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. 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:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. no evidence
of miosis.
III, IV, VI: EOMI without nystagmus. Normal saccades. no
evidence
of ptosis
V: Facial sensation intact to light touch. sweating
symmetrically
throughout face
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
No 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, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, No dysmetria on FNF
-Gait: deferred due to patient discomfort bc of profound
dizziness
Discharge Physical Exam:
========================
Vitals: reviewed in metavision
General: Awake, cooperative, in no acute distress.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time.
Able
to relate history without difficulty. Language is fluent with
normal prosody and no paraphasic errors. Able to follow both
midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades. No
evidence
of ptosis.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch throughout.
-DTRs: deferred
-___: No intention tremor, No dysmetria on finger nose
finger. No ataxia with heel to shin.
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 03:40PM BLOOD WBC-5.6 RBC-4.51* Hgb-13.3* Hct-41.2
MCV-91 MCH-29.5 MCHC-32.3 RDW-11.9 RDWSD-39.3 Plt ___
___ 03:40PM BLOOD Neuts-74.3* ___ Monos-3.4*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-4.18 AbsLymp-1.21
AbsMono-0.19* AbsEos-0.00* AbsBaso-0.02
___ 03:40PM BLOOD ___ PTT-150* ___
___ 03:40PM BLOOD Plt ___
___ 03:40PM BLOOD Glucose-127* UreaN-13 Creat-1.0 Na-140
K-5.7* Cl-107 HCO3-18* AnGap-15
___ 03:40PM BLOOD ALT-23 AST-49* AlkPhos-61 TotBili-0.4
___ 03:40PM BLOOD Lipase-19
___ 03:40PM BLOOD cTropnT-<0.01
___ 03:40PM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.2 Mg-2.1
Cholest-253*
___ 03:40PM BLOOD %HbA1c-5.0 eAG-97
___ 03:40PM BLOOD Triglyc-58 HDL-57 CHOL/HD-4.4
LDLcalc-184*
___ 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
MRI HEAD W/O CONTRAST:
1. Acute infarcts involving the right greater than left
cerebellar hemispheres, most likely resulting from the known
basilar artery thrombosis.
2. Loss of flow void is noted in the basilar artery in the same
region as demonstrated on CTA from the day prior. However,
complete evaluation is not possible as this is a non
angiographic examination.
INTERVAL/DISCHARGE LABS:
___ 06:25AM BLOOD WBC-3.5* RBC-4.20* Hgb-12.3* Hct-38.6*
MCV-92 MCH-29.3 MCHC-31.9* RDW-11.9 RDWSD-39.9 Plt ___
___ 06:25AM BLOOD ___ PTT-46.0* ___
___ 08:55AM BLOOD ___ PTT-46.0* ___
___ 06:12AM BLOOD ___ PTT-51.9* ___
___ 06:14AM BLOOD ___ PTT-43.2* ___
___ 03:49PM BLOOD LMWH-0.74
___ 06:25AM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-142
K-4.7 Cl-106 HCO3-26 AnGap-10
___ 06:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Medications on Admission:
None
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Warfarin 5 mg PO DAILY
RX *Coumadin 1 mg 5 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
Vertebral artery dissection
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/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with vertebral dissection c/b basilar artery
thrombus // evaluate thrombus, communicating arteries and vessels, r/o
infarct
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Reference CTA head and neck dated ___.
FINDINGS:
There are scattered foci of acute infarction in both inferior cerebellar
hemispheres, right greater than (4:5). These correspond with increased T2
signal (9:4). No additional infarction is identified. There is no evidence
of hemorrhage or mass. Loss of flow void within the basilar artery is noted
in a similar location as the thrombus demonstrated on CTA from 1 day prior
(9:7). However this is a non angiographic examination and complete evaluation
of the basilar artery is not possible. The ventricles and sulci are normal in
caliber and configuration.
Mild mucosal thickening is noted in the maxillary sinuses and anterior ethmoid
air cells. Mastoid air cells and middle ear cavities are clear. The imaged
portions of the orbits are unremarkable.
IMPRESSION:
1. Acute infarcts involving the right greater than left cerebellar
hemispheres, most likely resulting from the known basilar artery thrombosis.
2. Loss of flow void is noted in the basilar artery in the same region as
demonstrated on CTA from the day prior. However, complete evaluation is not
possible as this is a non angiographic examination.
NOTIFICATION: The finding of cerebellar infarction was documented in the
clinical notes in OMR at the time of interpretation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Vomiting, Transfer
Diagnosed with Dizziness and giddiness
temperature: 96.9
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 120.0
dbp: 65.0
level of pain: 0
level of acuity: 1.0 | SUMMARY:
========
Mr. ___ is a ___ year old man with no significant past
medical history who presented with a left vertebral dissection
and basilar artery thrombus.
#LEFT VERTEBRAL ARTERY DISSECTION
#BASILAR ARTERY THROMBUS
#CEREBELLAR INFARCTS
He initially presented with acute onset nausea and dizziness,
found to have a left vertebral artery dissection and basilar
artery thrombus. He was started on a heparin gtt. He was
admitted to the neuro ICU for frequent neurochecks, but remained
neurologically intact. An MRI was performed that showed
bilateral scattered infarcts in the cerebellum. He was
transitioned to lovenox from heparin and was started on warfarin
on ___. He was then transferred to the ___.
In the NIMU, he was monitored closely (remaining normotensive
during his NIMU course). He had only one episode on ___ when
he had symptoms including nausea, dizziness, vertigo, tinnitus
after exertion that were referable to the brainstem, possibly
related to overexertion and inadequate hydration. He was
encouraged to increase PO fluid intake and did not require
additional fluids or PRN antihypertensives. He was started on
atorvastatin 80mg daily and continued on warfarin except for 2
days (___) when his warfarin doses had to be held for a
supratherapeutic INR of 4.2. He was given education on
restrictions related to his dissection prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
Past Medical History:
DMII, GERD, morbid obesity, depression, LBP, lumbar disk
displacement
Social History:
___
Family History:
NC
Physical Exam:
Vitals: AVSS, see flowsheets
GEN: No distress, pleasant, conversant
HEENT: Sclera non-icteric, neck is supple without
lymphadenopathy, thyromegaly or JVD
HEART: RRR with no murmurs
CHEST: No increased work of breathing, clear to auscultation
bilaterally, no crackles or wheezes
ABDOMEN: Soft, non-tender, no rebound or guarding
INCISIONS: Incisions are clean, dry and intact without erythema
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
___ 09:49PM GLUCOSE-140* UREA N-15 CREAT-0.7 SODIUM-140
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
___ 09:49PM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-143* TOT
BILI-0.3
___ 09:49PM LIPASE-30
___ 09:49PM WBC-11.4* RBC-4.05# HGB-11.3# HCT-35.2#
MCV-87 MCH-27.9 MCHC-32.1 RDW-14.7 RDWSD-46.9*
___ 08:25AM URINE HOURS-RANDOM
___ 08:25AM URINE UCG-NEGATIVE
___ 08:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.5 LEUK-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H
2. Omeprazole 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
4. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*20 Tablet
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative pain, status-post open cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with s/p cholecystectomy ?biloma on CT// ?fluid
pocket, biliary dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT from earlier same day.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 9 mm.
GALLBLADDER: The patient is status post cholecystectomy. There is a 3.8 x 1.6
cm fluid collection within the cholecystectomy bed.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. A fluid collection within the cholecystectomy bed is re-demonstrated,
better assessed on prior CT from earlier today.
2. Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain, Type 2 diabetes mellitus without complications
temperature: 97.7
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | ___ was admitted to ___
on ___ for pain control and evaluation of imaging studies
obtained at an OSH concerning for biloma in the setting of her
recent open cholecyctectomy. On review of the imaging
studies with several surgeons and radiologists, it was
determined that the fluid collection on the outside hospital CT
scan was a small fluid collection consistent with normal
post-operative changes.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ ESRD ___ HD, HTN, IDDM currently on INH for tx of
latent TB, presenting from ___ clinic due to worsening dyspnea
along with progressive cough and overall malaise.
He first met new PCP ___ ___ at which time he complained of a
cough for at least 6 months duration. Prior to that visit, he
had a positive PPD and had AFB smears x3 in ___ which were
negative. He endorsed 15lb weight loss and hempoptysis. He was
referred to ID and saw them on ___ -> initiated on isoniazid
+B6 for 9 months for latent TB treatment. Since that time
patient denies any interval improvement in symptoms, and rather
his cough is maybe worse.
Day of arrival he was seen in the ___ clinic where patient noted
chest tightness and cough productive of thick yellow sputum. His
BP was 198/100 in the clinic, with 92% SaO2.
In the ED, initial vitals were 98.6 86 197/97 16 96% RA
Labs notable for K 6.0. Patient received levaquin and
ceftriaxone
Prior to transfer 98.3 82 176/105 14 98% RA
On the floor, he denies any fevers or night sweats but notes
some chills. He notes minimal increase in peripheral edema.
Notes epigastric pain worse with laying flat or food sometimes.
Also notes lose stools and nause+emesis that is chronic for
about ___ mo. Emesis caused by eating too much food. No pain
with food/water. Last significant emesis during ___.
Malaise along with current constant cough really bad in last 4
weeks. Wants to try crackers
Past Medical History:
ESRD on hemodialysis: presumed secondary to diabetes and/or
hypertension, HD on MWF; left radiocephalic AVF placed ___,
started HD ___
Diabetes ___ type II: diagnosed ___ with associated lower
extremity neuropathy
Hypertension: diagnosed around ___
Neck pain: C5 radiculopathy on EMG with C4-5 and C5-6 stenosis
on the right, followed by Dr. ___ at ___
Shoulder pain: ___
Family History:
Father: alive and healthy
Mother: diabetes ___ type II
One aunt with ESRD on HD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0, 190/98, 88, 94%RA
General: Coughing during entire exam and causes him discomfort.
NAD. AAOx3.
HEENT: Moist mucosa, pink conjuctiva, no scleral icterus
Neck: Venous pulsation up to mid neck
CV: S1/S2 without murmur, rate in the ___, fistual thrill
appreciated
Lungs: comfortable breathing but coughing significantly non
productive
Abdomen: Tender mid epigastrium and RUQ
GU: no foley
Ext: Left fistula with thrill
Neuro: CN ___ grossly intact
Skin: Dry chronic venous stasis changes of b/l legs. Midline
chest scar from younger years well healed
DISCHARGE PHYSICAL EXAM:
VS: T 98, HR 81, RR 17, BP 193/111, SpO2 94-95%
General: Coughing during entire exam. NAD. AAOx3.
HEENT: Moist mucosa, pink conjuctiva, no scleral icterus
Neck: JVD to mid neck
CV: RRR S1/S2 without murmur; hemodialysis in fistula
Lungs: CTAB, comfortable breathing but non productive cough
Abdomen: obese, nontender, nondistened, w/o appreciable
organomegaly
GU: no foley
Ext: Left fistula with hemodialysis currently; Dry chronic
venous stasis changes of b/l legs.
Neuro: CN ___ grossly intact
Pertinent Results:
ADMISSION RESULTS:
------------------
___ 10:19PM URINE HOURS-RANDOM UREA N-208 CREAT-58
SODIUM-89 POTASSIUM-22 CHLORIDE-50
___ 10:19PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN->600
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-MOD
___ 10:19PM URINE RBC-5* WBC-79* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 06:00PM GLUCOSE-268* UREA N-73* CREAT-18.3*#
SODIUM-139 POTASSIUM-6.1* CHLORIDE-96 TOTAL CO2-29 ANION GAP-20
___ 06:00PM estGFR-Using this
___ 06:00PM CALCIUM-8.3* PHOSPHATE-6.4* MAGNESIUM-2.3
___ 06:00PM WBC-9.6 RBC-3.82* HGB-10.8* HCT-35.4* MCV-93
MCH-28.3 MCHC-30.5* RDW-13.8
___ 06:00PM NEUTS-69 BANDS-1 LYMPHS-13* MONOS-11 EOS-6*
BASOS-0 ___ MYELOS-0
___ 06:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:00PM PLT SMR-NORMAL PLT COUNT-149*
___ 02:40PM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-92 TOT
BILI-0.4
___ 02:40PM WBC-10.7 RBC-4.02* HGB-11.1* HCT-37.7* MCV-94
MCH-27.7 MCHC-29.5* RDW-14.4 PLT COUNT-151
___ 02:40PM NEUTS-69.5 LYMPHS-16.3* MONOS-11.0 EOS-2.8
BASOS-0.4
PERTINENT RESULTS:
------------------
___ 07:29AM BLOOD %HbA1c-9.7* eAG-232*
___ 10:19PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:19PM URINE Blood-SM Nitrite-NEG Protein->600
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-MOD
___ 10:19PM URINE RBC-5* WBC-79* Bacteri-FEW Yeast-NONE
Epi-<1
___ 10:19PM URINE Hours-RANDOM UreaN-208 Creat-58 Na-89
K-22 Cl-50
DISCHARGE RESULTS:
------------------
___ 07:29AM BLOOD WBC-8.8 RBC-3.49* Hgb-10.4* Hct-32.5*
MCV-93 MCH-29.7 MCHC-31.9 RDW-14.0 Plt ___
___ 07:29AM BLOOD Plt ___
___ 07:29AM BLOOD Glucose-307* UreaN-78* Creat-19.2* Na-141
K-6.1* Cl-97 HCO3-29 AnGap-21*
___ 07:29AM BLOOD Calcium-7.9* Phos-7.0* Mg-2.4
MICROBIOLOGY:
-------------
___ BLOOD CX: PENDING
___ URINE LEGIONELLA Ag: NEGATIVE
___ SPUTUM CX: CONTAMINATED
___ STOOL CX: CONSISTENCY NOT ACCEPTABLE FOR BACTERIAL CULTURE
___ VRE SWAB: PENDING
IMAGING:
--------
___ PA-LAT
FINDINGS:
Bilateral hilar opacities, right greater than left, similar
compared to the prior study from ___, compatible with
moderate pulmonary edema. Moderate cardiomegaly is unchanged.
Mild pectus deformity is again noted, likely accentuating the
right lower lung opacity. There is no large pleural effusion
pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Carvedilol 12.5 mg PO BID
6. HydrALAzine 50 mg PO BID
7. Glargine 25 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
8. Isoniazid ___ mg PO 3X/WEEK (___)
9. Losartan Potassium 50 mg PO BID
10. Omeprazole 10 mg PO DAILY
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Aspirin 81 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Ferrous Sulfate 325 mg PO BID
15. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. HydrALAzine 50 mg PO BID
8. Glargine 25 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
9. Isoniazid ___ mg PO 3X/WEEK (___)
10. Losartan Potassium 50 mg PO BID
RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*90
Tablet Refills:*0
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 10 mg PO DAILY
13. Pyridoxine 50 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Vitamin D ___ UNIT PO DAILY
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
Please talk to your primary care doctor if this does not help
you
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff inhaled
twice a day Disp #*1 Inhaler Refills:*0
17. Loratadine 10 mg PO EVERY OTHER DAY
RX *loratadine 10 mg 1 tablet(s) by mouth 3 times per week Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Chronic cough
#Pulmonary edema
#End stage renal disease
#Hypertensive urgency
#Diabetes ___ type 2, poorly controlled
#Dyspepsia
#SECONDARY DIAGNOSES:
#Latent tuberculosis infection
#Anemia of chronic kidney disease
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: ___ year old man with cough, hx of ESRD on HD, some chills // ?
infiltrates ? edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made multiple prior studies, including most recent
radiographs of the chest from ___, dating back to ___.
FINDINGS:
Bilateral hilar opacities, right greater than left, similar compared to the
prior study from ___, compatible with moderate pulmonary edema.
Moderate cardiomegaly is unchanged. Mild pectus deformity is again noted,
likely accentuating the right lower lung opacity. There is no large pleural
effusion pneumothorax.
IMPRESSION:
Bilateral hilar opacities likely reflect moderate pulmonary edema.
Cardiomegaly is stable.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, ILI
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.6
heartrate: 86.0
resprate: 16.0
o2sat: 96.0
sbp: 197.0
dbp: 97.0
level of pain: 0
level of acuity: 3.0 | ___ yo homeless M with LTBI on INH, ESRD on HD TTS, HTN c/b LVH,
poorly controlled DM2, and childhood asthma presenting with
subacute on chronic cough x ~10 months, early satiety with N+V x
~9 months, and loose stools ~7 months.
#Subacute on Chronic Cough:
Patient was initially admitted for a question of a health care
associated pneumonia, and was started on clindamycin and
ceftriaxone initially. This decision was based on a CXR that
demonstrated pulmonary edema, with a pectus deformity causing
appearance of RLL consolidation. However, given absent
hypoxemia, fever, leukocytosis it is unlikely that he has a
bacterial pneumonia (HCAP) and as such the antibiotics were
discontinued on hospital day 1.
We think the subacute component of his cough could represent
worsening of a chronic problem such as hypervolemia with
pulmonary edema, chronic asthma, GERD, or possibly subacute
infection with atypical organism. That said, his estimated dry
weight per HD is <300 lbs, though he has consistently been above
305 lbs at all outpatient visits since late ___, which may
suggest that he never fully gets his lungs dry. Of note, he
frequently asks to stop HD sessions ___ minutes early, so he
never reaches his goal ultrafiltration or estimated dry weight
of ~297 lbs.
Given that he had childhood asthma that required overnight
hospitalizations, with his last asthma attack in his late
adolescence, it is possible that this is secondary asthma.
Given that albuterol provided temporary abatement of symptoms,
we started asthma treatment with fluticasone in addition to
albuterol. PFTs may be considered in the outpatient setting.
A multimodal approach aimed at allergic post-nasal drip,
GERD, and asthma seemed reasonable. As such, he was given:
albuterol ___ puffs q6h standing, fluticasone 110 mcg 2 puffs
daily, loratadine 10MG every other day (HD dosing). If he does
not show symptomatic improvement, then further workup is
warranted, but the new medications such as PPI, fluticasone, and
loratidine should be discontinued.
#Early satiety w/dyspepsia/nausea/emesis: Notably he does not
describe dysphagia or odynophagia to liquids or solids. GERD
symptoms are not prominent, though occasionally he has
epigastric discomfort. Gastroparesis is certainly possible given
poorly controlled diabetes. Consider possible gastric emptying
study vs possible EGD as an outpatient to further evaluate.
#Possible GERD: continue home omeprazole dose.
#Loose stools: Per patient, ___ bowel movements per day x 10
months. Painless, without nocturnal symptoms. His weight has
been relatively stable x9 months despite reported weight loss.
Patient later endorsed soft stool (not loose/watery). He did not
show evidence of diarrhea during his admission.
#Latent TB: Continued daily isoniazid treatment with pyridoxine
inpatient. Of note, patient endorses forgetting about half of
his isoniazid pills. LFTs normal. Recommend avoidance of
quinolones/macrolides therapy in treating future infections in
order to avoid possibility of resistant tuberculosis. Arranged
follow-up Dr. ___ in one month for his LTBI therapy,
appointment pending at discharge.
#Hypertensive Urgency: BPs 170s-200s in clinic, maintained
170's-200's/90's-100's inpatient despite hemodialysis and home
medications given. His BPs were somewhat improved after giving
his home medications.
#Diabetes ___, type II: Hb A1c 10.6 in ___. On Lantus
and humalog insulin at home, though patient endorses not having
regular access to a refrigerator for his insulin. Inpatient was
on Glargine at 20 U qAM (25U qAM at home) with Humalog meal
time. A HgA1C was obtained and was 9.7% at the time of
discharge.
#ESRD on HD: ___ via LUE AVF. Last HD ___, then ___.
Patient endorses missing ~1 HD session per month, and also has
not been receiving full HD sessions secondary to headache
towards end. Had pulmonary edema on admission CXR. Dry wt
estimated to be ~295 (135 kg). Patient was counseled to try and
get the full HD sessions. Continued nephrocaps, sevelamer,
cholecalciferol, and renal diet while inpatient. Will continue
regular dialysis schedule outpatient.
#Anemia of CKD: Hgb ~10, at baseline. Provided EPO 6000 Units
qHD and Venofer 100 mg qHD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
surgical glue
Attending: ___.
Chief Complaint:
Fever and redness around IPG site
Major Surgical or Invasive Procedure:
Removal of L DBS battery and debridement, removal of L extension
cable
History of Present Illness:
___ year old female with history of medically refractory torsion
dystonia s/p DBS placement in ___ most recently s/p battery
change ___ ___. She presents with complaints
of increased pain and fever. She was febrile to 101 two nights
prior to admission. She initially thought she had the flu, but
noticed her IPG site was swollen. She was referred to the ED for
evaluation. A collection was tapped in the ED which was
concerning for purulent drainage. She was taken to the OR for a
wound washout and removal of her stimulator and extension leads
to the level of occiput.
Past Medical History:
DYSTONIA
ANAL FISSURE
MEDICALLY REFRACTORY TORSION DYSTONIA
HYPERTENSION
Had mild HTN prior to pregnancy. Was taking labetalol. HTN
higher after pregnancy, but not pre-eclampsia. Changed to
Norvasc. ___ cardiology Dr. ___ ___ normal
INFERTILITY
RSI ___. did IVF. Dr. ___.
H/O ABNORMAL PAP SMEAR ___
had ASCUS and ? + HPV. 3 Paps since then normal.
Social History:
___
Family History:
Family Hx:
Mother Living ___ HYPERTENSION
DIABETES TYPE II
ARTHRITIS
COLONIC POLYPS ?adenoma
BREAST CANCER ___
Father ___ ___ ___ PLACEMENT
MITRAL VALVE
REPLACEMENT
HYPERTENSION
DYT1 Had the gene
___ symptoms
Sister Living ___ HYPERTENSION Not a DYT1
carrier
MGM Deceased ___ COLON CANCER
Brother Living ___ ___ CRAMP ___ Brother
MGF Deceased ___ MYOCARDIAL
INFARCTION
PGM Deceased ___ HYPERTENSION
STROKE
PGF Deceased ___'sMYOCARDIAL
INFARCTION
Physical Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: ___ bilaterally
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [ x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
Wound:
Left crani incisions
[x]Clean, dry, intact
[x]Staples
Left chest incision
[x]Clean, dry, intact, very mild erythema
[x]Staples
Chest drain site - removed ___
[x]Clean, dry, intact
[x]Staples
Pertinent Results:
Please see OMR for pertinent results.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ female with dystonia status post better exchange to a
here with fevers.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph performed ___ and ___.
FINDINGS:
Left chest wall stimulator again noted, with leads coursing superiorly and out
of view is grossly unchanged compared to prior exam. Lungs are moderately
well inflated. Linear bibasilar and retrocardiac opacification likely
reflects platelike atelectasis. No focal consolidation is seen to suggest
pneumonia. Tiny bilateral pleural effusions are suspected given blunted CP
angles on the lateral view. No large pneumothorax. The cardiomediastinal
silhouette is otherwise unchanged.
IMPRESSION:
1. Tiny bilateral pleural effusions.
2. No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: SKULL, ___ VIEWS
INDICATION: ___ year old woman with bilateral deep brain stimulators, s/p
removal pulse generator and lead extensions.// Pulse generators and lead
extensions were removed due to concern for infection. Xrays to look for
retained lead fragments. Please include lateral of the skull and neck.
TECHNIQUE: Frontal and lateral views of the skull
COMPARISON: Skull radiographs ___
FINDINGS:
On lateral view, 1.5 cm curvilinear density is identified overlying the
parietal region. The morphology of this density is similar to the tip of the
previous lead that was present in ___ study. Finding is
suspicious for retained lead fragment. The finding is not well visualized on
frontal view, but likely located on the left side, adjacent to the cranium.
Other leads appear unchanged in position.
IMPRESSION:
1.5 cm curvilinear density overlying the parietal region is suspicious for
retained lead fragment. The finding is not well visualized on frontal view,
but likely located in the left parietal region, external to the cranium.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 9:39 am, 15 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old woman with bilateral deep brain stimulators, s/p
removal pulse generator and lead extensions.// Evaluate pulse generator site
s/p removal to ensure no retained fragments Evaluate pulse generator site
s/p removal to ensure no retained fragments
IMPRESSION:
Compared to chest radiographs ___ and ___.
Left pectoral generator and ascending leads have been removed since ___. Aside from a row of skin staples, there are no visible retained metal
fragments. No pneumothorax or pleural effusion. Lungs clear. Heart size
normal. Dilated upper lobe vessels suggest mild volume overload.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman s/p bilateral DBS, and removal of infected IPH
and lead extensions// **Please protocol to include the base of the skull to
the upper chest at the level of the generator chest pocket. Evaluate deep
brain stimulator leads in head and neck to evaluate post removal
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 3.3 s, 25.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 289.6
mGy-cm.
Total DLP (Body) = 290 mGy-cm.
COMPARISON: ___ chest radiographs
FINDINGS:
In the anterior left chest wall, there is a 7.6 x 2.1 x 7.1 cm rim enhancing
fluid collection with few locules of subcutaneous emphysema and adjacent fat
stranding consistent with abscess. Along the collapse superior portion of the
abscess, there is a surgical drain. There are few locules gas in the anterior
aspect of the left pectoralis major. Extending superiorly toward the neck,,
the deep brain stimulator tract appears collapsed with a single locule of gas
in the left supraclavicular region (series 2, image 63). The remainder of the
tract demonstrates calcification, but no significant adjacent fat stranding to
suggest infection. Cervical lymph nodes are prominent in number and size,
measuring up to 1.1 cm at level 2A on the left.
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.The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
IMPRESSION:
A left chest wall fluid collection/abscess measures up to 7.6 cm. With a
surgical drain is located along the collapsed superior portion . No evidence
of infection along the stimulator tract in the subcutaneous soft tissues of
the neck.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Wound eval
Diagnosed with Fever, unspecified
temperature: 98.9
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 87.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ year old female with a history of medically
refractory torsion dystonia s/p DBS placement in ___ most
recently s/p battery change ___ ___
presented to the ED with complaints of increased pain and fever.
She was febrile to 101 two nights prior to admission. A
collection was tapped in the ED which was concerning for
purulent drainage from the L IPG site. She was taken to the OR
for a wound washout and removal of her stimulator and extension
leads to the level of occiput. She was then transferred to the
floor for further management.
#Infected hardware s/p IPG removal
Ms. ___ underwent neuro checks every 4 hours on the floor
after returning from the operating room. Skull X-ray
demonstrated a small retained fragment, while neck CT
demonstrated no retained fragments and a small chest wall
abscess. ___ was consulted for drainage of this abscess, but
stated that the abscess was too small to drain and it would be
better for her to follow up with additional imaging as an
outpatient to assess for resolution. Infectious disease was
consulted and Ms. ___ was started on Vancomycin and
Ceftriaxone. Ceftriaxone was discontinued on POD2, and
Vancomycin was discontinued and replaced with Bactrim on POD3.
She will complete a four week course of Bactrim as an outpatient
and will follow up with ID ___ weeks after discharge for an
ultrasound of the chest wall and to assess antibiotic plans.
Wound cultures grew out coagulase positive staphylococcus, while
blood cultures did not grow out organisms.
#DYT1 Dystonia
Neurology was consulted for management of dystonia. They
discussed the possibility of outpatient botox injections with
the patient, to which she was amenable. Should this not
alleviate her symptoms, she was given a prescription for
Baclofen to be taken at night PRN. Notably, she will have to
stop breastfeeding if she takes the Baclofen, and this was
communicated to her. Neurology will be calling her to coordinate
outpatient follow up.
At the time of discharge, Ms. ___ was ambulating
independently and was afebrile. She was instructed to follow-up
for any symptoms concerning for returning infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral ureteral stones
Major Surgical or Invasive Procedure:
Cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral
ureteral stent placement.
History of Present Illness:
This is a ___ year old male presenting with 1 day history of left
flank pain and dysuria. Upon further work up, he was found to
have a 5 mm left UVJ stone and 1.9 cm proximal right ureteral
stone. He has a history of kidney stones
in the past which he passed spontaneously. He has never required
surgery for stones. He is afebrile and hemodynamically stable.
WBC 11. Cr 1.5. U/A
negative for infection.
Past Medical History:
overweight
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd, obese
Flank pain improved
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 06:17AM BLOOD WBC-6.2 RBC-4.87 Hgb-14.8 Hct-44.4 MCV-91
MCH-30.4 MCHC-33.3 RDW-13.0 RDWSD-43.7 Plt ___
___ 10:50AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.4 Hct-44.3 MCV-92
MCH-29.8 MCHC-32.5 RDW-13.1 RDWSD-44.1 Plt ___
___ 01:25PM BLOOD WBC-11.1* RBC-5.77 Hgb-17.4 Hct-51.7*
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.2 RDWSD-43.4 Plt ___
___ 01:25PM BLOOD Neuts-77.0* Lymphs-13.1* Monos-8.6
Eos-0.3*
Baso-0.5 Im ___ AbsNeut-8.55* AbsLymp-1.45 AbsMono-0.95*
AbsEos-0.03* AbsBaso-0.06
___ 06:17AM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 10:50AM BLOOD Glucose-132* UreaN-16 Creat-1.5* Na-141
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 09:44PM BLOOD Glucose-151* UreaN-16 Creat-1.7* Na-140
K-5.0 Cl-102 HCO3-21* AnGap-17
___ 01:25PM BLOOD Glucose-153* UreaN-17 Creat-1.5* Na-139
K-4.9 Cl-101 HCO3-20* AnGap-18
___ 01:25PM BLOOD ALT-73* AST-36 AlkPhos-72 TotBili-0.5
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE prophylaxis
RX *nitrofurantoin monohyd/m-cryst 100 mg ONE capsule(s) by
mouth once Disp #*2 Capsule Refills:*0
4. Oxybutynin 5 mg PO TID:PRN bladder spasms
5. Senna 8.6 mg PO ONCE Duration: 1 Dose
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral ureterolithiasis.
acute kidney injury (creatinine up to 1.7)
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 bilateral nephrolithiasis// evaluate
bilateral ureteral stones
TECHNIQUE: Multiple supine portable images were obtained.
COMPARISON: CT scan dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Residual
contrast within the bilateral renal collecting systems from recent IV contrast
administration is again noted with bilateral hydronephrosis right greater than
left. There is a calcific density overlying the proximal right ureter
measuring 19 mm, corresponding to previously seen proximal ureter obstructing
stone. Previously seen left distal ureter 5 mm stone is not definitely seen
on this exam.
IMPRESSION:
Residual contrast within the bilateral renal collecting systems with note of
bilateral hydronephrosis, right greater than left. Known stone
re-demonstrated within the right UPJ. Known left distal ureteral stone not
clearly seen.
Radiology Report
EXAMINATION: Intraoperative fluoroscopy, abdomen.
INDICATION: Ureteral stent placement.
TECHNIQUE: 7 fluoroscopic spot images of the abdomen were obtained in the
operating room without presence of radiologist.
DOSE: Fluoroscopy time 19.8 seconds, cumulative dose 14.45 mGy.
COMPARISON: CT is available from ___ and abdominal radiographs
are available from ___.
FINDINGS:
These views depict ongoing bilateral ureteral stent placements. On the right,
ureteropelvic junction stone is visualized as well as hydronephrosis.
IMPRESSION:
Ongoing bilateral retrograde ureteral stent placement in the operating room.
Please refer to the operative note if needed for further information.
Radiology Report
EXAMINATION: CTU (ABD/PEL) W/CONTRAST
INDICATION: History: ___ with flank pain, elevated Cr// r/o AAA,
nephrolithiasis, other abnormalities of GU system
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Spiral Acquisition 7.3 s, 57.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,580.2 mGy-cm.
Total DLP (Body) = 1,581 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. Otherwise, the visualized lung
fields are within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Liver is diffusely hypoattenuating relative to the spleen which
raises possibility of hepatic steatosis, incompletely assessed on current
study. There are areas of focal fatty sparing in the gallbladder fossa.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is moderate to severe hydronephrosis in the right kidney
secondary to a 1.9 cm obstructing stone in the proximal right ureter (average
Hounsfield units 959) (02:48). There is no perinephric abnormality on the
right. There is left hydronephrosis secondary to a 5 mm stone is seen in the
distal left ureter immediately proximal to the UVJ (2:90). There is mild left
perinephric and left periureteral stranding.
GASTROINTESTINAL: There is a small hiatal hernia and the distal esophagus is
fluid-filled. No bowel obstruction or bowel wall thickening is seen. The
appendix is normal.
PELVIS: The urinary bladder is unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Moderate to severe right hydronephrosis secondary to 1.9 cm obstructing
stone in the proximal right ureter. No definite perinephric abnormality.
2. Mild left hydronephrosis secondary to a 5 mm stone seen in the distal left
ureter immediately proximal to the UVJ. Mild left perinephric and left
periureteral stranding.
3. Hepatic steatosis.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Dysuria, L Flank pain
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 97.1
heartrate: 96.0
resprate: 20.0
o2sat: 99.0
sbp: 147.0
dbp: 102.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was admitted Dr. ___ service for
nephrolithiasis
management with known bilateral ureteral stone and taken
urgently to the operative theatre where he underwent cystoscopy,
left ureteroscopy, laser lithotripsy, and bilateral ureteral
stent placement. He tolerated the procedure well and recovered
in the PACU before transfer to the general surgical floor. See
the dictated operative note for full details. Overnight, the
patient was hydrated with intravenous fluids and received
appropriate perioperative prophylactic antibiotics. Intravenous
fluids and Flomax were given to help facilitate passage of
stones. At discharge on POD1, patients pain was controlled
with oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. His labs
were
checked and he was advised to follow up as directed. He was was
explicitly advised to follow up as directed as the indwelling
ureteral stent must be removed on the left and he will still
need definitive stone management on the right. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
change in behavior
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female professor at ___ with no
known psychiatric history who was brought in by NEU security for
erratic behavior. History largely taken from psychiatric consult
note and ED notes as pt is somnolent and uncooperative with
interview upon arrival to floor. Psych consult spoke with close
work friend ___ and ___ roommate ___ who
both confirmed various
details of her history. Pt has had increasing psychosocial
stressors at work and in family. Grandmother recently passed.
Also had increasing stress at work.
.
In the ED, initial VS: 97.6 95 129/91 20 100%. During interview
with psychiatry, pt became agitated, screaming loudly. She
received haldol 5mg x 2 IM and ativan 2mg x 2 IM and placed in 4
point soft restraints. Following administration of haldol and
ativan, pt became tachycardic to the 130s. EKG showed sinus
tachycardia. HR decreased to 110s after IV fluids but then
increased to 160s again. Toxicology consult was obtained; felt
that tachycardia could be due to anticholinergic effects of
haldol or paradoxical rxn to ativan. Recommended discontinuation
of haldol and liberalization of ativan for agitation.
.
Currently, pt is extremely lethargic and somnolent. Awakens to
loud voice and sternal rub but quickly falls back asleep.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7 118/91 118 18 98%RA
GENERAL - Somnolent, awakes to voice but quick to fall asleep
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, tachycardic, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no facial asymmetry, moving all
extremities, follows commands when awake
.
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.8 BP 105/78 HR 78 RR 18 O2 Sat 96% RA
General: Patient lying in bed, arousable to voice.
HEENT: MMM.
CV: RRR. No murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally. No crackles or
wheezes. Nml work of breathing. No accessory muscle use.
ABD: BS+. Soft. NT/ND.
EXT: WWP. No clubbing, cyanosis, or edema. 2+ DPs bilaterally.
NEURO: Arousable. Oriented to person, place, and time ___
and ___.
Pertinent Results:
ADMISSION LABS
.
___ 06:39PM GLUCOSE-120* UREA N-16 CREAT-1.0 SODIUM-142
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
___ 06:39PM CALCIUM-10.1 PHOSPHATE-3.6 MAGNESIUM-2.3
___ 06:39PM TSH-1.8
___ 06:39PM T4-8.8
___ 06:39PM CORTISOL-25.4*
___ 06:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:39PM WBC-6.4 RBC-4.49 HGB-14.2 HCT-41.4 MCV-92
MCH-31.6 MCHC-34.4 RDW-12.1
___ 06:39PM NEUTS-58.2 ___ MONOS-4.2 EOS-0.7
BASOS-1.1
___ 06:39PM PLT COUNT-277
___ 06:05PM URINE UCG-NEGATIVE
___ 06:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:05PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 06:05PM URINE RBC-8* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1 RENAL EPI-<1
___ 06:05PM URINE MUCOUS-RARE
.
ADMISSION DIAGNOSTICS
ECG (___): Sinus tachycardia.
.
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-6.3 RBC-4.06* Hgb-12.8 Hct-36.3
MCV-89 MCH-31.4 MCHC-35.1* RDW-12.3 Plt ___
___ 04:30AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-136
K-4.3 Cl-104 HCO3-25 AnGap-11
___ 04:20AM BLOOD ALT-49* AST-40 LD(LDH)-190 AlkPhos-74
TotBili-0.5
.
MICROBIOLOGY:
___ 5:19 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
.
___ 12:44 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
___ 10:50 am BLOOD CULTURE
Blood Culture, Routine (Pending) times 2
.
___ 09:34AM BLOOD HIV Ab-NEGATIVE
.
OTHER DIAGNOSTICS:
___ 04:20AM BLOOD CERULOPLASMIN-PND
___ 04:20AM BLOOD ___- PND
.
IMAGING:
Head CT:
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent. There is
preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear.
IMPRESSION: No evidence of acute intracranial process.
.
Head MRI with and without contrast:
FINDINGS:
There are several scattered FLAIR hyperintense foci in the
cerebral white
matter, in the centrum semiovale, subcortical and
periventricular white matter, in the frontal and the parietal
lobes on both sides and a few in the occipital lobes. However,
there is no associated abnormal enhancement in these foci. There
is no focus of slow diffusion allowing for artifacts at the
tissue interfaces. On the GRE sequence, there is no focus of
negative susceptibility. Pituitary gland is mildly prominent
with a convex superior border, however, this may be within
normal limits for the patient's age. The ventricles and
extra-axial CSF spaces are unremarkable.
Minimal increase in the FLAIR signal intensity in the right
hippocampus is of equivocal significance, superiorly (series 7,
image 10) and on post-contrast images relates to enhancment of
the adjacent choroid plexus- seen end-on on axial images and
better characterized on coronal and sagittal MPRAGE sequences.
Major intracranial arterial flow voids are noted. A few
retention cysts are noted in the maxillary sinuses, left more
than right.
IMPRESSION:
1. Several small scattered FLAIR hyperintense foci in the
cerebral white matter in the frontal and the parietal lobes
predominantly, without associated enhancement. These are
nonspecific in appearance and can be seen with small vessel
ischemic changes, post-inflammatory sequela, post-infectious
sequela,vasculitis type of disorders or less likely
demyelinating disease given the appearance and distribution. As
no prior studies are available, a followup can be considered in
a few weeks or earlier as clinically necessary, to assess
stability/progression after correlation clinically and with labs
to assess underlying risk factors.
2. No focal abnormal enhancing lesions noted.
Medications on Admission:
None
Discharge Medications:
1. haloperidol 5 mg Tablet Sig: One half Tablet PO twice a day.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Psychosis, NOS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Acute psychosis of unknown origin, to evaluate for acute process.
COMPARISON: CT head done on ___.
TECHNIQUE: MR of the head without and with IV contrast.
FINDINGS:
There are several scattered FLAIR hyperintense foci in the cerebral white
matter, in the centrum semiovale, subcortical and periventricular white
matter, in the frontal and the parietal lobes on both sides and a few in the
occipital lobes. However, there is no associated abnormal enhancement in
these foci. There is no focus of slow diffusion allowing for artifacts at the
tissue interfaces. On the GRE sequence, there is no focus of negative
susceptibility.
Pituitary gland is mildly prominent with a convex superior border, however,
this may be within normal limits for the patient's age.
The ventricles and extra-axial CSF spaces are unremarkable.
Minimal increase in the FLAIR signal intensity in the right hippocampus is of
equivocal significance, superiorly (series 7, image 10) and on post-contrast
images relates to enhancment of the adjacent choroid plexus- seen end-on on
axial images and better characterized on coronal and sagittal MPRAGE
sequences.
Major intracranial arterial flow voids are noted.
A few retention cysts are noted in the maxillary sinuses, left more than
right.
IMPRESSION:
1. Several small scattered FLAIR hyperintense foci in the cerebral white
matter in the frontal and the parietal lobes predominantly, without associated
enhancement. These are nonspecific in appearance and can be seen with small
vessel ischemic changes, post-inflammatory sequela, post-infectious
sequela,vasculitis type of disorders or less likely demyelinating disease
given the appearance and distribution. As no prior studies are available, a
followup can be considered in a few weeks or earlier as clinically necessary,
to assess stability/progression after correlation clinically and with labs to
assess underlying risk factors.
2. No focal abnormal enhancing lesions noted.
Radiology Report
INDICATION: Acute mental status change.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent. There is preservation of gray-white matter
differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION: No evidence of acute intracranial process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: DISORGANIZED THINKING
Diagnosed with ALTERED MENTAL STATUS , TACHYCARDIA NOS
temperature: 97.6
heartrate: 95.0
resprate: 20.0
o2sat: 100.0
sbp: 129.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | # Psychosis: Patient with no psychiatric history presented with
what seemed to be first psychotic break in setting of increasing
psychosocial stressors. Serum and urine toxin screen was
negative, arguing against substance-related mania. The patient
was admitted to medicine to rule out organic causes of
psychosis. Work-up included Head CT, head MRI, TSH, HIV
serology, serum coritisol, infectious work-up, and liver
function tests. The patient was also empirically started on IV
acyclovir out of concern that she may have an underlying HSV
encephalitis. Neurology was consulted for the concern of an
encephalitis that was the cause of her symptoms. Neurology was
thought that the patient's symptoms were more consistent with a
psyhciatric diagnosis and recommended getting a brain MRI as
well as serum ___ and ___ and ___ were
pending on day of discharge. All other work-up proved to be
negative. The patient was followed by psychiatry throughout the
admission. She was started on 2.5mg haldol twice daily. On day
of discharge, psychiatry deemed that there were no psychiatric
contraindication to discharge home with her mother. The patient
was scheduled for an appointment at ___ Partial
Hospitalization Program- ___., ___.
___ at 9am. The patient was discharged on haldol
2.5 mg PO BID. The patient and the patient's mother agreed to
return to the ED or call ___ should symptoms worsen again or she
experiences any SI/HI. Mother is to remain with patient after
discharge to monitor symptoms and assist with getting her to
treatment.
OUTPATIENT ISSUES: Continuation of haldol 2.5mg twice daily.
Follow-up at ___ Partial Hospitalization Program-
___., ___. ___ at 9am.
.
# Abnormal Head MRI: Several small scattered FLAIR hyperintense
foci in the cerebral white matter in the frontal and the
parietal lobes predominantly, without associated enhancement
were noted on head MRI. Per radiology, these are nonspecific in
appearance and can be seen with small vessel ischemic changes,
post-inflammatory sequela, post-infectious sequela,vasculitis
type of disorders or less likely demyelinating disease given the
appearance and distribution. Neurology recommended that this by
followed-up by neurology on an outpatient basis. Given the
holiday weekend, a follow-up appointment could not be arranged.
However, the patient was given the telephone number to contact
the neurology office for an appointment for within two weeks
from discharge date.
OUTPATIENT ISSUES: Follow-up on an outpatient basis with
neurology regarding hyperintensities noted on Head MRI.
Follow-up of pending ___ and ___ that was obtained as
part of neurology work-up.
___ was positive at 1:160, cerruloplasm normal range at 26
.
# Hematuria: Patient was noted to have hematuria on a urine
analysis on admission. Urine culture was drawn that showed mixed
bacterial flora consistent with contamination. A repeat urine
analysis did not show blood.
.
# Tachycardia: Patient with episodes of tachycardia, heart rate
ranging 110s to 160s in the emergency department. EKGs showing
sinus tachycardia. Heart rate increased with agitation/activity
and was in the low 100s while sleeping on morning of admission.
Given onset of tachycardia following ativan/haldol
administration, toxicology consult obtained who suggested
tachycardia could be secondary to anticholinergic effect of
haldol or paradoxical reaction to ativan. The patient's heart
rate trended down through the admission. The patient was
challenged with oral haldol and had no other rebound
tachycardia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Ataxia and LUE weakness
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
Ms. ___ is a ___ year old female who is known to the
neurosurgery department, a patient of Dr. ___ with a known
brainstem cavernous malformation who called the neurosurgery
office earlier today with complaints of LUE weakness and ataxia.
Patient was instructed to go to the nearest ED, while at OSH ___
negative for acute new hemorrhage. Patient requested transfer to
___ as she is followed closely by Dr. ___. On presentation
to the ED neurosurgery was consulted.
On exam, patient lying in stretcher in NAD. Patient states that
she noticed today her gait was off balance and she was having
difficulty writing with her left arm that was getting
progressively worse. Patient states that she has an occipital
pressure and headache however states this is common for her. She
denies visual changes, nausea, vomiting, lightheadedness,
dizziness, bowel or bladder complaints or any other complaints.
Patient does endorse tingling in her fingertips which she states
has been present since prior CVAs.
Past Medical History:
Brain stem cavernous malformation with hemorrhage ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
-------------
On Admission
-------------
PHYSICAL EXAM:
T: 98 BP: 104/80 HR: 87 R: 18 O2Sats: 100% Room air
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally EOMs: Intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
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.
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, except for left
tricep and finger intrinsics ___ and left Q/H ___. No pronator
drift noted.
Sensation: Intact to light touch.
Coordination: Dysmetria on left, rapid alternating
movements slowed.
-------------
On Discharge
-------------
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for pertinent lab/imaging studies.
Medications on Admission:
Oral contraceptive
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Dexamethasone 1 mg PO AS DIRECTED Duration: 7 Days
4mg q6hr x 8 doses
3mg q6hr x 8 doses
2mg q6hr x 4 doses
2mg q8hr x 3 doses
1mg q8hr x 3 doses
RX *dexamethasone 1 mg as directed by mouth as directed Disp
#*73 Tablet Refills:*0
3. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Brain stem cavernous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ w/ cavernous malformation complicated by multiple hemorrhages
presenting with LUE weakness and gait instability. Question of hemorrhage and
evaluate cavernous malformation.
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: ___ and ___.
FINDINGS:
Re-demonstrated is a 1.9 x 1.7 x 1.5 cm mixed T2 hyperintensity medullary
lesion with extensive blooming artifact, compatible with known cavernous
malformation. The volume of blood within the lesion appears greater than on
the recent prior study. The volume of enhancement appears similar to prior.
Postcontrast MPRAGE imaging demonstrates a tiny vascular lesion along the
superior aspect of the lesion likely representing a small developmental venous
anomaly. There is again intrinsic T1 enhancement on postcontrast imaging
(series 14, image 4). There is increased T2/FLAIR signal abnormality
associated with lesion, increased compared to prior which may represent
evolution and increase of blood products.
There is no evidence of infarction or of other hemorrhage. The ventricles and
sulci are normal in size and configuration. No mass effect or midline shift.
IMPRESSION:
Medullary lesion is consistent with cavernous malformation with interval
increase in T2/FLAIR signal abnormality, likely representing increased
evolving blood products.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Weakness, Unsteady gait
Diagnosed with Weakness, Unsteadiness on feet
temperature: 98.0
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 104.0
dbp: 80.0
level of pain: 2
level of acuity: 2.0 | Ms ___ was admitted to the ___ for monitoring and
observation out of concern for possible rehemorrhage of her
known brain stem cavernous malformation. MRI was performed which
showed no significant hemorrhage, but increased local edema and
evolution of blood products. She was given a 10mg dose of IV
dexamethasone, and started on a one week dexamethasone taper.
#Disposition
___ evaluated her and determined she was at her baseline, had an
adequate support system, and had strategies in place to make a
home discharge safe. She was discharged home with plans for the
clinic to contact her for close outpatient follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
S/p assault to face
Major Surgical or Invasive Procedure:
___ fixation, bilateral mandible fracture
History of Present Illness:
___ h/op COPD, alcohol abuse, and ___ transferred from
___ after being brought to their ED with EtOH on board after
an assault. He was in some type of altercation and walked into a
fire station early AM ___ from which he was brought to an
OSH. He was noted to have multiple facial lacerations and
ongoing
pharyngeal bleeding. A head CT was negative for neural injuries
but revealed bilateral mandibular fractures and a nasal
fracture.
He was intubated for airway protection given that he was
bleeding
and transferred to ___ for further management.
Past Medical History:
COPD, EtOH abuse
Psych History:
PTSD- from childhood abuse
Psychiatrist/therapist: multiple in the past. Cannot recall the
name of most recent provider, seen 2 months ago at ___
___. Stopped going because, "I didn't need the
medicine."
Past med trials of mx antidepressants and antianxiety including
Zoloft, Paxil, Xanax and Seroquel.
Denies Past Suicide Attempt, SIB.
Social History:
___
Family History:
Alcoholism on both genetic parents mother and father.
Physical Exam:
Exam Upon Admission:
General: Intubated and sedated, NAD
Head is atraumatic, normocephalic
Eyes: EOMI, PERRL
Face: 4 cm chin laceration, multiple facial abrasions.Bilateral
nasal
bone swelling. mild lower ___ facial edema, L TMJ very tender
Lungs: intubated, CTA b/l
CV: Regular rate and rhythm
Abdomen: soft, non distended, non tender and no guarding
Extr/Back: No deformities
Skin: Warm and dry
Neuro: Responds appropriately to commands
Physical examination upon discharge:
vital signs: 97.9, hr=79, bp=127/78, 20, 96% room air
General: Dressed in room, NAD
HEENT: swollen jaw, suture line under neck with staples, mild
erythema mid-staple line
CV: ns1, s2, -s3, -s4
LUNGS: clear
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., no calf tenderness
Pertinent Results:
___ 06:01PM GLUCOSE-74 UREA N-10 CREAT-0.6 SODIUM-143
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-25 ANION GAP-10
___ 06:01PM CALCIUM-7.1* PHOSPHATE-2.8 MAGNESIUM-1.3*
___ 06:01PM WBC-7.6 RBC-2.73* HGB-8.8* HCT-27.0* MCV-99*
MCH-32.2* MCHC-32.6 RDW-15.8*
___ 06:01PM PLT COUNT-137*
___ 05:21PM TYPE-ART TEMP-37.1 RATES-14/ TIDAL VOL-500
PEEP-5 O2-40 PO2-149* PCO2-50* PH-7.34* TOTAL CO2-28 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
chest x-ray: ___:
1. Study was re-read once outside hospital CT scan was uploaded
and apparent mediastinal widening is due to abundant mediastinal
fat.
2. Although no fracture or other bone abnormality is seen,
conventional chest radiographs are not appropriate for detection
or characterization of chest cage lesions. Any focal findings
should be clearly marked and imaged with either bone detail
views or CT scanning.
___: MRA
No evidence of dissection or occlusion involving the head and
neck vessels.
___: CT of the sinus:
1. Status post open reduction and internal fixation of multiple
anterior
mandibular fractures. No evidence of hardware failure.
2. Extensive, acute on chronic, multifocal sinus disease, as
above
___: chest x-ray:
In comparison with study of ___, the patient has taken a
better
inspiration. There is now a bibasilar opacification consistent
with a
combination of atelectatic changes and pleural effusions.
Monitoring and
support devices are unchanged. Continued enlargement of the
cardiac
silhouette, but no definite vascular congestion or acute focal
pneumonia
Medications on Admission:
None known
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q8H
RX *acetaminophen 500 mg/5 mL 10 cc by mouth every eight (8)
hours Disp ___ Milliliter Refills:*0
2. Bacitracin Ointment 1 Appl TP BID
RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram
apply to suture line under chin twice a day Disp #*1 Tube
Refills:*0
3. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 1 tablet(s) by mouth
once a day Disp #*20 Tablet Refills:*0
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % rinse and spit 15 cc twice a
day Disp #*420 Milliliter Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 cc by mouth twice a day Disp
___ Milliliter Refills:*1
6. OxycoDONE Liquid ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg/5 mL ___ cc by mouth every 3 hours Disp
#*360 Milliliter Refills:*0
7. Sarna Lotion 1 Appl TP QID:PRN itching
8. Senna 8.6 mg PO BID:PRN constipation
9. Cephalexin 500 mg PO Q6H
RX *cephalexin 250 mg/5 mL 10 cc by mouth every six (6) hours
Disp #*240 Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
S/p assault
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: ___ year old man + EtOH, found by fireman s/p assault, intubated
for airway protection, coughing blood. Assess for pneumothorax, hemothorax
TECHNIQUE: Single portable frontal supine chest radiograph.
COMPARISON: None.
FINDINGS:
An endotracheal tube is in appropriate position 4.6 cm above the level of the
carina.
The lungs are hypoinflated with crowding of vasculature. No pleural effusion
or pneumothorax. The mediastinum is mildly widened measuring 8.9 cm however
this study was re- read with the outside hospital CT scan up-loaded and the
mediastinum is within normal limits. Heart size and hila are unremarkable.
No displaced rib fractures.
IMPRESSION:
1. Study was re-read once outside hospital CT scan was uploaded and apparent
mediastinal widening is due to abundant mediastinal fat.
2. Although no fracture or other bone abnormality is seen, conventional chest
radiographs are not appropriate for detection or characterization of chest
cage lesions. Any focal findings should be clearly marked and imaged with
either bone detail views or CT scanning.
Radiology Report
EXAMINATION: MRA BRAIN AND NECK
INDICATION: ___ year old man with head trauma, C2 fx // vacular injury
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions. Dynamic
MRA of the neck was performed during administration of 14 ml of Multihance
intravenous contrast. Three dimensional maximum intensity projection and
segmented images were generated. This report is based on interpretation of all
of these images.
COMPARISON: Head CT of ___
FINDINGS:
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
The vertebral arteries are unremarkable. There is no evidence of dissection.
The origins of the great vessels, subclavian and vertebral arteries appear
normal bilaterally. Known mandibular fracture is better appreciated on the CT
of the brain from outside hospital.
IMPRESSION:
No evidence of dissection or occlusion involving the head and neck vessels.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ year old man with bilateral mandibular fractures s/p ORIF
today, currently nasally intubated // OMFS requesting CT MAXILLOFACIAL
ICLUDING MANDIBLE WITHOUT CONTRAST, WITH 3D RECONSTRUCTION
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal reformatted
images were also obtained.
DOSE: DLP: 628 mGy-cm
CTDI: 26 mGy
COMPARISON: None available.
FINDINGS:
The patient is intubated, and both an endotracheal tube and nasogastric tube
are incompletely visualized within the upper oropharynx. There is extensive
mucosal thickening involving the bilateral maxillary sinuses, sphenoid
sinuses, and frontal sinuses, in addition to the bilateral anterior and
posterior ethmoidal air cells. Air-fluid levels are seen within the maxillary
sinuses, an secretions are noted throughout the nasopharynx, some of which may
be due to the patient's intubated status. The ostiomeatal units are
attenuated and obscured on the right and left, respectively, secondary to the
extensive mucosal thickening. The nasal septum is deviated towards the right,
and there is a comminuted fracture of the nasal bone.
Obliquely oriented fractures are noted through the anterior body of the right
and left mandible. The patient is status post internal fixation of these
fractures, with intact surgical plating and fixation screws extending along
the anterior surface of the mandible. There is no evidence of hardware
failure. Several tiny foci of gas adjacent to the mandible are likely
postoperative in nature. Additional postsurgical changes are noted, including
adjacent soft tissue swelling and cutaneous surgical staples.
IMPRESSION:
1. Status post open reduction and internal fixation of multiple anterior
mandibular fractures. No evidence of hardware failure.
2. Extensive, acute on chronic, multifocal sinus disease, as above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with mandibular fracture s/p repair and seizures
from EtOH withdrawal // ? interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiac size is top-normal. Mediastinal contours are unchanged. ET tube is
in standard position. NG tube tip is out of view below the diaphragm. There
are low lung volumes with bibasilar atelectasis. There is mild vascular
congestion. Retrocardiac opacities have increased likely atelectasis. There
is no evident pneumothorax. Skin staples and hardware material in the
mandible are noted
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with intubated in tsicu, fever // interval
change interval change
IMPRESSION:
In comparison with study of ___, the patient has taken a better
inspiration. There is now a bibasilar opacification consistent with a
combination of atelectatic changes and pleural effusions. Monitoring and
support devices are unchanged. Continued enlargement of the cardiac
silhouette, but no definite vascular congestion or acute focal pneumonia.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with ngt output >3L yesterday, already 1.8L since
midnight,? ileus, ? ngt tip placement.
TECHNIQUE: Supine portable abdominal radiograph.
COMPARISON: Chest x-ray dated ___.
FINDINGS:
Bowel gas pattern is nonspecific with air in the small and large bowel.
Nasogastric tube is in appropriate position. No free intra-abdominal air.
Right basilar atelectasis better assessed on same day chest x-ray.
IMPRESSION:
1. Nonspecific bowel-gas pattern.
2. Nasogastric tube in appropriate position.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ASSAULT
Diagnosed with FX SYMPHY MANDIB BDY-OPN, NASAL BONE FX-CLOSED, UNARMED FIGHT OR BRAWL, OPEN WOUND OF JAW
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___: The patient was involved in an altercation and and
incurred bilateral mandible fractures and nasal fractures. He
was intubated at an OSH for bleeding, and was transferred to
___ and admitted to ___. Plan per OMFS was for repair on
___. He did spike a fever to 101.6, and was given tylenol, and
blood/urine cx were sent. Due to his history of ETOH, he was
given Ativan at that time, and was started on ___
___: Vent was weaned to CPAP, and he was off all sedation.
RISBI was
22, so he was extubated. He was switched to a Phenobarb
protocol from CIWA scale (Ativan). His C-collar was cleared at
that time, SQH was started and he was made NPO at midnight in
preparation for OR with OMFS on ___.
___: Pt nasotracheally intubated. He underwent fixation of
right subcondylar mandible fractures, extraction of teeth #
24,25,26,27, closed reduction of mandibular alveolar fracture,
repair of chin laceration.
___: He underwent a seizure post OR that was managed with
just Phenobarb taper. His HCT dropped from 27 to 19.5, and he
was transfused 1 unit of blood. He was febrile to 100.5, he had
blood clots suctioned from the oral cavity. JP R neck had 145 CC
serosanguinous output, and JP L had 25 CC serosanguinous output.
___: He was extubated. The patient pulled his NGT and foley was
d/c'd. He was again febrile to 100.1. JP R had 20 CC
serosanguinous output, JP L had 10 CC serosanguinous output. No
other events. He continued on his Phenobarb taper. He was
voiding without difficulty.
___: He continued on his Phenobarb taper. No acute events
overnight. Pt was transferred to the floor.
___: JP drains were removed. Rehabiliation process started.
The patient continued on Phenobarbital taper, no further
evidence of sz. activity. The patient was tolerating a full
liquid diet, he was ambulatory.
___: The patient was discharged to the ___
___ in stable condition. Phenobarb d/c., prescription for pain
meds was given. A follow-up appointment was made with the ___
service. Social worker met with patient and addressed out-reach
programs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
stab wounds
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: ___ s/p stab to L flank, R trapezius, and R anteromedial
neck w/likely old L carotid dissection found on CTA. Patient's
brother stabbed him multiple times. Was intoxicated at the time.
No respiratory distress, no difficulty swallowing, conversant,
no difficulty speaking. No chest or abdominal pain. Neuro exam
intact. No numbness/tingling. Was transferred here from ___ for further evaluation. CT head was negative. CTA neck
showed air tracking along the right neck stab wound towards the
left side of the neck, ending a few centimeters below the area
of the left carotid dissection. The dissection itself is 1cm
superior to the carotid bifurcation in the ICA, extending for
about 5mm. Patient is asymptomatic, no focal neurologic
findings.
Does have a history of previous L-sided blunt trauma resulting
in a mandibular fracture.
Past Medical History:
Past Medical History:
HTN, anxiety, ?cirrhosis
Past Surgical History:
RUE fasciotomy, mandibular fixation
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam:
Vitals: 98.3, 94, 150/89, 16, 100%RA
GEN: A&Ox3, NAD
NEURO: CN II-XII intact, no focal weakness
HEENT: R neck stab wound (not probed on exam)
CV: RRR
PULM: Clear to auscultation b/l
Ext: No ___ edema, ___ warm and well perfused
Physical Exam:
Vitals: 98.3, 94, 150/89, 16, 100%RA
GEN: A&Ox3, NAD
NEURO: CN II-XII intact, no focal weakness
HEENT: R neck stab wound
CV: RRR
PULM: Clear to auscultation b/l
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Carotid duplex ___ -
IMPRESSION: Bilateral less than 40% carotid stenosis with
minimal plaque. There is no evidence of carotid dissection
bilaterally in the visualized portion of the carotid arteries.
Imaging:
CT head neg
CT a/p neg, ?hip dislocation
CTA neck: Dissection in the left internal carotid artery (2:162)
begins
approximately 1 cm above the bifurcation of the common carotid
artery and extends for approximately ___arotid
artery and their major
branches appear intact without evidence of active extravasation.
No evidence of disruption of the internal jugular veins.
Extensive subcutaneous gas tracks along the anterior tissue
planes in the neck. The esophagus is filled with air but appear
intact. Left clavicle fracture.
Medications on Admission:
Atenolol, ativan
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth Daily Disp #*30 Tablet Refills:*2
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain Duration:
5 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple stab wounds
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Stab wounds to the left neck.
COMPARISON: None.
FINDINGS: Portable supine frontal view of the chest.
The lung volumes are low; however, no opacity, pleural effusion or
pneumothorax is seen. The cardiac and mediastinal contours are within normal
limits for technique. The left clavicle is fractured and displaced; however,
the edges are rounded and ill-defined suggesting that this is chronic. There
are degenerative changes in the left glenohumeral joint. No displaced rib
fracture is detected on this lung-technique film.
IMPRESSION:
1) No acute pulmonary process identified.
2) Ununited left clavicular fracture that is thought to be old.
Osteoarthritis in the left glenohumeral joint.
Radiology Report
STUDY: CTA of the neck.
CLINICAL INDICATION: ___ male patient with history of stab wound.
COMPARISON: No prior examinations of the neck are available.
TECHNIQUE: After the administration of intravenous non-ionic contrast
material, axial images were obtained through the neck, sagittal, axial and
coronal reformations were reviewed.
FINDINGS: There is dissection of the left internal carotid artery with a
small pseudoaneurysm (series #2, image #162), the dissection begins
approximately at 1 cm above the cervical carotid bifurcation and extends for
approximately 5 mm. The common carotid arteries and their major branches
appear intact without evidence of active extravasation. There is no evidence
of disruption of the internal jugular veins. There is extensive subcutaneous
gas tracking along the anterior tissue planes through the neck. The esophagus
is filled with air, but appears intact. The left clavicle fracture possibly
is chronic in nature, please correlate clinically.
IMPRESSION: There is dissection of the left internal carotid artery with a
small pseudoaneurysm as described in detail above. Subcutaneus emphysema
tracking along the anterior neck tissue plane. Apparently, there is no
evidence of active contrast extravasation.
These findings were discovered and communicated via phone call to Dr. ___ by
Dr. ___ at 5:15 a.m. on ___.
Radiology Report
CLINICAL INDICATION: Stab wound to neck and back.
TECHNIQUE: Multidetector CT scan through the abdomen and pelvis was performed
after the administration of Omnipaque intravenous contrast. Coronal and
sagittal reformatted images were obtained.
DLP: 887.63 mGy-cm.
COMPARISON: None.
FINDINGS: There is bibasilar atelectasis; otherwise, the lung bases are
clear. The heart size is normal. There is no pleural or pericardial
effusion.
The liver enhances homogeneously without focal lesions or evidence of
intrahepatic biliary duct dilation. The portal vein is patent. Prominent
celiac lymph nodes are not enlarged by CT size criteria. The gallbladder
appears normal. The pancreas is unremarkable. The spleen is enlarged,
measuring up to 17 cm. There is minimal fat stranding around the liver. The
kidneys enhance homogeneously and excrete contrast bilaterally. Adrenal
glands appear normal.
Esophageal and periesophageal varices are suggested. The stomach contains a
minimal amount of fluid and is otherwise unremarkable. The small and large
bowel are unremarkable without evidence of wall thickening or adjacent fat
stranding. The appendix is visualized in the right lower quadrant and appears
normal.
The bladder is partially filled and appears normal. The prostate is
unremarkable. There is no free fluid, free air or abnormal lymphadenopathy.
The aorta is normal in caliber without evidence of dissection.
SUBCUTANEOUS AND OSSEOUS STRUCTURES: No fracture is identified; however, the
left hip is externally rotated, although this may be positional.
There is subcutaneous air as well as fat stranding and breaks within the skin
behind the right abdomen (2:33 and 2:62). No focal hematoma or disruption of
the deep fascia is identified.
IMPRESSION:
1. No evidence of acute intra-abdominal injury. Findings suggesting
superficial right posterior injury.
2. Splenomegaly, mildy prominent celiac lymph nodes, and findings suggesting
esophageal varices. No clear morphological changes in the liver; however,
findings are concerning for liver disease with portal hypertension.
3. The left hip appears to be externally rotated. This may simply be due to
positioning; however, injury is not excluded. Correlation with physical exam
findings is recommended.
Radiology Report
CLINICAL INDICATION: Stab wounds to the left neck.
TECHNIQUE: Multidetector CT scan through the head was performed without the
administration of IV contrast. Coronal, sagittal and thin-section bone
algorithm reconstructed images were obtained.
DLP: 1025.72 mGy-cm.
CTDI VOLUME: 62.20 mGy.
COMPARISON: None.
FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute
large vascular territorial infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent. Gray-white matter
differentiation is preserved.
No fracture is identified. The paranasal sinuses and mastoid air cells are
clear. The globes are unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
STUDY: Carotid series complete.
REASON: Left carotid dissection noted on CT.
FINDINGS: Duplex was performed of bilateral carotid arteries. Minimal
homogeneous plaque is seen in the carotid bifurcations bilaterally. No
intimal flap is seen bilaterally.
On the right, peak velocities are 108 124 and 101 in the ICA, CCA and ECA.
This is consistent with less than 40% stenosis.
On the left, peak velocities are 109, 136 and 117 in the ICA, CCA and ECA.
This is consistent with less than 40% stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis with minimal plaque.
There is no evidence of carotid dissection bilaterally in the visualized
portion of the carotid arteries.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: STAB TO NECK
Diagnosed with OPEN WOUND OF NECK NEC, OPN WND LATERAL ABDOMEN, OPEN WOUND OF BACK, FX CLAVICLE NOS-CLOSED, ASSAULT-CUTTING INSTR, DISSECTION OF CAROTID ARTERY, ALCOHOL ABUSE-UNSPEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Pt was admitted to trauma surgery service on ___. Vascular
surgery consulted for evaulation of stab wounds with possible
involvment of carotid artery. He was monitored closely. Received
appropriate pain control. Social work consulted for substance
use and safety of home environment. On repeat duplex ultrasound
___, there were no defects to the carotid. He was discharged
home on ___ with aspirin. No focal neuro deficits on exam. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien / shellfish derived / nafcillin
Attending: ___.
Chief Complaint:
Weakness, fall, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of advanced dementia, systolic CHF (EF35%) ___ ischemic
CM, s/p bioprothestic MVR, atrial fibrillation on xarelto, h/o
VT/VF and AF s/p AVJ ablation s/p BiV ICD, PVD s/p L external
iliac to femoral bypass presenting for evaluation of slowly
progressive decline in his mental status particularly over the
last week.
Patient limited historian. Denies pain. Says he's had trouble
swallowing. Unsure if any falls. Unable to confirm history
personally from family, so mostly derived from ED ___. "Has had
decreased p.o. intake over the last 2 days, episode of vomiting
today. Per his son was at bedside the patient has had occasional
falls, difficulty with ambulation and episodes of emesis over
the
last 2 days. Of note the patient has had progressive dysphasia
and recently had an EGD that confirmed that he did have
esophageal hiatal hernia without reflux but with severe ___
esophagitis with ulceration, no evidence of malignancy.
GI note from ___: "Patient underwent endoscopy to evaluate
dysphagia shows severe ___ esophagitis and some retained
food
in stomach. will treat with fluconazole for 14 days 200 mg bid"
PCP ___ ___: "We will continue to treat his xerosis with a
emollient and I discussed skin care including choice of soap.
We
discussed possible risk factors for his ___ esophagitis. I
advised him that the likelihood of chronic viral infection is
remote, but he has had multiple blood transfusions in the past.
He agrees to
HIV, HBV and HCV serology along with a lymphocyte profile."
In the ED, initial VS were: 97.8 116/59 66 18 96/RA
Orthostatics: 147/72@80 lying -> 136/72@80 sitting -> 127/72@81
standing.
Exam notable for: Orientation x1, trace edema bilaterally
ECG: Paced, Sgarbossa negative
Labs showed:
- WBC 4.8 Hb 9.4 Plt 139
- Cr 1.8 Bicarb 19 AG 21 lytes otherwise WNL
- INR 2.3
Imaging showed:
- CXR: No PNA
- CT A/P:
1. No acute findings in the abdomen or pelvis.
2. Large stool ball in the rectum.
- CT C-spine:
No cervical spine fracture or malalignment
- CT head:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
- XR R elbow: No evidence of fracture or dislocation. No
erosions.
Patient received:
___ 14:29 IVF NS ___ Started
___ 17:07 IVF NS 500 mL ___ Stopped (2h
___
___ 17:24 IVF LR ___ Started 100 mL/hr
___ 17:47 IVF LR ___ Confirmed Rate
Changed
to 50 mL/hr
___ 18:15 PO/NG QUEtiapine Fumarate 25 mg
___
___ 19:01 PO/NG Rivaroxaban 15 mg ___
___ 20:23 PO Pravastatin 40 mg ___
___ 20:23 PO Tamsulosin .4 mg ___
___ 20:23 PO/NG QUEtiapine Fumarate 75 mg
___
___ 20:23 PO/NG Senna 8.6 mg ___
___ 20:23 PO/NG Labetalol 200 mg ___
___ 20:24 PO/NG Lactulose 30 mL ___
On arrival to the floor, patient is somnolent but responsive. Is
limited historian. Reports some abdominal discomfort, unsure
when
his last bowel movement was. Denies black or bloody stool.
REVIEW OF SYSTEMS: As above, limited by patient cooperation.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Systolic Heart failure- (LVEF = 35 %) ___
- CAD s/p CABG in ___
- Mitral Valve replacement due to severe MR in ___
(Bioprosthetic)
- Syncopal episode leading to MVA. Suspected to be due to VT/VF
s/p dual chamber ICD at ___ in ___.
- Atrial fibrillation s/p AV junctional ablation and placement
of a biventricular ICD device in ___
3. OTHER PAST MEDICAL HISTORY
- Hypothyroid
- Cholelithiasis
- Anemia
- PVD / Femoral aneurysm
- OSA on home CPAP
- Depression
- Cervical spondylosis
- Gout
- Sigmoid diverticulitis
PAST SURGICAL HISTORY:
- EVAR ___ coil embolization ___
- Left external iliac to femoral bifurcation bypass ___.
- CABG ___
- MVR ___ Bioprosthetic
- B/l cataracts
- Dual chamber ICD ___ (___)
- Trach/PEG s/p MVC ___, now removed
Social History:
___
Family History:
father with cardiac disease, specifics unknown
Physical Exam:
ADMISSION:
VS: 97.4 132/74 81 20 99/RA
GENERAL: Somnolent, NAD, arousable, dry MMM, limited historian
but following commands
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, no nystagmus. No
oropharyngeal ___ appreciable (exam limited by patient
cooperation)
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants alghough some
discomfort in lower regions, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing; trace edema bl ___
___: 2+ DP pulses bilaterally
NEURO: A&Ox1, moving all 4 extremities with purpose
SKIN: scaling ecchymosis over arm, warm and well perfused
GU: some BR blood at meatus of penis
DISCHARGE:
97.7 146/82 82 16 100 Ra
GENERAL: Alert, pleasant, NAD
HEENT: anicteric sclera, no thrush
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Few crackles at left base, no wheezes or rhonchi,
breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, no ttp
EXTREMITIES: warm, trace edema in ___ bilaterally
NEURO: Alert and oriented to self only, moving all 4 extremities
with purpose
SKIN: scaling ecchymosis and bruising over arm, warm and well
perfused
Pertinent Results:
ADMISSION:
___ 12:50PM BLOOD WBC-4.8 RBC-3.16* Hgb-9.4* Hct-29.0*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.2 RDWSD-51.1* Plt ___
___ 12:50PM BLOOD Neuts-79.4* Lymphs-8.3* Monos-7.3 Eos-3.3
Baso-1.3* Im ___ AbsNeut-3.81 AbsLymp-0.40* AbsMono-0.35
AbsEos-0.16 AbsBaso-0.06
___ 12:50PM BLOOD ___ PTT-41.1* ___
___ 12:50PM BLOOD Glucose-115* UreaN-36* Creat-1.8* Na-142
K-4.1 Cl-102 HCO3-19* AnGap-21*
___ 07:05AM BLOOD TotProt-5.4* Calcium-8.7 Phos-3.7 Mg-1.6
UricAcd-6.7
___ 12:50PM BLOOD ALT-8 AST-30 LD(LDH)-278* AlkPhos-88
Amylase-31 TotBili-0.9
___ 12:50PM BLOOD calTIBC-233* Ferritn-316 TRF-179*
___ 07:05AM BLOOD VitB12-421
___ 01:01PM BLOOD Lactate-1.5
___ 05:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:20PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
NOTABLE:
___ 07:05AM BLOOD TSH-5.9*
___ 07:05AM BLOOD Free T4-0.9*
___ 12:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:05AM BLOOD PEP-NO SPECIFI IgG-699* IgA-206 IgM-59
DISCHARGE:
___ 05:30AM BLOOD WBC-3.3* RBC-3.26* Hgb-9.6* Hct-29.7*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.0 RDWSD-50.1* Plt ___
___ 05:30AM BLOOD Glucose-101* UreaN-14 Creat-1.1 Na-143
K-3.7 Cl-103 HCO3-21* AnGap-19*
___ 05:30AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7
MICRO:
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING:
___ Elbow X ray:
No comparison. Three views of the right elbow are provided.
Parts of a
venous access device are visualized in the cubital fossa and
projecting over the joint. No other soft tissue abnormalities.
No evidence of fracture or dislocation. No erosions.
___ CT head without contrast:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
___ CT A/P without contrast:
1. No acute findings in the abdomen or pelvis.No acute fracture.
2. Large stool ball in the rectum.
___ CT C spine without contrast:
No cervical spine fracture or malalignment.
___ Chest X ray:
The cardiomediastinal silhouette remains enlarged, but is not
significantly changed. No focal consolidations are seen. There
is mild pulmonary vascular congestion without interstitial
edema. No pleural effusion or pneumothorax.
Again seen is a left chest wall AICD with lead wires terminating
in their
expected locations
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Labetalol 200 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Rivaroxaban 15 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Ferrous Sulfate 325 mg PO BID
7. urea 10 % topical TID:PRN
8. Tamsulosin 0.4 mg PO QHS
9. Levothyroxine Sodium 25 mcg PO DAILY
10. QUEtiapine Fumarate 75 mg PO QHS
11. Senna 17.2 mg PO BID
12. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
13. Aqua Care (urea) 10 % topical TID:PRN
14. Bisacodyl ___ID:PRN Constipation - First Line
15. Calcium Carbonate 500 mg PO Q6H:PRN indigestion
16. Docusate Sodium 100 mg PO BID
17. Doxycycline Hyclate 100 mg PO Q12H
18. QUEtiapine Fumarate 25 mg PO QPM
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Aqua Care (urea) 10 % topical TID:PRN
6. Bisacodyl ___ID:PRN Constipation - First Line
7. Calcium Carbonate 500 mg PO Q6H:PRN indigestion
8. Docusate Sodium 100 mg PO BID
9. Doxycycline Hyclate 100 mg PO Q12H
10. Ferrous Sulfate 325 mg PO BID
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Labetalol 200 mg PO BID
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Pravastatin 40 mg PO QPM
15. Rivaroxaban 15 mg PO DAILY
16. Senna 17.2 mg PO BID
17. Tamsulosin 0.4 mg PO QHS
18. urea 10 % topical TID:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute metabolic Encephalopathy
Constipation
Acute kidney injury secondary to Dehydration
Chronic Systolic CHF
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with right elbow pain status post fall// Evaluate
for fracture Evaluate for fracture
IMPRESSION:
No comparison. Three views of the right elbow are provided. Parts of a
venous access device are visualized in the cubital fossa and projecting over
the joint. No other soft tissue abnormalities. No evidence of fracture or
dislocation. No erosions.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with slowly declining altered mental status in the
context of frequent falls and patient on Xarelto// Evaluate for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: Outside reference CT head from ___.
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema,or mass-effect.
Large area of encephalomalacia involving the right posterior temporoparietal
lobes is unchanged. There is prominence of the ventricles and sulci
suggestive of involutional changes. Extensive subcortical and periventricular
white-matter hypodensities are nonspecific, but likely represent sequela of
chronic ischemic small vessel disease.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoid air cells. The visualized portion of the other paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ s/p unwitnessed fall// evaluate for fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 470.0
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: CT cervical spine from ___.
FINDINGS:
Alignment is maintained. No fractures are identified.There is fusion of the
posterior aspect of the C4 and C5 vertebral bodies and fusion of the bilateral
facet joint. There is no significant canal or foraminal narrowing.There is no
prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITHOUT CONTRAST
INDICATION: ___ s/p unwitnessed fall NO_PO contrast// evaluate for 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 6.5 s, 51.1 cm; CTDIvol = 9.1 mGy (Body) DLP = 465.9
mGy-cm.
Total DLP (Body) = 466 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Heart is moderately enlarged.
Partially imaged cardiac lead wires are again noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
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. Bilateral low-density
lesions, likely simple renal cysts measure up to 3 cm in the right lower pole.
There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber and wall thickness throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is normal. A large stool ball is noted within the
rectum.
PELVIS: The urinary bladder is unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Patient is post aorta bi-iliac stent graft with extension of graft
into the right common iliac artery. Aneurysmal dilatation of the infrarenal
abdominal aorta to 3.7 x 3.2 cm is stable (3:279). Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Rod and screw fixation of the left proximal femur is again noted.
SOFT TISSUES: There is a small fat containing left inguinal hernia. The
abdominal and pelvic walls are otherwise within normal limits.
IMPRESSION:
1. No acute findings in the abdomen or pelvis.No acute fracture.
2. Large stool ball in the rectum.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: ___ with weakness and vomiting// eval for pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple chest radiographs, most recent from ___.
FINDINGS:
The cardiomediastinal silhouette remains enlarged, but is not significantly
changed. No focal consolidations are seen. There is mild pulmonary vascular
congestion without interstitial edema. No pleural effusion or pneumothorax.
Again seen is a left chest wall AICD with lead wires terminating in their
expected locations
IMPRESSION:
No pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 116.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old male with past medical history of
dementia, systolic CHF, bioprothestic MVR, atrial fibrillation
on xarelto, history of VT/VF, atrial fibrillation, peripheral
vascular disease, admitted with metabolic encephalopathy,
dehydration and constipation, now renal function and mental
status back to baseline, able to be discharged to rehab
# Nausea/vomiting
# Contipation:
Patient's son described decreased PO intake within the 2 days
prior to presentation as well as a few episodes of non-bloody,
non-bilious emesis. A CT A/P was done in the ED which showed a
large stool ball and no other acute findings. He was treated
with an aggressive bowel regimen and had bowel movements with
improvement in his nausea. He had no episodes of emesis and was
able to tolerate a diet and maintain his nutritional and
hydration status. Started and continued miralax at discharge.
# Acute kidney injury: Baseline Cr around 1 but was 1.8 on
admission. Likely prerenal in the setting of poor PO intake
secondary to nausea and constipation. Resolved to baseline with
IV fluids. .
# Acute metabolic Encephalopathy
# Dementia with behavioral disturbance
Patient with baseline severe dementia admitted with lethargy in
the setting of dehydration and ___ as above. After IV fluids
and moving bowels his mental status improved to his baseline per
his son. At baseline, he was non-lethargic, alert and oriented
to self only but calm and answered questions appropriately. An
infectious work up for other causes of encephalopathy was done
and was unremarkable. TSH and B12 were unremarkable.
# Gait instability:
# Fall: Patient's son described more instability with walking
and falls. A trauma work up including CT head was negative. ___
assessed the patient and recommended discharge to rehab. B12,
TSH, and SPEP were sent and were normal.
# Dysphagia
Evaluated by speech and swallow with recommendation for pureed
solids and thin liquids.
# Chronic Systolic CHF
Initially dehydrated as above. Continued Labetalol. Of note,
has not been maintained on metoprolol or lisinopril for unclear
reasons. If consistent with goals of care, would consider
starting. Per report from his facility, he is no longer on a
diuretic. Once taking PO, he remained euvolemic without the
need for diuresis this admission.
# Afib
# History of VT/VF
Patient continued on rivaroxaban
# Dementia
Discontinued Seroquel given initial encephalopathy. Course
notable for absence of agitated, behavioral disturbance or other
indication for this medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
codeine / Penicillins
Attending: ___
Chief Complaint:
Chest pain, Shortness of breath
Major Surgical or Invasive Procedure:
___
1. Urgent coronary artery bypass graft x3; left internal mammary
artery to left anterior descending artery, and saphenous vein
graft to ramus and posterior descending arteries.
2. Mitral valve replacement with a 27 mm ___ mechanical
valve.
History of Present Illness:
Mrs. ___ is ___ ___ yo current smoker who has had minimal
past medical care. On ___ she presented to an outside hosptal
with intermittent SSCP which was worse with exertion. She
presented with hypertension, SBP>200 and frothy pink sputum. She
was given lasix and lisinopril. She ruled in for a NSTEMI, and
was taken for cardiac cath, report not in chart but per report
___, 100%LCx,90%oRCA, 90%mRCA.
Past Medical History:
CAD
- Mitral Regurgitation
- Obesity
- Hypertension
- Peripheral arterial disease
- COPD
Social History:
___
Family History:
No Premature coronary artery disease
Physical Exam:
Pulse:60 Resp:18 O2 sat:98% on 2L NC
B/P Right:140/78 Left:
Height:5'3" Weight 180lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs coarse rhonch bilat with productive cough, no
wheezes, no rales
Heart: RRR [x] Irregular [] Murmur [x] grade ___ systolic
murmur loudest at apex
Abdomen: Soft [x] obese,non-distended [x] non-tender [x] bowel
sounds +[x]
Extremities: Warm [x], well-perfused [x] No Edema [] _____
Varicosities: None x
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+-cath site w/small ecchymotic
area, no hematoma
DP Right:dopp Left:dopp
___ Right:dopp Left:dopp
Radial Right:1+ Left:1+
Carotid Bruit Right:none Left:none
Pertinent Results:
Carotid U/S ___: 1. No significant right ICA or CCA
stenosis. 2. Approximately 40% left ICA stenosis.
.
Vein Mapping ___: The greater saphenous veins are patent
throughout their entire course, please see digitized images on
PACS for formal sequential measurements.
.
Echo ___: PREBYPASS: 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. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. MR
increased to 3+ will increase in BP vs. ischemia. Due to the
eccentric nature of the regurgitant jet (posterior directed),
its severity may be significantly underestimated (Coanda
effect). The mitral valve tenting height is 13 mm and the
tenting area is 1.9 cm2. First POSTBYPASS Period:
Biventricular systolic function is preserved. There is a ring
annuloplasty in the mitral position. However MR remains moderate
in quantity and is still posteriorly directed. Second
POSTBYPASS: Biventricular systolic function remains normal.
There is a well seated, well functioning bileaflet mechanical
valve in the ___ position. MR is present which is normal in
quantity and location (washing jets) for this type of
prosthesis. TR is mild. The remaining study is unchanged from
prebypass.
.
___ 08:15AM BLOOD WBC-9.5 RBC-3.16* Hgb-9.3* Hct-28.9*
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.6* Plt ___
___ 08:30AM BLOOD WBC-9.3 RBC-3.34* Hgb-9.6* Hct-30.2*
MCV-90 MCH-28.9 MCHC-32.0 RDW-15.9* Plt ___
___ 08:15AM BLOOD ___ PTT-57.7* ___
___ 08:30AM BLOOD ___ PTT-58.4* ___
___ 12:35AM BLOOD ___ PTT-45.3* ___
___ 01:50PM BLOOD ___ PTT-36.3 ___
___ 06:40AM BLOOD ___ PTT-34.0 ___
___ 07:00AM BLOOD ___ PTT-40.1* ___
___ 04:30AM BLOOD ___ PTT-40.9* ___
___ 08:50AM BLOOD ___ PTT-38.2* ___
___ 01:55PM BLOOD ___ PTT-38.7* ___
___ 12:50PM BLOOD ___ PTT-37.4* ___
___ 06:00AM BLOOD ___ PTT-72.9* ___
___ 04:21AM BLOOD ___ PTT-48.0* ___
___ 08:15AM BLOOD UreaN-22* Creat-0.7 Na-141 K-4.2 Cl-101
___ 08:30AM BLOOD Glucose-88 UreaN-24* Creat-0.8 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
Medications on Admission:
Medications at home:
1) fish oil
2) garlic tab
Medications on transfer:
1) Lisinopril 5 mg PO Daily
2) Aspirin 325 mg PO Daily
3) Atorvastatin 80 mg PO Daily
4) Plavix 75 mg PO Daily
5) Lovenox 80 mg SC Twice Daily
6) Metoprolol tartrate 25 mg PO Twice Daily
7) Acetaminiphen 650 mg PO Q 4 hours PRN Pain
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
4. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL
___ liquid(s) by mouth every six (6) hours Disp #*1 Bottle
Refills:*0
5. Furosemide 40 mg PO BID Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth twice
a day Disp #*14 Packet Refills:*0
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Myocardial infarction, coronary artery disease s/p coronary
artery bypass graft x 3
- Mitral valve regurgitation s/p Mitral valve replacement
- Acute systolic Congestive heart failure
Past medical history:
- Obesity
- Hypertension
- Peripheral arterial disease
- COPD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - eschar at inferior pole, no drainage or erythema
Leg - healing well, no erythema or drainage.
Edema: 1+
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation for CABG.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Moderate cardiomegaly with no
evidence suggesting pulmonary edema. Bilateral small pleural effusions,
better appreciated on the lateral than on the frontal radiograph. The
effusions are accompanied by small areas of atelectasis. No lung nodules or
masses. No evidence of pneumonia.
Radiology Report
CAROTID STUDY
HISTORY: Coronary artery disease.
FINDINGS: Mild calcific plaque involving the internal carotid arteries
bilaterally. Peak systolic velocities on the right are 71, 84, 112, 88, and
139 cm/sec for the proximal, mid, and distal ICA and CCA and ECA,
respectively. Similar values on the left are 135, 87, 81, 96, and 162 cm/sec.
There is antegrade flow involving both vertebral arteries. The ICA/CCA ratio
is 1.2 on the right and 1.4 on the left.
IMPRESSION: Findings as stated above which indicate:
1. No significant right ICA or CCA stenosis.
2. Approximately 40% left ICA stenosis.
Radiology Report
Vein mapping prior to cardiac bypass.
FINDINGS: The greater saphenous veins are patent throughout their entire
course, please see digitized images on PACS for formal sequential
measurements.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Status post CABG and mitral valve replacement.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP supine.
FINDINGS: The patient is status post interval mitral valve replacement
surgery. The patient is intubated. The endotracheal tube terminates about 6
cm above the carina. An orogastric tube passes into the stomach where it
loops once, its distal course not visualized. A chest tube projects over the
left lower hemithorax. There is apparently at least one mediastinal drain,
although not optimally visualized.A Swan-Ganz catheter terminates in the right
main pulmonary artery. The mediastinum is similar in configuration with
indistinct contours that can be expected immediately following surgery. There
is probably a small left basilar pleural effusion as well as minor atelectasis
at the left lung base. Trace air is present in the right cardiophrenic angle,
also not unanticipated after surgery.
IMPRESSION: Anticipated post-operative findings.
Radiology Report
HISTORY: ___ female with removal of chest tubes.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Frontal and lateral chest radiograph demonstrate interval removal of
endotracheal tube, enteric tube, and Swan Ganz catheter. There is increased
right pleural effusion and adjacent atelectasis but improved left atelectasis.
Left-sided pleural effusion is similar in appearance. The cardiomediastinal
silhouette is stable. No pneumothorax.
IMPRESSION:
Increased right-sided pleural effusion with adjacent atelectasis. Improved
left-sided atelectasis with persistent and unchanged left pleural effusion.
Radiology Report
PA AND LATERAL CHEST FILM, ___ AT 1530
CLINICAL INDICATION: ___ status post CABG and MVR with persistent
productive cough, question pneumonia.
Comparison is made to the patient's previous study of ___ at 1443.
PA and lateral views of the chest, ___ at 1530 is submitted.
IMPRESSION:
Stably enlarged cardiac contours status post median sternotomy with mitral
valve annular ring and CABG. There is persistent bibasilar patchy opacity
with likely associated small effusions. These findings may reflect
compressive atelectasis, although aspiration or pneumonia should also be
considered. No evidence of pulmonary edema. No pneumothorax. Overall, the
appearance is not significantly changed since ___.
Radiology Report
INDICATION: ___ female status post CABG and mitral valve replacement.
Assess for pleural effusions.
COMPARISON: Chest radiographs dating back to ___, most recent
from ___.
PA AND LATERAL CHEST RADIOGRAPHS: Overall aeration of the lungs is unchanged
compared to most recent prior from one day prior. There are bibasilar
consolidations, left greater than right, likely a combination of atelectasis
and pleural fluid. The upper lungs are clear. There is no interstitial
edema. No pneumothorax is evident. A radiopaque prosthetic mitral valve is
in unchanged expected position. Median sternotomy wires are intact.
IMPRESSION: Unchanged probable basilar atelectasis and effusions, moderate on
the left and small on the right.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Transfer
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, HYPERCHOLESTEROLEMIA
temperature: 97.9
heartrate: 65.0
resprate: 18.0
o2sat: 93.0
sbp: 169.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ was transferred from outside hospital with a
myocardial infarction and cardiac cath that revealed severe
three vessel coronary artery disease. Upon admission she was
medically managed and underwent appropriate work-up prior to
surgery. On ___ she was brought to the operating room where
she underwent 1. Urgent coronary artery bypass graft x3; left
internal mammary artery to left anterior descending artery, and
saphenous vein graft to ramus and posterior descending arteries.
Mitral valve replacement with a 27 mm ___ mechanical valve.
The cardiopulmonary bypass time was 168 minutes with a cross
clamp of 141 minutes. She tolerated the operation well and
following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. She remained hemodynamically
stable, sedation was weaned, awoke neurologically intact and was
extubated. All other tubes, lines and drains were removed per
cardiac surgery protocol without complication. She was started
on Beta-blockers, diuretics and these were titrated as needed.
On POD1 she was transferred from the ICU to the stepdown floor
for continued recovery. Chest tubes and pacing wires were
discontinued without complication. Heparin bridge was started
with coumadin on POD2 for her mechanical valve, INR goal
2.5-3.5. She received a course of Keflex for erythema at ___
site. She was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 12 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with ___ in good condition with
appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
closed reduction under anathesia, right ankle
History of Present Illness:
HPI:
___ male who presents to the emergency room today for
right leg pain. The patient was climbing over a fence last night
and had a fall resulting in injury to the right leg. The patient
was seen at outside hospital where he was found to have a
midshaft fibular fracture and a medial and posterior malleolus
fracture. The patient denies any other injury. He says the pain
is increasing. He took approximately 3 oxycodone around noon
today prior to our evaluation. He denies any numbness or
tingling
in the foot.
PMH:
none
MED:
none
ALL:
nkda
SH:
Denies any etoh, tobacco or illicit drug use
PE:
A&O x 3
Calm in mild discomfort
Chest: ctab
Abd: soft, non tender
RLE skin clean and intact
Significant swelling, ecchymosis noted in the distal leg
especially around the medial malleolus and into the foot
The anterior compartment is somewhat tense, posterior
compartment
is soft
No pain with passive motion of the toes, there is pain with
passive dorsi and plantar flexion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
LABS: Laboratory data was reviewed and notable for normal
coagulation profile, hct 45
IMAGING:
Plain films were reviewed and notable for right midshaft fibula
fracture, medial and posterior malleolus fracture
Past Medical History:
none
Social History:
___
Family History:
n/c
Physical Exam:
A&O x 3
Calm in mild discomfort
Chest: ctab
Abd: soft, non tender
RLE skin clean and intact
Significant swelling, ecchymosis noted in the distal leg
especially around the medial malleolus and into the foot
The anterior compartment and posterior compartments
are soft
No pain with passive motion of the toes, passive dorsi and
plantar flexion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
___ 04:30PM BLOOD Glucose-79 UreaN-12 Creat-1.1 Na-135
K-4.1 Cl-98 HCO3-21* AnGap-20
___ 04:30PM BLOOD Plt ___
___ 04:48PM BLOOD ___ PTT-31.0 ___
___ 04:30PM BLOOD Neuts-75.6* Lymphs-14.8* Monos-6.6
Eos-2.3 Baso-0.7
___ 04:30PM BLOOD WBC-13.6* RBC-5.21 Hgb-16.0 Hct-45.2
MCV-87 MCH-30.7 MCHC-35.3* RDW-12.9 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*61 Tablet Refills:*0
4. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right ankle 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
HISTORY: Intraoperative fluoroscopic imaging post closed reduction.
Two intraoperative fluoroscopic images are compared with prior radiographs
performed ___. A minimally displaced medial malleolar fracture is
again present with unchanged alignment. There appears to be improved
alignment of the ankle mortise with decreased lateral subluxation of the talar
dome (difficullt assessment).
A minimally displaced posterior malleolar fracture is better visualized on the
current study. The imaged portions of the right foot are intact. The distal
fibula is intact. Cast material projects over the ankle.
IMPRESSION: Minimally displaced bimalleolar fracture with probable improved
alignment of the ankle mortise post closed reduction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R TIB FIB FRACTURE
Diagnosed with FX MEDIAL MALLEOLUS-CLOS, UNSPECIFIED FALL, FX SHAFT FIBULA-CLOSED
temperature: 97.6
heartrate: 105.0
resprate: 18.0
o2sat: 97.0
sbp: 156.0
dbp: 94.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was admitted to the Orthopedic service on ___
for a right ankle fracture. On ___ he underwent closed
reduction and cast application under anesthesia without
complication. His pain was controlled with PO oxycodone,
tylenol and IV morphine. On HD3 he cleared physical therapy and
was medically stable for discharge. He will follow up in 2 weeks
to assess swelling of ankle and possible surgical intervention
at this time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nucynta / Hydromet
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with PMH notable for NASH
cirrhosis c/b recurrent admissions for HE and grade 2 varices
s/p banding, GAVE s/p APC in ___, HFpEF, HTN, and T2DM,
presenting with 3 days of worsening weakness.
Per both patient and her husband at bedside, Ms. ___ has
been quite weak for sometime now with her chronic medical
problems, namely cirrhosis. However, about 3 days ago, her
husband noted that she was unable to get up, even with
assistance. She began endorsing pain in her bilateral upper
thighs long the lateral aspects and almost fell multiple times,
including on day of admission due to her weakness. Her husband
comments that she may be a little more confused than usual, but
has been making about 3 BM's per day. She has been taking her
home rifaximin and lactulose as instructed.
Otherwise, the patient was sick with a cold about 2 weeks ago,
which has resolved. She denies any infectious symptoms of
fevers, chills, lingering cough, N/V, abdominal pain, rash, or
dysuria/urinary frequency. Her husband does note that her UTI's
in the past have been asymptomatic. She also denies any
hematochezia, but states that he stool is always dark with iron.
Recent medication changes include decrease in her dose of Lasix
from 20mg to 10mg PO daily and spironolactone from 50mg to 25mg
PO daily about 2 weeks PTA, at instruction of outpatient
hepatologist (Dr. ___. She does feel that her legs are
swollen, most from her ongoing pyoderma gangrenosum and that her
abdomen is slightly more swollen than usual. Denies any
shortness of breath or orthopnea.
At baseline, she is essentially non-ambulatory, sitting in a
sofa most of the day and not walking. This is attributed to
chronic fatigue and weakness from her liver disease and chronic
pain in her lower extremities due to PG. With regards to mental
status, the patient's husband feels that she may be slightly
more confused than usual, but they presented to the ED mostly
due to worsening of her weakness.
In the ED, initial VS were: 98.7 60 163/55 17 99% RA
Exam was notable for:
-No asterixis
-B/l ___ weakness, unable to lift up against gravity
-___ strength to upper extremities for muscle bulk, intact
cerebellar and sensory function grossly
-rectal exam showed guaiac+ dark mucous in vault without frank
melena
Hepatology was consulted and recommended RUQ ultrasound,
Hepatitis A, B, and C serologies, CK, 50g of 25% albumin,
lactulose q4h, rifaximin 550 bid, and ___ admission.
Work-up was notable for:
-Hemolyzed blood sample with K 4.7, Bicarb 14 (without AG),
BUN/Cr 35/0.8 (baseline Cr 0.9-1), CK 7758, AST 742, ALT 742, AP
364, Lipase 190, Albumin 3
-Hepatitis serologies pending
-Hgb 12, Plt 129
-lactate 1.2
-U/A showing moderate leuks, large blood, negative nitrites, 100
protein, 4 RBC, 17 WBC, few bacteria, albeit with ___ yeast
-Ucx and Blood cx x2 sent (pending)
Imaging showed:
-CXR with no acute cardiopulmonary processes but interval
vertebral body ehigh loss at level of T12
-Liver/Gallbladder U/S showing hepatic cirrhosis without focal
lesion and patient vasculature without cholelithitasis or acute
cholecystitis
Patient was given:
-500cc IVF
-50g of 25% albumin
-Ceftriaxone 1g IV x1
-Lactulose 30mg PO x1
On transfer, patient's vitals were 98.2 149/77 78 18 95RA.
On the floor, she reports the same history as above and is
without acute complaint, endorsing the same b/l leg weakness and
pain as well as leg pain overlying sites of pyoderma
gangrenosum.
Past Medical History:
- ___ cirrhosis complicated by hepatic encephalopathy and
grade 2 varices s/p banding
- HFpEF (LVEF 65%)
- Celiac disease
- Hypertension
- Diabetes mellitus type II complicated by neuropathy
- Hyperlipidemia
- Pyoderma gangrinosum
- Lumbar spondylosis
- History of compression fracture
- History of bladder surgery
- Cough-variant asthma
Social History:
___
Family History:
No history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
VITALS: 98.2 149/77 78 18 95RA
General: chronically ill appearing, malnourished
HEENT: temporal wasting appreciated; no scleral icterus; EOMI,
PERRL, MMM, tongue midline on protrusion, no appreciable tongue
fasciculations
Neck: symmetric, supple, brisk carotid upstrokes; no bruits
appreciated b/l; JVP appears to be about 8cm with prominent
carotid pulsations
CV: RRR with ___ mid-systolic murmur, no appreciable radiation
to carotids or axilla; no r/g
Lungs: CTAB with initial crackles that clear with repeated
inspiration; no r/w
Abdomen: Soft, mildly distended, mild TTP over RUQ with negative
___ sign; no r/g;
GU: no foley
Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l
with +erythema and increased warmth surrounding b/l anterior
shins, which are bandaged over sites of PG (c/d/I); tenderness
to palpation over b/l lateral thighs from hips to knees without
tenderness appreciated in hip joints; distal pulses intact
Neuro: alert and appropriately interactive on exam; ___ strength
in b/l UE; no asterixis appreciated; on strength exam, unable to
lift b/l ___ up against gravity; sensation intact and symmetric
throughout
Skin: b/l PG wounds c/d/i
DISCHARGE PHYSICAL EXAM
=================
Vitals: 99.1 127/49 75 18 95%RA
General: NAD, malnourished
HEENT: temporal wasting appreciated; no scleral icterus; EOMI,
PERRL, MMM, tongue midline on protrusion, no appreciable tongue
fasciculations
Neck: symmetric, supple, brisk carotid upstrokes; no bruits
appreciated b/l; JVP appears to be about 8cm with prominent
carotid pulsations
CV: RRR with ___ mid-systolic murmur, no appreciable radiation
to carotids or axilla; no r/g
Lungs: CTAB, no r/w
Abdomen: Soft, mildly distended, NT
GU: no foley
Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l
with +erythema and increased warmth surrounding b/l anterior
shins, which are bandaged over sites of PG (c/d/I); tenderness
to palpation over b/l lateral thighs from hips to knees without
tenderness appreciated in hip joints; distal pulses intact
Neuro: alert and appropriately interactive on exam; ___ strength
in b/l UE; no asterixis appreciated; on strength exam, lower
extremities ___ in hip flexion, knee flexion, extension,
dorsiflexion and plantar flexion; sensation intact and symmetric
throughout
Skin: b/l PG wounds c/d/I bandaged with mild erythema but not
spreading
Pertinent Results:
ADMISSION LABS
===========
___ 11:45AM BLOOD WBC-7.9 RBC-3.34* Hgb-12.0 Hct-35.2
MCV-105* MCH-35.9* MCHC-34.1 RDW-17.3* RDWSD-66.0* Plt ___
___ 11:45AM BLOOD Neuts-68.7 Lymphs-12.6* Monos-12.9
Eos-4.3 Baso-0.9 Im ___ AbsNeut-5.45# AbsLymp-1.00*
AbsMono-1.02* AbsEos-0.34 AbsBaso-0.07
___ 11:45AM BLOOD ___ PTT-28.7 ___
___ 11:45AM BLOOD Glucose-125* UreaN-35* Creat-0.8 Na-139
K-4.7 Cl-112* HCO3-14* AnGap-18
___ 11:45AM BLOOD ALT-542* AST-742* CK(CPK)-7758*
AlkPhos-364* TotBili-0.9
___ 11:45AM BLOOD Albumin-3.0* Calcium-10.2 Phos-2.2*
Mg-2.0
NOTABLE LABS
=========
___ 06:40AM BLOOD Glucose-61* UreaN-22* Creat-0.6 Na-141
K-4.4 Cl-112* HCO3-18* AnGap-15
___ 06:43AM BLOOD ALT-319* AST-386* CK(CPK)-2207*
AlkPhos-285* TotBili-0.9
___ 06:40AM BLOOD ALT-301* AST-342* CK(CPK)-1856*
AlkPhos-276* TotBili-1.2
___ 07:04AM BLOOD WBC-5.8 RBC-2.53* Hgb-9.1* Hct-26.7*
MCV-106* MCH-36.0* MCHC-34.1 RDW-17.6* RDWSD-67.9* Plt ___
___ 07:04AM BLOOD Glucose-66* UreaN-31* Creat-0.8 Na-149*
K-4.5 Cl-122* HCO3-12* AnGap-21*
___ 09:25PM BLOOD ALT-356* AST-481* LD(___)-353*
CK(CPK)-3634* AlkPhos-249* TotBili-0.8
___ 07:04AM BLOOD ALT-333* AST-435* LD(LDH)-334*
CK(CPK)-2580* AlkPhos-248* TotBili-0.9
___ 11:45AM BLOOD HBsAg-Negative HBsAb-Negative HAV
Ab-Positive IgM HBc-Negative
___ 09:25PM BLOOD CRP-10.5*
___ 11:45AM BLOOD HCV Ab-Negative
___ 12:07PM BLOOD Lactate-1.2
___ 09:25PM BLOOD SED RATE-31
MICROBIOLOGY
==========
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
CIPROFLOXACIN SUSCEPTIBILITY REQUESTED BY ___ ___
(___) @ 1420
ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CIPROFLOXACIN--------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
IMAGING
======
___ CXR
No acute cardiopulmonary process.
Interval vertebral body height loss at T12 since ___, to
be correlated
with physical exam as acuity cannot be determined.
___ ABD ULTRASOUND
1. Hepatic cirrhosis without focal lesion. Patent hepatic
vasculature.
2. Cholelithiasis without evidence for acute cholecystitis.
DISCHARGE LABS
==========
___ 05:38AM BLOOD WBC-8.7 RBC-2.58* Hgb-9.6* Hct-26.9*
MCV-104* MCH-37.2* MCHC-35.7 RDW-17.9* RDWSD-66.8* Plt ___
___ 05:38AM BLOOD ___ PTT-89.2* ___
___ 05:38AM BLOOD Glucose-50* UreaN-33* Creat-0.8 Na-140
K-4.3 Cl-110* HCO3-17* AnGap-17
___ 05:38AM BLOOD ALT-196* AST-156* CK(CPK)-124
AlkPhos-280* TotBili-1.1
___ 05:38AM BLOOD Calcium-10.3 Phos-3.3 Mg-1.8
___ 09:25PM BLOOD CRP-10.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Gabapentin 200 mg PO QHS
11. Alendronate Sodium 70 mg PO QWED
12. Rifaximin 550 mg PO BID
13. Lactulose 30 mL PO TID
14. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO DAILY Duration: 7 Days
End date ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Daily Disp
#*7 Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QWED
3. Aspirin 81 mg PO DAILY
4. Furosemide 10 mg PO DAILY
5. Gabapentin 200 mg PO QHS
6. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 30 mL PO TID
8. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nadolol 20 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Sertraline 50 mg PO DAILY
14. Spironolactone 25 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until you talk to your doctor and
your blood enzymes return to normal
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Rhabdomyolysis
Urinary tract infection
Toxic metabolic encephalopathy
Hepatic encephalopathy
Secondary
Chronic diastolic heart failure
Diabetes mellitus
Pyoderma gangrenosusm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with altered mental status // Pneumonia
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___ chest x-ray and ___ torso CT.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema. Cardiac
silhouette is mildly enlarged, unchanged. When compared to ___,
there is interval height loss T12.
IMPRESSION:
No acute cardiopulmonary process.
Interval vertebral body height loss at T12 since ___, to be correlated
with physical exam as acuity cannot be determined.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with elevated transaminase, altered mental status // Please
eval with dopplers, ? portal vein thrombosis, cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites. Hepatic
arteries and hepatic veins are all patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.8 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis. Right
kidney measures 10.9 cm in sagittal dimension.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature.
2. Cholelithiasis without evidence for acute cholecystitis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Confusion, Presyncope
Diagnosed with Hepatic failure, unspecified without coma, Urinary tract infection, site not specified, Altered mental status, unspecified
temperature: 98.7
heartrate: 60.0
resprate: 17.0
o2sat: 99.0
sbp: 163.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ y/o woman with a PMH notable for NASH
cirrhosis c/b recurrent HE, GAVE s/p APC, PG, and brittle T2DM,
presenting with acute onset b/l ___ weakness and pain (in
proximal distribution) in setting of chronic weakness and labs
notable for transaminitis and CK >7000 and UTI now with CK and
LFT downtrending after fluid resuscitation. It is likely she
developed rhabdomyelisis in the setting of acute confusion
caused by the UTI. With volume resuscitation and treatment of
the UTI, her symptoms improved.
#Rhabdomyolysis, weakness: The patient's elevated CK >7000 on
admission. AST and ALT elevation are likely in [large] part due
to rhabdo as well. Likely etiology of immobility at home in
setting of acute confusion due to UTI. Drug-mediated causes also
possible including atorvastatin as potential trigger and statin
was held. No crush injuries or compartment syndrome suspected
based on history or exam. Inflammatory etiology investigated but
inflammatory makers low-normal at CRP 10.5, ESR 31 not
suggestive of PMR. She was given 500cc NS, 50g 25% albumin, and
total 50g 5% albumin during her hospital course in increments of
12.5g. CK trended down with level at discharge 124. Physical
therapy evaluated the patient and recommended rehab.
#UTI: Patient has positive blood and WBCs on U/A. History of UTI
and three days of confusion coming in may be reflection of
infection. She received 1 dose of Ceftriaxone in ED empirically.
Urine culture grew mixed bacterial flora. History of Klebsiella
oxytoca infection in ___ sensitive only to cipro, ___,
zosyn. E. coli resistant to cipro noted in ___. She was started
on ciprofloxacin 500mg Q12H on ___ with planned 7 day course;
however urine cultures came back as Enterococcus with multiple
resistances (Including cipro) and sensitive to doxycycline. We
therefore started doxycycline 100mg daily for 7 days (end date
___
#Transaminitis: Attributed to rhabdo with normal bilirubin with
labs remaining at baseline synthetic hepatic function would
suggest non-liver etiology.
#Metabolic and hepatic encephalopathy: Likely secondary to UTI
and reduced bowel movements prior to admission. Improved with
fluid resuscitation, continuing lactulose and rifaximin, and
treatment of UTI. She was at baseline on HD #2.
#NASH cirrhosis: History of NASH cirrhosis c/b HE and GE varices
and GAVE s/p APC in ___. Appears compensated at this time.
She was continue on home PPI, nadolol, nutritional supplements.
#HFpEF: Currently euvolemic appearing. ___ edema is likely due to
local inflammation and slight hypoalbuminemia.
-holding diuretic as above, I/s/o potential rhabdo. Furosemide
and spironolactone held with plan to restart at discharge.
#Celiac disease: gluten-free diet
#Hypertension: Held diuretics and continued home nadolol.
#T2 Diabetes mellitus complicated by neuropathy: She was
continued on home lantus, ISS, gabapentin.
#HLP: holding home statin in the setting of transaminitis and
elevated CK
#Pyoderma gangrenosum/Venous stasis uclers: Per recent
outpatient notes, patient is not on any oral therapy and is
recently s/p 10 day course of PO Keflex for ___ cellulitis.
She was given local wound care without signs of worsening or
cellulitis.
#Iron deficiency anemia: per patient she has anemia at baseline,
treated with PO iron.
#Depression: continued home sertraline
TRANSITIONAL ISSUES
==============
#NEW MEDICATIONS
- Doxycycline
#CHANGED MEDICATIONS
- None
#HELD MEDICATIONS
- Atorvastatin was STOPPED
[] Restart diuretics on discharge (held for elevated CK and
elevated LFT during admission)
[] Reassess if a lower dose of a statin or different lipid
lowering regimen as CK and LFT improve
[] Dermatology follow up for lower extremity ulcers is scheduled
for ___
[] Urogynecology follow up is scheduled for ___
#CODE: Full (confirmed with patient and husband)
#CONTACT: Husband - ___ ___
#DISCHARGE WEIGHT - 121 Pounds |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Avandia / Glucophage / Lactose / aspirin
Attending: ___
Chief Complaint:
vaginal bleeding
malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with history of HTN, DM2,
CKDV, gout who presents with 1 day of vaginal bleeding and
several weeks of malaise and poor appetite. The vaginal bleeding
started this morning. She's never had anything like this since
going through menopause. It's small volume, but was concerning
enough to her and her family to present to the ED. In terms of
her fatigue and poor appetite, it has been occurring over the
last several months, and she's been told by her PCP and
nephrologist that it's likely secondary to her kidney disease.
She notes that she can't taste food very well (not a metallic
taste) and therefore doesn't feel like eating and so has been
loosing weight. No change in bowel habits. She denies any chest
pain, palpitations, shortness of breath, cough, wheeze. She also
denies abdominal pain, abdominal distension or bloating. No
fevers, chills, or nightsweats.
In the ED:
- initial vital signs: 98.4 100 169/82 18 99% RA
- Exam notable for abdominal distension, guaiac negative stool.
Vaginal exam with moderate ___ bloody discharge with
some cervical changes, no tenderness to palpation.
- Labs were significant for Creatinine 4.3 (baseline 4.1), BUN
74, bicarb 17, Mg 1.1, phos 4.9; mild leukocytosis 10.6,
normocytic anemia H/H 8.5/26.2 (baseline 9.4/29.4) , MCV 89,
plts 237, normal coags. LFTs with elevated alk phos 124
otherwise within normal limits.
- UA showed few bacteria, 24 WBC, large leuks, small blood, 300
protein, negative ketones.
- Imaging: Pelvic ultrasound showed: Heterogeneous endometrium
with fluid in the endometrial canal.
- OBGYN was consulted for vaginal bleeding who recommended
outpatient endometrial biopsy for post-menopausal bleeding.
- Vitals prior to transfer: 98.5 81 126/68 14 100% RA
On arrival to the floor, pt has no complaints. Describes feeling
tired, but no other complaints.
Past Medical History:
CKD
HTN
DM (sees Podiatry at ___, see ophthalmology at ___)
hyperlipidemia
obesity
History of palpitations
Cholecystectomy surgery in ___
Colonoscopy ___ normal: repeat ___ years
Social History:
___
Family History:
+diabetes, +colon CA, -heart disease, +ovarian CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 145/79 81 18 100% on RA
GEN: NAD, pleasant, surrounded by family, picking at a sandwich
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB
COR: RRR, no murmurs
ABD: obese, NT, ND, normal BS
GYN: deferred, given family members and recent exam in ED
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, upper and lower extremity
strength symmetrical and intact, mild short term memory
impairment
DISCHARGE PHYSICAL EXAM:
VS: 98.3 160/81 80 18 100% RA
GEN: NAD, pleasant, NAD
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB
COR: RRR, no murmurs
ABD: obese, NT, ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, upper and lower extremity
strength symmetrical and intact
Pertinent Results:
ADMISSION LABS:
___ 12:05PM BLOOD WBC-10.6* RBC-2.96* Hgb-8.5*# Hct-26.2*#
MCV-89 MCH-28.7 MCHC-32.4 RDW-12.9 RDWSD-41.0 Plt ___
___ 12:05PM BLOOD Neuts-61.4 ___ Monos-7.0 Eos-4.3
Baso-0.5 Im ___ AbsNeut-6.51* AbsLymp-2.80 AbsMono-0.74
AbsEos-0.46 AbsBaso-0.05
___ 12:05PM BLOOD Glucose-91 UreaN-74* Creat-4.3*# Na-143
K-4.9 Cl-110* HCO3-17* AnGap-21
___ 12:05PM BLOOD ALT-14 AST-16 AlkPhos-124* TotBili-0.2
___ 12:05PM BLOOD Albumin-3.6 Calcium-8.0* Phos-4.9*#
Mg-1.1*
___ 12:05PM BLOOD TSH-3.2
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-8.7 RBC-2.83* Hgb-8.3* Hct-25.3*
MCV-89 MCH-29.3 MCHC-32.8 RDW-12.9 RDWSD-41.4 Plt ___
___ 07:30AM BLOOD Glucose-79 UreaN-64* Creat-4.1* Na-144
K-4.7 Cl-111* HCO3-19* AnGap-19
___ 07:30AM BLOOD ALT-15 AST-19 AlkPhos-121* TotBili-0.2
___ 07:30AM BLOOD Albumin-3.3* Calcium-7.7* Phos-4.9*
Mg-1.0*
IMAGING:
IMAGING:
___:
Pelvic Ultrasound: Preliminary Report
Heterogeneous endometrium with fluid in the endometrial canal.
Ovaries are not visualized however there are no adnexal masses
identified. No free fluid in the pelvis.
RECOMMENDATION(S): Endometrial biopsy when clinically
appropriate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
4. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Epoetin ___ ___ units SC Q5 WEEKS
6. Atorvastatin 40 mg PO QPM
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Amlodipine 5 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. GlipiZIDE 10 mg PO BID
13. Acetaminophen 325 mg PO DAILY
14. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
9. Torsemide 10 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
12. Epoetin ___ ___ units SC Q5 WEEKS
13. GlipiZIDE 10 mg PO BID
14. Potassium Chloride 20 mEq PO DAILY
15. Outpatient Lab Work
Please have electrolytes drawn ___ and have then sent to
PCP: Dr. ___: ___
Fax: ___ ICD10: CKD N18.5
16. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Postmenopausal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with vaginal bleeding/tenderness // acut eprocess
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 on ___
FINDINGS:
The uterus is anteverted and measures 7.3 x 2.7 x 5.4 cm. The endometrial
canal is distended with fluid and the split endometrial thickness measures 6
mm. There is no increased vascularity within the surrounding endometrium, no
discrete mass identified.
The ovaries are not visualized. No adnexal masses are identified. There is
no free fluid in the pelvis.
IMPRESSION:
Heterogeneous, thickened endometrium with fluid in the endometrial canal.
Ovaries are not visualized however there are no adnexal masses identified. No
free fluid in the pelvis.
RECOMMENDATION(S): In this postmenopausal patient with bleeding and thickened
heterogeneous appearance of the endometrium, further correlation with
endometrial sampling is recommended.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: BLOOD FROM VAGINA
Diagnosed with Acute kidney failure, unspecified, Abnormal uterine and vaginal bleeding, unspecified
temperature: 98.4
heartrate: 100.0
resprate: 18.0
o2sat: 99.0
sbp: 169.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | ___ woman with history of HTN, DM2, CKD V (baseline Cr
___, gout presenting with acute episode of vaginal bleeding as
well as several weeks of malaise and decreased appetite
# Post Menopausal Bleeding: Concerning for malignancy given
history of weight loss with associated bleeding, pelvic
ultrasound with heterogeneous endometrium. Alternatively
consider atrophic bleeding, especially given that decreased
appetite may be secondary to renal disease. She will follow-up
with outpatient GYN for endometrial biopsy.
# Anemia:
Patient with baseline normocytic anemia secondary to chronic
disease and CKD, on procrit q5 weeks as outpatient. Baseline Hgb
___ down to 8.5 on admission. Most likely secondary to acute
episode of vaginal bleeding, possible malignancy with post
menopausal vaginal bleeding.
# Weakness: No neurologic deficits on exam. Most likely
secondary to CKD, although malignancy is also on the ddx. No
signs/symptoms of depression. TSH normal. Patient has upcoming
renal appointment with Dr. ___ to discuss initiation of RRT;
no indication for inpatient renal consult at this time.
# asymptomatic pyuria: WBCs in urine from ED without symptoms
(other than very longstanding generalized weakness, which is
more likely related to her renal disease), started on CTX
unfortunately without urine culture. Given low level bacteria
and asymptomatic nature, this was deemed unlikely to be a UTI
her antbiotics were discontinued. Blood cultures remain no
growth to date, but recommend a repeat urinalysis and culture
with further w/u as necessary. (Discussed this by phone with Dr.
___ team at ___ on ___, and gave my phone
number for any further follow up, since patient did not answer
my call.)
CHRONIC MEDICAL ISSUES:
#CKDV:
Creatinine at baseline ___. Patient met with nephrology nurse
___ discussing renal replacement therapy options, has not made
decision per Atrius records. She was continued on calcitriol
0.25mcg three times/week, and Vit D3 ___ IU daily and started
on sodium bicarbonate 650 mg BID for low bicarb and given lab
slip to have electrolytes rechecked ___.
# HTN: Normotensive in ED and on admission. Continue home
metoprolol XL 25mg PO daily, amlodipine 5mg PO daily, and
torsemide 10mg PO daily.
# DM2: Continued home regimen lantus of 19 U QHS, ISS.
Discharged home on home regimen with lantus, novolog scale and
glipizide.
# Glaucoma: Continued on home latanoprost 0.005% qhs and timolol
0.5% gel forming solution 1 gtt both eyes qAM
# HLD: Continued on home atorvastatin 40 mg PO qhs
# Gout: continued on home allopurinol ___ PO daily (stable
dose with current renal function)
# GERD: continued on home omeprazole 20 mg daily
# Chronic pain: continued on home acetaminophen 325mg PO q4-6h
prn pain
TRANSITIONAL ISSUES:
================
-Patient to call and schedule appointment with gynecology on
___ for endometrial biopsy.
-Started on sodium bicarbonate for low bicarb during admission.
-Labs to be checked and sent to PCP ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iron
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMH of afib on coumadin, diastolic
heart failure, and known bradycardia (previously considered for
pacemaker) who presents from home with AMS and ongoing
bradycardia. Pt. has several admissions and evaluations leading
up to this presentation that are summarized below:
Pt. was recently admitted to ___ from ___ to ___ with
cough found to have a COPD exacerbation. Pt. was treated
empirically with vanc/cefepime later transitioned to prednisone
40mg ___nd azithromycin 5 day course (day 1 ___.
Pt. was also noted to have frequent ventricular ectopy and
bradycardia on telemetry (HRs to ___ with coughing episodes).
She was noted to be asymptomatic during these episodes, thought
to be ___ increased vagal tone ___ to coughing. Hospital course
was also complicated by delirium in the setting of baseline
dementia.
She also was recently seen in the ED following prior admission
with lip swelling treated with benadryl, prednisone (4 day
course), and
H2-blocker with improvement (ED course complicated by SBPs in
200s). She was then seen in ED with episode of chest pain. Pt.
had negative troponins with no significant changes seen on EKG.
She was noted to have bradycardia on this eval. She had a
normal head CT.
Per pt's daughter, since time of original ___ admission, pt.
has not regained her baseline functioning. She remains weak and
was noted to have ongoing cough and ___ production over the
most recent several days. She also endorses more confusion in
her mother. Other than these symptoms, pt. has not complained
of lightheadedness, dizziness, chest pain, SOB, orthopnea, PND,
palpitations, N/V/D, abdominal pain, or muscle aches. She does
note decreased urinary frequency and some constipation. She
also does note ongoing exudative type drainage from her mouth.
This began following first ED evaluation for lip swelling. This
was in the setting of new changes in vision over the last 2
weeks per the pt. On day of presentation, pt. was noted to be
unarousable, sitting at breakfast table unresponsive. Pt's
daughter checked vital signs at this time which revealed HR
50-60, BP 140-150/60-70, Sat 98%. Pt. unresponsive episode
lasted on the order of approximately 1 hour. She was
transferred to the ED via EMS who noted her blood glucose to be
at 128.
In the ED, initial vitals were 98.3, 120, 121/66, 18, 99% on RA.
Pt. was with HRs in ___ following commands, alert, oriented,
but drowsy. She was then noted to have symptomatic bradycardia
with HRs in ___. EKG at this time revealed afib with delayed
ventricular conduction. UA reveals negative leuks, negative
nitrites, 30 protein, trace hematuria. Labs notable for bicarb
33, lactate 2.0, WBC 6.8, Hct 44.7. Pt. received atropine with
improvement bradycardia. ___ revealed no acute intracranial
process. Blood cx. and Urine cx were sent. Pt. was transferred
to cardiology for further evaluation.
Past Medical History:
Afib on coumadin
COPD with 2 liters home O2
Heart Failure with Preserved EF
Osteoarthritis
Right cerebellar infarct found incidentally, never symptomatic
___ disease
HTN
h/o PE Pulmonary embolism ___ ___reaking her L
shoulder
Hospitalization at ___ for UTI - Prior UTI with VRE and MRSA
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=================================
VS: 98.2, 152/85, 66 (___), 22, 100% on RA
General: NAD, somnolent but arousable to voice, answers
questions appropriately
HEENT: NCAT, pupils minimally reactive to light, no evidence of
conjunctival inflammation, evidence of superficial oral mucosal
and oropharynx ulceration with minimal lower lip swelling
Neck: Supple, no LAD, JVP 8cm
CV: Irregular, S1/S2, no m/r/g/c
Lungs: Poor respiratory effort, limited exam, otherwise CTAB
with decreased breath sounds at the bases
Abdomen: Soft, NT, ND, +BS, no rebound or guarding
GU: Foley in place
Ext: WWP, no ___ edema, 2+ DP pulses
Neuro: moving all extremities, exam limited by pt's ability to
follow commands appropriately, sensation intact light touch all
extremities
DISCHARGE PHYSICAL EXAMINATION:
=================================
VS: 98.1, 145/74, 61 afib, 18, 96% on RA
General: NAD, intermittently somnolent but arousable to voice,
oriented to person, intermittently to place and time
HEENT: NCAT, pupils minimally reactive to light, no evidence of
conjunctival inflammation, healing lip and oropharynx
ulcerations
Neck: Supple, no LAD, JVP 8cm
CV: Irregular, Bradycardic, S1/S2, no m/r/g/c
Lungs: Poor respiratory effort, limited exam, otherwise CTAB
Abdomen: Soft, NT, ND, +BS, no rebound or guarding
GU: Foley in place
Ext: WWP, no ___ edema, 2+ DP pulses
Neuro: moving all extremities, exam limited by pt's ability to
follow commands appropriately, sensation intact light touch all
extremities
Pertinent Results:
ADMISSION LABS
=================
___ 11:54AM BLOOD WBC-6.8 RBC-4.29 Hgb-13.6 Hct-44.7
MCV-104* MCH-31.8 MCHC-30.5* RDW-16.0* Plt ___
___ 11:54AM BLOOD Neuts-82.8* Lymphs-8.9* Monos-5.4 Eos-2.6
Baso-0.3
___ 06:45AM BLOOD ___ PTT-43.0* ___
___ 11:54AM BLOOD Glucose-129* UreaN-23* Creat-0.9 Na-133
K-7.8* Cl-96 HCO3-32 AnGap-13
___ 11:54AM BLOOD ALT-34 AST-108* LD(LDH)-1169* AlkPhos-49
TotBili-0.4
___ 11:54AM BLOOD Albumin-3.4*
___ 11:59AM BLOOD Glucose-124* Lactate-2.0 Na-140 K-4.2
Cl-93* calHCO3-33*
NOTABLE LABS
=============
___ 06:45AM BLOOD WBC-8.7 RBC-4.05* Hgb-12.8 Hct-42.4
MCV-105* MCH-31.7 MCHC-30.2* RDW-16.1* Plt ___
___ 06:15AM BLOOD WBC-6.0 RBC-3.59* Hgb-11.9* Hct-36.9
MCV-103* MCH-33.3* MCHC-32.4 RDW-15.7* Plt ___
___ 05:50AM BLOOD WBC-4.8 RBC-3.92* Hgb-12.6 Hct-41.0
MCV-105* MCH-32.2* MCHC-30.7* RDW-16.3* Plt ___
___ 06:45AM BLOOD ___ PTT-45.9* ___
___ 06:15AM BLOOD ___ PTT-45.2* ___
___ 06:45AM BLOOD ___ PTT-45.9* ___
___ 05:50AM BLOOD ___ PTT-45.6* ___
___ 06:45AM BLOOD Glucose-76 UreaN-20 Creat-0.9 Na-144
K-3.6 Cl-99 HCO3-38* AnGap-11
___ 06:15AM BLOOD Glucose-95 UreaN-22* Creat-0.9 Na-143
K-3.8 Cl-103 HCO3-35* AnGap-9
___ 05:50AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-100 HCO3-33* AnGap-12
___ 06:45AM BLOOD VitB12-1239* Folate-14.8
___ 06:10AM BLOOD Homocys-13.2
___ 06:45AM BLOOD TSH-1.9
___ 05:26AM BLOOD Type-ART pO2-109* pCO2-53* pH-7.40
calTCO2-34* Base XS-6
DISCHARGE LABS
=================
___ 06:10AM BLOOD WBC-4.2 RBC-3.77* Hgb-12.4 Hct-37.4
MCV-99* MCH-32.9* MCHC-33.2 RDW-15.9* Plt ___
___ 06:10AM BLOOD ___ PTT-43.5* ___
___ 06:10AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-139
K-3.6 Cl-101 HCO3-30 AnGap-12
___ 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
STUDIES
===========
ECG (___): Atrial fibrillation with slow ventricular
response and a narrow QRS complex. Leftward axis. Non-specific
repolarization abnormalities. Compared to the previous tracing
of ___ the ventricular response in atrial fibrillation has
slowed further.
CXR (___): IMPRESSION: No evidence of acute cardiopulmonary
disease.
CT HEAD (___): IMPRESSION: Stable areas of atrophy,
encephalomalacia, and white matter disease. No evidence of
acute process.
MRA BRAIN AND NECK W/O CONTRAST (___):
MR brain: There is no acute infarct or intracerebral
hemorrhage. A chronic right cerebellar infarct is again noted.
Principal intracranial vascular flowvoids are preserved. No
extra-axial blood or fluid collection is present. The ventricles
and sulci are prominent, consistent with age related
involutional changes. Mild small vessel ischemic disease is
seen. No diffusion abnormality is detected. No intracranial mass
is identified.
MRA brain and neck: MRA is limited due to patient motion. Normal
flow is seen in the bilateral ICAs and MCAs, but the peripheral
branches of these vessels cannot be evaluated. The distal left
vertebral artery is not visualized on this exam and is probably
congenitally small. Limited evaluation is performed of the neck
vessels with 2D time-of-flight, which demonstrates no high-grade
stenosis or occlusion.
IMPRESSION: 1. No acute intracranial process. 2. Limited MRA
due to patient motion. No high-grade stenosis or occlusion
detected.
MICRO
========
Blood Cultures: All returned negative
Urine Culture ___ and ___: No growth final
Radiology Report
CHEST RADIOGRAPH
HISTORY: Altered mental status.
COMPARISONS: ___ and ___.
TECHNIQUE: Chest, AP upright portable.
FINDINGS: The cardiac, mediastinal and hilar contours appear stable. Lung
volumes remain low. Minimal opacification at each lung base suggests minor
atelectasis. Otherwise, the lungs appear clear. There are no pleural
effusions or pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Radiology Report
HEAD CT
HISTORY: Altered mental status.
COMPARISONS: ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Areas of volume loss in the brain, most noteworthy along the left
frontal and temporal lobes as well as in the right cerebellar hemisphere,
appear stable, in addition to more generalized background atrophy. Patchy but
substantial areas of white matter hypodensity in the white matter of cerebral
hemispheres appear unchanged. The degree of ventricular dilatation appears
stable and not probably out of proportion to the extent of generalized
atrophy. Volume loss is also striking in the anterior temporal lobes and
along the cerebellum. There is no evidence for intracranial hemorrhage. The
mastoid air cells appear clear. The visualized paranasal sinuses also appear
clear. Cavernous carotid and vertebral artiers calcifications are prominent.
There has been no significant change.
IMPRESSION: Stable areas of atrophy, encephalomalacia, and white matter
disease. No evidence of acute process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with history of past strokes and ___
now admitted with episode of unresponsiveness // new stroke, also looking for
evidence of MSA
TECHNIQUE: Mr imaging of the brain and MRA imaging of the brain and neck were
performed. Sequences include axial FLAIR, axial MRA 3D TOF, sagittal T1, axial
T2, axial GRE, axial MRA 2D TOF, and diffusion imaging. .
COMPARISON: Comparison is made with CT head from ___ and MR head from
___.
FINDINGS:
MR brain: There is no acute infarct or intracerebral hemorrhage. A chronic
right cerebellar infarct is again noted. Principal intracranial vascular flow
voids are preserved. No extra-axial blood or fluid collection is present. The
ventricles and sulci are prominent, consistent with age related involutional
changes. Mild small vessel ischemic disease is seen. No diffusion abnormality
is detected. No intracranial mass is identified.
MRA brain and neck: MRA is limited due to patient motion. Normal flow is seen
in the bilateral ICAs and MCAs, but the peripheral branches of these vessels
cannot be evaluated. The distal left vertebral artery is not visualized on
this exam and is probably congenitally small. Limited evaluation is performed
of the neck vessels with 2D time-of-flight, which demonstrates no high-grade
stenosis or occlusion.
IMPRESSION:
1. No acute intracranial process.
2. Limited MRA due to patient motion. No high-grade stenosis or occlusion
detected.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness, ALT MS
Diagnosed with CARDIAC DYSRHYTHMIAS NEC, ALTERED MENTAL STATUS
temperature: 98.3
heartrate: 120.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ with PMH of afib
on coumadin, diastolic heart failure, and known bradycardia
(previously considered for pacemaker) who presents from home
with AMS and ongoing bradycardia. Pt. was witnessed to have
several episodes of AMS that were not related to bradycardia.
She had no events of hypoglycemia. Her TSH returned normal. Pt.
noted to have ulceration of lip and oropharynx. Dermatology
consulted thought may be ___ thrush +- HSV stomatitis. For
thrush and evidence of vulvovaginitis, pt. given 2 doses of
fluconazole with resolution of symptoms. She was without any
other clear source of infection in addition to pan-negative
culture data. Neurology evaluated the pt. and believed that her
___ Disease was likely not contributing to her AMS.
Autonomic Neurology evaluated and thought her clinical situation
may be consistent with ___ body dementia given her recent
hallucinations, but it may also have been due to delirium.
Overall pt's presentation was attributed to worsening dementia
with likely ongoing hypoactive delirium ___ recent
hospitalization, pain from oropharyngeal ulceration, and ongoing
vulvovaginitis. Her mental status improved slightly with
improved pain control and treatment of her vulvovaginitis.
ACTIVE ISSUES
==============
# Altered Mental Status: Pt. with waxing and waning mental
status consistent with hypoactive delirium. Thought to be
multifactorial with contributing factors including admission
where new onset delirium was noted, significant constipation,
vulvovaginits/thrush (in the setting of recent course of
prednisone/azithro), and pain from healing oral mucosal
ulcerations. Pt. initially presented with bradycardia which was
not thought to be contributing factor as pt's mental status
acutely worsened on different occasions during the
hospitalization without evidence of bradycardia at that time.
For concern of hypoperfusion, pt's blood pressure regimen was
discontinued. Infectious work-up was sent including blood
cultures, urine cultures, and CXR all which returned negative.
Thyroid function was checked and TSH returned normal. Pt. was
without evidence of hypoglycemia. For concern of worsening of
her underlying dementia and ___ Disease, neurology and
autonomics was consulted. An MRI Brain/Neck was done which
revealed no acute intracranial process. Autonomics thought that
her overall presentation may be consistent with ___ Body
Dementia vs. Hypoactive Delirum. She remained somewhat
somnolent with evidence of ongoing delirium and dementia at time
of discharge.
# Atrial Fibrillation with Slow Ventricular Rate: Pt. with
evidence of atrial fibrilation with slow ventricular rate on
admission. Per family, this has been well documented and
investigated in the past. Per daughter, pacemaker had been
considered prior. She also had evidence on admission of afib
with RVR. This clinical picture suggests possible sick sinus
syndrome. Pt. was thought to be asymptomatic from her
bradycardia as she has had multiple episodes of AMS without
bradycardia. Outpatient cards follow-up was arranged.
# Vasovagal Presyncope: In AM ___, pt. had brief episode of
hypotension and diaphoresis following straining episode and
massive bowel movement. This was thought to be ___ vasovagal
presyncope. Pt. was started on a bowel regimen without repeat
episode.
# Lip and Soft Palate Oral Mucosal Ulceration: Pt. presented
recently with lip swelling/lip ulceration/ and palate ulceration
which previously was thought to be a possible allergic reaction.
Dermatology was consulted for evaluation and felt that pt's
condition was most consistent with HSV stomatitis. Pt. was out
of the treatment window for anti-virals. Various mouth care and
lip care was enacted with viscous lidocaine, mupirocin, orabase,
and nystatin swish and spit for possible thrush component. Pt's
symptoms improved during hospitalization.
# Blurry Vision: Pt. complained of worsening blurry vision.
This was difficult to assess given pt's mental status. This was
thought to be related to recent anticholinergic/cholinergic
medications pt. had received recently. Case was discussed with
ophthalmology who thought that given lack of conjunctival
injection or drainage, unlikely infectious or other concerning
etiology at this time. Pt was given saline eye drops and
outpatient ophthalmology follow-up was recommended.
# Vulvovaginitis: Pt. with evidence of white exudative vaginal
discharge. Given recent course of prednisone and clinical
presentation, her symptoms were thought ___ candidal
vulvovaginitis. She was given 2 doses of fluconazole 150mg with
resolution of symptoms.
CHRONIC ISSUES
==================
# ___ disease: Continued home Carbidopa-levodopa.
# HTN: Continued on valsartan when SBP>110. Amlodipine was
discontinued at discharge.
# HFpEF: Continued lasix daily.
# Atrial fibrillation: Stable. No rate control needed.
Continued on warfarin.
# GERD: Continued home PPI.
TRANSITIONAL ISSUES
=====================
# Goals of Care: Palliative Care saw pt. during hospitalization.
Hospice was described. Pt. and family seem interested. Would
continue to discuss code status, goals of care, and possible
hospice transition as outpatient.
# Blurry Vision: Pt. c/o blurry vision worsening recently.
Discussed case with ___ on admission. No evidence of
conjunctival injection or acute process requiring inpatient
evaluation. They recommended outpatient follow-up.
# Thrush: Pt. should continue on nystatin swish and spit until
resolution of symptoms, no longer than 2 week duration. If
symptoms persist, pt. should be evaluated.
# Vulvovaginitis: Pt. given 2 doses of fluconazole with
resolution of symptoms. If whitish vaginal discharge remains,
pt. should be evaluated for further treatment.
# Bradycardia: Likely sick sinus syndrome. Stable for several
years per family. Would consider d/c'ing timolol as patients can
have bradycardic effect on medication.
# Autonomic Neurology Eval: Pt. seen by autonomics. Recommended
to have SPEP/UPEP for further evaluation. ___
pending at discharge.
# Hypertension: continued on valsartan, but amlodipine was
discontinued given her BPs were low in 100-110s range on
admission. Goal BP for her is between 130-160 systolic.
# COPD: has used home O2, but here in the hospital was satting
well on room air. Can continue to monitor saturations at home
and use O2 as needed
# CHF: will continue lasix 20mg daily and recommend following
daily weights and sypmtoms (leg edema, shortness of breath) for
further titration as an outpatient.
# Macrocytic Anemia: B12 and folate return normal. Further
work-up is recommended.
# CODE: Full, confirmed but family will continue discussing this
in the setting of her goals of care
# CONTACT: ___ (daughter, HCP, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Adefovir / sulfamethoxazole-trimethoprim / sotalol /
levetiracetam
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old ___ speaking man with h/o ESRD (on HD
___, ESLD (s/p liver transplant ___, on cyclosporine), Afib
(on ASA), T1DM, CAD, recent upper GIB (___) and previous
subdural hematoma with neurologic deficits (___), recent
admission ___, AMS and petechial rash, found to have
sepsis with MRSA bacteremia. The most likely source of the
patient's bacteremia was thought to be bacterial seeding through
his HD graft during HD.
By report from ___ patient has had a "change in mental status,
refusing meds, meals, and fluids," for the past several days. On
___ patient pulled out tubing, dialysis session was unable to
be finished. He is on cyclosporine for immunosuppression. Blood
sugars 200s.
Discussed with RN in ___ at ___, states the patient has been
refusing any medications, food, has been intermittently agitated
while getting IVs and dialysis. He has been very withdrawn and
not speaking. Fall last week, fell on backside, no headstrike or
LOC.
The ED also had a discussion with patient her ___
interpreter, patient endorses depression but denies suicidality.
He does state that he does not want an IV or any treatment. The
ED also discussed in detail with the patient's son, ___.
The patient's son reports that his father has been refusing care
but has not been expressing any depression or suicidal thoughts
to him. Psych was consulted, felt that patient does not have
capacity due to delirium.
In the ED, initial vitals: 98.0 60 187/81 16 100% RA
- Exam notable for: Dry MM, Abd soft, non-distended, mild
epigastric tenderness, no focal neuro deficits.
- Labs notable for: h/h 9.1/27.9, plt 72, creat 5.2, BUN 32,
bicarb 21, AG 19, lactate 1.0, UA 182 WBC, lg leuks
- Imaging notable for: CT head limited study but no obvious
bleeding, CXR no acute cardiopulmonary process, moderate
compression of a vertebral body at thoracolumbar junction of
indeterminate age.
- RUQUS also ordered with read pending
- Patient given: Lorazepam 2 mg, 1L nS, acetominphen 1 g,
Cefepime 2g, Vancomycin 1 g.
The patient was seen by psych who felt that due to delirium the
patient lacked capacity and HCP should be invoked.
- The patient was also seen by hepatology who recommended
obtaining RUQUS and admitting to ___.
- Vitals prior to transfer: 97.5 54 169/85 18 99%RA
Of note, the patient was admitted in ___ to ___
for MRSA bacteremia thought to be due to seeding from HD graft.
TTE and TEE were both negative for vegetations. He was continued
on vancomyin dosed by level after HD, with a plan to continue
through ___ with goal vancomycin level ___. He followed
up with OPAT/ ID clinic.
On arrival to the floor, pt somnolent, arousable, unable to
participate in questions
Past Medical History:
Afib on aspirin; Coumadin held given ___
CAD: cardiac cath in ___ w/ 40% mid LAD and 40% diagonal
stenoses. Circumflex with 40-50% mid stenosis; RCA with mild
diffuse disease; 50% PDA stenosis.
DM type 1
SDH ___ with severe neurologic deficits (mostly nonverbal)
S/p tracheostomy
ESRD on HD
Hx of liver transplant ___
Hx of seizures
S/p inguinal hernia repair (3x Left, 2x Right)
Papillary thyroid CA, s/p hemithyroidectomy ___
GERD
HTN
CVA
Social History:
___
Family History:
No family history of hepatocellular carcinoma or cirrhosis,
diabetes. 4 adult children, all in good health. Brother with
cardiac problems
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals: 97.5 153/82 HR 61 18 99 RA
General: somnolent, arousable, unable to follow commands
HEENT: Sclera anicteric, dry MM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in anterolateral lung
fields, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
scar noted
GU: condom cath in place
Ext: Warm, well perfused, no cyanosis or edema. ___ AVG noted
Skin: Without rashes or lesions
Neuro: +withdrawal to pain, good tone
DISCHARGE PHYSICAL EXAM
=================
Vitals: 98.5 145/72 54 16 99%RA
General: awake, says he feels good this AM
HEENT: Sclera anicteric, dry MM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in anterolateral lung
fields, no wheezes, rales, rhonchi
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
scar noted
Ext: no cyanosis or edema. LUE AVG noted
Skin: Without rashes or lesions
Neuro: moving all extremities symmetrically
Pertinent Results:
ADMISSION LABS
===========
___ 11:30PM ___ PTT-24.8* ___
___ 11:30PM NEUTS-64.4 ___ MONOS-7.2 EOS-7.0
BASOS-0.2 IM ___ AbsNeut-2.67 AbsLymp-0.87* AbsMono-0.30
AbsEos-0.29 AbsBaso-0.01
___ 11:30PM WBC-4.2# RBC-2.93* HGB-9.1* HCT-27.9* MCV-95
MCH-31.1 MCHC-32.6 RDW-15.0 RDWSD-51.7*
___ 11:30PM ALBUMIN-3.4* CALCIUM-8.2* PHOSPHATE-7.0*
MAGNESIUM-2.5
___ 11:30PM LIPASE-10
___ 11:30PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-58 TOT
BILI-0.4
___ 11:30PM GLUCOSE-125* UREA N-38* CREAT-5.2* SODIUM-136
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
___ 12:09AM LACTATE-1.0
___ 12:30AM URINE RBC-9* WBC->182* BACTERIA-MOD YEAST-NONE
EPI-0
___ 12:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
MICROBIOLOGY:
___ Blood culture --> Negative.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefepime > 16 MCG/ML sensitivity testing performed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CXR ___: No acute cardiopulmonary process.
Moderate compression of a vertebral body at thoracolumbar
junction of indeterminate age, this level was not well seen on
prior studies.
CT Head ___:
1. Severely motion limited examination.
2. No gross intracranial hemorrhage.
CT HEAD WITHOUT CONTRAST ___
Redemonstrated right putaminal and adjacent white matter chronic
lacune,
unchanged since multiple prior exams. There is no evidence of
recent
infarction or of hemorrhage.
TTE ___
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the basal to mid inferior wall, inferolateral wall, and mid to
distal anterolateral wall . The remaining segments contract
normally (LVEF = 40 %). Doppler parameters are indeterminate for
left ventricular diastolic function. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild left ventricular cavity dilation with regional
systolic dysfunction c/w CAD. Mildly dilated right ventricular
cavity size with mild global systolic dysfunction. Moderate
mitral regurgitation. Dilated aortic root. Pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___,
pulmonary pressures are higher.
DISCHARGE LABS
===========================================
___ 06:30AM BLOOD WBC-2.3* RBC-3.02* Hgb-9.2* Hct-28.4*
MCV-94 MCH-30.5 MCHC-32.4 RDW-14.6 RDWSD-49.8* Plt Ct-63*
___ 06:30AM BLOOD ___ PTT-30.1 ___
___ 06:30AM BLOOD Glucose-99 UreaN-43* Creat-5.1*# Na-135
K-4.7 Cl-93* HCO3-28 AnGap-19
___ 06:30AM BLOOD ALT-22 AST-15 AlkPhos-69 TotBili-0.5
___ 06:30AM BLOOD Calcium-9.2 Phos-6.6* Mg-2.7*
___ 10:08AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Positive*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
7. Entecavir 0.5 mg PO 1X/WEEK (___)
8. FoLIC Acid 1 mg PO 3X/WEEK (___)
9. Isosorbide Dinitrate 40 mg PO TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. LevETIRAcetam 250 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Senna 8.6 mg PO QHS
14. Sertraline 25 mg PO DAILY
15. Vitamin D 1200 UNIT PO DAILY
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Levothyroxine Sodium 100 mcg PO DAILY
18. Nitroglycerin Ointment 2% 2 in TP DAILY:PRN SBP>160
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. Amoxicillin-Clavulanic Acid ___ mg PO Q24H UTI
23. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
24. Vancomycin 1000 mg IV HD PROTOCOL
25. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
26. Lisinopril 30 mg PO QHS
27. Metoprolol Tartrate 50 mg PO Q6H
28. Glargine 10 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Discharge Medications:
1. Sulfameth/Trimethoprim SS 1 TAB PO BID
last day antibiotic: ___. Glargine 10 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
3. Senna 8.6 mg PO BID:PRN constipation
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
5. Amlodipine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
11. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
12. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
13. Entecavir 0.5 mg PO 1X/WEEK (___)
14. FoLIC Acid 1 mg PO 3X/WEEK (___)
15. Isosorbide Dinitrate 40 mg PO TID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
17. LevETIRAcetam 250 mg PO BID
18. Levothyroxine Sodium 100 mcg PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. Metoprolol Tartrate 50 mg PO Q6H
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Pantoprazole 40 mg PO Q24H
23. Sertraline 25 mg PO DAILY
24. sevelamer CARBONATE 800 mg PO TID W/MEALS
please use powder formulation
25. Vitamin D 1200 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Toxic metabolic encephalopathy
Urinary tract infection
Secondary:
HBV cirrhosis s/p liver transplant ___
ESRD
Hypertension
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: CT HEAD W/O CONTRAST
INDICATION: ___ with generalized abd pain, hx liver transplant // Eval for
acute process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.5 cm; CTDIvol = 48.9 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 5.0 s, 10.6 cm; CTDIvol = 47.3 mGy (Head) DLP =
501.7 mGy-cm.
Total DLP (Head) = 1,405 mGy-cm.
COMPARISON: Noncontrast CT of the head from ___.
.
FINDINGS:
Severely motion limited examination. There is no evidence of hemorrhage or
ovaries infarction. Ventricles periventricular white matter hypodensities
appear unchanged. Again seen is a right putaminal and adjacent white matter
chronic lacune, unchanged since ___ No osseous abnormalities
seen.
IMPRESSION:
1. Severely motion limited examination.
2. In the left pons without large or recent infarction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with recent fall, AMS, hx of subdural hematoma
// ? ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
DLP: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol
= 51.4 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head without contrast ___
FINDINGS:
There is no evidence of hemorrhage, edema, or mass. Again seen is a right
putaminal and adjacent white matter chronic lacune, unchanged since multiple
prior exams. There is no evidence of recent infarct. There is prominence of
the ventricles and sulci in an atrophic pattern, unchanged. Ill-defined
periventricular and subcortical white matter hypodensities are nonspecific but
likely due to the chronic sequela of small-vessel ischemic disease. The
basilar cisterns remain patent. Atherosclerotic calcifications are seen in
the bilateral carotid siphons.
There is no evidence of 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. Redemonstrated right putaminal and adjacent white matter chronic lacune,
unchanged since multiple prior exams. There is no evidence of recent
infarction or of hemorrhage.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Urinary tract infection, site not specified, Altered mental status, unspecified
temperature: 98.0
heartrate: 60.0
resprate: 16.0
o2sat: 100.0
sbp: 187.0
dbp: 81.0
level of pain: unable
level of acuity: 3.0 | Mr. ___ is a ___ year old ___ speaking man with ESRD (on
HD ___, HBV cirrhosis s/p liver transplant ___ on
cyclosporine c/b large varices and recent upper GIB (___),
Afib (on ASA), T1DM, CAD and previous subdural hematoma with
persistent neurologic deficits (___), recent admission
___ for MRSA bacteremia thought to be seeding from HD graft,
who presented with acute encephalopathy and fever, found to have
a UTI.
#Goals of care:
Patient often refuses medications and will try to pull out lines
at dialysis. Today he very clearly said no to the transport team
when he was going to be brought to dialysis. There was a family
meeting (___) and the patient's wife and son expressed that
they had considered hospice for him if his mental status is not
going to improve beyond his new baseline since the
stroke/hemorrhage. The wife and son expressed the afternoon to
think about the next best step for the patient. They will not
pursue hospice at this time.
# Toxic Metabolic Encephalopathy:
Patient presented more lethargic and less responsive than his
baseline, likely in the setting of UTI. Patient has history of
encephalopathy with infections previously. CT head limited given
pt agitation but no gross intracranial hemorrhage seen. His
mental status improved with treatment of UTI as below. Neurology
was consulted to discuss his long term prognosis. Infectious
encephalopathy, which appears to be resolving. On head CT there
is no evidence of repeat infarct or new hemorrhage, however he
does have significant frontal lobe atrophy. As such, Mr. ___ is
expected to return to his cognitive baseline, with the
understanding that this baseline will likely involve persistent
deficits in executive functioning and that he will likely not
improve beyond where he has been in the past 12 months. This
assessment was provided to Mr. ___ and his son as part of a
family meeting held ___.
#Sepsis ___ urinary source:
UA suggestive of UTI, with cultures growing E coli. Patient
intermittently tachycardic to 110s. As above, patient appears to
have had similar encephalopathy in the past in the setting of
infections, and he has also increased his rate before with
infections. Blood pressures remained stable. He was initially
treated with IV cefepime (___), then zosyn (___), then
transitioned to Bactrim (___-). He was given IV albumin for
volume repletion, which improved his tachycardia. He was
continued on Bactrim SS BID with a plan for a total 2 week
course to end ___.
# HBV cirrhosis s/p liver transplant ___: c/b large varices w/
UGI bleed ___. Continued home cyclosporine 75 mg po q12h,
home entecavir 0.5 mg PO 3X/WEEK (___), home Pantoprazole
40 mg PO Q24H.
#Pancytopenia: Likely secondary to longstanding
immunosuppression with cyclosporine and possibly lamictal
effect; likely worsened in the setting of acute infection. His
CBC was trended.
#ESRD: Continued HD ___. Continued Calcium Acetate 667 mg PO
TID W/MEALS; sevelamer CARBONATE 800 mg PO TID W/MEALS
#T1DM: On home glargine 10U qHS, 3U qAC, and ISS
#HLD: Continued atorvastatin
#CAD: Patient has a history of CAD with cardiac cath in ___
w/ 40% mid LAD and 40% diagonal stenoses. Circumflex with 40-50%
mid stenosis; RCA with mild diffuse disease; 50% PDA stenosis.
Continued isosorbide dinitrate, metoprolol, atorvastatin, and
aspirin
#Papillary thyroid cancer s/p thyroidectomy: Continued
levothyroxine 100 mcg daily.
#HTN: Continued home amlodipine, isosorbide. Held lisinopril and
clonidine.
#Afib: CHADS-VASC 5 but not on anticoagulation given a history
of subdural hematoma and GI bleed. Continued metoprolol tartrate
50 mg Q6H.
#h/o seizure disorder: continued home LevETIRAcetam 250 mg PO
BID
#h/o depression: continued home Sertraline 25 mg PO DAILY
#Vitamin D deficiency: continued home Vitamin D 1200 UNIT PO
DAILY
#Glaucoma: continued home Latanoprost 0.005% Ophth. Soln. 1 DROP
BOTH EYES QHS
Transitional issues
===================
- New medications: Bactrim (___)
- Recommend urology follow up for recurrent UTIs
- Follow up glucose control and adjust insulin as needed
- Lisinopril discontinued as blood pressures well controlled
without it (and sometimes on lower end in systolics 100s)
- Recommend nutrition follow up for discussion of feeding tube
if patient continues to refuse medications and food, while
family choosing to continue to pursue aggressive care
- Cyclosporine level goal 50-100
- Draw next cyclosporine on ___ and fax results to
___: ___
- Continue goals of care discussion with family
- HCP ___ (son) ___
- Code status: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Increased oral secretions
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old young woman with a past medical
history of cerebral palsy who presents with increased mucous
production for the past 2 weeks. She is non-verbal and is
accompanied by her father who serves as the historian. She does
have oral secretions at baseline, managed successfully as an
outpatient with ranitidine. However, over the past two weeks she
has had an increase sputum production with a mild cough and
associated chest tightness. He has tried over the count
expectorants with intermittent improvement throughout the past
two weeks. However, the mucous production was more pronounced
today, which prompted him to bring his daughter to the ___. There
is no associated wheezing or shortness of breath. There is no
nausea or vomiting. There are no sick contacts. He notes that
she has maintained her appetite and there has been no decreased
PO intake at home. No change in urination/color/appearance.
There is no history of DVT/PE in the patient or in the family.
The patient is wheelchair bound and thus relatively immobile.
Initial vitals in the ___ 100.2 130 136/89 25 98% RA
EKG revealed sinus tachycardia at 137. Lactate notable for 3.9
and she received 2L IVF. Preliminary read of ___ did not
reveal evidence of pneumonia. She received 1g ceftriaxone and a
flu swab was sent.
On the floor, Vitals were: T99.2 P ___ BP 139/92 R22 O2 sat 98%
RA
Review of sytems: Obtained via patient's father
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion.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:
Anemia
Cerebral palsy
Constipation
Eczema
Secondary amenorrhea
Social History:
___
Family History:
Mother with diabetes
Father with hypertension
Physical Exam:
ON ADMISSION:
General: Young woman lying in bed appearing uncomfortable,
non-verbal at baseline but groaning, mildly diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear, increased saliva
in oral cavity
Neck: supple, JVP not elevated, no LAD
Lungs: Exam limited due to limited participation but no clear
rhonchi or wheezes
CV: Tachycardic, no m/r/g
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, contractures in wrists and arms bilaterally
Skin: Mildly diaphoretic
Neuro: Non-verbal at baseline
ON DISCHARGE:
General: Young woman lying in bed appearing comfortable and
smiling
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Exam limited due to limited participation but no clear
rhonchi or wheezes
CV: Tachycardic, no m/r/g
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, contractures in wrists and arms bilaterally
Skin: Dry, no lesions or rashes
Neuro: Non-verbal at baseline
Pertinent Results:
ON ADMISSION:
___ 02:00PM BLOOD WBC-9.4 RBC-5.14 Hgb-11.0* Hct-38.0
MCV-74* MCH-21.3* MCHC-28.8* RDW-15.5 Plt ___
___ 02:00PM BLOOD Neuts-86.0* Lymphs-10.5* Monos-2.2
Eos-1.0 Baso-0.2
___ 02:00PM BLOOD Glucose-157* UreaN-4* Creat-0.6 Na-137
K-4.8 Cl-100 HCO3-23 AnGap-19
___ 02:00PM BLOOD Calcium-9.4 Phos-2.5* Mg-2.2
PERTINENT INTERVAL:
___ 02:14PM BLOOD Lactate-3.9*
___ 04:17PM BLOOD Lactate-3.2*
___ 07:16AM BLOOD Lactate-1.0
___ 10:50AM BLOOD Na-141 K-3.2* Cl-107
___ 05:20PM BLOOD Na-139 K-3.8 Cl-105
ON DISCHARGE:
___ 06:15AM BLOOD WBC-7.2 RBC-4.18* Hgb-9.2* Hct-30.4*
MCV-73* MCH-22.0* MCHC-30.3* RDW-15.2 Plt ___
___ 05:20PM BLOOD Na-139 K-3.8 Cl-105
IMAGING:
___
Baseline artifact. Sinus tachycardia. Non-specific ST-T wave
changes. No
previous tracing available for comparison.
IntervalsAxes
___
___
___ CXR ___
IMPRESSION: Limited examination. No evidence of acute
cardiopulmonary
process.
___ LENIs
IMPRESSION: No evidence of lower extremity deep venous
thrombosis in either the right or the left lower extremity.
___ CTA Chest
1. No evidence of pulmonary embolism.
2. Endoluminal filling defects seen within the right lower lobe
bronchi,
particularly within the posterior and lateral basilar
bronchopulmonary
segments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN pruritis
2. MedroxyPROGESTERone Acetate 10 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Ranitidine 150 mg PO BID
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN pruritis
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Ranitidine 150 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
5. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
6. MedroxyPROGESTERone Acetate 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Increased oral secretions
Endobronchial plugging
Tachycardia
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
PORTABLE CHEST, ___.
HISTORY: ___ female with cough.
COMPARISON: None.
FINDINGS: Single portable view of the chest. Slight limitation due to shells
and cardiac wires overlying the patient's chest. The lungs appear grossly
clear. Cardiomediastinal silhouette is normal. No acute osseous
abnormalities identified.
IMPRESSION: No visualized acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with cough and fever. Please perform a
lateral view to evaluate for pneumonia.
COMPARISON: Frontal chest radiograph performed approximately one hour prior
to this exam.
TECHNIQUE: A leftward rotated AP view and a lateral view of the chest were
obtained.
FINDINGS: The frontal view is extremely rotated to the left, with complete
projection of the mediastinum over the left lung, which limits assessment.
The expanded right lung is unremarkable. Assessment in the lateral view is
also limited due to superimposition of the arms, but allowing for technical
limitations, there is no spine sign, pleural effusion, or abnormality in the
anterior mediastinum. No pneumothorax is identified. Artifacts from external
hair devices are again seen.
IMPRESSION: Limited examination. No evidence of acute cardiopulmonary
process.
Radiology Report
HISTORY: ___ woman with tachycardia.
TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous
system of both lower extremities was performed.
COMPARISON: None available
FINDINGS:
There is normal compression and augmentation of the common femoral veins,
proximal, mid and distal superficial femoral veins as well as the popliteal
veins in both lower extremities. The peroneal and posterior tibial veins were
visualized in both calves and demonstrate wall to wall flow. There is normal
phasicity of the common femoral veins bilaterally.
IMPRESSION: No evidence of lower extremity deep venous thrombosis in either
the right or the left lower extremity.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ year old woman with tachycardia // please assess for PE
Additional history acquired that the patient has cerebral palsy and has had
significant mucus production.
TECHNIQUE: CTA of the chest was performed after the administration of IV
contrast. 100 mL of Omnipaque was administered for this examination.
DOSE: DLP: 235 mGy-cm.
COMPARISON: None.
FINDINGS:
Examination of the pulmonary arterial tree demonstrates no evidence of
pulmonary embolism. Evaluation of the aorta demonstrates no acute aortic
abnormality. There is a common trunk of the innominate artery and left common
carotid artery ("bovine arch"), normal variant.
Examination of soft tissue windows demonstrates no evidence of axillary,
mediastinal, or hilar lymphadenopathy. An 8 mm right hilar lymph node is seen
(series 3, image 44).
There is very minimal soft tissue density seen in the anterior mediastinum,
consistent with residual thymic tissue, and probably physiologic in a patient
of this age. The heart and pericardium appear grossly unremarkable.
Examination of the lung windows demonstrate endoluminal filling defects within
the right lower lobe lateral and posterior bronchi. In a patient of this age
and given the clinical presentation, this is likely mucus plugging. There is
no pulmonary consolidation evident.
There is some ground-glass opacity and loss of volume involving the left lower
lobe, likely due to chest wall morphology.
Maximum intensity projection images of the chest and pulmonary arteries
confirm these findings.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Endoluminal filling defects seen within the right lower lobe bronchi,
particularly within the posterior and lateral basilar bronchopulmonary
segments.
NOTIFICATION: The findings regarding endobronchial plugging were discussed
by Dr. ___ with Dr. ___ on the telephone on ___ at 1:55 ___, 5
minutes after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, N/V
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 100.2
heartrate: 130.0
resprate: 25.0
o2sat: 98.0
sbp: 136.0
dbp: 89.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is a ___ year old young woman with a past medical
history of cerebral palsy who presents with increased mucous
production x2 weeks, found to be tachycardic in the ___ with
elevated lactate and admitted to medicine for further
management.
# Increased mucous production/increased oral secretions: Ms.
___ presented with increased oral secretions appearing
uncomfortable and moaning on initial exam, with fever to 100.2.
Given her symptoms and low grade fever, she was treated
empirically for community acquired pneumonia with Ceftriaxone
and Azithromycin. The other etiology of presentation included
the possibility that she had a sore throat and was reluctant to
swallow her secretions, which eventually built up and caused her
distress. She underwent CTA to further evaluate her tachycardia
as below, with the incidental findings of endobronchial plugging
of the right lower lobe. She underwent suctioning overnight and
was back to her baseline on hospital day #2, according to her
father who is her primary caregiver. She is discharged home to
complete a course of antibiotics for CAP and with ___ services
for deep suctioning three times weekly. Respiratory viral
culture is pending on discharge and the patient was instructed
to wear a mask until contacted with the final results.
# Tachycardia: Ms. ___ presented with tachycardia to the
130s, confirmed on EKG to be sinus tachycardia, as well as
elevated lactate to 3.9. She received a total of 5L IVF with
improvement of heart rate to the low 100s. Initial EKG was
concerning for S1, Q3, T3 pattern. Given that her tachycardia
did not completely resolve even after 5L IVF, she was evaluated
for PE. LENIs were negative for DVT and CTA scan was negative
for PE (though notable for incidental findings as described
above). The etiology of her tachycardia was thought in part
secondary to hypovolemia as well as physiologic response to
endobronchial plugging. Prior to discharge she demonstrated the
ability to tolerate PO intake and she was discharged with ___
services for deep suctioning as above.
# Cerebral Palsy: Patient undergoing ___ as outpatient.
Disposable liners provided in house for incontinence.
# Constipation: Continued on home Miralax
# Secondary amenorrhea: Patient on medroxyprogesterone as needed
for no menstruation every ___ months. She is currently not
taking this medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
___: Left TFN
History of Present Illness:
HPI: ___ female with coronary artery disease, prior STEMI with
stent placement and pacemaker placement for cardiac arrest,
aortic stenosis with a mean gradient of 17 mmHg (low gradient)
who presents after likely mechanical fall at her living
facility.
The details surrounding the fall are unclear as the patient has
some dementia at baseline. In discussing with her son it is
likely that she had a mechanical fall. Workup in the ED has
been
negative. She is currently endorsing pain in the hip. She is
denying pain elsewhere.
She lives independently with her husband. She is able to walk
around the house without any shortness of breath.
Past Medical History:
PAST MEDICAL HISTORY:
-Anemia
-Bilateral carotid bruits
-Systolic ejection murmur possibly aortic stenosis
-Congestive heart failure
-Hyperlipidemia
-Hypertension
-Hyponatremia
-Acute myocardial infarction ___
-Cognitive impairment
PAST SURGICAL HISTORY:
-Pacemaker placement ___
-Pylonidal cyst
-Bilateral cataract surgery
-Olecranon left side surgery ___ after being hit by a car
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, breathing comfortably
Pulm: breathing non-labored
Abd: soft, non-tender
MSK:
Left lower extremity:
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. CARVedilol 6.25 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Nightly Disp
#*30 Syringe Refills:*0
5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
Take for 5 total days (last day ___
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
Every 12 hours Disp #*6 Capsule Refills:*0
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed Disp #*15 Tablet Refills:*0
7. Senna 8.6 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. CARVedilol 6.25 mg PO BID
11. Clopidogrel 75 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric 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).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall, left hip pain// eval for fx
TECHNIQUE: AP view pelvis and AP and lateral views of the left hip and femur
COMPARISON: None.
FINDINGS:
There is a comminuted left intertrochanteric fracture involving the greater
and lesser trochanters, and with varus angulation of the left femoral head.
No dislocation is seen. There is no fracture of the more distal left femur.
Degenerative changes are seen at the pubic symphysis and sacroiliac joints.
Severe degenerative changes are seen at the partially imaged lower lumbar
spine. Mild to moderate bilateral hip degenerative changes. Partially imaged
knee demonstrates narrowing of the medial joint compartment. No definite
suprapatellar joint effusion is seen. There are extensive vascular
calcifications. There is likely diffuse calcification of the partially imaged
distal aorta and proximal bilateral common iliac arteries. Pelvic phleboliths
are seen.
IMPRESSION:
Comminuted, displaced left intertrochanteric fracture, with varus angulation
of the femoral head. No fracture of the more distal left femur.
Radiology Report
INDICATION: History: ___ with fall, eval for traumatic injury, PNA// eval for
traumatic injury, PNA
TECHNIQUE: Single AP supine portable view of the chest
COMPARISON: None.
FINDINGS:
Dual lead left-sided pacer device is seen with lead extending the expected
positions of the right atrium right ventricle. No focal consolidation, large
pleural effusion, or evidence of pneumothorax is seen. Cardiac silhouette
size is mildly enlarged. Mediastinal contours are unremarkable. Aortic
calcifications are seen. There is no pulmonary edema. No displaced rib
fracture is identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: ORIF LEFT HIP
IMPRESSION:
Spot images are submitted for documentation of an invasive procedure performed
under imaging guidance with no radiologist in attendance. For details of the
procedure, please refer to the operative report.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip pain, s/p Fall
Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 96.5
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 182.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for left TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated left lower extremity , and will be
discharged on Lovenox for DVT prophylaxis and will also continue
her dual antiplatelet therapy. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine / Penicillins
Attending: ___
Chief Complaint:
dysarthria, left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ PMHx L frontal lobe infarct (___), L
temporal-parietal grade 2 meningioma s/p resection ___, CAD s/p
MI, HFpEF, stage III CKD, PAD, HTN, T2DM on insulin, and atrial
fibrillation not on AC (unclear reason) who presents with
dysarthria and left facial droop.
At baseline, patient lives with her daughter and granddaughter.
She requires assistance with ADLs but is able to ambulate
independently. On the morning of presentation, pt was at her
baseline. Her granddaughter left for work at 10a. Shortly
thereafter, after 10:30a, her daughter heard a thud upstairs. Pt
reports she was walking out of the bathroom to grab her phone
and
slipped on a hanger. She denies hitting her head or losing
awareness; she landed on her butt. Her daughter helped her to
standing position and patient was then able to stand unassisted.
Pt's daughter then noted pt was slurring her speech and had a
right facial droop so EMS was called.
In the ED, patient was a code stroke. NIHSS 2 for dysarthria and
left nasolabial fold flattening (right facial droop had resolved
at the time of my assessment, confirmed with daughter, and
daughter stated that left NLFF was chronic). ___ showed a 1.9
cm extra-axial hyperdense lesion that likely represented a
meningioma (vs. bleed) and "mixed sclerotic and lytic lesions by
an abnormal soft tissue density primarily located in the
anterior
portion of the middle cranial fossa extending to the left
sphenoid sinus with an intra-orbital component" (chronicity
unclear). Due to minimal deficits and possible IPH (although
less
likely), tPA was deferred.
Of note, pt was recently diagnosed with an E. coli UTI and
underwent treatment with Cipro 250 mg bid x 5 days.
On neurologic review of systems, the patient reports chronic
visual and hearing loss bilaterally. Pt denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies vertigo, tinnitus, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
1. Chronic kidney disease.
2. Congestive heart failure (diastolic stress test ___
outside hospital, EF of 60%)
3. Coronary artery disease status post myocardial infarction
4. Type 2 diabetes
5. GERD
6. Hyperlipidemia
7. Hypertension
8. Atrial fibrillation
9. Pulmonary hypertension
10. Chronic anemia
11. Osteoarthritis
12. Paget's disease of the pelvis
13. Glaucoma
14. Peripheral neuropathy (on gabapentin)
15. Macular degeneration (legally blind)
16. L temporal-parietal grade 2 meningioma s/p resection ___
17. Depression
18. L frontal lobe infarct (___)
Social History:
___
Family History:
(per OMR, confirmed with patient/daughter)
Her mother is deceased in her ___ of breast cancer with
metastasis to the brain. Her father died at the age of ___ of an
MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 98.1 77 158/78 16 100% RA
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric, R eye is opacified
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Able to recall a
history, although looks to daughter to answer questions about
her
medical history. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves - L pupil 2->1.5. R eye opacified. Blinks to
threat in left eye (right eye blind/opacified). EOMI. V1-V3
without deficits to light touch bilaterally. L NLFF at rest,
able
to activate. Hearing decreased to finger rub bilaterally. Mild
dysarthria. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Power intact throughout apart from L deltoid 4+.
- Sensory - No deficits to light touch bilaterally.
-DTRs: ___ reflexes throughout. Plantar response mute
bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.5, HR 66-79, BP 166-177/75-88, 99-98%RA
Gen: thin older woman lying in bed, NAD
HEENT: NCAT, R eye is opacified with no light perception, no
oropharyngeal lesions, moist mucous membranes
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. She smiles frequently and speaks quietly, not fully
answering questions at times. Naming impaired (calls key a
"baby" and cactus "bunny ears"; able to name glove and feather).
In cookie jar picture, identifies woman but does not appreciate
two young children; calls the cookie jar "two big eyes". Able to
repeat "It's a sunny day in ___. No extinction. No
left-right confusion. No acalculia.
- Cranial Nerves - L pupil 2->1.5. R eye opacified. Blinks to
threat in left eye (right eye blind/opacified). EOMI without
nystagmus. Right hemianopia (does not identify fingers in right
visual field). V1-V3 without deficits to light touch
bilaterally. L NLFF at rest, able to activate, improving.
Hearing decreased to finger rub bilaterally. Mild dysarthria.
Palate elevation symmetric. Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. +Left pronator drift. No tremor
or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 ___ 5 5
R 5 ___ ___ 5 5 ___ 5 5
- Sensory - No deficits to light touch bilaterally.
- DTRs: ___ reflexes throughout. Plantar response mute
bilaterally.
- Coordination - No dysmetria with finger to nose testing with
right hand. With left hand, consistently reaches left of target
(both nose and hand) with no ataxia or intention tremor.
- Gait - Able to ambulate slowly with two-person assistance,
shuffling gait
Pertinent Results:
___ 10:45AM BLOOD WBC-5.8 RBC-4.29 Hgb-11.8 Hct-35.0 MCV-82
MCH-27.5 MCHC-33.7 RDW-16.0* RDWSD-47.3* Plt ___
___ 10:45AM BLOOD Neuts-60.8 ___ Monos-6.8 Eos-3.1
Baso-0.7 Im ___ AbsNeut-3.50 AbsLymp-1.63 AbsMono-0.39
AbsEos-0.18 AbsBaso-0.04
___ 10:45AM BLOOD Glucose-250* UreaN-15 Creat-1.4* Na-132*
K-5.1 Cl-98 HCO3-17* AnGap-22*
___ 11:07AM BLOOD Creat-1.9*
___ 10:45AM BLOOD ALT-24 AST-56* AlkPhos-90 TotBili-0.5
___ 10:45AM BLOOD cTropnT-0.03*
___ 07:50PM BLOOD cTropnT-0.04*
___ 12:50AM BLOOD cTropnT-0.03*
___ 10:45AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.3 Mg-1.8
___ 05:25AM BLOOD %HbA1c-8.5* eAG-197*
___ 05:25AM BLOOD Triglyc-80 HDL-56 CHOL/HD-2.5 LDLcalc-66
___ 05:35AM BLOOD Glucose-119* UreaN-15 Creat-1.2* Na-140
K-3.4 Cl-104 HCO3-24 AnGap-15
IMAGING
NCHCT (___):
1. A 1.9 cm extra-axial hyperdense lesion with suggestion of
calcifications in the right parietal convexity without
hyperostosis of the overlying bone. This may represent a
meningioma but cannot definitively exclude extra-axial
hemorrhage.
2. Expansion of the sphenoid triangle with mixed sclerotic and
lytic lesions by an abnormal soft tissue density primarily
located in the anterior portion of the middle cranial fossa
extending to the left sphenoid sinus with an intra-orbital
component leading to mass effect on the left lateral rectus
muscle, retro-orbital fat, and proptosis. These findings may be
related to an intraosseous meningioma with soft tissue extension
and postoperative changes from prior left pterional craniotomy.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST (___):
1. Status post left pterional craniotomy for meningioma, with
area of
enhancement in the left middle cranial fossa as described above,
suspicious for recurrence.
2. Redemonstration of calcified right parietal meningioma.
3. Acute infarction within the right frontal temporal lobes and
in the left precentral gyrus.
4. Chronic infarction within the right cerebellar hemisphere.
No intracranial hemorrhage.
5. Diffuse parenchymal volume loss with nonspecific white matter
signal
abnormality, likely a sequela of chronic small vessel ischemic
disease.
6. Unremarkable MRA head.
7. Difficult to assess right vertebral artery with areas of non
enhancement which may be related to atherosclerotic disease.
Otherwise, unremarkable MRA neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
4. Furosemide 20 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Januvia (SITagliptin) 100 mg oral DAILY
7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Glargine 15 Units Bedtime
10. Atorvastatin 20 mg PO QPM
Discharge Medications:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
4. Furosemide 20 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Januvia (SITagliptin) 100 mg oral DAILY
7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Apixaban 2.5mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right MCA stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ED CODE STROKE ONLY CT
INDICATION: ___ with history of meningioma status post resection in ___ in
___ with SLURRED SPEECH, Left facial droop// ICH. FRACTURE
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a 1.9 x 1.0 cm extra-axial hyperdense lesion at the right parietal
convexity with suggestion of calcifications but no overlying bony changes such
as hyperostosis. This may represent a meningioma or extra-axial hemorrhage,
correlate with prior imaging or follow-up MR.
___ is status post left pterional craniotomy with encephalomalacia in the
left frontal and temporal lobe, potentially related to postsurgical changes
for resection of mass lesion.
There is expansion of the sphenoid triangle with mixed sclerotic and lucent
areas and abnormal soft tissue component extending from the region of the
prior surgical bed into the left sphenoid sinus. There is an additional
orbital soft tissue component measuring 4.2 x 1.5 cm leading to mass effect on
the left lateral rectus muscle and the retro-orbital fat with left proptosis
(2; 11). An additional extra-axial component is located in the anterior
portion of the middle cranial fossa. These changes may be due to an
intraosseous meningioma with postoperative changes, correlate with prior
imaging or follow-up with MR evaluation.
Hypodensity in the cerebellum on the right is consistent with old infarct.
Bilateral scattered basal ganglia hypodensities consistent with old lacunar
infarcts. Periventricular and subcortical white matter hypodensities are
nonspecific but likely represent sequelae of chronic small vessel disease.
There is no midline shift. The ventricles and sulci are normal in size and
configuration.
The frontal sinuses, maxillary sinuses, ethmoid sinuses and mastoid air cells
are clear. Scleral band about the right globe noted.
IMPRESSION:
1. A 1.9 cm extra-axial hyperdense lesion with suggestion of calcifications
in the right parietal convexity without hyperostosis of the overlying bone.
This may represent a meningioma but cannot definitively exclude extra-axial
hemorrhage.
2. Expansion of the sphenoid triangle with mixed sclerotic and lytic lesions
by an abnormal soft tissue density primarily located in the anterior portion
of the middle cranial fossa extending to the left sphenoid sinus with an
intra-orbital component leading to mass effect on the left lateral rectus
muscle, retro-orbital fat, and proptosis. These findings may be related to an
intraosseous meningioma with soft tissue extension and postoperative changes
from prior left pterional craniotomy.
RECOMMENDATION(S): For both of the above findings, correlate with prior
imaging or alternatively follow-up with MR.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with SLURRED SPEECH, Left facial droop// ICH. FRACTURE
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 21.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 475.2
mGy-cm.
Total DLP (Body) = 475 mGy-cm.
COMPARISON: Noncontrast head CT performed on the same day.
FINDINGS:
There is reversal of cervical lordosis without malalignment. No fractures are
identified.
Multilevel degenerative changes most severe at C3-C4 through C5-C6 with
intervertebral disc height loss, uncovertebral hypertrophy, and facet
arthropathy. Superimposed post posterior disc bulges at C3-C4 and C4-C5 lead
to at least moderate spinal canal narrowing and presumed spinal cord
remodeling.
There is no prevertebral edema.
Known soft tissue lesion extending into the sphenoid sinus is better seen on
head CT performed on same day.
A 1.4 cm hypodense right thyroid nodule is identified, no follow-up imaging is
needed given size and age. The included lung apices are unremarkable.
IMPRESSION:
1. No fracture or malalignment.
2. Degenerative changes with posterior disc bulge at C3-C4 and C4-C5 causing
at least moderate spinal canal narrowing and presumed spinal cord remodeling.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old woman with hx meningioma, new dysarthria, transient R
nasal labial fold; also odd lesion in L middle cranial fossa. Evaluate for
infarct, also further evaluation of left middle cranial fossa lesion
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 13 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___
FINDINGS:
MRI BRAIN:
Patient is status post left pterional craniotomy for resection of known
meningioma. There is a 4.1 cm TV x 5.3 cm AP x 6.8 cm enhancing mass within
the left middle cranial fossa corresponding to mixed lytic and sclerotic
lesion seen on prior CT. Superiorly, the mass is lateral to the orbit
exerting mass effect on the lateral rectus muscle with resulting proptosis.
Medially, the mass extends into the left sphenoid sinus with enhancement along
the left aspect of the cavernous sinus with preserved flow voids. There is
extension through the left pterygopalatine fossa and possibly the sphenoid
palatine foramen and likely foramina rotundum. There is enhancement within
the left anterior temporal lobe extra-axial space with adjacent cystic
encephalomalacia within the left temporal lobe.
There is slow diffusion within the right frontal temporal lobes and within the
left precentral gyrus. There is no intracranial hemorrhage. There is chronic
infarction within the right cerebellum. There is a calcified right parietal
extra-axial mass measuring 2.1 cm TV x 1.4 cm AP x 1.6 cm SI. There is
diffuse parenchymal volume loss with prominence of the ventricles and sulci.
There are nonspecific periventricular and subcortical FLAIR hyperintensity in
addition to the pons, likely a sequela of chronic small vessel ischemic
disease.
There is mild mucosal thickening of bilateral ethmoid and sphenoid air cells.
There is right scleral banding. Patient is status post bilateral lens
replacement again seen is left orbital proptosis. The dural venous sinuses
appear patent on post-contrast MPRAGE images.
MRA BRAIN:
The intracranial vasculature appears patent without evidence of stenosis,
occlusion, or aneurysm. There is a left dominant vertebral artery.
MRA NECK:
It is difficult to assess enhancement within the right vertebral artery with
areas of non enhancement, which may be related to atherosclerotic disease or
artifactual related to technique. Within the confines of the study, the
bilateral internal and common carotid arteries appear patent without internal
carotid artery stenosis by NASCET criteria. The left vertebral artery appears
patent.
IMPRESSION:
1. Status post left pterional craniotomy for meningioma, with area of
enhancement in the left middle cranial fossa as described above, suspicious
for recurrence.
2. Redemonstration of calcified right parietal meningioma.
3. Acute infarction within the right frontal temporal lobes and in the left
precentral gyrus.
4. Chronic infarction within the right cerebellar hemisphere. No intracranial
hemorrhage.
5. Diffuse parenchymal volume loss with nonspecific white matter signal
abnormality, likely a sequela of chronic small vessel ischemic disease.
6. Unremarkable MRA head.
7. Difficult to assess right vertebral artery with areas of non enhancement
which may be related to atherosclerotic disease. Otherwise, unremarkable MRA
neck.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:40 am, 2
minutes after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Slurred speech
Diagnosed with Cerebral infarction, unspecified, Slurred speech
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is an ___ year old woman with a PMHx of L frontal lobe
infarct (___), L temporal-parietal grade 2 meningioma s/p
resection ___, CAD s/p MI, HFpEF, stage III CKD, HTN, T2DM on
insulin, and atrial fibrillation not on AC (unclear reason) who
is admitted to the Neurology stroke service with L facial
weakness and dysarthria secondary to an acute
ischemic/hemorrhagic stroke in the R MCA. Exam notable for
dysarthria, left NLFF but good activation and left pronator
drift with subtle left proximal weakness that has improved. MRI
with acute infarction within the right temporoparietal lobe and
a small infarction in the left precentral gyrus, as well as
chronic infarction within the right cerebellar hemisphere and
diffuse parenchymal volume loss with nonspecific white matter
signal abnormality, likely a sequela of chronic small vessel
ischemic disease.
Her stroke was most likely secondary to a cardioembolic event,
given her history of atrial fibrillation not on AC and pattern
of acute MRI changes. Her calculated CHADS-VASc Score is 9,
indicating a ___ risk of stroke per year. The benefits of
anticoagulation for prevention of further strokes is greater
than the risk of bleeding in this situation. Therefore, we have
added Apixaban 2.5mg BID to her current medication regimen. She
technically qualifies for 5mg BID dosing, given that her Cr at
discharge was below 1.5 and her body weight is greater than 60
kg. However, because she is ___ and her Cr was 1.9 on
admission, coupled with her history of neurosurgery (meningioma
s/p resection), we will start her on 2.5mg BID for ___ weeks,
with a plan to increase her dose to 5mg BID at her stroke
followup appointment, if tolerated.
Her deficits improved greatly prior to discharge and the only
notbale weakness was in the L IO muscles with subtle L pronator
drift, as well as mild dysarthria. She also has chronic visual
deficits. She will continue rehab at home with home ___, with
speech/swallow follow up. |
Name: ___. Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Robitussin A-C / Clindamycin / Lipitor / latex
Attending: ___
Chief Complaint:
right arm numbness and transient aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of atrial fibrillation
on aspirin/amiodarone therapy, hypertension, hyperlipidemia,
left sided subclavian steal and a lung nodule who presents to
the ED with a brief episode of right arm numbness and impaired
speech. On the morning of admission, she had just finished
eating breakfast when she went into her room and started folding
clothes. She noticed that her right hand felt numb. It was not
clumsy at the time and she noted that she was able to fold
clothes without difficulty. Shortly thereafter, she noted that
the tongue felt like it was pushing upwards on the right side of
her mouth. She went to speak to her daughter about this and
noted that she simply couldn't get any words out. When finally
she could use some words to express herself, her speech was
slow, stuttering and slurred. Apparently she was able to write
her thoughts down. She had ___ difficulty comprehending commands
around her. The numbness went away within 5 minutes but the
speech difficulties persisted for about 1 hour. Her daughter now
reports that the right side of her face was droopy, but is much
improved now. The daughter also confirmed that her mother's
speech and fluency was much better than previous.
Review of systems is positive for difficulties with left sided
thigh pain and some recent issues with neck pain. She has not
had nausea, emesis, chest pain, congestion, cough, abdominal
pain, dysuria, hematuria. She denied double vision or headache
during these symptoms.
Past Medical History:
- Dyslipidemia
- Hypertension
- Paroxysmal Atrial Fibrillation, only on aspirin/plavix
Was admitted in ___ with AF with RVR. She was briefly on a
heparin IV gtt but this was stopped after cardiac enzymes
remained flat and normal. She has remained on aspirin. It
appears from OMR notes from her PCP that he has had numerous
conversations with her about switching to warfarin, but she has
declined.
- Rheumatic Heart Disease with moderate MR. ___ mitral stenosis
seen on echo in ___.
- Mild Pulmonary Hypertension
- GERD
- Urinary urgency
- Left Subclavian Stenosis
Noted to have asymmetric blood pressures (R>L) in ___ when
seeing cardiology, also noted to have a carotid bruit. Carotid
U/s followed by MRA ___ identified subclavian steal physiology
with retrograde left vertebral artery flow.
- History of Cervical Cancer in ___, s/p TAH/BSO
- Left thalamic calcification: noted to be possibly "cavernoma"
on an MRI in ___
Social History:
___
Family History:
Patient's brother passed away from MI at the age of ___.
Mother suspected of passing from MI as well.
___ family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
T 98.1, 74, 141/66 (left), 18, 100%. She was awake, alert and
was pleasant and cooperative. Neck was supple and with full ROM.
Chest was without adventitious sounds and her heart rate was
regular. Lungs were clear. Pulses were equal. Abdomen was soft.
Lower extremities were warm and well perfused.
Neurologically, she was awake, alert and oriented x 3. She could
follow simple commands without difficulty. She was attentive to
the examiner. She was able to name objects on the ___ card,
she could read and had ___ visual neglect. She repeated simple
sentences without difficulty, but had trouble with more
complicated sentences such as ___ ifs, ands, or buts about it".
Language was fluent but her talking speed was slower than usual
(per daughter). Speech was slightly dysarthric.
Pupils were equal, round and reactive. Eye movements were full
and visual fields were full to confrontation. The right NLF was
flattened compared with the right. ___ ptosis. Tongue deviated to
the right, but palate elevated symmetrically. Facial sensation
was intact to light touch and pin bilaterally.
Motor examination identified full strength in all major muscle
groups without pronator drift or tremors/asterixis. Rapid
alternating movements were without asymmetry. Confrontation
testing identified ___ strength in all four extremities.
Reflexes were 2+ throughout with downgoing toes.
Sensory examination identified normal pinprick and light touch
throughout. Cortical sensation on both palms was symmetric - she
appeared to get only 60-70% accuracy on both palms. She had ___
finger-nose dysmetria or tremor.
Gait was normal
DISCHARGE EXAM: Normal speech. Nonfocal neurological exam
Pertinent Results:
Labs:
BMP: 139 ___ AGap=18
5.4 23 1.0
(hemolyzed)
CBC: 9.2, 42.8, 288
___: 11.5 PTT: 28.5 INR: 1.1
NCHCT: Hyperdense lesion in the left thalamus, consistent with
stable cavernoma
MRI/MRA head (___): Age-related involutional and chronic
microangiopathic changes without evidence of acute infarct,
hemorrhage, or mass effect.
Entire left vertebral artery is markedly diminished in caliber
with severe stenosis just beyond the origin likely related to
atheromatous disease, as well as diminutive right A1 and P1
segments.
Echocardiogram (___): The left atrium is elongated. ___
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF = 65%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and ___ aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. The mitral valve
shows characteristic rheumatic deformity. There is ___ mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is ___ pericardial
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Slurred speech, right hand numbness.
COMPARISON: Head CT ___.
TECHNIQUE: Axial MDCT images were obtained through the brain without the
administration of IV contrast. Coronal and sagittal reformats were also
examined.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or
large vascular territory infarction. The ventricles and sulci are normal in
size and configuration for age. Again seen is a left thalamic rounded
calcific density, stable compared to prior studies. Bilateral basal ganglia
calcifications are also noted. The basal cisterns are patent, and gray white
matter differentiation is maintained.
No fracture is identified. Atherosclerotic calcifications of the carotid
siphons are noted. The mastoid air cells and middle ear cavities are clear.
Secretions in the left sphenoid sinus and partial opacification of the right
mastoid air cells are present. Note is made of a right lens replacement.
Additionally, elongation of the posterior right globe is present, consistent
with known staphyloma.
IMPRESSION: No acute intracranial process.
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of pulmonary nodules, questionable nodule on radiograph.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of a minimal parenchymal opacity, located in the left apex, and very likely
the result of overlying vascular and parenchymal structures. The structure
has not grown or changed in morphology.
No other changes. No pleural effusions. Borderline size of the cardiac
silhouette. Tortuosity of the thoracic aorta. Normal hilar and mediastinal
structures.
Radiology Report
HISTORY: ___ year old woman with new right sided weakness and
aphasia/dysarthria.
TECHNIQUE: Multiplanar multi sequence MR images of the head were performed
before and after the administration of intravenous contrast. Non contrast MRA
of the head, and pre- and post-contrast MRA of the neck, were obtained.
COMPARISON: CT head ___ ; MR head ___.
FINDINGS:
MR Brain: MRI of the brain demonstrates no evidence of hemorrhage or
infarction. There are small scattered T2/FLAIR high signal foci throughout the
brain consistent; in light of the patient's age, these are probably sequela of
chronic microvascular changes. Gray white matter differentiation is otherwise
maintained. Ventricular, cisternal, and sulcal prominence may be a function
of age-related parenchymal volume loss. There is a stable coarse
calcification within the left thalamus. The paranasal sinuses and mastoid air
cells demonstrate normal signal. The right globe lens replacement changes are
noted. The sella turcica, craniocervical junction, orbits are otherwise
unremarkable.
MRA Head: Normal flow signal is noted in the petrous, cavernous, and
supraclinoid portions of the internal carotid arteries. The right A1 segment
is diminutive likely related to atherosclerosis. The anterior and middle
cerebral or vertebral arteries are otherwise unremarkable. The anterior
communicating artery region unremarkable. The right P1 segment is
hypoplastic. The posterior cerebral arteries and basilar artery are otherwise
unremarkable. The superior cerebellar arteries are normal. The right
vertebral artery is dominant; the intradural segment of the right vertebral
artery appears patent. The left intradural vertebral artery is diminutive
likely related to atheromatous disease. The posterior communicating arteries
are seen. No arterial other stenosis, saccular aneurysm, or AVM is
identified.
MRA Neck: There is common origin to the innominate and left common carotid
artery, a normal variant. The common, internal, and external carotid arteries
demonstrate normal flow signal and enhancement. No stenosis is identified.
The origins of the innominate, left common carotid, and left subclavian
arteries are normal. The right vertebral artery is unremarkable. The entire
left vertebral artery is markedly diminished in caliber just beyond the origin
likely related to atheromatous disease.
IMPRESSION:
Age-related involutional and chronic microangiopathic changes without evidence
of acute infarct, hemorrhage, or mass effect.
Entire left vertebral artery is markedly diminished in caliber with severe
stenosis just beyond the origin likely related to atheromatous disease, as
well as diminutive right A1 and P1 segments.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Numbness, Slurred speech
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 98.1
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | ___ woman w AFib on amio and ASA, history of left subclavian
steal syndrome, HTN/HLD who developed acute onset of right hand
numbness followed by diminished speech output and dysarthria
initially concerning for TIA/stroke. On admission, her symptoms
had largely resolved and neurological exam was significant only
for mildly slurred speech. Code Stroke was called with ___
for dysarthria. CT/CTA and MRI have showed ___ acute lesion or
gross vascular compromise, although severe stenosis of the left
vertebral artery due to atherosclerosis was seen. Labs do not
identify gross metabolic disturbances. TIA with possible
thromboembolic etiology from transient Afib vs small vessel
disease. ___ evidence to support vertebrobasilar ischemia despite
her history of subclavian steal. During this admission she had a
brief run of transient questionable Afib with HR 130s that
resolved in less than 30 seconds. We had lengthly discussions
about her stroke risk due to paroxysmal Afib going forward, but
she continues to defer anticoagulation due to concerns about
bleeding. She would like to discuss possibly starting Pradaxa
after discussion with her PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o well controlled asthma presenting with 4 day h/o
abdominal pain. Patient notes that she developed sharp RUQ/RLQ
pain 4 days ago toward the end of her menses. The pain was
constant and gradually worsened and spread across her abdomen.
Over the same period, she has experienced nausea and
constipation with last bowel movement ___ days ago. She reports
chills but no fever, denies dysuria, frequency urgency. No
recent travel or sick contacts. No h/o abdominal surgery.
In the ED, initial VS were 98.7 128 137/85 18 100% RA. Physical
exam was significant for diffuse abdominal tenderness, no CMT or
adnexal tenderness on bimanual exam and small amount of heme
negative brown stool on rectal exam. Labs showed normal CBC with
WBC 8.4, lactate 1, ALT 8, AST 13, AP 41, Tbili 0.4, lipase 20,
negative UA, negative urine HCG. KUB showed nonspecific bowel
gas pattern and CT abd/pelvis showed enhancement in the proximal
jejunum folllowed by a segment of mildly dilated bowel, which
was fecalized, gastroenteritis vs resolving small bowel
obstruction. ACS was consulted and saw no acute need for
surgical intervention. Recommended admission for bowel regimen
and pain control. The patient was given 4mg IV morphine x 1, 1mg
IV hydromorphone x 3 and ondansetron 2mg IV x 2 and transferred
to medicine for further management.
Past Medical History:
Asthma: since childhood, last exacerbation ___ years ago. Never
hospitalized or intubated.
Social History:
___
Family History:
Father had MI age ___, paternal GM died of MI age ___, maternal
aunt has breast cancer. No family h/o IBD
Physical Exam:
ADMISSION:
VS - 98.5 115/68 70 18 100% RA 75.5kg
GEN - Overweight young female, tearful, oriented
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - soft, ND, hypoactive bowel sounds, diffusely tender to
palpation, no guarding or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO: CN II-XII intact, motor function grossly normal
SKIN: no ulcers or lesions
DISCHARGE:
VS - Tm 98.7 ___ 100% RA
GEN - Overweight young female, NAD
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - soft, ND, hypoactive bowel sounds, diffusely tender to
palpation, no guarding or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
Pertinent Results:
ADMISSION LABS:
___ 06:09PM LACTATE-0.6
___ 01:20PM URINE UCG-NEGATIVE
___ 01:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 01:01PM LACTATE-1.0
___ 12:50PM GLUCOSE-88 UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
___ 12:50PM ALT(SGPT)-8 AST(SGOT)-13 ALK PHOS-41 TOT
BILI-0.4
___ 12:50PM LIPASE-20
___ 12:50PM ALBUMIN-4.4
___ 12:50PM WBC-8.4 RBC-4.14* HGB-13.1 HCT-39.6 MCV-96
MCH-31.5 MCHC-33.0 RDW-13.0
___ 12:50PM NEUTS-65.3 ___ MONOS-4.1 EOS-0.9
BASOS-0.5
___ 12:50PM PLT COUNT-324
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-10.2 RBC-4.12* Hgb-12.9 Hct-39.7
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.0 Plt ___
___ 07:20AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
___ 07:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 07:00AM BLOOD TSH-1.7
IMAGING/STUDIES:
KUB ___
FINDINGS: The stomach is non-distended. There are no dilated
loops of large or small bowel or air-fluid levels. No free air
is seen. Stool and air are seen throughout all portions of the
colon, including the rectum. IMPRESSION: Unremarkable bowel
gas pattern.
CT ABD/PELVIS W/ CONTRAST ___
FINDINGS:
ABDOMEN: The visualized lung bases are clear. There are no
pleural
effusions. The liver is homogeneous in texture with no focal
lesions. There is no biliary ductal dilatation. The
gallbladder is normal. The spleen, pancreas, and adrenal glands
are normal. Multifocal chronic scar formation is seen in the
bilateral kidneys. The kidneys are otherwise unremarkable.
The stomach is normal in caliber and unremarkable. In the left
upper quadrant, a long segment of perhaps mildly thickened
enhancing small bowel is followed by a mild dilated and
distended segment with fecalization of contents. This is
followed by a somewhat gradual transition in caliber to fairly
collapsed distal small bowel. There are no findings to suggest
internal hernia. There is no mesenteric swelling, twisting, or
other changes.
There is no retroperitoneal or mesenteric lymphadenopathy. The
intra-abdominal aorta and its major branches are normal in
appearance.
PELVIS: The sigmoid colon and rectum are normal in appearance.
The distal ureters and bladder are normal. The uterus is
unremarkable. There is no pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion
suspicious for
infection or malignancy is seen.
IMPRESSION: 1. Slight bowel wall thickening and enhancement in
the proximal jejunum followed by a segment of mildly dilated
bowel, which is fecalized. This is followed by a non-abrupt
transition zone and a region of collapsed small bowel. These
findings could be secondary to an inflammatory process such as
gastroenteritis or could represent intermittent, partial, or
resolving small
bowel obstruction, although dilatation is not striking.
Correlation with
physical findings and clinical presentation are recommended.
There are no findings to suggest internal hernia or mesenteric
involvement. 2. Multifocal chronic scar formation in the
bilateral kidneys.
KUB ___
FINDINGS: The bowel gas pattern is unremarkable. There is a
gas-filled
stomach as well as gas-filled large bowel, however, no evidence
of distention. There appears to be less of a fecal load compared
to the study from ___. There is no pneumatosis or
free air.
IMPRESSION: No evidence of obstruction. Decreased interval
amount of fecal load compared to the study from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Polyethylene Glycol 17 g PO DAILY
Stop medication if you have loose stools.
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 packet(s)
by mouth Daily Disp #*30 Packet Refills:*11
3. Psyllium 1 PKT PO DAILY
Hold for loose stools.
RX *psyllium 1 packet(s) by mouth Daily Disp #*30 Packet
Refills:*11
4. Bisacodyl 10 mg PO/PR DAILY constipation Duration: 2 Weeks
RX *bisacodyl 5 mg ___ tablet(s) by mouth or rectum Daily Disp
#*60 Tablet Refills:*0
5. Lorazepam 0.5 mg PO BID: PRN anxiety
Do not take if sedated or driving.
RX *lorazepam 0.5 mg 1 tablet by mouth Twice a day Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Constipation
Depressed mood
Secondary diagnosis:
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE ABDOMEN
HISTORY: Diffuse abdominal pain and peritoneal signs.
COMPARISONS: None.
TECHNIQUE: Abdomen, three views.
FINDINGS: The stomach is non-distended. There are no dilated loops of large
or small bowel or air-fluid levels. No free air is seen. Stool and air are
seen throughout all portions of the colon, including the rectum.
IMPRESSION: Unremarkable bowel gas pattern.
Radiology Report
HISTORY: ___ female with diffuse peritoneal abdominal pain.
TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast
was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: None.
FINDINGS:
ABDOMEN: The visualized lung bases are clear. There are no pleural
effusions.
The liver is homogeneous in texture with no focal lesions. There is no
biliary ductal dilatation. The gallbladder is normal. The spleen, pancreas,
and adrenal glands are normal. Multifocal chronic scar formation is seen in
the bilateral kidneys. The kidneys are otherwise unremarkable.
The stomach is normal in caliber and unremarkable. In the left upper
quadrant, a long segment of perhaps mildly thickened enhancing small bowel is
followed by a mild dilated and distended segment with fecalization of
contents. This is followed by a somewhat gradual transition in caliber to
fairly collapsed distal small bowel. There are no findings to suggest
internal hernia. There is no mesenteric swelling, twisting, or other changes.
There is no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal
aorta and its major branches are normal in appearance.
PELVIS: The sigmoid colon and rectum are normal in appearance. The distal
ureters and bladder are normal. The uterus is unremarkable. There is no
pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen.
IMPRESSION:
1. Slight bowel wall thickening and enhancement in the proximal jejunum
followed by a segment of mildly dilated bowel, which is fecalized. This is
followed by a non-abrupt transition zone and a region of collapsed small
bowel. These findings could be secondary to an inflammatory process such as
gastroenteritis or could represent intermittent, partial, or resolving small
bowel obstruction, although dilatation is not striking. Correlation with
physical findings and clinical presentation are recommended. There are no
findings to suggest internal hernia or mesenteric involvement.
2. Multifocal chronic scar formation in the bilateral kidneys.
Radiology Report
INDICATION: ___ female with severe constipation, who presents for
evaluation of abdominal pain, question change in fecal load since the initial
KUB.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS: The bowel gas pattern is unremarkable. There is a gas-filled
stomach as well as gas-filled large bowel, however, no evidence of distention.
There appears to be less of a fecal load compared to the study from ___. There is no pneumatosis or free air.
IMPRESSION:
No evidence of obstruction. Decreased interval amount of fecal load compared
to the study from ___.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.7
heartrate: 128.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 85.0
level of pain: 8
level of acuity: 3.0 | ___ with h/o well controlled asthma who presented with 4 day h/o
abdominal pain in the setting of constipation.
# Constipation: Presented with ___ days of constipation, no
prior h/o severe constipation. Reported that she eats plenty of
fruits and vegetables, drinks ___ glasses of water daily and
had had occasional constipation relieved with OTC laxatives, no
chronic laxative use. No recent changes in medications or diet,
no narcotic pain meds at home, although received several doses
of morphine and hydromorphone in ED. Based on imaging and ACS
consult, no concern for active SBP, although inflammation on CT
abd/pelvis may represent resolving obstruction. Was started on
bowel regimen which was gradually intensified. Pt was able to
have several bowel movements on day of discharge. Discharged
patient home with bowel regimen and plan to follow up with
nutrition for outpatient nutrition education to prevent
recurrent constipation.
.
# Abdominal Pain: Gradual onset in the setting of severe
constipation. Initial KUB suggestive of constipation, CT abd
pelvis with nonspecific inflammation of proximal jejunem. Abd
exam remained benign, pain improved after patient was able to
move bowels, repeat KUB showed decreased fecal load. Repeat
lipase, LFTs normal.
.
# Anxiety/Depressed mood: Likely contributor to abdominal
pain/constipation. Patient was noted to have significant
anxiety/depressed mood related to stress from difficult family
dynamic. Reported tension between herself and her husband
related to fertility issues. Has very strained relationship with
her mother, who she reports forced her to undergo a medical
procedure in the ___ as a teenager which she now
believes was a tubal ligation. Her mother reportedly is very
intrusive in her family life and she and her husband decided
during the admission to move to another ___ to
mitigate the situation. She was initially very tearful, but
affect greatly improved after discussion with SW. Medical team
recommended continued outpatient SW follow up and consideration
of initiating SSRI if symptoms persist. Discharged home with
short course of low dose lorazepam.
.
# Asthma: Well controlled on rescue inhaler only. Never
hospitalized or intubated for asthma. Continued prn albuterol
MDI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Betoptic S / Alphagan P / Travatan
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left hip hemiartrhoplasty
History of Present Illness:
The patient is an ___ y/o F with severe Alzheimer's, HTN,
osteoarthritis, osteoporosis with one month long history of
inability to bear weight on the LLE who presented on ___ after
imaging showed femoral neck fracture and is now s/p L
hemiarthoplasty, found to have urinary retention and UTI with
post op course complicated by anemia.
Past Medical History:
Alzheimer's disease
GERD
HTN
Anxiety/depression
Osteoarthritis
Osteoporosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: Patient is lethargic but arousable, appears comfortable.
Unable to participate meaningfully in exam due to baseline
mental status
Cardio: RRR
Resp: breathing unlabored
MSK:
LLE:
Dressing in place over surgical incision, c/d/i, no swelling,
induration, erythema around incision site. Foot wwp, moves foot
and toes spontaneously.
Radiology Report
INDICATION: ___ with fall a month ago // fx?
TECHNIQUE: AP view of pelvis. AP and lateral views of the proximal distal
left femur.
COMPARISON: None
FINDINGS:
There is a left femoral neck fracture with significant impaction. The
fracture margins are perhaps minimally smoother than expected for an acute
fracture and given trauma 1 month prior this could be compatible with a
fracture of this age. Vertically oriented lucency through the proximal right
femur may be projectional due to overlying soft tissues. No other fractures
identified. Distally the left femur is unremarkable. The pubic symphysis and
SI joints are intact.
IMPRESSION:
Recent impacted left femoral neck fracture which could be from trauma 1 month
prior.
Vertically-oriented lucency within the proximal right femur may be due to
overlying tissues however if patient has symptoms on the right side, consider
additional imaging to exclude fracture.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: LEFT HEMI, FX.
IMPRESSION:
In comparison with the study of ___, there is now a left hemiarthroplasty
in place in the left hip. No evidence of hardware failure complication.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: L Hip pain
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL, HYPERTENSION NOS, ALZHEIMER'S DISEASE
temperature: 98.6
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 81.0
level of pain: 13
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 left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to her baseline diet and oral medications by POD#2.
The patient was given perioperative antibiotics and
anticoagulation per routine. She did require blood transfusion
for postop Hct of 22.5. Her Hct stabalized at 33.3 2 days
post-transfusion. The patient was also found to have UTI with
pan-resistant E. coli and was started on IV meropenem per
medicine recommendations, which she will continue upon
discharge. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, 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's family
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: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
admitted with febrile neutropenia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old woman with DLBCL finishing C6
DA-EPOCH-R who is admitted from the ED with febrile neutropenia.
Patient speaks ___, and history is taken with the aid
of
her husband, at bedside.
Patient was admitted ___ to ___ for C6 EPOCH, which she
tolerated well. However, she reports having significant fatigue
and dizziness since discharge. Last week she also developed new
body aches and intermittent headaches. She noted a new mouth
sore
(typical following her chemotherapy) on ___, and by ___
she was having low grade temperatures (but not ___. She was
seen in clinic on day of admission where she was noted to be
neutropenic and she was started on empiric levofloxacin and also
received filgrastim. After returning home she noted a T of 100.8
and she presented to the ED. Patient currently denies headache.
No dysphagia or odynophagia. No rhinitis or ST. No CP, SOB or
cough. No N/V, but does have poor appetite. No abdominal pain or
diarrhea. Nl BM. No rectal pain. No dysuria. No new joint pains
or swelling. No sick contacts.
In the ED, initial VS were pain 2, T 99.8, HR 101, BP 143/76, RR
20, O2 100%RA. Later spiked T of 102.8. Initial labs notable for
Na 134, K 3.8, HCO3 23, Cr 0.5, WBC 0.6 (ANC 90), HCT 22.3, PLT
60, ALT 19, AST 19, ALP 96, TBili 0.4, lactate 2.4, UA negative.
CXR showed no acute process. Patient was given 1LNS along with
IV
vancomycin and cefepime and po APAP. VS Prior to transfer were T
99.7, HR 94, BP 1113/51, RR 16, O2 97%RA.
Past Medical History:
Hematologic/Oncologic History:
- ___: Presents to ___ ED with back pain for 2 weeks. CTA
Chest demonstrates paraspinal masses bilaterally at the T3
vertebral level which appear to extend into the neural foramina
bilaterally with subtle cortical destruction and mottling of the
T3 vertebra, multiple splenic hypodense lesions measuring up to
1.8 cm, and bilateral axillary lymphadenopathy.
- ___: CT Abdomen/Pelvis demonstrates multiple hypoenhancing
splenic lesions, measuring up to 1.8 cm., multiple enlarged
lymph
nodes throughout the retroperitoneum, pelvic wall (left external
iliac) and mesentery.
- ___: MRI whole spine shows a paraspinal mass at T3 with
diffuse infiltration of the T3 vertebral body extending into the
posterior elements. Of note, the paraspinal mass extends
through
the bilateral neural foramen and to the epidural space at T3-T4
encroaching on the spinal canal and resulting in moderate to
severe spinal canal stenosis, and an enhancing lesion within the
L1 vertebral body extending into the posterior elements as well
as a smaller focal lesion of the L2 vertebral body suspicious
for
additional sites of malignancy.
- ___ and ___: 3 unsuccessful attempts at lymph node
biopsy (2 in the left axilla and 1 in the left pelvis).
- ___: Left pelvic lymph node biopsy demonstrates fragments
of a lymph node with fibrosis and a T-cell predominant lymphoid
population. FISH positive for del(13q). FISH negative for
high-grade lymphoma panel.
- ___: Paraspinal mass core needle biopsy shows a
CD5-positive diffuse large B cell lymphoma. By
immunohistochemistry, the cells are immunoreactive for CD20,
CD5,
BCL-6, BCL-2, and MUM1. CD3 highlighs scattered tumor
infiltrating lymphocytes. The Ki-___ proliferation index is high,
averaging 90%. CD138 and CD21 are negative. Expression of CD5
may occur ___ in a
subset of diffuse large B cell lymphoma or may result from large
cell transformation of a low grade B cell lymphoma, such as
CLL/SLL (Richter transformation). Cytogenetics are positive for
BCL6 rearrangement. FISH is negative for CLL panel, including
del(13q).
- ___: MRI Brain shows a punctate enhancing focus within the
right putamen, which raises suspicion for a metastatic deposit
given the patient's known thoracic spine mass.
- ___: TTE shows LVEF > 55%.
- ___: C1 da-EPOCH-R, dose level 1.
- ___: C1 rituximab.
- ___: Repeat MRI brain shows stable 2-3 mm enhancing focus
in the right putamen, without a correlate on T2 weighted/FLAIR
or
diffusion-weighted images, with diagnostic considerations
including malignancy versus a capillary telangiectasia.
- ___: C1 intrathecal methotrexate. CSF analysis with 1
nucleated cell, 65% Lymphs, 35% Monos, protein 40, glucose 85.
- ___: Discharged to home.
- ___: C2 rituximab.
- ___: C2D1 da-EPOCH, dose level 1, uncapped vincristine.
- ___: C2 intrathecal methotrexate. No evidence of
lymphomatous involvement by flow cytometry.
- ___: C3 da-EPOCH-R, dose level 2, uncapped vincristine.
- ___: C4 da-EPOCH-R, dose level 2, uncapped vincristine,
prednisone decreased to 100 mg daily because of agitation and
difficulty sleeping.
- ___: Surveillance MRI spine demonstrates partial
resolution of multiple vertebral body abnormalities, with no
evidence of spinal canal compromise or spinal cord encroachment
and complete resolution of the previously noted paraspinal mass
-
- ___: Surveillance CT torso demonstrates resolution of the
paraspinal mass at T3, substantially smaller bilateral axillary
lymph nodes, an unchanged 1.2 cm hypoattenutating right thyroid
nodule, unchanged bilateral 4 mm right lower lobe pulmonary
nodules, resolution of previously noted hypoattenuating splenic
nodules, interval decrease in size of the retroperitoneal and
pelvic sidewall lymph nodes, and no new enlarging lymph nodes.
- ___: C5 da-EPOCH-R, dose level 3, uncapped vincristine.
- ___: C6 da-EPOCH-R, dose level 2, uncapped vincristine.
Past Medical History:
- CD5-positive high-grade diffuse large B cell lymphoma, as
above
- Chronic hepatitis B, on entecavir
- Possible G6PD deficiency, normal testing on ___
- Positive PPD, status-post treatment
- Hypertension
- Cesarean section
Social History:
___
Family History:
no known history of cancer. Mother had lower back pain and hip
fracture at age ___. Father died in ~___ y.o from unknown cause.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T 98.8 HR 96 BP 108/69 RR 18 SAT 98% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
=========================
___ 1252 Temp: 98.4 PO BP: 123/71 HR: 91 RR: 18 O2 sat: 99%
O2 delivery: RA
GEN: WDWN female in NAD. Lying comfortably in bed.
EYES: NC/AT. Sclera anicteric. MMM. Multiple teeth missing,
otherwise oropharynx without erythema or exudates.
CV: RRR with normal S1 and S2. No murmurs, rubs or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Soft, non-tender/non-distended. Normoactive BS. No masses
appreciated.
MUSKULOSKELATAL: Warm, well perfused. No ___ edema or erythema.
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all
extremities.
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
================
___ 09:35AM BLOOD WBC-0.4* RBC-2.30* Hgb-7.1* Hct-21.5*
MCV-94 MCH-30.9 MCHC-33.0 RDW-15.7* RDWSD-54.3* Plt Ct-50*
___ 09:35AM BLOOD Neuts-8* Bands-1 ___ Monos-29*
Eos-8* Baso-5* ___ Metas-1* Myelos-0 NRBC-2* AbsNeut-0.04*
AbsLymp-0.19* AbsMono-0.12* AbsEos-0.03* AbsBaso-0.02
___ 09:35AM BLOOD UreaN-5* Creat-0.4 Na-138 K-3.5 Cl-104
HCO3-24 AnGap-10
___ 09:35AM BLOOD ALT-16 AST-14 LD(LDH)-207 AlkPhos-84
TotBili-0.4
___ 09:35AM BLOOD TotProt-5.3* Albumin-3.6 Globuln-1.7*
Calcium-8.2* Phos-2.8 Mg-1.9 UricAcd-2.4
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-4.2 RBC-2.90* Hgb-8.8* Hct-27.3*
MCV-94 MCH-30.3 MCHC-32.2 RDW-18.0* RDWSD-59.4* Plt ___
___ 12:00AM BLOOD Neuts-58 Bands-1 ___ Monos-10 Eos-2
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-2.48 AbsLymp-1.18*
AbsMono-0.42 AbsEos-0.08 AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL Tear Dr-OCCASIONAL
___ 12:00AM BLOOD Plt Smr-LOW* Plt ___
___ 12:00AM BLOOD Glucose-139* UreaN-12 Creat-0.4 Na-135
K-3.7 Cl-98 HCO3-24 AnGap-13
___ 12:00AM BLOOD ALT-20 AST-28 LD(LDH)-589* AlkPhos-113*
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.2 Mg-2.0
MICROBIOLOGY:
=============
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. amLODIPine 5 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. Docusate Sodium 200 mg PO BID
5. Entecavir 0.5 mg PO DAILY
6. LORazepam 0.5 mg PO Q6H:PRN Nausea, anxiety
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
11. Filgrastim-sndz 300 mcg SC Q24H
12. Ondansetron 4 mg PO Q8H:PRN Nausea
13. Levofloxacin 750 mg PO Q24H
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN constipation
2. Acyclovir 400 mg PO Q8H
3. amLODIPine 5 mg PO DAILY
4. Docusate Sodium 200 mg PO BID
5. Entecavir 0.5 mg PO DAILY
6. LORazepam 0.5 mg PO Q6H:PRN Nausea, anxiety
7. Ondansetron 4 mg PO Q8H:PRN Nausea
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
#Febrile Neutropenia
#DLBCL
SECONDARY DIAGNOSIS:
=====================
#Chronic HBV infection
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 DLBCL and fever// eval for pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Right chest wall port terminates in the lower SVC.A subtle opacity is seen in
the retrocardiac region. No pleural effusion or pneumothorax is seen. The
cardiac and mediastinal silhouettes are unremarkable.
Projecting over only on the lateral view are radiopaque foreign objects, one
of which appears like a nail, is external to the patient as demonstrated by a
repeat lateral view.
IMPRESSION:
Subtle opacity in the retrocardiac region could be seen in the setting of an
infectious process.
NOTIFICATION: Updated findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:45 pm, 10 minutes after
discovery of the findings.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere
temperature: 99.8
heartrate: 101.0
resprate: 20.0
o2sat: 100.0
sbp: 143.0
dbp: 76.0
level of pain: 2
level of acuity: 3.0 | ASSESSMENT AND PLAN: Ms. ___ is a ___ y/o female with a hx
of high-grade DLBCL (CD5+, BCL6 gene arrangement) s/p cycle 6
da-EPOCH-R (c6d1 ___ who presented with febrile
neutropenia. Overall, she is doing well clinically and HD
stable.
#Febrile neutropenia: Presented with ___ SIRS (fever/HR) and
elevated lactate concerning for severe sepsis. Additionally, ANC
was 90 on admission. Initially, she was started on vancomycin,
cefepime, and oseltamivir. However, no infectious source was
found; therefore, we de-escalated antibiotics.
-Cefepime ___ Vancomcyin [___]
-Discontinued Tamiflu with viral swab negative
-BCx/urine culture--NTD
#Diffuse large B-cell lymphoma: Diagnosed with high grade DLBCL
in ___. Cytogenetics notable for CD5+ and BCL6
rearrangement. Initial involvement of C3 paraspinal mass,
spleen, putamen, and diffuse lymph nodes (axillary,
retroperitoneal, pelvic, mesenteric). S/p 6 cycles of da-EPOCH-R
with prophylactic
intrathecal MTX. Plan to re-image after cycle 6. Currently, she
is day 18 of cycle 6 of EPOCH. Her counts have recovered.
-VZV PPx: Continue acyclovir 400 mg q8h
-PCP ___: Discontinued atovaquone at discharge per Dr.
___
-___ up scheduled for ___ with Dr. ___ scheduled for ___
#Pancytopenia: Resolved. Likely due to most recent cycle of
EPOCH-R. Filgrastim discontinued ___ with counts recovery.
She needed PRBCs transfusion on ___ but no other transfusions
needed during her hospital course.
-Transfuse for Hgb <7 or plt <10
#Chronic HBV Infection: Receiving monthly viral load monitoring.
Last level on ___ was detected but less than 1.3. Continue
home regimen of entecavir |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
___ Redo Mitral valve replacement with a 29 mm ___
mechanical valve. (Prior mechanical aortic valve)
History of Present Illness:
___ male with bicuspid aortic
valve stenosis and mitral
regurgitation post-tandem surgical mechanical AVR/MVR, complete
heart block post-CRTP, valvular cardiomyopathy and recent
hospitalization for ICD upgrade after sustained monomorphic VT
who presents several hours after last discharge with
palpitations.
Mr. ___ states that after going home, walking around his
house,
eating dinner, and taking a shower he became sweaty, pale, and
felt that his heart was pounding and had an "unusual rhythm,"
though he did not check his HR. He then self-medicated with an
extra dose of Metoprolol XL 25 mg. He states that after this he
felt less sweaty but continued to feel that his heart was
beating
quickly.
In the ED, initial vitals: Afebrile, heart rate 90, BP 148/78
- Exam notable for:
GEN: uncomfortable but alert and oriented
RESP: lungs clear
CV: paced rhythm, no tachycardia
ABD: soft, non-tender
EXT: warm and well perfused
- Labs notable for: TropT 0.02, Cr 1.1, WBC 5.9, UA with small
blood, INR 1.6
- Imaging notable for: CXR with
- Pt given: No medications
- Cardiology consulted and interrogated pacemaker: No evidence
of
VT. Would still recommend admission for close monitoring, daily
EKGs, ambulation tomorrow.
Upon arrival to the floor, the patient corroborates the above
history. He states that his palpitations have mostly abated and
he is reassured being hooked up to monitors, though he states
that he "is not leaving the hospital until after [my] surgery".
He states that "it does not matter what your textbooks tell you
or what the interrogation of my pacemaker shows, I know there is
something wrong and I am not leaving until my valve is
repaired".
He denies current chest pain, palpitations, shortness of breath,
diaphoresis, nausea, vomiting, lower extremity swelling.
Past Medical History:
Cardiac History:
-Bicuspid aortic valve, severe aortic stenosis post-aortic
valve
replacement with a 27 mm ___ mechanical valve (___).
-Mitral regurgitation post-repair with radical reconstruction
and 30 ___ II ring (___).
-Complete heart block post-CRTP (___).
-Valvular cardiomyopathy.
-Atrial fibrillation.
Other PMH:
-Hypertension.
-Dyslipidemia.
-Benign prostatic hypertrophy.
-H. pylori gastritis post-quadruple therapy (___).
-Shingles.
-Herniorrhaphy.
Social History:
___
Family History:
There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
PHYSICAL EXAM:
VITALS: Temp 97.7 HR 67 BP 109/64 RR 16 SaO2 99%RA
GENERAL: Well appearing man in NAD. AAOx3.
HEENT: PERRL, EOMI, MMM.
NECK: JVP < 10 cm at 90 degrees. Pacemaker pocket in left chest
with
clear dressing, no tenderness, no evidence of hematoma.
CARDIAC: RRR, S1/prosthetic S2, systolic murmur at base,
holosystolic across precordium and most pronounced at apex.
LUNGS: CTAB, no crackles/wheezing/rhonchi.
ABDOMEN: Soft, non tender, non distended. No palpable
hepatosplenomegaly.
EXTREMITIES: Warm, well perfused, no ___ edema. R PICC without
erythema.
SKIN: No visible rashes.
NEURO: A&Ox3, motor and sensation grossly intact.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs I/O
24 HR Data (last updated ___ @ 1147)
Temp: 98.5 (Tm 99.4), BP: 130/87 (117-139/67-87), HR: 80
(66-80), RR: 20 (___), O2 sat: 100% (97-100), O2 delivery: Ra
Fluid Balance (last updated ___ @ 1147)
Last 8 hours Total cumulative -715ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 835ml, Urine Amt 835ml
Last 24 hours Total cumulative -755ml
IN: Total 480ml, PO Amt 480ml
OUT: Total 1235ml, Urine Amt 1235ml
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] Moves all extremities [x](L)UE weakness
and mobilization improving. LLE can lift, boot in place
Follows commands [x]
Cardiovascular: RRR [x]
Respiratory: CTA [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Softly distended [x] NT[x]
Extremities:
Right Upper extremity Warm [x] Edema-
Left Upper extremity Warm [x] Edema -
Right Lower extremity Warm [x] Edema-
Left Lower extremity Warm [x] Edema -
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Pertinent Results:
ADMISSION LAB RESULTS
======================
___ 04:56AM BLOOD WBC-4.5 RBC-3.22* Hgb-9.3* Hct-30.1*
MCV-94 MCH-28.9 MCHC-30.9* RDW-18.2* RDWSD-56.8* Plt ___
___ 04:56AM BLOOD ___ PTT-28.9 ___
___ 04:56AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-138
K-4.4 Cl-106 HCO3-24 AnGap-8*
___ 04:56AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
DISCHARGE LAB RESULTS
=======================
___ 05:20AM BLOOD WBC-7.4 RBC-3.48* Hgb-10.0* Hct-31.9*
MCV-92 MCH-28.7 MCHC-31.3* RDW-15.2 RDWSD-50.8* Plt ___
___ 05:20AM BLOOD ___
___ 06:30AM BLOOD ___
___ 04:35AM BLOOD ___ PTT-83.1* ___
___ 10:57AM BLOOD ___ PTT-49.8* ___
___ 05:20AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-139
K-4.3 Cl-100 HCO3-28 AnGap-11
___ 02:00AM BLOOD ALT-20 AST-50* LD(LDH)-794* AlkPhos-44
TotBili-1.2
___ 01:10AM BLOOD cTropnT-0.02*
___ 05:20AM BLOOD Mg-1.9
___ 01:16PM BLOOD %HbA1c-4.4 eAG-80
IMAGING
=======
PA/LAT CXR ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous pulmonary edema has largely cleared. Right lower lobe
shows
persistent atelectasis adjacent to moderate right pleural
effusion. Severe cardiomegaly unchanged. No pneumothorax.
Transvenous right atrial ventricular pacer defibrillator leads
and 2
epicardial leads are continuous from the left pectoral
generator.
.
CTA Head/Neck ___
IMPRESSION:
1. No definite evidence for acute large territorial infarct,
intracranial
hemorrhage or intracranial mass effect noncontrast CT head.
2. Asymmetric hypodensity of the right frontal white matter
likely represents
sequela of chronic microangiopathy however subtle acute infarct
could
potentially be obscured.
3. Suboptimal CTA examination secondary to contrast bolus
timing. Within this
confines: 9 mm left supraclinoid ICA aneurysm with ___s
well as a 5 mm
right supraclinoid ICA aneurysm. The remainder of the
intracranial
circulation demonstrates no evidence of high-grade stenosis or
occlusion.
4. Unremarkable CTA of the neck within confines of technically
suboptimal
exam.
5. CT perfusion does not demonstrate CBF less than 30%.
6. Additional findings as described above.
.
TEE ___ (*preliminary*)
Conclusions
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is severely
dilated. Overall left ventricular systolic function is
moderately to severely depressed with moderate global
hypokinesis and a suggestion of more severe hypokinesis in the
mid and distal anterior wall. (LVEF= 30 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The riight ventricle
displays severe hypokinesis of the mid and distal free wall. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are focal calcifications in the aortic arch. There
are simple atheroma in the descending thoracic aorta. A
bileaflet aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. The transaortic
gradient is normal for this prosthesis. There is mild aortic
valve stenosis (valve area 1.9cm2) as is expected. Though
expected, no aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. A mitral valve annuloplasty
ring is present. The annuloplasty ring has dehisced from the
anterior mitral annulus. Severe (4+) mitral regurgitation is
seen through the middle of the valve as well. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion. Dr. ___ was notified in person of the
results in the operating room at the time of the study.
Post Bypass
The left ventricu;ar function is 35-40%.The mechanical mitral
valve is well seated with no paravalvular leak.The transvalvular
gradients peak of 6mm Hg and mean of 3 mmHg The rest of the exam
is unchanged.
.
___ CXR
1. No focal consolidation or pulmonary edema.
2. Stable moderate cardiomegaly with mild pulmonary vascular
congestion,
however no overt interstitial edema.
.
___ Noncontrast Chest CT
IMPRESSION:
1. Fusiform enlargement of the ascending thoracic aorta
measuring up to 4.2 cm, with ascending aortic calcifications 2
cm distal to the aortic valvular plane.
2. Multiple bilateral ground-glass pulmonary nodules measuring
up to 1.4 cm, which could reflect infection with edema, though
could also represent true pulmonary nodules, and short-term
follow-up CT is recommended.
3. Mild interstitial edema.
4. Status post AVR and MVR with expected postsurgical changes.
RECOMMENDATION(S): 3 month follow-up CT chest is recommended to
document
stability and/or resolution of multiple bilateral ground-glass
pulmonary
nodules.
Medications on Admission:
1. Furosemide 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Warfarin 5 mg PO 6X/WEEK (___)
6. Warfarin 7.5 mg PO 1X/WEEK (___)
7. Warfarin 7.5 mg PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Amiodarone 400 mg PO BID Duration: 5 Days
then decrease to 400mg daily x 5 days, then decrease to 200mg
daily continuous
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. GuaiFENesin ER 1200 mg PO Q12H Duration: 4 Days
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*10 Tablet Refills:*0
7. Metoprolol Tartrate 25 mg PO TID
hold if SBP<90 or HR<55
8. Polyethylene Glycol 17 g PO DAILY
9. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
10. Ramelteon 8 mg PO QHS:PRN sleep
Should be given 30 minutes before bedtime
11. Ranitidine 150 mg PO BID
12. Senna 17.2 mg PO DAILY
13. Warfarin 5 mg PO ONCE Duration: 1 Dose
please dose daily for INR 2.5-3.5 (Mechanical AVR &
MVR/afib/CVA)
14. ___ MD to order daily dose PO DAILY16
please dose daily for INR 2.5-3.5 (Mechanical AVR &
MVR/afib/CVA)
15. Aspirin EC 81 mg PO DAILY
16. Furosemide 20 mg PO DAILY Duration: 7 Days
17. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until SBP consistently
>140
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Redosternotomy s/p Mechanical Mitral Valve Replacement
RV lead extractions with upgrade to a CRT-D device on ___
postop ischemic stroke with Left weakness
Secondary:
aortic stenosis s/p prior Mechanical Aortic Valve Replacement
and Mitral valve repair with 30mm ___ II ring and LV
epicardial lead placement ___
Complete Heart Block-s/p Permanent PaceMaker ___
hypertension
hyperlipidemia
BPH
Shingles
Valvular cardiomyopathy
mitral regurgitation
Atrial fibrillation
H. pylori gastritis post-quadruple therapy (___)
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-left ___ edema 1+
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with recent MI and new pacemaker/defibrilator now
with palpitations. Evaluation for effusion, cardiomegaly.
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison to prior chest radiograph from ___.
FINDINGS:
Cardiac pacemaker device again projects over the left chest wall, with pacer
leads extending into the right atrium and right ventricle. Two myocardial
pacer leads remain in stable position. Median sternotomy wires remain intact
and well aligned. Cardiac valve prostheses are unchanged. Interval removal
of right-sided PICC line. Moderately enlarged cardiac silhouette is stable.
Mild pulmonary vascular congestion without overt interstitial edema. Lungs
are clear without focal consolidation. No pleural effusion or pneumothorax is
seen.
IMPRESSION:
1. No focal consolidation or pulmonary edema.
2. Stable moderate cardiomegaly with mild pulmonary vascular congestion,
however no overt interstitial edema.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with S/P MVR// fast track extubation, effusion
pneumothx Contact name: ___, Phone: 1
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Interval redo median sternotomy and mitral valve replacement. And left chest
wall dual lead ICD is present. The tip the Swan-Ganz catheter likely projects
over the left lower lobe pulmonary artery. The tip of the endotracheal tube
projects over the midthoracic trachea. An enteric tube extends to the
stomach. Mediastinal drains and chest tubes are present.
There is mild pulmonary edema. No focal consolidation, pleural effusion or
pneumothorax identified. Pneumomediastinum is present. The size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Mild pulmonary edema.
The tip of the Swan-Ganz catheter projects over the left lower lobe pulmonary
artery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with MVR// PA line reposition
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the Swan-Ganz catheter has been minimally retracted however still
projects over the left pulmonary artery. Mild pulmonary edema. Otherwise no
significant interval change.
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: ___ year old man s/p redosternotomy with Mech MVR (prior Mech AVR,
MVrepair)// eval for bleed, shift, mass
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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 27.2 mGy (Head) DLP =
13.6 mGy-cm.
4) Spiral Acquisition 5.6 s, 43.7 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,400.1 mGy-cm.
Total DLP (Head) = 4,831 mGy-cm.
COMPARISON: Carotid ultrasound of ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Asymmetric hypodensity of the right frontal white matter (series 2, image 21)
could represent sequela chronic microangiopathy however subtle underlying
acute infarct could potentially be obscured. Otherwise, no other evidence for
acute large territory infarct. There is no intra or extra-axial mass effect
or acute hemorrhage.. The sulci, ventricles and cisterns are within expected
limits for the degree of mild senescent related global cerebral volume loss.
There is mild mucosal thickening of the ethmoid air cells and right inferior
maxillary sinus. The orbits are unremarkable. The mastoid air cells middle
ears are well pneumatized and clear. The patient is intubated.
CTA HEAD: The examination is suboptimal secondary to timing of contrast bolus.
Within this confine:
1. 6 x 9 mm left supraclinoid internal carotid artery aneurysm with 4 mm neck
(603:37).
2. Additional 5 mm aneurysm arising from the right supraclinoid internal
carotid artery (601:26).
The remainder of the intracranial ICA, ACA, MCA and the posterior circulation
are unremarkable within confines of technically suboptimal exam.
No other aneurysms are identified. There is no evidence of high-grade
stenosis or occlusion.
CTA NECK: The examination is suboptimal secondary to timing of contrast bolus.
Within this confine:
The carotidandvertebral arteries and their major branches appear unremarkable
with no evidence of stenosis or occlusion. There is no evidence of internal
carotid stenosis by NASCET criteria.
CTP:
CBF <30% volume = 0 mL, indicating no infarct core
Tmax >6.0s volume = 4 mL, negligible
Mismatch volume = 4 mL, negligible
Mismatch ratio = negligible mismatch ratio.
OTHER: Very minimal by apical pneumothorax. Postsurgical emphysema along the
superior mediastinum, anterior chest extending to right lateral neck base is
identified. Evaluation of the upper chest and lower neck is suboptimal
secondary to the degree of postoperative edema. Within this confines: No
evidence of cervical lymphadenopathy by size criteria. The thyroid is
unremarkable. The patient is intubated with endotracheal tube terminating
above the carina and enteric few terminating beyond the field of view.
Allowing for respiratory motion artifact, the visualized lungs are grossly
clear. No suspicious osseous abnormality. The patient is status post median
sternotomy by paired
IMPRESSION:
1. No definite evidence for acute large territorial infarct, intracranial
hemorrhage or intracranial mass effect noncontrast CT head.
2. Asymmetric hypodensity of the right frontal white matter likely represents
sequela of chronic microangiopathy however subtle acute infarct could
potentially be obscured.
3. Suboptimal CTA examination secondary to contrast bolus timing. Within this
confines: 9 mm left supraclinoid ICA aneurysm with 4 mm neck as well as a 5 mm
right supraclinoid ICA aneurysm. The remainder of the intracranial
circulation demonstrates no evidence of high-grade stenosis or occlusion.
4. Unremarkable CTA of the neck within confines of technically suboptimal
exam.
5. CT perfusion does not demonstrate CBF less than 30%.
6. Additional findings as described above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p Redo, MVR, CTs d/c'd// eval for ptx
eval for ptx
IMPRESSION:
Compared to chest radiographs ___ through ___.
Dense opacification of the left lower lobe is new, more likely collapse than
pneumonia. Moderate pulmonary edema has redistributed, now most pronounced in
the dependent right lung. Small pleural effusions are unchanged. Moderate
enlargement of cardiac silhouette may have increased, function of lower lung
volumes and relative increase in central venous return with the termination of
positive pressure ventilation.
Sternal wires are intact and aligned. Transvenous right atrial ventricular
pacer defibrillator leads and epicardial leads unchanged in their respective
positions. Right jugular sheath ends in the mid SVC following removal of the
Swan-Ganz catheter.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with POD 5 Redo MVR, PPM// effusion. lead
placement effusion. lead placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous pulmonary edema has largely cleared. Right lower lobe shows
persistent atelectasis adjacent to moderate right pleural effusion. Severe
cardiomegaly unchanged. No pneumothorax.
Transvenous right atrial ventricular pacer defibrillator leads and 2
epicardial leads are continuous from the left pectoral generator.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man// increased swelling and coolness of left lower
extremity f/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: No relevant comparison identified.
FINDINGS:
Moderate to severe soft tissue swelling is noted over the level of the calf.
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow demonstrated
in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Moderate to severe soft tissue swelling over the left calf. No evidence of
deep venous thrombosis in the left lower extremity veins.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with Palpitations
temperature: 99.4
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 148.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ MEDICAL COURSE:
___ male with bicuspid aortic valve stenosis and mitral
regurgitation post-tandem surgical mechanical AVR/MVR, complete
heart block post-CRTP, valvular cardiomyopathy and recent
hospitalization for ICD upgrade after sustained monomorphic VT
who presented after last discharge with ongoing palpitations,
with plan for MV paravalvular leak repair. on ___, he went to
the OR for his MV paravalvular leak repair.
#Monomorphic VT, sustained, s/p ICD upgrade
#Palpitations
Mr. ___ presented with continued palpitations after CRTD
placement and lead extraction on ___. No events with pacer
interrogation. Patient noted to have short runs of non-sustained
VTs on telemetry accompanied by palpitations. Concern for pocket
hematoma noted on ___ in the setting of heparin infusion.
#HFrEF ___ LVEF 37%)
#Valvular cardiomyopathy post-tandem mechanical AVR/mitral
repair.
# Severe MR
___ on ___ showing severe MR with dehiscence of the mitral
annular ring. Currently appears euvolemic so he was kept on his
home diuretic dosing.
#Hemolytic anemia iso mechanical valve
Stable.
#Hepatitis B
Patient with positive HepB core Ab. HBV viral load was
nondetectable during last admission. RUQUS with normal hepatic
parenchyma.
#Pulmonary Nodules
Incidentally found on ___nd 3 month
follow up scan recommended by radiology.
#Small Left hematoma s/p ICD upgrade |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Iodine / Augmentin / adhesive,contrast media demerol
Attending: ___
Chief Complaint:
Transferred for ___ and anemia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old lady with history of CAD s/p CABG *3
((LIMA-LAD, SVG to OM1, SVG to PDA), cath in ___ w/occluded SVGs
x 2, patent LIMA), Type I Diabetes with ESRD s/p renal
transplant in ___ on chronic immunosuppressive agents and
severe gastroparesis presenting from OSH with elevated Cr and
anemia.
She had presented to ___ yesterday with decreased
urine output x1 week with no urine output for 24 hours and
weakness, noted to not be in retention, but with Cr elevated to
3.2 from baseline of 2.3 and HCT of 17 from baseline of 28. She
was transfused 2U PRBC but not given IV furosemide according to
her husband. ___ was WNL prior to the transfusion.
She was transferred to BI for renal evaluation.
On arrival to the ED, initial VS were notable for brady to
40-60.
Per notes, "seemed intoxicated." Creatinine 2.8. HCT 23.2.
Benign exam. US notable for no hydro, high resistive index.
Renal fellow felt findings non-specific. Placed foley, not
retaining, 100cc/out, UA pending. Trop 0.04. EKG: biphase T
waves laterally, sinus brady. Got 1 more unit pRBCs.
Admitted to hepatorenal for further management.
This morning, she was very lethargic but not confused. She has
been this way for one week. She also notes weakness in her arms
and jaw, along with pain. This started one week ago. She has no
fam hx of neurolgical disorders. Feels that her eyes close by
themselves at the end of the evening. Feels that her symptoms
worsen in the evening. No dysuria. No cough, no shortness of
breath, no chest pain. History also obtained from husband, meds
as well. He notes no changes in diuretics except to decrease
metolazone from BID to QD one month ago.
*** Records also obtained from ___: recent labs and ED
evaluation note ***
Past Medical History:
Diabetes Type 1, s/p renal transplant in ___, with a history of
episodes of diabetic ketoacidosis
Dyslipidemia
Hypertension
CAD s/p CABG, in ___ anatomy as follows: LIMA-LAD, SVG to OM1,
SVG to PDA. As on ___ cath all vein grafts occluded only
LIMA-LAD patent. ejection fraction of 55%.
Gastroparesis secondary to DM.
Left below the knee amputation in ___.
Vascular procedures on the right lower extremity.
Heel ulcers due to diabetes, s/p bypass graft surgeries
Peripheral neuropathy
CVA x2.
S/p cholecystectomy
S/p cataract surgery
Depression.
Social History:
___
Family History:
Uncle with diabetes
Sister died of colon CA
Mother died of brain CA
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS - 97.7 - 150/57 - 49 - 20 - 100 on 3L - bg 114
i/o: out 400.
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate but very lethargic.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple.
CV: RR ,S1, S2. ___ systolic murmur
foley in
Chest: diffuse crackles throughout
Abd: Soft, NTND. No HSM or tenderness. Transplant on left, no
edema/bruising.
Ext: S/p left BKA. 1+ pitting edema right leg
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.1 - 128/44 - 52 - 18 - 100ra - bs 267
i.o 250/500, yest 1080/1450
Wt 47.8kg <-- 48.3kg (from 50.1kg)
Gen: WDWN middle aged female in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple.
CV: RR, S1, S2. ___ systolic murmur
gu: no foley
Chest: diffuse crackles halfway up on posterior lung exam
Abd: Soft, NTND. No HSM or tenderness. Transplant on left, no
edema/bruising.
Ext: S/p left BKA. trace pitting edema right leg
SKIN: very dry
Pertinent Results:
ADMISSION LABS
==========
___ 10:40PM BLOOD WBC-4.2 RBC-2.65* Hgb-7.7* Hct-23.2*
MCV-88# MCH-29.2 MCHC-33.3# RDW-13.3 Plt ___
___ 10:40PM BLOOD Neuts-66 Bands-0 ___ Monos-2 Eos-1
Baso-0 ___ Myelos-0
___ 10:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 10:40PM BLOOD ___ PTT-30.6 ___
___ 10:40PM BLOOD Glucose-118* UreaN-100* Creat-2.8* Na-136
K-4.9 Cl-101 HCO3-26 AnGap-14
___ 10:40PM BLOOD ALT-25 AST-20 LD(LDH)-172 CK(CPK)-43
AlkPhos-141* TotBili-0.4 DirBili-0.2 IndBili-0.2
___ 10:40PM BLOOD Albumin-3.7
___ 09:00AM BLOOD Calcium-8.3* Phos-4.7* Mg-3.0*
___ 10:50PM BLOOD Glucose-99 Lactate-0.9
TACRO LEVELS
=========
___ 09:00AM BLOOD tacroFK-2.5*
___ 07:15AM BLOOD tacroFK-2.1*
___ 07:32AM BLOOD tacroFK-<2.0
___ 07:38AM BLOOD tacroFK-2.3*
___ 07:10AM BLOOD tacroFK-4.6*
___ 07:30AM BLOOD tacroFK-6.3
OTHER PERTINENT LABS
===============
___ 07:15AM BLOOD %HbA1c-8.8* eAG-206*
___ 10:40PM BLOOD Hapto-125
___ 03:15PM BLOOD calTIBC-195* Ferritn-617* TRF-150*
___ 10:40PM BLOOD CK-MB-4
DISCHARGE LABS
===========
___ 07:30AM BLOOD WBC-4.4 RBC-3.14* Hgb-9.3* Hct-27.1*
MCV-86 MCH-29.5 MCHC-34.1 RDW-13.3 Plt ___
___ 07:30AM BLOOD Glucose-105* UreaN-89* Creat-2.3* Na-132*
K-4.1 Cl-93* HCO3-30 AnGap-13
___ 07:30AM BLOOD Mg-2.2
CARDIAC ENZYMES
============
___ 10:40PM BLOOD cTropnT-0.04*
___ 09:00AM BLOOD cTropnT-0.03*
URINE STUDIES
=========
___ 01:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 01:45AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 02:55PM URINE Color-Straw Appear-Clear Sp ___
___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 02:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
MICROBIOLOGY
==========
___ CULTURE-FINAL
___ Culture, Routine-FINAL
___ Culture, Routine-FINAL
___ VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
(negative)
___ CULTURE-FINAL
___ Culture, Routine-FINAL
EKG
===
Sinus bradycardia. Diffuse non-specific ST-T wave abnormalities
most
pronounced in the anterolateral leads. Compared to the previous
tracing
of ___ there has been a slowing of the sinus rate and the
anterolateral
ST-T wave abnormalities are slightly more prominent.
___
___
EKG ___
=========
Sinus bradycardia. Low limb lead voltage. Delayed precordial R
wave
transition. Q-T interval prolongation. Compared to the previous
tracing
of ___ no diagnostic interim change.
___
___
RENAL ULTRASOUND
=============
No hydronephrosis or new echogenicity of the renal transplant.
Renal arteries
have a tardus parvus waveform, a new finding, and high resistive
indices
ranging up to 0.9, similar to prior. Diastolic flow is either
minimal or
reversed. Small amount of ascites.
CXR
===
IMPRESSION:
1. Early cardiac decompensation.
2. Faint right lower lobe opacity could represent either
asymmetric edema or pneumonia.
3. Vague nodule in right upper lung, for which CT or repeat
chest radiograph after therapy is recommended.
CXR
===
In addition to chronic pulmonary vascular congestion, there is
progressive
consolidation at the base of the right lung, consistent with
pneumonia.
Moderate cardiomegaly is longstanding. Tiny right pleural
effusion may be
present. No pneumothorax.
ECHO
====
ResultsMeasurementsNormal Range
Left Atrium - Long Axis Dimension:*4.9 cm<= 4.0 cm
Left Atrium - Four Chamber Length:5.2 cm<= 5.2 cm
Left Atrium - Peak Pulm Vein S:0.6 m/s
Left Atrium - Peak Pulm Vein D:0.9 m/s
Left Atrium - Peak Pulm Vein A:0.2 m/s< 0.4 m/s
Right Atrium - Four Chamber Length:*5.2 cm<= 5.0 cm
Left Ventricle - Septal Wall Thickness:
0.9 cm0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
0.9 cm0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
4.4 cm<= 5.6 cm
Left Ventricle - Systolic Dimension:
3.2 cm
Left Ventricle - Fractional Shortening:
*0.27>= 0.29
Left Ventricle - Ejection Fraction:
50%>= 55%
Left Ventricle - Stroke Volume:
94 ml/beat
Left Ventricle - Cardiac Output:
4.68 L/min
Left Ventricle - Cardiac Index:
2.82>= 2.0 L/min/M2
Left Ventricle - Lateral Peak E':
*0.07 m/s> 0.08 m/s
Left Ventricle - Septal Peak E':
*0.05 m/s> 0.08 m/s
Left Ventricle - Ratio E/E':
*18< 15
Aorta - Sinus Level:2.8 cm<= 3.6 cm
Aorta - Ascending:3.2 cm<= 3.4 cm
Aortic Valve - Peak Velocity:
1.6 m/sec<= 2.0 m/sec
Aortic Valve - LVOT VTI:
33
Aortic Valve - LVOT diam:
1.9 cm
Mitral Valve - E Wave:1.1 m/sec
Mitral Valve - A Wave:0.6 m/sec
Mitral Valve - E/A ratio:1.83
Mitral Valve - E Wave deceleration time:170 ms140-250 ms
TR ___ (+ RA = PASP):
*36 mm Hg<= 25 mm Hg
Pulmonic Valve - Peak Velocity:1.0 m/sec<= 1.5 m/sec
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color Doppler. IVC dilated (>2.1cm) with <50% decrease with
sniff (estimated RA pressure (>=15 mmHg).
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. Mildly depressed LVEF. TDI E/e'
>15, suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. RV function depressed.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. Significant PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor suprasternal
views.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 50 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Mildly depressed global left ventricular systolic
function with increased left ventricular filling pressure.
Depressed right ventricular systolic function. Moderate to
severe tricuspid regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
biventricular systolic dysfunction is new. The severity of
tricuspid has increased (previously mild). Moderate pulmonary
artery systolic hypertension is now seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN neuropathy
5. Glargine 8 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Metolazone 2.5 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. PredniSONE 3 mg PO DAILY
9. Prochlorperazine 10 mg PO TID
10. Ropinirole 1.5 mg PO QPM
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Tacrolimus 1 mg PO Q12H
13. Torsemide 100 mg PO BID
14. Aspirin 325 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Citalopram 20 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
18. Mycophenolate Mofetil 500 mg PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN neuropathy
6. Metolazone 2.5 mg PO DAILY
7. PredniSONE 3 mg PO DAILY
8. Ropinirole 1.5 mg PO QPM
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Prochlorperazine 10 mg PO Q8H:PRN nausea
DO NOT TAKE IF NOT NEEDED.
13. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
14. Metoprolol Tartrate 25 mg PO BID
15. Mycophenolate Mofetil 500 mg PO BID
16. Epoetin Alfa ___ UNIT SC QMOWEFR
17. Citalopram 20 mg PO DAILY
18. Levofloxacin 750 mg PO Q48H Duration: 2 Days
RX *levofloxacin 750 mg one tablet(s) by mouth EVERY 2 DAYS Disp
#*2 Tablet Refills:*0
19. Glargine 7 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
20. Outpatient Lab Work
icd-9 996.81: please draw AM tacrolimus level before 8 am an
send to Dr. ___ at ___.
21. Torsemide 100 mg PO BID
22. Tacrolimus 1 mg PO Q12H
23. Outpatient Lab Work
Please check hematocrit on ___ and send to Dr. ___
___ at ___. icd-9 996.81.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: CHF exacerbation
Acute kidney injury
Chronic kidney dysfunction
Type 1 Diabetes
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
PA AND LATERAL CHEST, ___.
HISTORY: ___ woman with renal transplant. Volume overload. New
fever.
IMPRESSION: AP chest compared to ___:
In addition to chronic pulmonary vascular congestion, there is progressive
consolidation at the base of the right lung, consistent with pneumonia.
Moderate cardiomegaly is longstanding. Tiny right pleural effusion may be
present. No pneumothorax.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ANEMIC/WEAKNESS
Diagnosed with RENAL & URETERAL DIS NOS, ANEMIA NOS, KIDNEY TRANSPLANT STATUS
temperature: 97.2
heartrate: 47.0
resprate: nan
o2sat: 97.0
sbp: 132.0
dbp: 27.0
level of pain: 5
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
===============
___ year old female with history of CAD s/p CABG, Type I Diabetes
with ESRD s/p renal transplant in ___ on chronic
immunosuppressive agents who was transferred to ___ with
elevated Cr, evidence of pulmonary vascular congestion, and
anemia (she received 4 units of pRBCs). Her creatinine was
actually at her baseline. She was diuresed and underwent work-up
which revealed new worsened biventricular systolic dysfunction.
She was also found to have community acquired pneumonia, and
underwent a 7 day course of levofloxacin. Her course was
complicated by labile blood sugars. She was started on EPO for
anemia related to kidney disease, and was discharged with
follow-up with a new nephrologist, as well as ___ transplant
nephrology.
ACTIVE ISSUES
=========
# CHF exacerbation with volume overload: She was noted to have
pulmonary vascular congestion on admission. She is s/p kidney
transplant in ___ with new worsened systolic function and
tricuspid regurgitation. Volume overload was in the context of
recent down-titration of diuretic medications in the past month.
Creatinine normalized to her baseline (mid 2.0's) during
admission. She was treated with intravenous diuresis and
restarted on her home regimen of metolazone and torsemide at
discharge.
- She may need pulmonary investigation in the future due to new
biventricular systolic dysfunction AND new pulmonary artery
hypertension (esp given that LV dysfunction seems more mild than
RV dysfunction).
# Pneumonia: She was noted to have radiographic findings of
pneumonia and was started on levofloxacin for treatment of
community acquired pneumonia. This regimen was not ideal given
her prolonged QTc, but she has a penicillin allergy. She
underwent an 8 day course (levofloxacin frequency was decreased
in the context of chronic kidney disease).
# Anemia: She was transferred from an OSH with significant
anemia, s/p 2 units of pRBCs at OSH and 2 units at ___. She
underwent work-up which was more consistent with anemia of
chronic [kidney] disease. She was guaiac negative in the ED and
had no evidence of hemolysis (of note, haptoglobin was normal
prior to transfusion at ___ - see scanned records
for further details). She was started on EPO during her
admission; this will be continued by her new nephrologist. She
was hemodynamically stable during admission.
# Acute on chronic kidney disease s/p renal transplant: She
underwent kidney transplant in ___. She was continued on her
immunosuppressives and tacrolimus level was sent daily. She
should follow up with Dr. ___ at ___, and will follow
with a new nephrologist closer to her home.
#) Diabetes (type 1): This appears to be brittle diabetes; she
had episodes of early morning hypoglycemia. ___ was consulted
and her insulin sliding scale and once daily lantus were
adjusted accordingly. This could also have been exacerbated by
changing renal dysfunction. By discharge, hypoglycemia resolved
and blood sugars were better controlled.
# Prolonged QTc: She had elevated QTc, possibly due to taking
standing prochlorperazine TID at home in conjunction with other
QTc prolonging medications, such as tacrolimus. Her magnesium
was consistently repleted. She was started on levofloxacin
during admission for pneumonia (due to allergies) and QTc was
carefully monitored. It was 485 on the day of discharge with
fully repleted magnesium.
CHRONIC ISSUES
==========
#) CAD/PVD: She was continued on aspirin, atorvastatin, and
clopidogrel.
# Tobacco cessation: She declined nicotine patches saying she
lacked cravings. She was counselled on the importance of
quitting tobacco, especially due to her chronic medical
problems. She is not yet ready to quit but will consider.
#) Depression: Continued cymbalta.
TRANSITIONAL ISSUES
==============
- Code status: DNR/DNI, confirmed with patient on admission.
- Emergency contact: husband, ___, ___, ___.
- Studies pending at discharge: All micro that was pending is
now finalized and added to discharge summary.
- She may need pulmonary investigation in the future due to new
biventricular systolic dysfunction and new pulmonary artery
hypertension, especially given that LV dysfunction seems more
mild than RV dysfunction.
- Use care with QTc prolonging medications (she and her husband
were counselled on only taking compazine as a PRN).
- Needs EPO prescription and monitoring of her HCT.
- She has follow-up with a hematologist for bone marrow biopsy
(this was rescheduled as she missed prior appointment during
admission).
- A copy of this discharge summary was faxed to Dr. ___ at
___ nephrologist) at
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right upper lobe lung mass
Non-ST elevation MI
Anemia
Hypotension secondary to dehydration and poor PO intake
Hypercalcemia
Hypoglycemia
DM2
Urinary Retention
Major Surgical or Invasive Procedure:
Ultrasound guided lung biopsy
History of Present Illness:
___ male with DM type II and HTN presenting with
hypotension, anemia, LBBB in setting of elevated troponin, and
right upper lobe opacity. Pt reports that his biggest
underlying complaint for several months has been right shoulder
pain for which he has been seeing his PCP. He has undergone
steroid injections and physical therapy with minimal relief. He
has felt increasing short of breath with physical therapy
sessions. He also noted frequent diarrhea, general malaise, and
poor appetite for at least 3 weeks. He believes he has had a
twenty lb weight loss over the course of several months. He has
also had subjective fevers/chills, night sweats, and urinary
frequency. He went to see a gastroenterologist on ___ for
his diarrhea. There he was noted to be hyoptensive with BPs in
systolic ___ and Hct was 21. He was referred to ___
___. At the ED, guaiac was reportedly negative. He
believes he had a colonoscopy in ___ that showed one polyp and
has not noticed black or bloody stools. EKG revealed LBBB
without any prior for comparison. Calcium was elevated to 11.7
(albumin 2.7). WBC 19.2. Hct 21. Blood sugars ___. Troponin I
was elevated to 1.9. Cardiology was consulted who felt that
this was likely demand ischemia from anemia. Pt denies chest
pain. He also had urinary retention; foley was placed with 1L
urine output. He was given aspirin and transfused 1 unit PRBC
prior to transfer to ___ ED for further evaluation.
At ___ ED, initial vitals were 97 76 104/60 17 100%RA. CXR
revealed opacification in right upper lobe. He received
levofloxacin 750mg iv for possible CAP. He reports subjective
fevers/chills but denies cough. He recently quit smoking in
___ and states that he sometimes has phlegm. Cardiology was
again consulted who performed bedside TTE showing symmetric LVH
with EF approximately 50% and some suggestion of inferoseptal
and inferior wall hypokinesis. Cardiology felt that he likely
had stable CAD and diastolic dysfunction and may have developed
a demand-related NSTEMI in setting of anemia. He was also noted
to have a pericardial effusion with no evidence of tamponade.
From here, he was transferred to the medical intensive care
unit.
In the MICU, he received a CT Chest/Abd/Pelvis which revealed a
large mass in the RUL from hilum to chest wall and eroding into
the ___ and third ribs, concerning for malignancy. He received
another 1 ___ and was transfered to the floor.
Past Medical History:
hypertension
diabetes
osteoarthritis
neuropathy
anemia
Social History:
___
Family History:
Father: DM, ETOH
No family history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98 106/53 84 16 100%RA
General: Alert, oriented, very thin male, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, decreased breath sounds at right upper lobe
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley draining clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Rectal: Good tone. Guiac negative.
Discharge Physical Exam:
Vitals: 97.9 100/59 89 18 100 RA FSBG 120-153
General: Alert, oriented, no acute distress, cachetic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation on right lung, decreased aeration
on left lung, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, unds present, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, significant clubbing, bo
cyanosis or edema
Neuro: Strength 4+/5 bilateral upper and lower extremities,
patellar reflex 2+ bilaterally, sensation intact bilateral lower
extremities
Pertinent Results:
ADMISSION LABS
___ 12:05AM BLOOD WBC-17.1* RBC-2.53* Hgb-7.5* Hct-24.1*
MCV-96 MCH-29.6 MCHC-31.0 RDW-13.9 Plt ___
___ 12:05AM BLOOD Neuts-83.9* Lymphs-10.7* Monos-3.7
Eos-1.4 Baso-0.4
___ 12:05AM BLOOD ___ PTT-28.0 ___
___ 12:05AM BLOOD Glucose-74 UreaN-24* Creat-1.0 Na-139
K-3.7 Cl-103 HCO3-26 AnGap-14
___ 04:55AM BLOOD ALT-8 AST-17 CK(CPK)-20* TotBili-0.6
___ 04:55AM BLOOD Lipase-8
___ 12:05AM BLOOD cTropnT-0.85*
___ 04:55AM BLOOD Albumin-3.2* Calcium-11.9* Phos-3.0
Mg-1.9
___ 12:22AM BLOOD Lactate-1.4
___ PTH= 6
___:05AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
IMAGING
___ Portable AP CXR
FINDINGS: There is opacification of the right upper lobe with
superior
deviation of the minor but without rightward mediastinal shift.
Two convex contours are seen inferior to this density. No
pleural effusion or
pneumothorax is detected on this view. Heart size is normal.
IMPRESSION: Right upper lobe opacification with abnormal
inferior margin and volume loss without mediastinal shift,
concerning for space occupying process in the right upper lobe
which may involve the mediastinum. Differential diagnosis
includes malignancy. CT is recommended for further evaluation.
___ CT Chest/Abd/Pelvis
IMPRESSION:
1. Large right upper lobe mass extending from the right hilum to
the right chest wall with destructive involvement of the second
and third right ribs. The right upper lobe bronchus is
completely occluded.
2. 6 mm subpleural nodule in the right lower lobe may represent
a satellite lesion. Attention on follow up.
3. Indeterminate left adrenal nodule, incompletely characterized
on this
study. This may represent a metastatic lesion. If no prior
imaging is
available characterizing this lesion, this could be further
evaluated by
adrenal protocol CT or MRI if clinically indicated.
4. No acute process in the abdomen or pelvis to explain
patient's chronic
diarrhea.
5. 1.8-cm right renal superior pole hypodensity with
intermediate density
(22HU) could be further evaluated by renal ultrasound.
6. Mild emphysema. Mild pulmonary artery enlargement suggests
underlying
pulmonary arterial hypertension.
7. Prostatic enlargement with circumferential bladder wall
thickening
suggests outflow obstruction.
8. No definite evidence of spinal metastases as clinically
queried, although MRI is more sensitive.
9. The imaged portion of the right shoulder is unremarkable.
Findings discussed with Dr. ___ fellow) by phone at
5:20pm
___.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
Transthoracic Echocardiogram
Conclusions
Focused study (apical views added to prior on call
echocardiogram dated ___
Overall left ventricular systolic function is moderately
depressed (quantitative biplane LVEF= 35-40 %) secondary to
akinesis of the apex, distal anterior septum, distal
anterior/inferior wall, and hypokinesis of the mid inferior wall
and inferior septum. No masses or thrombi are seen in the left
ventricle. The mitral valve leaflets are structurally normal.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. Mild-moderate pulmonary artery
systolic hypertension.
Compared with the prior study dated ___, the LV apex and
distal segments of the LV are better visualized with evidence of
moderate regional and global systolic dysfunction c/w CAD.
Mild-moderate elevation of pulmonary pressures is also
appreciated.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 12:13
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-17.2* RBC-2.87* Hgb-8.5* Hct-27.6*
MCV-96 MCH-29.6 MCHC-30.7* RDW-14.3 Plt ___
___ 06:25AM BLOOD Glucose-132* UreaN-16 Creat-0.8 Na-139
K-3.7 Cl-105 HCO3-26 AnGap-12
___ 06:25AM BLOOD Albumin-2.5* Calcium-10.2 Phos-2.4*
Mg-2.1
___ 11:12AM BLOOD Albumin-2.9* Calcium-9.8 Phos-2.2*
___ 04:30PM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Enalapril Maleate 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Glimepiride 4mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
hold if SBP < 90 or HR < 60
3. Cyanocobalamin 100 mcg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Tamsulosin 0.4 mg PO HS
holf for sbp < 100
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Senna 2 TAB PO BID:PRN constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Docusate Sodium 200 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right upper lobe lung mass
Non-ST elevation MI
Anemia of Chronic Disease
Hypotension secondary to dehydration and poor PO intake
Hypercalcemia
Hypoglycemia
Type-II Diabetes
Urinary Retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with dyspnea.
COMPARISON: None available.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in an upright position.
FINDINGS: There is opacification of the right upper lobe with superior
deviation of the minor but without rightward mediastinal shift. Two convex
contours are seen inferior to this density. No pleural effusion or
pneumothorax is detected on this view. Heart size is normal.
IMPRESSION: Right upper lobe opacification with abnormal inferior margin and
volume loss without mediastinal shift, concerning for space occupying process
in the right upper lobe which may involve the mediastinum. Differential
diagnosis includes malignancy. CT is recommended for further evaluation.
These findings and recommendations were discussed with Dr. ___ by Dr.
___ by telephone at 1:05 a.m. on ___ at the time of discovery of these
findings.
Radiology Report
CLINICAL HISTORY: ___ man with right upper lobe lung mass with
shortness of breath and right shoulder pain and diarrhea.
COMPARISON: Chest radiograph ___.
TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic
symphysis were displayed with 5-mm slice thickness with oral and 100 mL
Omnipaque intravenous contrast. Coronal and sagittal reformats were displayed
with 5-mm slice thickness.
CT CHEST: No nodules are seen in the thyroid gland. The thoracic aorta is
normal in caliber with mild atherosclerotic calcifications. The pulmonary
artery is borderline enlarged with the right main pulmonary artery measuring
2.8 cm, which may suggest underlying pulmonary arterial hypertension.
Contrast bolus timing is not optimized to evaluate for pulmonary embolism, but
there is no large central PE. No pathologically enlarged axillary or
mediastinal lymph nodes are identified. No left hilar lymph node enlargement.
The heart and pericardium are normal aside from mild coronary artery
calcifications. No pleural effusion is seen.
Within the right upper lobe, there is an 11.1 x 9.0 x 9.4 cm heterogeneously
enhancing mass with central hypodensity, which may represent necrosis. The
mass extends from the right superior hilum to the right chest wall with bony
destruction of the right second and third ribs. No right infrahilar lymph node
enlargement is seen. The right upper lobe bronchus is completely occluded by
the mass with occlusion of the right upper lobe pulmonary arteries. The right
middle and lower lobe bronchi are patent. Left airways are patent to the
subsegmental levels. There is left apical pleural parenchymal scarring. A
6-mm subpleural lesion in the right lower lobe (2:42) is seen. There is mild
emphysema bilaterally with mild dependent atelectasis at the left lung base.
CT ABDOMEN: The liver is normal without focal liver lesion identified. There
is no intra- or extra-hepatic bile duct dilation. The gallbladder is
distended without radiopaque stones. The spleen, pancreas, and right adrenal
gland are normal. A 1.8 x 2.0 cm left adrenal nodule (35 ___ is incompletely
characterized on this single phase study. The kidneys enhance symmetrically
and excrete contrast promptly without hydronephrosis. A 1.8-cm hypodensity in
the right renal superior pole (2:69) has intermediate density (22HU). A 4.6 x
4.2 cm simple cyst is seen in the left renal inferior pole.
The small and large bowel are normal in course and caliber without
obstruction. There is no free air. The aorta is of normal caliber throughout
with dense atherosclerotic calcifications at its inferior portion extending
into the iliac arteries. The main portal vein, splenic vein, and SMV are
patent. No pathologically enlarged mesenteric or retroperitoneal lymph nodes
are identified. Diffuse mesenteric haziness with subcutaneous edema are likely
anasarca.
CT PELVIS: The rectum is normal. Diverticula are seen in the sigmoid colon
without inflammatory changes. The bladder is partially decompressed with a
Foley catheter in place with a thick wall. A bladder diverticulum with air is
seen at the right aspect of the bladder (2:120). The prostate is enlarged with
protrusion of the median lobe into the bladder base and prostatic
calcifications. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: Osseous destruction of the right second and third ribs is due
to the large right upper lobe cancer. No other lesion suspicious for
infection or malignancy is seen. No definite evidence of spinal metastases as
clinically queried. The visualized portion of the right shoulder is
unremarkable.
IMPRESSION:
1. Large right upper lobe mass extending from the right hilum to the right
chest wall with destructive involvement of the second and third right ribs.
The right upper lobe bronchus is completely occluded.
2. 6 mm subpleural nodule in the right lower lobe may represent a satellite
lesion. Attention on follow up.
3. Indeterminate left adrenal nodule, incompletely characterized on this
study. This may represent a metastatic lesion. If no prior imaging is
available characterizing this lesion, this could be further evaluated by
adrenal protocol CT or MRI if clinically indicated.
4. No acute process in the abdomen or pelvis to explain patient's chronic
diarrhea.
5. 1.8-cm right renal superior pole hypodensity with intermediate density
(22HU) could be further evaluated by renal ultrasound.
6. Mild emphysema. Mild pulmonary artery enlargement suggests underlying
pulmonary arterial hypertension.
7. Prostatic enlargement with circumferential bladder wall thickening
suggests outflow obstruction.
8. No definite evidence of spinal metastases as clinically queried, although
MRI is more sensitive.
9. The imaged portion of the right shoulder is unremarkable.
Findings discussed with Dr. ___ fellow) by phone at 5:20pm
___.
Radiology Report
STUDY: Skeletal survey ___.
CLINICAL HISTORY: ___ male with large lung mass, likely malignant.
Patient has hypercalcemia and has lytic lesions.
FINDINGS: Comparison is made to the CT torso study performed on the same day.
LATERAL SKULL: There are no focal lytic or blastic lesions.
THORACIC/LUMBAR SPINE: There is increased opacity involving the right upper
chest consistent with known large lung lesion. Scalloping of the fourth rib
on the right side is likely related to the underlying mass. There are no
compression deformities of the thoracic vertebral bodies. The intervertebral
disc spaces are preserved. The cervical spine demonstrates degenerative
changes with loss of intervertebral disc height and spurring worse at C4-C5.
Imaging of the lumbar spine demonstrates five non-rib-bearing lumbar-type
vertebral bodies. There is contrast material seen within the colon consistent
with the recent CT. No large destructive lesions are seen within the
vertebral bodies. There are degenerative changes with loss of intervertebral
disc height at L5/S1.
PELVIS AND FEMURS: Sacroiliac joints are within normal limits. There are
mild-to-moderate degenerative changes of both hip joints with spur in the
superolateral acetabula. Vascular calcifications are seen bilaterally.
HUMERI: Bilateral humeri demonstrate no focal lytic or blastic lesions.
IMPRESSION:
1. No focal lytic bone lesions.
2. Large right upper lobe lung mass, better assess on the prior CT scan.
3. Degenerative changes.
Radiology Report
ULTRASOUND INTERVENTIONAL PROCEDURE DATED ___
INDICATION: ___ man with right upper lobe mass, anemia, and
hypercalcemia. Biopsy of lung mass in the right upper lobe.
COMPARISON: Comparison is made to previous CT dated ___.
PHYSICIANS: Dr. ___ and Dr. ___ performed the
procedure. Dr. ___ attending radiologist, was present throughout the
procedure.
SEDATION: Moderate sedation was provided by administering divided doses of
fentanyl 25 mcg and Versed 0.5 mg throughout the total intraservice time of 20
minutes during which the patient's hemodynamic parameters were continuously
monitored.
PROCEDURE: Following a detailed discussion of the risks, benefits, and
alternatives to the procedure, written informed consent was obtained. The
patient was transported to the ultrasound suite and placed in a supine
position. Initial preprocedure ultrasound was performed for purposes of
lesion localization and skin point localization prior to biopsy. An
appropriate skin point was obtained within the right axilla. A preprocedural
timeout was performed using unique patient identifiers as per ___ protocol.
The skin overlying the right axilla was prepped and draped in usual sterile
fashion. Approximately 6 mL of 1% lidocaine was infiltrated into the skin,
subcutaneous tissues, and to the lesion for local anesthesia. An 18-gauge
core biopsy needle was advanced into the lesion and two 18-gauge core biopsy
samples were obtained. On-site cytology confirmed sample adequacy. The
patient tolerated the procedure well. There were no immediate complications.
The patient was transferred back to the floor in stable condition. POE orders
were entered online.
IMPRESSION: Technically successful ultrasound-guided right upper lobe lung
lesion biopsy with two 18-gauge core biopsy samples obtained. No immediate
complications. Samples sent to Pathology for further analysis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOW HCT /ELEVATED TROP
Diagnosed with SHORTNESS OF BREATH, ANEMIA NOS, MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT
temperature: 97.0
heartrate: 76.0
resprate: 17.0
o2sat: 100.0
sbp: 104.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | RUL lung mass: Initial finding of space occupying process on CXR
prompted CT evaluation, which revealed a substantial RUL mass
from hilum to chest wall, destroying the second and third ribs.
This large mass was biopsied through US guidance, and the
results were still pending at the time of discharge. The medical
team discussed with the patient that malignancy was high on the
list of differential diagnosis.
Urinary retention: At ___, 1L urine output was
obtained after foley was inserted. At home, patient notes that
he will urinate frequently and excrete very small volumes. At
___, Abd CT revealed symmetric bladder wall thickening and
enlarged prostate, suggestive of outflow tract obstruction. He
received a foley for two days, and then failed two trials to
void with 700 mL and 800 mL of residual in the bladder. The
patient reported he did not feel the urge to urinate with these
volumes. He was started on tamulosin 0.4 mg QHS for presumptive
BPH.
Hypercalcemia: At ___, patient's corrected calcium
was 12.7. At ___, PTH of 6 which is markedly low. Likely
hypercalcemia of malignancy given imaging findings. Ordered
PTHrP to confirm diagnosis, which was still pending at
discharge. Received aggressive IV hydration for a total of
about ___ liters since admission, and his calcium trended
dowards to correct calcium of 11.5. He also received 1 dose of
pamidronate and 1 dose of lasix to further diminish his
hypercalcemia. We discontinued his Vitamin D therapy given his
hypercalcemia. Consideration should be given to starting a
bisphosphonate routinely if confirmed hypercalcemia of
malignacy. On discharge, his calcium was WNL at 10.2.
Phosphorus was low at 2.4 on day of discharge and he required
several packets of neutraphos for repletion. His electrolytes
should be checked on a daily basis and repleted as needed while
at rehab.
Hypoglycemia/DM2: Pt reports low blood sugars at home and had
sugars in ___ at ___. Hypoglycemia likely from poor
po intake in setting of continued oral hypoglycemics
(glimeprimide, metformin). During hospitalization, held
hypoglycemic agents and monitor QID fingersticks. FSBG came up
nicely to 120s-150s after IVF. Given his lack of appetite, we
discontinued his oral anti-hyperglycemics in order to prevent
further hypoglycemic episodes.
Anemia, inflammation: Pt with Hct of 21 at ___ and
received 1 unit PRBC prior to transfer from ___. Etiology of
anemia initially unclear butt likely anemia of chronic disease
given RUL lung mass. Guaiac negative with good rectal tone.
Additionally had colonoscopy in ___ which showed 1 rectal polyp
but was otherwise unremarkable. He received 1U PRBC in the MICU
prior to transfer to the floor. Hct was 29 on the floor and
stable throughout the remainder of the hospitalization. Iron
studies showed high ferritin and low TIBC, suggesting anemia of
chronic disease as the primary etiology.
chronic systolic CHF: TTE showed significant inferior wall
motion abnormalities with diminished EF (35-40%). His enalapril
was held throughout his hospitalization secondary to hypotension
in the setting of hypovolemia; similarly, initiation of diuretic
therapy was held.
Leukocytosis: On admission, his WBC was elevated to ___. Pt
does not have localizing symptoms to suggest infection, urine
culture and blood cultures with no growth, Chest CT with
complete oblieration of RUL suggesting no physical space for
infection. No fevers documented at ___ or here and
continued to be afebrile in the throughout the hospitalization.
Possibly stress response vs consequence of malignancy.
Hypotension (resolved): Pt with reported low blood pressures in
systolic ___ at PCP's office. At our ED and in the MICU,
BPs were 100s-110s. After IVF on the floor, BPs remained in 110s
and he was not orthostatic. Hypotension was likely secondary to
volume depletion (diarrhea, frequent urination secondary to
hypercalcemia, poor po intake). Infectious cause was considered
possible given elevated WBC of ___, however patient was
afebrile and reported no localizing symptoms. He received 750mg
IV levofloxacin for right upper lobe opacity concerning for PNA,
but this was discontinued as malignancy appeared more likely
than pneumonia. Additionally also had TTE to look for
pericardial effusion which was negative.
NSTEMI (resolved)/CAD: Had elevated trop I at ___
and in house with elevated trop T of 0.85. EKG showed LBBB with
nonspecific ischemic changes (STE in V1-3, STD V5-6). There
were no prior EKGs for comparison, but did not meet Sgarbossa
criteria for diagnosing an acute MI in the setting of a LBBB.
Cardiology saw the pt and felt he likely has stable CAD and
diastolic dysfunction and presented with demand-related ischemia
in setting of anemia and hypovolemia. Bedside TTE suggested
inferoseptal and inferior wall hypokinesis, with normal RV, EF
50%, moderate pericardial effusion without tamponade. His
troponins peaked at 0.87 and trended downwards thereafter. A
formal TTE revealed diminished EF (35-40%), inferior wall motion
abnormalities, and mitral regurgitation. Once his hypotension
resolved, he was started on a low dose beta blocker.
Diarrhea (resolved): Pt reported history of IBS and frequent
diarrhea at home. Initially he had diarrhea, and in the context
of marked leukocytosis, C. diff toxin assay was sent and he was
empirically started on antibiotics. C. diff assay was negative
and the diarrhea resolved spontaneously. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___
Chief Complaint:
Nausea and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hx of T2DM, ESRD s/p cadaveric kidney txp in ___
c/b ACR ___, HTN, hypothyroidism p/w 2 weeks of dull, gnawing
LUQ abdominal pain and nausea. He notes that he has lost all
appetite and has had very little except crackers and water with
his pills over the last two weeks. He has never had anything
like this before. He denies hx of gallstones, EtOH use, new
medications, OTC supplements. Nothing has made it worse or
better but pain has been persistent over the two weeks. He
denies vomiting, constipation, black or bloody stools, diarrhea.
He denies confusion or change in urination. He initially
presented to ___ and was found to have Na 125 creatine
1.5 BUN 16 AST 156 ALT 259, alk phos 93.
___ tried to transfer for ___ but hospital is full so
transfered to ___ for futher care.
In the ED initial vitals were:99.8 72 146/78 18 98%
- Labs were significant for UA with protein/glucose/ketones, K
5.2->4.8, Na 128, Bicarb 19, Cl 96, Cr 1.3, BUN 18, Glu 317, Mg
1.5, ALT 269, AST 155, Lipase 514, AP 100, Tbili 0.4, Alb 4.0,
H/H 12.3/36.8, Plt 138
- Patient was given 2L NS, IV ondansetron 4mg, MMF 500mg,
tacrolimus 1mg, insulin
Vitals prior to transfer were: 99.3 80 168/65 16 99% RA
On the floor, patient notes that pain is unchanged over the last
several weeks and continues at ___.
Review of Systems: As per HPI otherwise negative
Past Medical History:
ESRD due to diabetes mellitus
Hypertension
Secondary hyperparathyroidism
CAD: negative stress test ___, EF 55%
Hematuria, cystoscopy ___ negative
Meatal stenosis, s/p dilatation ___
Diverticulosis, by colonoscopy ___
s/p amputation of lt middle toe d/t MRSA osteomyelitis ___
s/p ablation d/t AF on ___ (no episodes since)
Social History:
___
Family History:
No hx of GI/pancreas issues
Physical Exam:
Vitals - T: 101.6 BP: 171/67 HR: 80 RR: 20 02 sat: 93%RA Wt
78.5kg FSG 258
GENERAL: Well appearing man lying in bed in NAD
HEENT: PERRL, anicteric sclera, pink conjunctiva, dry MM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Trace crackles at bases bilaterally, no dullness to
percussion, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, mild tenderness to palpation over
RUQ and epigastrium, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AAOx3, motor and sensory exam grossly
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 08:25PM BLOOD WBC-4.5 RBC-4.05* Hgb-12.3* Hct-36.8*
MCV-91 MCH-30.4 MCHC-33.4 RDW-13.4 Plt ___
___ 08:25PM BLOOD Neuts-58 Bands-1 ___ Monos-6 Eos-0
Baso-0 Atyps-2* ___ Myelos-1* Plasma-1* Other-1*
___ 05:44AM BLOOD ___ PTT-26.2 ___
___ 08:25PM BLOOD Glucose-317* UreaN-18 Creat-1.3* Na-128*
K-5.2* Cl-96 HCO3-19* AnGap-18
___ 05:44AM BLOOD Glucose-270* UreaN-14 Creat-1.2 Na-129*
K-4.4 Cl-97 HCO3-21* AnGap-15
___ 08:25PM BLOOD ALT-269* AST-155* AlkPhos-100 TotBili-0.4
___ 05:44AM BLOOD ALT-271* AST-195* AlkPhos-89 TotBili-0.4
___ 08:25PM BLOOD Lipase-514*
___ 05:44AM BLOOD Lipase-75*
___ 08:25PM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.0 Mg-1.5*
___ 05:44AM BLOOD Hapto-251*
___ 08:25PM BLOOD Triglyc-232*
___ 05:44AM BLOOD Osmolal-277
___ 08:25PM BLOOD tacroFK-5.0
___ 06:19AM BLOOD Lactate-1.2
URINE
___ 09:55PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 09:55PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:55PM URINE Color-Yellow Appear-Clear Sp ___
MICRO
Blood culture pending at time of discharge x2
Urine culture pending at time of discharge
CMV viral load pending at time of discharge
IMAGING:
CXR
IMPRESSION:
Blunting of several pleural sulci could be due to small
effusions or pleural scarring. There is the suggestion of tiny
pleural calcifications along the diaphragmatic surface which, if
present, would suggest prior asbestos exposure. Lungs are
grossly clear. Nipple shadow should not be mistaken for lung
nodules. Cardiomediastinal and hilar silhouettes are normal.
Graft ultrasound
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
pelvi-infundibular thickening, and renal sinus fat is normal.
There is no hydronephrosis. There is no perinephric fluid
collection.
The resistive index of intrarenal arteries ranges from 0.66 to
0.73, within the normal range. Acceleration times and peak
systolic velocities of the main renal artery are normal.
Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Right Upper Quadrant Ultrasound
FINDINGS:
LIVER: The liver echotexture is normal and the contour is
smooth. There is no focal liver lesion. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic bile duct dilation. The CBD
measures 4 mm.
GALLBLADDER: There are no stones. There is no gallbladder wall
thickening.
PANCREAS: The head and body of the pancreas are normal. The
tail was not well seen due to overlying bowel gas.
RETROPERITONEUM: The imaged portions of the aorta and IVC are
within normal limits.
IMPRESSION:
Normal right upper quadrant abdominal ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Mycophenolate Mofetil 500 mg PO TID
4. Amlodipine 5 mg PO BID
5. Gabapentin 200 mg PO QHS
6. PredniSONE 5 mg PO DAILY
7. Tacrolimus 1 mg PO Q12H
8. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Gabapentin 200 mg PO QHS
4. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Mycophenolate Mofetil 500 mg PO TID
7. PredniSONE 5 mg PO DAILY
8. Tacrolimus 1 mg PO Q12H
9. Ciprofloxacin 400 mg IV Q12H
10. Ganciclovir 390 mg IV Q12H
11. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
12. Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Abdominal pain and fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ man status post renal transplant, presenting with
elevated LFTs.
TECHNIQUE: Grayscale and color Doppler ultrasound examination of the abdomen
was performed.
COMPARISON: None.
FINDINGS:
LIVER: The liver echotexture is normal and the contour is smooth. There is no
focal liver lesion. The main portal vein is patent with hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no intrahepatic bile duct dilation. The CBD measures 4
mm.
GALLBLADDER: There are no stones. There is no gallbladder wall thickening.
PANCREAS: The head and body of the pancreas are normal. The tail was not well
seen due to overlying bowel gas.
RETROPERITONEUM: The imaged portions of the aorta and IVC are within normal
limits.
IMPRESSION:
Normal right upper quadrant abdominal ultrasound.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ man status post renal transplantation 10 months ago,
presenting with elevated creatinine.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound images of the
renal transplant were obtained.
COMPARISON: None available.
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 pelvi-infundibular thickening, and renal sinus fat is normal. There is
no hydronephrosis. There is no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.66 to 0.73, within
the normal range. Acceleration times and peak systolic velocities of the main
renal artery are normal. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with renal txp now presenting with pancreatitis
// Evidence of pleural effusions? Evidence of pleural effusions?
COMPARISON: There are no prior chest radiographs available.
IMPRESSION:
Blunting of several pleural sulci could be due to small effusions or pleural
scarring. There is the suggestion of tiny pleural calcifications along the
diaphragmatic surface which, if present, would suggest prior asbestos
exposure. Lungs are grossly clear. Nipple shadow should not be mistaken for
lung nodules. Cardiomediastinal and hilar silhouettes are normal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with ACUTE PANCREATITIS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, KIDNEY TRANSPLANT STATUS
temperature: 99.8
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 78.0
level of pain: 2
level of acuity: 2.0 | ___ yo M with history of T2DM, ESRD s/p cadaveric kidney txp in
___ c/b acute cellular rejection ___, HTN, hypothyroidism
p/w fever, abdominal pain, elevated lipase and transaminitis.
# Fever/Lipase/Transaminitis: Most concerning for CMV given
recipient CMV negative and donor positive, received Valcyte
until ___ but records indicate inconsistently filled. In
addition, the patient had lipase 500 with some concern for
pancreatitis. Triglyercides 232, Ca normal, no history of active
EtOH and remote EtOH without reported history of pancreatitis.
He was given cipro/flagyl when he spiked in the morning, made
NPO and given 1LNS with second liter hanging at time of
discharge. Initial RUQ ultrasound is reassuring with normal
pancreas head and no evidence of stone or ductal dilation,
however LFT's are uptrending. CMV viral load and hepatitis
serologies pending at time of discharge, the patient was given a
dose of gancyclovir prior to transfer. Plan at the time was CT
abd/pelvis with oral contrast only but the study was not
completed. Blood and urine cultures pending at time of
discharge.
# DM: Sugars poorly controlled on arrival, ___ in 300's with some
ketones in urine (likely starvation), no AG but bicarb 21, given
8units humalog and 30 units glargine (home dose is 40 at night)
in the context of NPO, will need tight glucose attention on
arrival.
# Abd Pain: See above, could also be coexistant gastroparesis,
got gastric emptying study read pending at time fo DC, started
protonix IV.
#Hyponatremia: Likely combination of hypovolemia in the setting
of poor PO intake and pseudohyponatremia from hyperglycemia.
Sodium corrects to 131 accounting for plasma glucose. IVF as
above.
#Hyperkalemia- chronic issue per records, has been on Florinef
in past. Now likely ___ mild acidosis and possibly hypovolemia
in the setting of pancreatitis. Improved in ED.
#Hypomagnesemia: Repleted 4g IV Mg sulfate
#Thrombocytopenia: Unclear etiology. ___ be ___ acute
inflammation. Sequestration unlikely without evidence of portal
congestion or enlarged spleen. No evidence of destruction or
bleeding (consumption). Would evaluate for HIT if continues to
drop though less likely. Hapto/fibrinogen normal.
#ESRD s/p DDRT: DDRT ___, s/p ACR ___ which was
treated with IV methylprednisone with peak creatinine 2.4.
Presents with Cr 1.3 which is now baseline, tacro trough 5.0, no
adjustments made to immunosuppressants.
#HTN- Mildly elevated in ED and uptrending, had not received
home medications all day. Cont'd Amlodipine and Aspirin 81. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ketorolac / Nalbuphine / Simvastatin / Atorvastatin / Crestor /
adhesive tape / Erythromycin Base / Green Pepper / Tizanidine /
ceftriaxone
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Hospital Medicine Admission Note
Time patient seen and examined today: 930 AM
CC: Left groin and leg pain
HPI(4): Ms. ___ is a ___ female with a past medical
history of chronic compression fractures presents with left
groin
and leg pain ___ the setting of increasingly frequent falls.
Patient is a vague historian and blends a lot of information,
often tangential to old history. However, she is generally
oriented and aware of HPI. Husband at bedside provides a more
clear history and timeline.
Patient has had increasing falls. Her acute pain started about 1
week ago after sliding off the side of her bed. She fell
directly
on her buttock and fell to the side. She has had other falls and
has hit her head. No reports of loss of consciousness. She has
no
prodrome to these episodes and seems like these are mechanical.
She specifically denies acute chest pain, palpitations,
shortness
of breath, diaphoresis, or abdominal pain. The episode 1 week
ago
off her bed, she attributes to wearing slippery shorts. Patient
is on chronic fentanyl and hydromorphone for back pain, but her
pain was so severe she could not ambulate (or move for that
matter) and husband brought her to the hospital. Pain has been
increasing over the last few days. Patient's pain started as
moderate and ___ the left groin. Now she describes it as severe
sharp pain, radiating all the way to the foot on the left side.
She has some numbness and tingling of the toes on the left. She
has chronic intermittent urinary incontinence without change.
The patient went to ___ ER and reportedly had
imaging
done. She reports they sent her home with outpatient follow up
with her primary orthopedic surgeon.
The patient has chronic intermittent shortness of breath and
cough related to tracheobronchomalacia and extensive surgical
history. She also endorses recent URI (2 weeks ago) treated with
5 days of levofloxacin. She believes she had a UTI at that time.
She endorses recurrent UTI. She states she is completing a
complicated vaginal yeast infection with a 3rd dose (of 3)
fluconazole tomorrow morning.
ROS: Pertinent positives and negatives as noted ___ the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
CHRONIC PANCREATITIS
RAPID GASTRIC EMPTYING
COMPRESSION FRACTURES
GASTROESOPHAGEAL REFLUX
DIABETES, TYPE II/HBP
HYPERLIPIDEMIA
IRON DEFICIENCY ANEMIA
SARCOIDOSIS
TRACHEOBRONCHOMALACIA
UNILATERAL VOCAL CORD PARALYSIS
NECK PAIN
RECURRENT UTI
CAD s/p MI, stent ___ LAD
# Tracheobronchomalacia,
- s/p TBP with mesh, ___
- s/p cervical tracheoplasty with mesh, ___
- s/p medialization laryngoplasty with GoreTex, left arytenoid
adduction, left pharyngoplasty, ___
# Sarcoidosis
# Diabetes mellitus
# Hypertension
# Hyperlipidemia
# Pancreatic disease
- s/p cholecystectomy, ___
- s/p sphincterotomy, ___
- numerous ERCP
# Chronic abdominal/back pain with history of detox
# Osteoarthritis
# Osteoporosis with compression fractures
# Peptic ulcer disease
# Gastroesophageal reflux disease
# Depression
PAST SURGICAL HISTORY:
1. Appendectomy. ___
2. Right ankle pinning, 1970s
3. Total abdominal hysterectomy, ___
4. Kyphoplasy, ___
5. Rib fracture, thought secondary to coughing (___)
6. Inguinal hernia repair
7. Left pharngoplasty, arytenoid adduction, and medialization
laryngoplasty (___)
Social History:
___
Family History:
Father: died of CVA
Mother: died of MI/COPD
Brother: died of MI (age ___
Physical Exam:
ADMISSION EXAMINATION
VITALS:
___ 1139 Temp: 97.6 PO BP: 157/63 HR: 63 RR: 18 O2 sat: 95%
O2 delivery: RA
GENERAL: Alert. ___ no apparent distress at rest, but appears
anxious. Moderate painful distress when moving about bed.
EYES: Anicteric, pupils equally round and reactive to light.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, but ?
structural abnormality on left posterior pharynx, no clear mass.
Left superior anterior cervical lymph node (patient recalls this
to be known lipoma-like growth).
CV: Heart regular, no murmur, no JVD. Radial and DP pulses
present.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Obese. Abdomen is soft, non-distended, non-tender. Bowel
sounds present.
GU: No suprapubic tenderness
MSK: Neck supple, moves all extremities, strength grossly
symmetric bilaterally ___ upper extremities. Left leg limited
range of motion and strength due to pain (per patient).
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs (as above), sensation to light
touch grossly intact ___ distal feet.
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
AVSS, NAD
RRR
CTAB
sntnd
wwp neg edema
A&O grossly, MAEE, no facial droop, abnormal voice per baseline
L hip with mild tenderness to movement and particularly with log
roll
no rash
Pertinent Results:
ADMISSION RESULTS
___ 12:00AM BLOOD WBC-6.5 RBC-3.99 Hgb-12.1 Hct-37.0 MCV-93
MCH-30.3 MCHC-32.7 RDW-13.3 RDWSD-45.1 Plt ___
___ 12:00AM BLOOD Glucose-159* UreaN-14 Creat-0.6 Na-131*
K-5.7* Cl-93* HCO3-26 AnGap-12
___ 06:15AM BLOOD Mg-1.5*
___ 08:02AM BLOOD %HbA1c-8.9* eAG-209*
==========
PERTINENT INTERVAL RESULTS
DATA:
___ L-SPINE W/O CONTRAST
1. Study limited by diffuse osteopenia.
2. Transitional anatomy as described.
3. Within limits of study, no acute fracture or traumatic
subluxation is identified.
4. Grossly stable multilevel vertebral augmentation, and a
similar distribution to the study of ___, including
some epidural cement at L1.
5. T12 and L1 stable chronic compression deformities.
6. Grossly stable multilevel degenerative changes are similar to
___ prior exam, allowing for difference ___ technique. Please
note that lumbar spine MRI is more sensitive for the evaluation
of vertebral canal neural foraminal narrowing.
7. Additional findings as described.
Outside images:
) lower extremity duplex that did not
reveal evidence of acute DVT.
2) CT abd/pelvis without major abnormality,
specifically no mention of bony abnormality or fracture. They
mention nonspecific pulmonary nodules that may need follow up
with outpatient pulmonologist.
CT CHEST:
IMPRESSION:
Left ventricular thrombus, chronicity and clear but element of
acute etiology
cannot be excluded. Echocardiography is recommended.
Near field areas ___ the posterior segment of the right upper
lobe as well as
basal lateral segment of the right lower lobe and posterior
segment of the
left lower lobe, most likely representing currently air filled
bronchiectasis,
cystic and less likely cavitated nodules
Multiple pre-existing and some new pulmonary nodules ___
conjunction with
mediastinal calcified lymphadenopathy might represent either
ongoing
sarcoidosis or combination of sarcoidosis ___ a typical
mycobacteria.
Dilated biliary and pancreatic ducts, reason unclear,
correlation with MRCP is
to be considered.
VIDEO SWALLOW
IMPRESSION:
Penetration with nectar thick liquids and thin liquids.
Instance aspiration
with thin liquids with sequential swallows.
TTE
CONCLUSION:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal
cavity size. There is mild regional left ventricular systolic
dysfunction with apical akinesis and severe
hypokinesis of the distal septum and anterior walls (see
schematic) and preserved/normal contractility of the
remaining segments. The apex is aneurysmal with a moderate 1.0cm
mobile left ventricular THROMBUS.
Overall left ventricular systolic function is normal. The
visually estimated left ventricular ejection
fraction is 45%. Left ventricular cardiac index is low normal
(2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests a
normal left ventricular filling pressure (PCWP less
than 12mmHg). 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. The aortic arch diameter is normal
with a normal descending aorta diameter. The
aortic valve leaflets (?#) appear structurally normal. There is
no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial
mitral regurgitation. The pulmonic valve leaflets are not well
seen. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic
pressure is borderline elevated. There is a trivial pericardial
effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with apical
akinesis/aneurysm and THROMBUS. No valvular pathology or
pathologic flow identified. Borderline
elevated pulmonary artery systolic pressure.
Compared with the prior TTE (images reviewed) of ___ , an
apical thrombus is now seen (prior
study was without echo contrast) and the estimated pulmonary
artery systolic pressure is now lower.
CLINICAL IMPLICATIONS: Based on the echocardiographic findings
and ___ ACC/AHA recommendations,
antibiotic prophylaxis is NOT recommended.
___ 05:00AM BLOOD ___ PTT-91.1* ___
___ 10:10AM BLOOD ___ PTT-88.0* ___
___ 08:10AM BLOOD Glucose-108* UreaN-20 Creat-0.5 Na-128*
K-4.7 Cl-92* HCO3-26 AnGap-10
___ 08:10PM BLOOD Glucose-192* UreaN-19 Creat-0.7 Na-128*
K-5.0 Cl-93* HCO3-25 AnGap-10
___ 07:40AM BLOOD Glucose-91 UreaN-20 Creat-0.5 Na-132*
K-4.9 Cl-95* HCO3-23 AnGap-14
___ 09:00AM BLOOD Glucose-152* UreaN-21* Creat-0.5 Na-134*
K-4.8 Cl-97 HCO3-24 AnGap-13
___ 06:50AM BLOOD Glucose-143* UreaN-18 Creat-0.6 Na-133*
K-5.4 Cl-98 HCO3-22 AnGap-13
___ 05:00AM BLOOD Glucose-219* UreaN-19 Creat-0.6 Na-130*
K-4.7 Cl-96 HCO3-25 AnGap-9*
___ 05:00AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.5*
___ 08:02AM BLOOD %HbA1c-8.9* eAG-209*
___ 08:10PM BLOOD Osmolal-281
___ 08:22AM BLOOD PTH-51
___ 08:24PM BLOOD freeCa-1.28
___ 01:12AM URINE Osmolal-422
___ 01:12AM URINE Hours-RANDOM Na-99
___ 12:29 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 8:36 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 5:07 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS Specimen
is only
screened for Cryptococcus species. New specimen is
recommended.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 4:46 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
=========
DISCHARGE RESULTS
___ 07:40AM BLOOD WBC-5.5 RBC-3.96 Hgb-12.0 Hct-37.6 MCV-95
MCH-30.3 MCHC-31.9* RDW-12.8 RDWSD-44.2 Plt ___
___ 10:10AM BLOOD ___ PTT-88.0* ___
___ 05:00AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fenofibrate 145 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. guaiFENesin 600 mg oral BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
5. Metoclopramide 10 mg PO QIDACHS
6. Nortriptyline 100 mg PO QHS
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Omeprazole 40 mg PO BID
9. Miconazole 2% Cream 1 Appl TP BID
10. Acetaminophen-Caff-Butalbital 1 TAB PO BID
11. diclofenac sodium 1 % TOPICAL Q4H
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
14. amLODIPine 10 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 80 mg PO QPM
17. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
18. Fentanyl Patch 37 mcg/h TD Q72H
19. Ferrous Sulfate 325 mg PO DAILY
20. Fluconazole 150 mg PO ONCE
21. Gabapentin 300 mg PO QHS
22. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
23. LORazepam 0.5 mg PO BID:PRN Anxiety
24. melatonin 10 mg oral QHS:PRN Insomia
25. methylcellulose (laxative) 15 mL oral DAILY:PRN Constipation
26. Metoprolol Succinate XL 25 mg PO QHS
27. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
28. Ondansetron ODT 4 mg PO BID:PRN Nausea/Vomiting - First Line
29. Pancrelipase 5000 1 CAP PO TID W/MEALS
30. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
31. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Benzonatate 100 mg PO TID
3. Enoxaparin Sodium 70 mg SC Q12H
4. Magnesium Oxide 400 mg PO TID Duration: 3 Doses
5. Warfarin 5 mg PO DAILY16
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
7. Glargine 20 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. LORazepam 0.5 mg PO Q8H:PRN Anxiety
RX *lorazepam 0.5 mg 1 TAB by mouth every eight (8) hours Disp
#*30 Tablet Refills:*0
9. Nortriptyline 75 mg PO QHS
RX *nortriptyline 75 mg 1 tab by mouth at bedtime Disp #*30
Capsule Refills:*0
10. Acetaminophen-Caff-Butalbital 1 TAB PO BID
RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 tab by
mouth twice a day Disp #*20 Capsule Refills:*0
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
13. amLODIPine 10 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 80 mg PO QPM
16. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
17. diclofenac sodium 1 % TOPICAL Q4H
18. Fenofibrate 145 mg PO DAILY
19. Fentanyl Patch 37 mcg/h TD Q72H
RX *fentanyl 37.5 mcg/hour 1 patch q72h Disp #*10 Patch
Refills:*0
20. Ferrous Sulfate 325 mg PO DAILY
21. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
22. Gabapentin 300 mg PO QHS
23. guaiFENesin 600 mg oral BID
24. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
25. melatonin 10 mg oral QHS:PRN Insomia
26. methylcellulose (laxative) 15 mL oral DAILY:PRN
Constipation
27. Metoclopramide 10 mg PO QIDACHS
28. Metoprolol Succinate XL 25 mg PO QHS
29. Miconazole 2% Cream 1 Appl TP BID
30. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
31. Omeprazole 40 mg PO BID
32. Ondansetron ODT 4 mg PO BID:PRN Nausea/Vomiting - First
Line
33. Pancrelipase 5000 1 CAP PO TID W/MEALS
34. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pain after fall
Hyponatremia
Poorly controlled type 2 diabetes mellitus
Tracheobronchomalacia
Chronic pain
Anxiety
SIADH
Cavitary lesions ___ lung
LV aneurysm
LV thrombus
Discharge Condition:
Ambulating with walker
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ with 2d hx of L leg pain/weakness// Eval for cause
of L leg pain/weakness Eval for cause of L leg pain/weakness
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.8 s, 30.8 cm; CTDIvol = 31.1 mGy (Body) DLP = 957.7
mGy-cm.
Total DLP (Body) = 958 mGy-cm.
COMPARISON: Reference lumbar spine dated ___.
FINDINGS:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level. Following this convention, the L1 vertebral body
demonstrates left sided rudimentary rib (see 02:34), and there is transitional
anatomy with partial lumbarization of S1 (602:39).
There is levoscoliosis of the lumbar spine. 3 mm retrolisthesis of L1 on L2
is unchanged. The visualized osseous structures are osteopenic.There is no
prevertebral soft tissue swelling. No definite acute fractures are identified.
Vertebral augmentation cement is re-demonstrated in T12, L1 and L4 in a
similar distribution. Height loss of T12 and L1 is similar. Retropulsion of
T12 and L1 posterior endplates into the canal, as well as some epidural cement
leakage is also unchanged (02:35). There is mild canal narrowing at L1 due to
the cement and retropulsion.
Allowing for difference in technique, grossly stable multilevel lumbar
spondylosis is noted, including loss of intervertebral disc height, vacuum
disc phenomena, disc bulges, disc osteophytes, and facet joint hypertrophy.
There is at least moderate neural foraminal narrowing on the left at L5-S1 due
to osteophytes. Overall, degenerative changes are similar to ___.
OTHER:
Subpleural fibrotic changes are noted at both lung bases. Bilateral renal
cysts are partially imaged. Severe aortoiliac calcification is present.
Within the limits of this noncontrast study there is no paravertebral or
paraspinal mass identified.
IMPRESSION:
1. Study limited by diffuse osteopenia.
2. Transitional anatomy as described.
3. Within limits of study, no acute fracture or traumatic subluxation is
identified.
4. Grossly stable multilevel vertebral augmentation, and a similar
distribution to the study of ___, including some epidural cement
at L1.
5. T12 and L1 stable chronic compression deformities.
6. Grossly stable multilevel degenerative changes are similar to ___ prior
exam, allowing for difference in technique. Please note that lumbar spine MRI
is more sensitive for the evaluation of vertebral canal neural foraminal
narrowing.
7. Additional findings as described.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with TBM, with increased cough// infiltrate?
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There is no focal consolidation, pleural effusion or pneumothorax. There is
unchanged right basilar fibrosis/scarring. The cardiomediastinal silhouette is
stable in appearance. There is a defect in the posterior aspect of the right
fourth rib, which may be postsurgical. Kyphoplasty changes are seen in several
lower thoracic and lumbar vertebral bodies.
Radiology Report
EXAMINATION: SECOND OPINION CT ABD/PELVIS
INDICATION: ___ year old woman with left hip and left pain, osh pelvic ct//
evaluate for fracture
TECHNIQUE: Please see a sign report for further details on techniques.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Prior abdominal CT from ___. Trachea CT from ___
FINDINGS:
LOWER CHEST:
New lung nodules in the middle lobe and left lung base (3:4) measuring
respectively 7 and 8 mm. Mild bronchial wall thickening. Several calcified
lymph nodes are noted in the mediastinum. There is no evidence of pleural or
pericardial effusion.
ABDOMEN AND PELVIS:
Hepatobiliary: The liver demonstrates homogenous attenuation throughout with
nodular contour. There is no evidence of focal lesions. Gas foci are noted
within the biliary tree, likely secondary to recent instrumentation. The
gallbladder is surgically absent.
Pancreas: The pancreas is again noted to be atrophic with no pancreatic duct
dilation. There is no peripancreatic stranding.
Spleen: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
Adrenals: The right and left adrenal glands are normal in size and shape.
Urinary: The kidneys are normal and symmetric in size with normal nephrogram.
There is no evidence of hydronephrosis. Multiple hypodense lesions are seen
in both kidneys measuring up to 4.7 cm, representing simple cysts (03:39).
There is no perinephric abnormality.
Gastrointestinal: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness and enhancement throughout.The colon and rectum
are within normal limits. The appendix is normal.
Pelvis: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
Reproductive Organs: The patient is status post hysterectomy.
Lymph Nodes: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
Vascular: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
Bones: There is no evidence of worrisome osseous lesions or acute fracture.
Prior vertebroplasty of L4, L1 and T12.
Soft Tissues: Diastasis of the rectus muscles.
IMPRESSION:
1. New lung nodules measuring up to 8 mm as compared to prior trachea CT from
___. This should be fully assessed by dedicated chest CT.
2. No evidence acute fractures within the visualized skeleton.
3. Redemonstration of an atrophic pancreas, evidence of chronic pancreatitis.
4. Patient is status post cholecystectomy and hysterectomy.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with tracheobronchomalacia, fall, found to have
siadh and pulmonary nodules// assess nodules, r/o cancer
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Pulmonary artery is mildly dilated, 3.3 cm. Aorta is normal in diameter.
Coronary calcifications are extensive. There is left ventricular aneurysm
containing small, 11 x 8 x 15 mm thrombus, series 5, image 52. It appearance
might be concerning for acute on chronic etiology.
Multiple calcified mediastinal and noncalcified mediastinal and hilar lymph
nodes are unchanged might represent sarcoidosis as previously suggested.
Esophagus is patulous, similar or progressed since previous examination.
Airways are patent to the subsegmental level bilaterally. Image portion of
the upper abdomen demonstrate pneumobilia, unchanged as well as dilatation of
the pancreatic duct, series 2, image 55, reason unclear. Previously nodular
appearance of the findings in the posterior segment of the right upper lobe
now has a air filled appearance and most likely represent a cystic
bronchiectasis and substantially less likely large cavitated nodule. The
overall ___ are 3 x 2 cm, series 4, image 91. Similar appearance is
also noted in the basal lateral segment of the right lower lobe (4:165) and
posterior segment of the left lower lobe (4:131), most likely representing
similar etiology.
Multiple pulmonary nodules are demonstrated scattered throughout the lungs,
the majority of them is stable but some are new, series 4, image 165, series
4, image 157..
Multiple liver renal cysts are bilateral.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
The patient is after lower thoracic vertebral plasty
IMPRESSION:
Left ventricular thrombus, chronicity and clear but element of acute etiology
cannot be excluded. Echocardiography is recommended.
Near field areas in the posterior segment of the right upper lobe as well as
basal lateral segment of the right lower lobe and posterior segment of the
left lower lobe, most likely representing currently air filled bronchiectasis,
cystic and less likely cavitated nodules
Multiple pre-existing and some new pulmonary nodules in conjunction with
mediastinal calcified lymphadenopathy might represent either ongoing
sarcoidosis or combination of sarcoidosis in a typical mycobacteria.
Dilated biliary and pancreatic ducts, reason unclear, correlation with MRCP is
to be considered.
Radiology Report
INDICATION: ___ year old woman with TBM, dysphagia, spinal surgeries, here w
worse dysphagia// r/o 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 min.
COMPARISON: None
FINDINGS:
Thin liquid, nectar thick liquid, purees, solid and barium pill with
administered in conjunction with speech pathologist.
There is complete velopharyngeal closure. There is normal hyolaryngeal
excursion. Intermittent penetration is seen with nectar thick liquid and thin
liquid with single sips. There was instance aspiration of thin liquids with
sequential swallows.
A barium tablet was administered and rapidly arrived to the stomach.
Of note, the esophagus appears distended by gas.
IMPRESSION:
Penetration with nectar thick liquids and thin liquids. Instance aspiration
with thin liquids with sequential swallows.
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: WHITE
Arrive by WALK IN
Chief complaint: L Leg pain
Diagnosed with Radiculopathy, lumbosacral region
temperature: 96.3
heartrate: 75.0
resprate: 22.0
o2sat: 96.0
sbp: 140.0
dbp: 76.0
level of pain: 10
level of acuity: 2.0 | ___ w chronic pain, TBM, sarcoid, aspiration, chronic
pancreatitis, with prior compression fractures, here with left
leg pain after mechanical fall. While here was found to have
SIADH, cavitary lung lesions, LV aneurysm with LV thrombus.
# mechanical fall
# L hip pain
No evidence of syncope or even of sedation by history (though at
risk for sedation as below). CT imaging at OSH and on re-read
here did not demonstrate any fracture. Her pain was managed with
uptitration of her hydromorphone (from 4mg to 6mg) and standing
acetaminophen, physical therapy. Her pain improved with this
management and has been improving almost daily.
# cavitary lesions: OSH CT abd/pelvis showed concern for
pulmonary nodules, for which she underwent a CT chest.
Surprisingly, was found to have cavitary lesions. Pulmonary was
consulted who felt that this was the result of structural lung
disease history (sarcoid, prior RUL calcified nodule and
bronchiectasis ___ the lower lobes upon which recurrent
aspiration is resulting recurrent injury, neumonitis/pneumonia,
and structural lung disease) which has resulted ___ the
development of two cavitary lesions. See below regarding
aspiration. It's also
possible this reflects chronic infection with NTM, most
worrisome would be M.abscessus and M.___, which is
progressing, especially given some ___ seen ___ the
anterior RML; alternatively these could reflect Actinomyces,
Nocardial, or Aspergillus infections, but all thought less
likely given non-toxic appearance. Finally, she has a history of
sarcoidosis, and it is possible this is a cavitary sarcoid
process which is slowly progressing. Underwent 3 induced sputa
___ returned with negative AFB, but as above no concern for
pulmonary TB, these were sent for non-tuberculous mycobacteria),
one of which showed commensal flora and staph aureus but per
pulmonary this is likely just oral flora rather than staph
cavitary pneumonia given how well she has been throughout
pulmonary wise. Pulmonary plans for repeat interval
CT/PFTs/evaluation as outpatient. They report that a positive
mycobacterial culture might not even need to be treated if it
occurred, but they will follow up with her as outpatient. They
also recommended aggressive treatment of aspiration as below.
# LV aneurysm and LV thrombus: this was found incidentally also
on the CT chest. Underwent TTE which showed 1cm clot ___ LV.
Cardiology was consulted and felt the aneurysm was consistent
with the prior distribution of her LAD infarction, although it
could be related to a stress-induced cardiomyopathy. Review of
her echo, showed that she has wall motion abnormalities present
after placement of the stent ___ ___. They felt sarcoidosis was
not consistent as etiology. Given the apical aneurysm with
associated clot, she was anticoagulated, initially w heparin
gtt-->LMWH as bridge to warfarin (d1 ___, d1
___. They recommend at least 3 months of
anticoagulation (___) with repeat TTE ___ 3 months to assess
for resolution of clot and presence of aneurysm. They would not
recommend ischemia evaluation at this time but can consider a
pMIBI as an outpatient. They advised against DOAC given not
approved for this indication.
# hyponatremia: appears euvolemic, worsened with IVF. Labs
consistent with SIADH. Likely Likely SIADH is caused by pain,
lung process. Home HCTZ was held throughout admission, pain was
treated, and she had 1.5L free water restriction. With the
restriction she had general improvement of her sodium, but at
times she may have been drinking more than this and this led to
very slight worsening of Na during last 2 days (see above for
trend), though anticipate this will improve again. Suggest
continued monitoring of Na, continued holding of HCTZ for now,
continued free water restriction. Consider salt tabs if
necessary. When SIADH resolves, can start to undo these
treatments. As a result of SIADH, we did not start SSRI as
below.
# Hypomagnesemia: required repletion ___ house, discharged on 3
dose regimen which will end on ___ but suggest monitoring.
# T2 DM: hgba1c 8.9%. Goal would not be very low given age and
multiple sedating meds, but would want lower than that.
Continued home Lantus 20U qd, but started aspart 3U QAC with
good effect. Note that patient is not on ACE.
# Hypertension: as above, held HCTZ. BP ___ normal range ___
house. Consider ACE as below.
# Chronic pancreatitis: continued home creon, reglan and ppi
# Chronic anxiety: was worsened ___ house, and had to increase
Lorazepam to TID prn from BID prn. Would ideally want to start
SSRI but given the sodium questions as above, this was deferred
for now.
# biliary ductal dilatation: noted incidentally on CT imaging.
# dysphagia:
# aspiration:
Aspiration likely multifactorial and related to vocal cord
dysfunction, known oropharyngeal dysphagia, multiple prior
thoracic surgeries/interventions which contribute to esophageal
dysfunction. Was followed by speech/swallow ___ house and
underwent video swallow. This showed mild-moderate oropharyngeal
dysphagia.
Her swallow is most remarkable for delayed swallow response
time, reduced laryngeal vestibular closure, and reduced
distention and duration of the upper esophageal sphincter, with
early closure and trace backflow into the pyriform sinuses.
These deficits resulted ___ intermittent penetration with
nectar-thick liquids and thin liquids, and frank aspiration with
sequential sips of thin liquids via straw. The patient's swallow
safety and efficiency were maximized using the below
compensatory swallow strategies. Of note, the dilated cervical
esophagus and reduced UES/PES
opening was seen during previous studies. The backflow into the
pyriform sinuses did not appear to impact this patient's swallow
safety this date. However, further work-up with gastroenterology
may be beneficial. This can be completed on an outpatient basis.
On follow up, she consistently remembered to swallow 2x per
bite/sip and only take single sips, but required cuing to sit
upright. By the end of the meal, she
recalled independently that during meals she should sit upright
and demonstrated this via repositioning herself when she
slouched to the L side.
# tracheobronchomalacia
# sarcoid
No steroids indicated. We continued home Advair (unclear if
actually has obstruction). Started on Acapella BID per pulm.
# chronic urinary incontinence: at baseline, recommend o/p
urodynamics
# HLD: continued home statin.
# recurrent UTI, recent yeast infection: received her last dose
of fluconazole (which she had been on as outpatient) on hospital
day 1. (Had already completed abx as o/p.)
>30 minutes spent on patient care and coordination on day of
discharge.
=============
TRANSITIONAL ISSUES
# Contacts/HCP/Surrogate and Communication:
Name of health care ___
Phone ___
Cell ___
Date on ___
Proxy form ___ chart: No
Filed on ___
Comments:Alternate: ___ (son) ___
- please wean hydromorphone back to home dose (4mg) from current
6mg as pain control improves
- please wean off standing APAP as able
- please continue physical therapy
- sputum cx, AFB (not for TB), fungal x3 (can be followed up as
o/p per pulm)
- o/p ENT for dysphagia as this may be contributing per pulm
- o/p GI with consideration of repeat emptying study per pulm
- please have patient follow up with her cardiologist (Dr. ___
at ___ ___ ___ for repeat TTE,
anticoagulation duration decision, consideration of pMIBI
- please complete enoxaparin bridge to warfarin, and after
therapeutic INR for 1d, can stop LMWH
- after discharge from rehab, will need to be set up with an
anticoagulation management clinic
- monitor sodium, initially qd to qod, continue free water
restriction (and reinforce), continue to hold HCTZ; consider
salt tabs; stop these treatments when SIADH resolves
- monitor Mg
- monitor FSG and adjust DM regimen as appropriate
- discuss with PCP why patient not on ACE with HTN/DM
- wean Lorazepam as able (particularly at least to BID prn which
is what she came ___ on) but ideally further reductions
- consider starting SSRI for anxiety when comfortable from a
sodium perspective
- consider psychiatry, geriatric psychiatry or geriatrics to
discuss pain/psych/deprescribing given fall risk
- recommend o/p MRCP given asymptomatic biliary ductal
dilatation
- swallowing recommendations:
1. Diet: Regular solids with thin liquids
2. Pills: whole or crushed ___ puree
3. Oral care: TID
4. Aspiration precautions:
- Fully upright for all PO intake
- Small, single sips of liquids at a time; no chugging
- Swallow x2 per bite/sip
- Alternate bites and sips
- recommend outpatient GI consultation to consider repeat
gastric emptying and consideration of esophageal motility
studies given her swallowing issues
- recommend outpatient ENT consultation to consider any ENT
interventions that may be helpful for her swallowing
- recommend continued speech/swallow evaluations as outpatient
- Acapella valve BID to help with pulmonary toilet please
- please schedule patient with outpatient INTERVENTIONAL
pulmonary visit with Dr. ___ at ___ (pt missed this routine
follow up while admitted)
- recommend outpatient gyn/urodynamics given chronic urinary
incontinence
- other than ___ pulmonary and ___ interventional pulmonary,
patient would otherwise prefer to follow up with specialists
closer to home for all issues |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___,pcn
Attending: ___.
Chief Complaint:
Head strike with supratherapuetic INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx afib, recent small stroke w/ minimal residual
deficit who was recently started on coumadin post stroke,
transferred from ___ after falling at home with head strike
and supratherapeutic INR. A head CT was negative at ___ but
due to lack of neurosurgical services, the patient was
transferred here.
The pt fell about 24 hours ago after getting up to urinate at
night. She denies symptoms prior to fall such as dizziness,
lightheadedness, vasovagal syptoms, and had no LOC. She fell
from standing as she reports tripping due to the thick carpeting
in her home, and hitting her right face on carpeted floor. She
reports difficulty with her walker as it sticks to the carpet.
After falling, she felt fine and reports getting up and going
back to bed before being found the subsequent morning by her ___
with a bruise over her right face at which point she presnted to
___.
The patient actually reports returning from hospitalization and
rehab just a few weeks ago after a "series of small strokes," at
which point she was started on warfarin. Up until the event
yesterday, she reports doing very well.
In the ED intial vitals were Pain 0, T 98.7, HR 53, BP 187/70 RR
13 O2 97% RA. Pt was admitted for observation. Notably, INR was
3.9.
On the floor, patient is comfortable and has no complaints.
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:
Afib
Anemia
Arthritis
HLD
Colostomy
CVA
Hypothyroidism
Celiac Disease
Social History:
___
Family History:
Mom- DM
Brother- CAD
Negative for cancer or CVA
Physical Exam:
ADMISSION EXAM:
Vitals- 98.4 BP 182/66 51 18 99% RA
General- Alert, oriented, no acute distress
HEENT- Bruise over left forehead/eye, PERRL, EOMI, 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, Harsh systolic
murmur heard throughout precordium with minimal radiation to
carotids.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, notable for
presence of ostomy bag
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, ___ strength and sensation in tact of
upper and lower extremities
DISCHARGE EXAM:
Vitals- 98.2, 144/67, 54, 16, 100% RA
General- Pleasant, sitting up in chair reading, NAD
HEENT- Normocephalic. Bruising around right eye from fall.
Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no carotid bruits
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Bradycardic with regular rhythm, normal S1 + S2, ___ harsh
systolic murmur heard best at LUSB and can be heard throughout
the precordium. NO rubs or gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Colostomy
bag in LLQ with both air and stool in the bag. Stool is brown in
color with no e/o frank blood
Neuro- A+O x 3
Pertinent Results:
ADMISSION LABS:
___ 08:26PM BLOOD WBC-6.0 RBC-3.44* Hgb-9.6* Hct-29.0*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.4 Plt ___
___ 08:26PM BLOOD Neuts-61.4 ___ Monos-5.8 Eos-2.7
Baso-0.6
___ 08:26PM BLOOD ___ PTT-39.4* ___
___ 08:26PM BLOOD Glucose-92 UreaN-26* Creat-1.1 Na-138
K-4.6 Cl-103 HCO3-29 AnGap-11
___ 08:26PM BLOOD Iron-41
___ 08:26PM BLOOD calTIBC-280 Ferritn-63 TRF-215
PERTINENT LABS:
___ 05:50AM BLOOD Hgb-9.7* Hct-28.1*
___ 05:15AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.8* Hct-28.9*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.6 Plt ___
___ 05:50AM BLOOD ___
___ 05:15AM BLOOD ___ PTT-35.3 ___
___ 05:50AM BLOOD Ret Aut-1.5
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-5.9 RBC-3.25* Hgb-9.2* Hct-27.3*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.7 Plt ___
___ 05:15AM BLOOD ___ PTT-35.1 ___
URINE:
___ 09:17PM URINE Color-Straw Appear-Clear Sp ___
___ 09:17PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 09:17PM URINE RBC-4* WBC-4 Bacteri-FEW Yeast-NONE
Epi-<1
MICRO: None
IMAGING:
___ ECG
Sinus bradycardia. Left anterior fascicular block. Baseline
artifact.
Otherwise, within normal limits. No previous tracing available
for comparison.
___ CAROTID SERIES COMPLETE
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is mild heterogeneous plaque in the
ICA. On the left there is mild heterogeneous plaque seen in the
ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 45/13, 74/20, 69/15,
cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak
systolic velocity is 106 cm/sec. The ICA/CCA ratio is .89.
These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak
systolic
velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec.
The ICA/CCA
ratio is 1.0. These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
IMPRESSION: Right ICA<40% stenosis.
Left ICA<40% stenosis.
___ ECG
Sinus bradycardia. P-R interval prolongation. Left atrial
abnormality. Left axis deviation with left anterior fascicular
block. Compared to the previous tracing of ___ there is no
significant diagnostic change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 300 mg PO Q2D
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Paroxetine 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Paroxetine 10 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
6. Amiodarone 100 mg PO DAILY
RX *amiodarone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES:
Fall
Atrial Fibrillation s/p embolic stroke
SECONDARY DIAGNOSES:
Hypertension
Celiac disease
Dyslipidemia
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
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with history of A/Fib, and recent small stroke,
with a non palpable left carotid pulse.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is mild heterogeneous plaque in the ICA. On the left there is
mild heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 45/13, 74/20, 69/15, cm/sec. CCA peak systolic
velocity is 83 cm/sec. ECA peak systolic velocity is 106 cm/sec. The ICA/CCA
ratio is .89. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak systolic
velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec. The ICA/CCA
ratio is 1.0. These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA<40% stenosis.
Left ICA<40% stenosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL, HIGH INR
Diagnosed with SYNCOPE AND COLLAPSE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, ABNORMAL COAGULATION PROFILE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.7
heartrate: 53.0
resprate: 18.0
o2sat: 97.0
sbp: 187.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ F with PMH significant for Afib, HTN, recent small strokes
with no residual defects now on warfarin and s/p fall at home
presenting from ___ for further evaluation with
concern for intracranial bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall, Left ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male who was dining at his
daughter's restaurant on the evening of admission. He had two
beers with dinner and then drove home. He was found down at his
door step by a friend confused and disoriented. He was brought
to the ED by ambulance.
Past Medical History:
- HLD
- Gout
- Bilateral knee replacement ___
- Appendectomy
Social History:
___
Family History:
Father deceased at age ___ from myocardial infarction. Mother
deceased age ___ from myocardial infarction.
Patient has 5 siblings all of whom have a history of cancer
ranging from breast cancer, to pancreatic cancer, lung cancer in
the non-Hodgkin lymphoma.
Physical Exam:
Upon admission:
Gen: Slightly uncomfortable laying on his back, asking for pain
medications for chest pain
HEENT: Abrasions above left eye
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. .
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to self only.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
_______________________________
Upon discharge:
Awake, alert, oriented to self, date, hospital, ___. Follows
commands briskly. Speech fluent.
PERRL, EOM-I. Left periorbital ecchymosis.
Face symmetric, tongue midline.
No drift.
Moves all extremities with grossly full strength.
Sensation grossly intact to LT throughout.
Anterior chest wall pain to palpation on left.
Pertinent Results:
CT C-Spine - ___:
No acute fracture or malalignment involving the cervical spine.
CT Chest - ___
1. Extensive coronary artery calcification and moderate to
severe aortic
valvular calcifications are present.
2. Nondisplaced left anterior rib fractures involving ribs 5
through 7. There is no pneumothorax.
CT Head - ___:
1. Increased left subdural collection with Ventricles remain
unchanged .
Basal cisterns remain patent.
2. Small foci of subarachnoid hemorrhage involves the posterior
left insular region not significantly change relative to prior
examination. No new hemorrhage.
FAST U/S - ___:
No free fluid identified on this limited abdominal ultrasound.
Medications on Admission:
Simvastatin 20mg daily
Vitamin B12-Folic acid
Aspirin 81mg daily
Citalopram 10mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Cyanocobalamin 50 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
OTC Medication - Ask your Pharmacist
7. Multivitamins 1 TAB PO DAILY
OTC Medication - Ask your Pharmacist
8. Senna 17.2 mg PO HS
OTC Medication - Ask your Pharmacist
9. Thiamine 100 mg PO DAILY
OTC Medication - Ask your Pharmacist
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
12. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
Chronic Left Subdural Hematoma
Rib fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with s/p fall unwitness known SAH from OSH left rib
pain // unwitness fall eval for trauma unwitness fall eval for trauma
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.2 mGy (Body) DLP = 811.7
mGy-cm.
Total DLP (Body) = 812 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no fracture or acute malalignment involving the cervical spine.
Multilevel degenerative changes are mild to moderate and most severe at the
C3-C4 and C5-C6 levels. Minimal central canal narrowing at these levels is
noted. There is no abnormal prevertebral soft tissue swelling. Extensive
atherosclerotic calcifications involve bilateral carotid bulbs. A small 6 mm
hypodensity is present within the left thyroid lobe (3:65). Imaged lung
apices demonstrate apical pleural parenchymal scarring involving the left
upper lobe.
IMPRESSION:
No acute fracture or malalignment involving the cervical spine.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male status post fall.
TECHNIQUE: Multi detector CT images through the chest were obtained after the
uneventful administration of intravenous contrast in soft tissue and bone
algorithm windows. Coronal and sagittal reformations were generated and
reviewed. Axial maximal intensity projection images were additionally
performed.
DOSE: Total DLP (Body) = 601 mGy-cm.
COMPARISON: None available.
FINDINGS:
The imaged thyroid gland is unremarkable in appearance. There is no axillary,
supraclavicular, mediastinal, or hilar adenopathy.
The ascending aorta is non aneurysmal. The main pulmonary artery is within
normal limits in caliber. Extensive coronary artery calcifications
predominantly involve the left anterior descending coronary artery. Moderate
to severe aortic valvular calcifications are additionally present. Heart is
normal in size. There is no pericardial effusion. Coronary artery
calcifications involve the lateral aortic arch as well as the descending
thoracic aorta. Note is made of a common origin of the right brachiocephalic
artery and left common carotid artery. The esophagus is unremarkable.
Airways are patent to the subsegmental level. Bibasilar atelectasis is mild.
There is no large mass or suspicious pulmonary nodule. Minimal biapical
pleural parenchymal scarring is symmetric. A ground-glass opacity within the
right upper lobe measures 7 mm (02:19). There is no pleural effusion or
pleural abnormality.
Although study is not tailored for subdiaphragmatic evaluation, imaged
portions demonstrate of the upper stomach demonstrates heterogeneous density
layering within the posterior gastric lumen dependently, most likely gastric
contents.
There is no pneumothorax. There is no focal bony lesion worrisome for
malignancy or infection. Nondisplaced left rib fractures involve the ___,
___, and 7th ribs anteriorly. Bones are diffusely demineralized. Minimal
rightward convex upper thoracic scoliosis is present.
IMPRESSION:
1. Extensive coronary artery calcification and moderate to severe aortic
valvular calcifications are present.
2. Nondisplaced left anterior rib fractures involving ribs 5 through 7. There
is no pneumothorax.
NOTIFICATION: Updated impression regarding rib fractures and impression of
likely gastric contents within the stomach discussed with the Dr. ___
telephone at 9:17 am on ___ after attending readout.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with s/p syncope intoxicated // eval for interval
change at 0500
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
COMPARISON: Head CT performed ___ at approximately 20:51
FINDINGS:
Relative to prior examination, a left frontal convexity subdural hemorrhage
appears to have increased in size measuring 6 mm in maximal thickness
previously 4 mm (02:14). This is associated with a a rightward shift of
normally midline structures approximately 4 mm. Trace amount of subarachnoid
blood is identified involving the left insular region has not progressed
(02:16). No new hemorrhage is present. There is no evidence of large acute
territorial infarction. Gray-white matter differentiation is preserved.
Basal cisterns are patent.
Subgaleal hematoma involving the left frontal scalp soft tissues is unchanged.
No underlying bony abnormality is present. Soft tissue swelling involves the
soft tissues lateral to the left orbit. The globe and orbits bilaterally are
otherwise unremarkable. Visualized paranasal sinuses demonstrate minimal
mucosal thickening within the ethmoidal air cells. Mastoid air cells and
middle ear cavities are clear bilaterally. Atherosclerotic calcifications
involving the carotid siphon are moderate to severe.
IMPRESSION:
1. Increased left subdural collection with Ventricles remain unchanged .
Basal cisterns remain patent.
2. Small foci of subarachnoid hemorrhage involves the posterior left insular
region not significantly change relative to prior examination. No new
hemorrhage.
NOTIFICATION: Findings discussed immediately with Dr. ___ via telephone
at 5:30 am on ___ at the time study was reviewed.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man status post found down with anterior rib
fracture// Trauma survey - rule out blood or free fluid in the abdomen status
post fall.
TECHNIQUE: Limited grey scale ultrasound images of the 4 quadrants of the
abdomen were obtained.
COMPARISON: None.
FINDINGS:
Limited gray scout ultrasound images of the 4 quadrants of the abdomen do not
demonstrate a any free fluid or fluid collections. The limited image of the
liver is grossly unremarkable.
IMPRESSION:
No free fluid identified on this limited abdominal ultrasound.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SAH
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 97.7
heartrate: 72.0
resprate: 18.0
o2sat: 97.0
sbp: 160.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old male with HLD, gout, mild dementia
admitted to Neurosurgery at ___ for close neurological
monitoring on ___ after a fall with loss of consciousness.
He is amnestic to the event. He was found to have a chronic
left-sided subdural collection and small, scattered foci of left
frontal traumatic SAH. Repeat CT head revealed interval
enlargement in chronic subdural collection. The patient remained
Neurologically intact with only mild intermittent confusion
during hospitalization, which is baseline per family report.
The patient complained of anterior chest wall pain. ACS was
consulted for finding of rib fractures. FAST ultrasound was
performed and was negative for intra-abdominal free fluid. Pain
control was recommended without further workup or investigation.
Medicine was also consulted given history concerning for
syncopal event, as patient does not recall the events
surrounding his injury. EKG was without evidence of arrhythmia.
TTE was without structural abnormalities. Orthostatics were also
negative when evaluated by Physical Therapy. No further
inpatient workup was deemed necessary, and the patient was
instructed to follow-up with his PCP.
The patient was evaluated by ___ who recommended discharge to
a rehabilitation facility. The patient was discharged to rehab
on ___ in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath and lower extremity swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR,
aortic regurgitation s/p bioprosthetic AVR (___) now s/p TAVR
(___), CHB s/p dual chamber PPM (___), pAfib s/p failed
DCCV (___) presenting with worsening shortness of breath
found to be in ___ exacerbation. Elevated BNP, volume
overloaded on exam. Prior hospitalization in ___ for
her TAVR with 26 ___ valve via transapical
approach was complicated by a tear in the left ventricle and
thoracotomy for repair. She also had heart block and was
implanted with a ___ pacemaker, Adapta L ADDRL1 with a
___ atrial lead 4076, and a ___ leadventricular 4076
on ___. Last checked by Dr. ___ on ___. She was
discharged to rehab on post-operative day ___. Readmit for
rapid atrial fibrillation and a dehisced thoracotomy incision.
Discharged back to rehab. Since the surgery, has had progressive
shortness of breath which is worse when lying down. Associated
with bilateral leg swelling. Was seen at ___ ED,
diuretics dose was increased and she was discharged. Presented
for outpatient echo today and was referred to ED for progressive
SOB.
In the ED, initial vitals were 97.8 80 126/64 18 100% 3L Nasal
Cannula. His labs were notable for WBC 8.4, Hg 10.6, Hct 30.9,
Plt 134, BNP notable for HCO3 35. proBNP 5255, lactate 1.1. INR
was 2.4. He had a CXR that demonstrated a left pleural effusion
and low left lung volume, right lung normal.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
Replacement of ascending aorta and aortic valve using a 23mm
aortic valve cryopreserved Homograft with reimplantation of the
coronary arteries in ___ @ ___. ___
Left Thoracotomy Wound Dehisence
___ Transcatheter aortic valve replacement with a 26 mm
___ valve via transapical approach.
___ Repair right femoral artery cannulation site
___ - permanent pacemaker ___ Model: ___
Diastolic chronic heart failure
Paroxysmal Atrial Fibrillation, failed ___ ___
Hypertension
Hyperlipidemia
Anxiety/Depression with Panic Attacks
Obesity
Ectopic Left Kidney
Social History:
___
Family History:
Mother - myocardial infarction ~___ deceased in early ___
Father - ___ infarction deceased ~___
Physical Exam:
ADMISSION
VS: Wt=184.2 lbs (182.3 lbs on discharge from previous
admission) T=98.3 BP=116/66 HR=83 RR=26 O2 sat=99% 3 L
General: Woman sitting in bed, taking breaths every few words
HEENT: MMM, PERRL
Neck: JVP to earlobe
CV: RRR, systolic murmur
Lungs: labored breathing with accessory muscle use, crackles at
the bases bilaterally, decreased breath sounds at LLL
Abdomen: soft, non-tender, +BS
GU: foley
Ext: warm, well-perfused, 2+ pitting edema to thighs
Neuro: A&Ox3, CNII-XII grossly intact
Skin: warm, dry, no rashes or lesions
PULSES: +2 pulses bilaterally
DISCHARGE
VS: 97.7-98.4, 119-137/62-67, 78-80, 20, 96-97% RA
Wt: 75.3 kg <- 75.3 kg <- 76.7 <- 79.2 kg <- 78 kg <- 79.8 kg <-
79.4 kg <- 81.7 kg (180 lbs) <- 82.4 kg <- 82.2 kg (182.3 lbs on
discharge from previous admission, per pt, dry weight is 183 lbs
or 83 kg)
I/O: ___
General: No acute distress
HEENT: MMM
Neck: decreased JVP ~1-2 cm above clavicle
CV: RRR, ___ systolic murmur
Lungs: CTA bilaterally, non-labored breathing
Abdomen: soft, non-tender, +BS
GU: no foley
Ext: warm, well-perfused, trace lower extremity pitting edema on
feet
Pertinent Results:
___ 01:00PM BLOOD WBC-8.4# RBC-3.54* Hgb-10.6* Hct-30.9*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.7* Plt ___
___ 01:00PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.3
Eos-1.3 Baso-0.1
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-136
K-3.6 Cl-91* HCO3-35* AnGap-14
___ 01:00PM BLOOD proBNP-5255*
___ 08:30PM BLOOD cTropnT-0.05*
___ 01:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
___ 01:17PM BLOOD Lactate-1.1
___ 04:55AM BLOOD WBC-6.4 RBC-3.55* Hgb-10.6* Hct-31.6*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.4 Plt ___
___ 09:35AM BLOOD ___
___ 06:25AM BLOOD Glucose-98 UreaN-21* Creat-0.9 Na-136
K-3.9 Cl-97 HCO3-30 AnGap-13
___ 06:45AM BLOOD proBNP-320___*
___ 06:25AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.9
Echo ___
IMPRESSION: Suboptimal image quality. A well seated
___ aortic valve was seen with normal gradients and
mild to moderate paravalvular aortic regurgitation. At least
mild pulmonary systolic arterial hypertension in the setting of
severe tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the image quality was poor on the current study. Only one
moderate quality transaortic continuous wave Doppler was
obtainable which showed a decrease in aortic transvalvular
gradient. The ejection fraction seems slightly less vigorous
with beat to beat variation due to atrial fibrillation. The
degree of tricuspid regurgitation has increased but was not well
visualized on the prior study.
EKG ___
Ventriclar pacing with probably underlying atrial fibrillation
and occasional intrinsic conduction. Occasional ventricular
premature contraction. Compared to the previous tracing of
___ the findings are similar.
CXR ___
IMPRESSION:
Small left pleural effusion with associated left basilar
atelectasis. Mild pulmonary vascular congestion, slightly worse
in the interval.
CXR ___
IMPRESSION:
In comparison with the study ___, there is little overall
change in the left pleural effusion with volume loss in the left
lower lobe. No evidence of pulmonary vascular congestion. The
right lung remains clear.
Chest CT ___
IMPRESSION:
Nonhemorrhagic left-sided pleural effusion with subsequent left
lower lobe atelectasis. Mild mediastinal lymph node enlargement.
Moderate cardiomegaly. Moderate coronary calcifications. Status
post CABG and aortic valve replacement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. diltiazem HCl 60 mg oral QID
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO TID
7. Senna 8.6 mg PO BID:PRN constipation
8. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Furosemide 80 mg PO DAILY
RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
6. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*3
7. Outpatient Lab Work
Please check INR ___ and call ___
___ at ___ with results.
8. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*3
9. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride 10 mEq 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*3
10. Outpatient Lab Work
Please draw chem 10 on ___ and call PCP ___ at
___ with the results.
11. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl 240 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic diastolic congestive heart failure exacerbation
Left lower lobe pleural effusion
Secondary:
Atrial fibrillation
Aortic stenosis s/p TAVR
Aortic regurgitation
Complete heart block s/p pacer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dyspnea, TAVR
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The patient is status post median sternotomy and transcatheter aortic valve
replacement. Left-sided pacemaker device is re- demonstrated with leads
terminating in the right atrium and right ventricle. Heart size remains
moderately enlarged. Mediastinal contours are unchanged with diffuse
atherosclerotic calcifications again noted. Mild pulmonary vascular congestion
is slightly worse in the interval. Small left pleural effusion with associated
atelectasis is present. Right lung remains otherwise grossly clear without new
focal consolidation present. No pneumothorax is identified. Multilevel
moderate degenerative changes are seen in the thoracic spine. Postsurgical
changes within the left lower ribs are re- demonstrated with a bridged device
again noted.
IMPRESSION:
Small left pleural effusion with associated left basilar atelectasis. Mild
pulmonary vascular congestion, slightly worse in the interval.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hx recent TAVR complicated by LV tear, now
s/p pacemaker for CHB w/ 4+TR and worsening dyspnea on exertion w/ CHF
exacerbation. // Eval for left pleural effusion. Eval for left pleural
effusion.
IMPRESSION:
In comparison with the study ___, there is little overall change in the
left pleural effusion with volume loss in the left lower lobe. No evidence of
pulmonary vascular congestion. The right lung remains clear.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with hx dCHF, recent TAVR, AR, ___ s/p pacer,
afib with chf exacerbation and ?left pleural effusion. // ?left pleural
effusion, ?persistent CHF exacerbation
TECHNIQUE: VOLUMETRIC CT ACQUISITIONS OVER THE ENTIRE THORAX IN INSPIRATION,
NO ADMINISTRATION OF CONTRAST MATERIAL, MULTIPLANAR RECONSTRUCTIONS.
DOSE: DLP: 552 mGy-cm
COMPARISON: No comparison available.
FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. Status post sternotomy. Left pectoral pacemaker in
situ. Status post aortic valve replacement. Moderate cardiomegaly and
calcification of the ascending aorta. Moderate coronary calcifications.
Moderate cardiomegaly. Moderate nonhemorrhagic left-sided pleural effusion
with subsequent atelectasis of the left lower lobe. Calcifications along the
left pericardium. Mild hiatal hernia. No hilar lymphadenopathy. Several
borderline to slightly enlarged lymph nodes in the mediastinum (2, 16). No
osteolytic lesions at the level of the ribs, the sternum and the vertebral
bodies. Mild bilateral apical thickening, symmetrical in distribution. The
assessment of the lung parenchyma is limited by severe respiratory motion are
defects. Signs of mild chronic interstitial fluid overload. No suspicious
masses or nodules. No evidence of diffuse lung disease. The airways are
patent.
IMPRESSION:
Nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe
atelectasis. Mild mediastinal lymph node enlargement. Moderate cardiomegaly.
Moderate coronary calcifications. Status post CABG and aortic valve
replacement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PLEURAL EFFUSION NOS
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR,
CHB s/p dual chamber PPM (___), pAfib s/p failed ___
(___), and aortic regurgitation s/p bioprosthetic AVR (___)
now s/p TAVR (___) who is presenting with worsening
shortness of breath and lower extremity swelling with a ___
exacerbation.
# Sub-acute on chronic ___ exacerbation - likely has been
worsening over course of month post-procedure as patient has had
difficulty breathing throughout this time period. Appeared
volume overloaded on admission exam (though cannot use JVP in
setting of TR), elevated BNP, R-sided disease with worsening TR
and likely exacerbated by L-sided disease due to HTN and AS. SOB
less likely due to pulmonary cause as no wheezes on exam and no
history of URI sx or previous pulmonary disease (remote history
of smoking). Recently started on lasix as an outpatient and per
husband has had multiple admissions for diuresis, with
intermittent improvement and then readmission. BP normal
throughout admission. Given recent hospitalizations with TAVR
and LV tear, also concern for arrythmias but no events on
telemetry during this admission. Diuresed to dry weight with IV
lasix transitioning to PO lasix, discharging on 80 mg PO lasix
daily. Continued metoprolol, ASA, statin. Discharge BNP 3209.
#AR s/p TAVR w/ LV tear requiring thoracotomy for repair:
Continued dressing changes for left thoracotomy wound healing.
Patient had two episodes of non-exertional left-sided
chest/flank pain during admission without EKG changes, improved
by Tylenol, attributed to wound.
#Pleural effusion: Patient noted to have small left-sided
pleural effusion with atelectasis on CXR, unchanged from prior
CXR in ___ s/p TAVR. CT chest confirmed nonhemorrhagic
left-sided pleural effusion with subsequent left lower lobe
atelectasis. Interventional radiology consulted and felt it was
too small to tap. As she was asymptomatic after diuresis,
further intervention was not performed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ciprofloxacin
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hx of 7.6cm AAA s/p open repair
via midline incision (___) and appendectomy presenting nausea,
vomiting and diarrhea. He was in his normal state of health
until
2 days ago when he developed these symptoms. He spent most of
yesterday with nonbilious vomiting. His nausea/vomiting has
improved today but he complains of continued nonbloody diarrhea.
Denies abdominal pain, fever, and chills. He was hospitalized
for
2 days in ___ for small bowel obstruction, which was managed
conservatively on the ACS service. He denies any recent travels
or changes in his appetite. CT scan was obtained today which
showed evidence of a partial small bowel obstruction.
Past Medical History:
- CORONARY ARTERY DISEASE: MI ___
- ADULT ONSET DIABETES MELLITUS
- BENIGN PROSTATIC HYPERTROPHY s/p turp
- COLONIC POLYPS latest colonoscopy in ___
- DIVERTICULOSIS
- HYPERLIPIDEMIA
- HYPERTENSION
- PERIPHERAL VASCULAR DISEASE s/p AAA repair in ___.
claudication w/ ___ mile walking, R popliteal obstruction per
___
- POLYMYALGIA RHEUMATICA
- S/P APPENDECTOMY
- stage IV chronic kidney disease due to underlying
hypertensive nephrosclerosis
Social History:
___
Family History:
Per OMR:
CAD in multiple family members- mother and brother both had
MI's. Father had cancer. Several family members had diabetes.
Physical Exam:
Exam on discharge:
98.7 98.7 76 136/58 20 98RA
Gen: NAD, A&Ox3
CV: RRR, No M/G/R
Abd: Soft, distention improved from admission, no rebound or
guarding,
no palpable or pulsatile masses, well healed midline incision
and
inferior right midline incision
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:10AM BLOOD WBC-4.5# RBC-2.96* Hgb-9.5* Hct-29.9*
MCV-101* MCH-32.1* MCHC-31.8* RDW-13.4 RDWSD-49.1* Plt ___
___ 02:15AM BLOOD WBC-11.8* RBC-3.68* Hgb-12.0*# Hct-36.8*#
MCV-100* MCH-32.6* MCHC-32.6 RDW-13.2 RDWSD-48.6* Plt ___
___ 06:10AM BLOOD Glucose-82 UreaN-46* Creat-2.4* Na-140
K-4.9 Cl-107 HCO3-27 AnGap-11
___ 02:15AM BLOOD Glucose-158* UreaN-53* Creat-2.5* Na-139
K-5.0 Cl-105 HCO3-22 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Ropinirole 2 mg PO DAILY
6. Melatin (melatonin) 3 mg oral QPM
7. Aspirin 81 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Citalopram 10 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Levothyroxine Sodium 50 mcg PO EVERY OTHER DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Ropinirole 2 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Finasteride 5 mg PO DAILY
7. Citalopram 10 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Levothyroxine Sodium 50 mcg PO EVERY OTHER DAY
10. Lisinopril 10 mg PO DAILY
11. Melatin (melatonin) 3 mg oral QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Partial bowel obstruction vs gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: +PO contrast; History: ___ with LLQ tenderness+PO contrast //
eval for diverticulitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 56.0 cm; CTDIvol = 16.4 mGy (Body) DLP = 916.6
mGy-cm.
Total DLP (Body) = 917 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
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 atrophic bilaterally. A hyperdense abnormality is
seen in the upper pole of left kidney. It is too small to definitively
characterize on this examination. There is no hydronephrosis. There is no
nephrolithiasis. Symmetric perinephric stranding is seen.
GASTROINTESTINAL: The stomach is unremarkable. Several loops of prominent
small bowel are seen in the mid and lower abdomen, reaching up to 2.7 cm, not
significantly different from the prior examination. These contain air-fluid
levels. Contrast is seen flowing from the more prominent loops into more
collapsed loops, making high-grade obstruction unlikely. Scattered colonic
diverticular noted without evidence of acute diverticulitis. The rectum is
unremarkable. The appendix is not definitively visualized.
PELVIS: The urinary bladder is distended. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: The infrarenal abdominal aorta is ectatic, similar to the prior
examination, reaching up to 3 cm in greatest dimension. The thoracic aorta is
also mildly ectatic, up to 3.9 cm in greatest dimension. Moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of diverticulitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Nausea with vomiting, unspecified, Diarrhea, unspecified
temperature: 97.1
heartrate: 60.0
resprate: 18.0
o2sat: 100.0
sbp: 110.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the emergency department and was Acute
Care Surgery Team. The patient was found to have a possible
small bowel obstruction vs gastroenteritis and was admitted for
observation. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by HD2. The patient received anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. The ___ hospital course
was otherwise unremarkable.
At the time of discharge, the patient was tolerating a regular
diet, passing flatus, and voiding/moving bowels spontaneously. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfamethoxazole / Cipro
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
___ cardiac catheterization - normal coronary arteries
History of Present Illness:
___ w/ h/o SVT, HTN, HLD, anxiety, CKD, and recent admission for
atrial fibrillation / flutter s/p ablation, presents with
recurrent palpitations. He was discharged on ___, after
undergoing flutter ablation procedure on ___. Earlier today, he
developed recurrent palpitations. There was not any associated
chest pain, dyspnea, nausea. He does note some diaphoresis,
which he attributes to anxiety. He was initially evaluated at an
OSH ED, where he was given IV diltiazem x2, w/o improvement in
his tachycardia. In our ED, he was persistently tachycardic to
~150. He was evaluated by EP, who recommended holding on further
CCB so that patient remains in a-flutter, with plan for repeat
EPS/ablation in the AM.
On the floor, patient complains only of anxiety.
Past Medical History:
1. CARDIAC RISK FACTORS: No HTN, HL, or DM.
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Plastic surgery for eyelids.
- Vaginal hysterectomy. She states no cervical cuff is present.
- Rotator cuff repair
- obesity
- obstructive sleep apnea on CPAP
- colonic adenoma
- anxiety with insomnia
Social History:
___
Family History:
- Mother: urinary incontinence, dementia, hypertension, aneurysm
in the brain, and a history of lung cancer which she survived.
- Father is deceased from alcohol abuse.
- Daughter (age ___ and son (36) are both living; They both have
cerebral palsy, spastic in all four extremities. They are
independently living at a domicile near Ms. ___.
- Brother: CAD, HLD
- Sister: well
Physical ___:
VS: T=97,8, BP=124/82 HR=81 RR=18 O2 sat= 98
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 no JVD appreciated.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
___ 08:50PM cTropnT-<0.01
___ 02:41PM ___ PTT-30.7 ___
___ 02:38PM GLUCOSE-77 UREA N-16 CREAT-0.6 SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 02:38PM GLUCOSE-77 UREA N-16 CREAT-0.6 SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 02:38PM estGFR-Using this
___ 02:38PM cTropnT-<0.01
___ 02:38PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 02:38PM WBC-6.1 RBC-4.80 HGB-14.9 HCT-45.0 MCV-94
MCH-31.1 MCHC-33.1 RDW-13.2
___ 02:38PM NEUTS-67.8 ___ MONOS-4.4 EOS-2.2
BASOS-0.4
___ 02:38PM PLT COUNT-175
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ibuprofen 600 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain with positive stress test
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cp // cp
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities identified. Surgical staples project over the neck bilaterally.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: 98.1
heartrate: 77.0
resprate: 20.0
o2sat: 100.0
sbp: 126.0
dbp: 105.0
level of pain: 6
level of acuity: 2.0 | # Unstable angina: Patient presented with anginal chest
discomfort and recent positive stress test. No EKG changes at
rest and cardiac enzymes negative x3. Story very atypical for
cardiac chest pain given not substernal, not associated with
exertion or relieved by rest. However, given positive stress
test gave full dose aspirin and plavix. Given mild nature of
pain at presentation, as well as ongoing nature for several
days, did not give heparin. The day after admission continued
aspirin at 81mg dose and added lopressor 6.25mg BID.
Additionally, performed LHC afternoon of ___, which showed
normal coronaries. Therefore, she was discharged late in the
day.
# Anxiety: Her home alprazolam 0.25mg qHS prn for insomnia was
continued
# OSA: Home CPAP was continued at night. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Low backpain and fevers
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ old man with history of DM2, CAD s/p CABG ___, redo in
___, multiple stents, AS s/p core valve ___, and lumbar
stenosis s/p L3-L5 laminectomies ___ and L3-L5 fusion ___
admitted from rehab with fevers.
Of note, patient recently admitted to ___ ___ for
revision of laminectomies and re-exploration in the setting of
progressive neurogenic claudication. He had L3-L5 fusion c/b
dural tear ___. Hospital course complicated by hypoxemia, angina
and ___.
He reports that since his discharge he has continued to have
baseline low back pain which has not improved. He also reports
that prior to discharge he began have loose stools. Her ports
frequent bloating and flatulence. He has had 3 BM/day without
blood/pus. He notes that the stools are watery.
In the ED initial vitals were: 97.9 85 65/36 (repeat was 107/49)
22 96% RA. Labs were significant for WBC 13.6, Cr 2.1 (from 1.2
on recent discharge), lactate 2.3. UA unremarkable. CXR was
unremarkable. Blood and urine cultures were drawn. Patient was
evaluated by spine who felt medicine admission would be
appropriate. EKG showed EKG: left bundle, sinus 85. Patient was
given 2L IVF boluses, vancomycin, cefepime, tylenol, oxycodone.
Vitals prior to transfer were:4 99.8 100 123/44 20 97% RA
On the floor, patient reports mild back pain unchanged from
prior discharge. He voices no further concerns.
Review of Systems:
(+) per HPI
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-CAD
-bare metal stent to left circumflex (___)
-Multiple coronary angioplasties and stents (?19)
-CABG (x3, ___, (SVG-LAD, SVG-RCA/OM)
-redo CABG (___), (LIMA-LAD, SVG-RCA, ligation of old SVG RCA)
-Left inframammary AV fistula
-known aortic stenosis
- s/p ___ for AV block -___
- insulin dependent DM
- HTN
- hyperlipidemia
- left internal carotid stenosis (50-69%)
- Hodgkin's dz (sp XRT neck, mediastinum)
- Lupus anticoagulant (on coumadin-subtherapeutic INR secondary
to bleeding)
- COPD
- asthma
- sleep apnea
- peptic ulcer disease
- papillary thyroid cancer s/p thyroidectomy
- BPH
- hematuria s/p left ureteropyeloscopy (cytology neg)
- spinal stenosis
- degenerative joint disease of the hips, knees and shoulders
- left shoulder fx/pinning secondary to MVA
- right wrist fx secondary to fall
- right carpal tunnel surgery
- back surgery x 2 (disc fusions)
- choleycystectomy
- tonsillectomy
- appendectomy
Social History:
___
Family History:
Father deceased, ___, CVA. Mother deceased, age
___ CAD. Sister deceased, age ___, breast Ca. Bother, age ___, A+W.
Son,age ___, parkinsons dz. Daughter, A+W.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - Tm 102 T:101.4 BP: 99/50 HR:93 RR:18 02 sat: 96% RA
GENERAL: Laying in bed in NAD, pleasant and cooperative
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, dry MM,
NECK: nontender supple neck, no LAD, no appreciable JVD
CARDIAC: RRR, S1/S2, ___ holosystolic murmur, no gallops or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
with good air movement throughout and no use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
BACK: no tenderness along spine
GU: Foley in place
NEURO: Alert and oriented x 4 (person, place, time and
situation). CN II-XII intact, Strength over ___ is diminished
4+/5 due to pain, UE ___ bilaterally and sensation intact to LT
bilaterally.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, Back surgical site dressing is c/d/i.
DISCHARGE PHYSICAL EXAM
Vitals- 97.9, 147/62, 89, 18, 99% RA, I/O since MN 440/750
(straight cath), 24HR ___
GENERAL: Laying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, dry MM,
NECK: nontender supple neck, no LAD, no appreciable JVD
CARDIAC: RRR, S1/S2, ___ holosystolic murmur, no gallops or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulse in R leg, 1+ DP pulse in L leg
BACK: no tenderness along spine
GU: Foley in place
NEURO: Alert and oriented x 3 (person, place, time). CN II-XII
intact. Sensation intact to LT bilaterally throughout
MOTOR: BUE grossly ___ throughout.
LUE below (improved from yesterday)
R L
Hip Flexion ___ ___ ___
Ankle Dorsiflexion ___ 4+/___ 4+/5
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. No splinter hemorrhages, or painful nodes noted on palms
or soles. Back surgical site has dressing soaked with
serosanguineous fluid. On removal of dressing, wound clean,
staples intact, non-purulent with gray tissue in superior
section.
Pertinent Results:
ADMISSION LABS
___ 09:00PM BLOOD WBC-13.6* RBC-4.38* Hgb-12.8* Hct-40.9
MCV-94 MCH-29.2 MCHC-31.3 RDW-15.9* Plt ___
___ 09:00PM BLOOD Neuts-90.4* Lymphs-4.2* Monos-4.4 Eos-0.5
Baso-0.4
___ 09:00PM BLOOD Plt ___
___ 09:00PM BLOOD Glucose-84 UreaN-49* Creat-2.1* Na-137
K-5.1 Cl-95* HCO3-33* AnGap-14
___ 09:00PM BLOOD estGFR-Using this
___ 09:00PM BLOOD HoldBLu-HOLD
___ 09:00PM BLOOD LtGrnHD-HOLD
___ 09:07PM BLOOD Lactate-2.3*
___ 06:55AM BLOOD WBC-13.4* RBC-4.09* Hgb-12.0* Hct-37.9*
MCV-93 MCH-29.2 MCHC-31.6 RDW-15.7* Plt ___
___ 06:55AM BLOOD Neuts-94.1* Lymphs-2.6* Monos-2.7 Eos-0.4
Baso-0.2
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-89 UreaN-44* Creat-1.6* Na-142
K-3.8 Cl-101 HCO3-28 AnGap-17
___ 06:55AM BLOOD ALT-20 AST-26 LD(LDH)-298* AlkPhos-76
TotBili-0.9
___ 06:55AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.7 Mg-1.6
___ 07:22AM BLOOD Lactate-2.0
DISCHARGE LABS
___ 05:35AM BLOOD WBC-6.7 RBC-3.94* Hgb-11.5* Hct-37.4*
MCV-95 MCH-29.2 MCHC-30.8* RDW-16.1* Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___ PTT-45.2* ___
___ 05:35AM BLOOD
___ 05:35AM BLOOD Glucose-63* UreaN-20 Creat-0.9 Na-145
K-3.5 Cl-108 HCO3-29 AnGap-12
___ 05:35AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.2 Cholest-PND
___ 05:35AM BLOOD Triglyc-PND HDL-PND LDLmeas-PND
MICROBIOLOGY
============
___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___. ___ 14:12
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ URINE CULTURE: <10,000 organisms/ml.
___ FLUID ASPIRATE FROM WOUND
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ C. DIFFICILE
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ - BLOOD
CULTURES
PENDING
RADIOLOGY
=========
___ - EKG
Normal sinus rhythm. Left bundle-branch block. No change from
the previous tracing dated ___.
___ - CHEST XRAY (PA & LAT)
AP AND LATERAL VIEWS OF THE CHEST: Postoperative changes with
median
sternotomy, mediastinal clips and aortic ___ are again
seen. Coronary artery stent is again identified. Left chest
wall dual-lead pacing device is unchanged in position. Fracture
of the superior most sternal wire is again noted. The lungs are
clear without significant effusion, consolidation or edema. No
acute osseous abnormality is identified.
IMPRESSION: No acute cardiopulmonary process.
___ - EKG
Normal sinus rhythm with frequent premature ventricular
complexes. Left
bundle-branch block. Compared to the previous tracing the
ventricular
premature complexes are new.
___ - CT C-SPINE W/ CONTRAST
No cervical spine fracture or malalignment
No fracture or visible fluid collection in the cervical spine
___ - CT T-SPINE W/ CONTRAST
1. No findings in the thoracic spine to explain patient's
fever.
2. Old left posterior 3rd rib fracture.
___ - CT L-SPINE W/ CONTRAST
1. Subcutaneous fluid collection at L2-3 and locules of air may
be
post-operative as discussed above, but correlate with recent
procedures. CT has low sensitivity for infection. Within this
limitation, there are no findings suggesting infection.
2. Healing fracture of the L3 spinous process.
___ - ECHO
No 2D echocardiographic evidence of endocarditis. Moderate
regional left ventricular systolic dysfunction c/w CAD. Well
seated aortic ___ bioprosthesis with mild posterior
paravalvular leak. Mild mitral regurgitation. Moderate pulmonary
artery hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Avodart (dutasteride) 0.5 mg oral daily
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 17.2 mg PO QHS
9. ALPRAZolam 1 mg PO DAILY:PRN anxiety
10. Klor-Con (potassium chloride) ___ meq oral BID
11. Metolazone 2.5 mg PO 2X/WEEK (MO,FR)
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
13. Theophylline ER 300 mg PO DAILY
14. Torsemide 60 mg PO EVERY OTHER DAY
15. Torsemide 40 mg PO EVERY OTHER DAY
16. Metoprolol Succinate XL 50 mg PO DAILY
17. NPH 25 Units Breakfast
NPH 25 Units Bedtime
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Avodart (dutasteride) 0.5 mg oral daily
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Senna 17.2 mg PO QHS
8. Tamsulosin 0.4 mg PO DAILY
9. ALPRAZolam 1 mg PO DAILY:PRN anxiety
10. Klor-Con (potassium chloride) ___ meq oral BID
11. Theophylline ER 300 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
13. Lisinopril 5 mg PO DAILY
14. Nafcillin 2 g IV Q4H
15. Warfarin 5 mg PO DAILY16
16. NPH 22 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
18. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MSSA Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair, requires TLSO brace when out of bed
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with fever, postop. Hypoxia and cough.
COMPARISON: ___.
FINDINGS:
AP AND LATERAL VIEWS OF THE CHEST: Postoperative changes with median
sternotomy, mediastinal clips and aortic ___ are again seen. Coronary
artery stent is again identified. Left chest wall dual-lead pacing device is
unchanged in position. Fracture of the superior most sternal wire is again
noted. The lungs are clear without significant effusion, consolidation or
edema. No acute osseous abnormality is identified.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT L-SPINE W/ CONTRAST
INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody
drainage at site, possible new neurologic deficits. Has pacemaker from ___
not MRI compatible. // Is there evidence of infection? epidural abscess?
epidural hematoma?
TECHNIQUE: CT of the lumbar spine was performed after the administration of
intravenous contrast. Sagittal and coronal reconstructions were prepared.
DOSE: DLP 1020.40 mGycm; CTDI 31.30mGy
COMPARISON: None.
FINDINGS:
The bones are diffusely demineralized. The patient has had a prior L3-5
laminectomy. There is a 3.1 x 1.6 cm fluid collection in the laminectomy site
between the L2 and L3 spinous processes, likely postoperative (501:31). More
inferiorly in the surgical bed is a locule of air that is also may be
postsurgical (3:65). The volume of air is somewhat more than expected this
long after the procedure, unless there has been further manipulation in the
surgical site, or a drain was more recently removed. There is a fracture with
callus formation of the L3 spinous process (02:48). The vertebral bodies are
normal in height and alignment.
There are mild disc bulges at L3-4, L4-5, and L5-S1. Obscuration of the
epidural fat may simply be post-operative. The thecal sac is thickened and
the right neural foraminal fat is not visible at L4-5 and L5-S1.
IMPRESSION:
1. Subcutaneous fluid collection at L2-3 and locules of air may be
post-operative as discussed above, but correlate with recent procedures. CT
has low sensitivity for infection. Within this limitation, there are no
findings suggesting infection.
2. Healing fracture of the L3 spinous process.
Radiology Report
EXAMINATION: CT C-spine with contrast.
INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody
drainage at site, possible new neurologic deficits. Has pacemaker from ___
not MRI compatible. Planning on 8am CT with pre-medication tonight // Is
there evidence of infection? epidural abscess? epidural hematoma? Lumbar
laminectomy with fever and drainage at surgical site. New neurologic defects.
Patient cannot have an MRI.
TECHNIQUE: MDCT data were acquired through the cervical spine with
intravenous contrast. Data were reconstructed using bone and soft tissue
algorithms and images were displayed in multiple planes.
DOSE: DLP: 762.34 mGy-cm
CTDIvol: 32.65 mGy
COMPARISON: None.
FINDINGS:
There is no cervical spine fracture or malalignment. Evaluation of the
intrathecal structures is limited. Vertebral body and disc heights are
preserved at all levels. However, the bones are diffusely demineralized.
There is no spinal canal narrowing. Pre and paravertebral soft tissues are
normal. Visualized portions of the aerodigestive tract are patent. The
visualized lung apices are clear. Note is made of an ossified ligamentum
flavum in the upper thoracic spine. Visualized portions of the skull base
show no abnormalities. The major cervical neck vessels are patent. A stent is
noted within the left internal carotid artery.
IMPRESSION:
No cervical spine fracture or malalignment
NOTIFICATION: No fracture or visible fluid collection in the cervical spine.
Radiology Report
EXAMINATION: CT T-SPINE W/ CONTRAST
INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody
drainage at site, possible new neurologic deficits. Has pacemaker from ___
not MRI compatible. Planning on 8am CT with pre-medication tonight // Is
there evidence of infection? epidural abscess? epidural hematoma? Recent
laminectomy with fever and inability to have an MRI.
TECHNIQUE: CT of the thoracic spine was performed after the administration of
IV contrast. Sagittal and coronal reconstructions were prepared.
DOSE: DLP 1198.94 mGy-cm; CTDI 31.47mGy
COMPARISON: None.
FINDINGS:
The thoracic vertebral bodies are demineralized, but normal in height and
alignment. Evaluation of the intrathecal contents is limited with CT. There is
an old fracture of the posterior left third rib (2:33). There is no high-grade
canal stenosis . The visualized lung fields and soft tissues are noteworthy
only for an aortic valve replacement and pacer leads.
IMPRESSION:
1. No findings in the thoracic spine to explain patient's fever.
2. Old left posterior 3rd rib fracture.
Radiology Report
INDICATION: ___ year old man with MSSA bacteremia, needs PICC, bedside PICC RN
not successful // please place PICC
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr.
___ resident) and Dr. ___ radiology attending)
performed the procedure. The attending, Dr. ___ was present and
supervising throughout the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: Lidocaine.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 00:22 min, 7 mGy
PROCEDURE: 1. Single lumen PICC placement through the basilic vein on the
right.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the basilic
vein on the right was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen PIC line measuring 39 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach single lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 39 cm basilic approach single lumen PICC with
tip in the distal SVC. The line is ready to use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 97.9
heartrate: nan
resprate: nan
o2sat: nan
sbp: 65.0
dbp: 36.0
level of pain: 3
level of acuity: 1.0 | ___ y/o man w/ h/o DM2, CAD s/p CABG ___, redo in ___, multiple
stents, AS s/p core valve ___, and severe lumbar stenosis s/p
L3-L5 laminectomies in ___ who represented to ___ on ___
for revision of laminectomies and re-exploration in
the setting of progressive neurogenic claudication, s/p L3-L5
fusion c/b dural tear intraoperatively on ___, recently
discharged, returning with back pain and fever of unknown
origin, found to have MSSA bacteremia.
# MSSA acute blood stream infection with sepsis: On
presentation, patient met ___ SIRS criteria for fever,
respiratory rate and leukocytosis with neutrophil predominance.
Given a complaint of diarrhea, C diff was sent, but came back
negative. Blood cultures on ___ grew methicillin-sensitive
staph aureus so patient was narrowed to Nafcillin 2g IV Q4H, ___
dose ___. WBC trended down to 6.7 by discharge. Given
patient's pacemaker was incompatible with MRI, we proceeded to
do a CT scan with contrast, premedicating him with benadryl,
prednisone, and IVF per protocol (over 13 hours) given his
documented anaphylactic allergy to contrast agents. He tolerated
the dye without incident. CT of his L spine with contrast on
___ showed subcutaneous fluid collection and pockets of air,
likely postoperative changes though cannot exclude underlying
infection given limitations of image modality. An aspiration of
the fluid pocket was negative for growth on culture. Urine and
sputum cultures, as well as multiple daily surveillance blood
cultures following treatment, were negative. Patient remained
afebrile throughout the rest of his hospital course, with no
focal neurological symptoms, though with notable weakness in R
lower extremity, which per him, predated his surgery. TEE on
___ showed 1+ mitral regurgitation, with no vegetations noted
on aortic ___. Our neurosurgery and infectious disease
teams saw and evaluated the patient throughout his
hospitalization, with recommendations to continue his Nafcillin
via a PICC line placed on ___ for a minimum of 2 week
course. He will follow-up with Infectious Disease on ___, who
will consider need for repeat imaging to assess the fluid
collection. Of note, if he is imaged w/ contrast dye, he will
need to be premedicated again.
# Spinal Stenosis s/p L3-L4 fusion: Patient underwent revision
laminectomies by neurosurgery on ___ with intraoperative
complication of dural tear which was repaired. His back pain was
maintained on PRN Oxycodone ___ Q4H with good effect. Our
physical therapy team also saw and evaluated him while inhouse.
Per neurosurgery, staples will come out on ___, and
have instructed he wear his TLSO brace when out of bed.
# ___: Patient initially presented with BUN of 49, creatinine of
2.1 on admission ___ Cr is 1.2). He had a foley
placed on admission given h/o urinary retention and was given
gentle fluid rescuscitation given his history of CHF. We also
held his lisinopril, renally dosed his meds, and trended his
kidney function and urine output. His kidneys responded well,
with a BUN to 20, and Cr to 0.9 at discharge. On discontinuing
his foley, he failed a void trial so foley was replaced which
will be managed at his rehab.
# Urinary retention: urinary retention prior to admission, w/
foley placement. Has h/o BPH. We did a due to void trial on
___, which he failed, and foley was replaced. Should have
ongoing trial of foley removal at rehab, with follow-up with a
Urologist as needed if unable. We continued avodart, tamsulosin.
# COPD/OSA: This was stable, without significant wheezing during
this hospitalization. He required no O2 during this
hospitalization. We also had PRN dual nebs, continued his home
theophylline, had him on continuous O2 monitoring, and placed
him on CPAP at night (though he declined use on several
occasions), and he remained stable throughout his hospital
course.
# chronic diastolic CHF: Last ECHO in ___ showed EF 35%. Repeat
ECHO on ___ showed EF stable at 35%, with no vegetations on
his valve. We held her metolazone, torsemide and lisinopril in
the setting of ___. Per patient, his metoprolol was discontinued
in the past because of severe hypoglycemia and hypotension but
we restarted a small dose of metoprolol succinate (12.5mg) given
his extensive cardiac history. We also sent a lipid panel, and
started simvastatin 10mg daily. We strictly monitored his fluid
input and output, monitored him on telemetry and repleted his
lytes as needed.
#) Volume status: he has previously been on torsemide 40mg QOD,
60mg QOD, and metolazone 2.5mg daily. Given ___, these diuretics
were stopped. He continues to have poor PO intake and is
euvolemic on exam, so we are sending him to rehab off of
diuretics, to be restarted as needed in the outpatient setting.
# s/p PPM for AV Block: Patient had a ___ model
___ dual-chamber pacemaker which was non compatible with MRI.
The implant date of this pacemaker was ___. We monitored
his cardiac function on telemetry throughout his hospital
course.
# History of lupus anticoagulant on Coumadin: Coumadin was held
at prior discharge and per neurosurgery, could be restarted 10
days post op (___). However, this was held during this
admission given his INR was elevated, likely secondary to poor
nutrition and ongoing bloodstream infection with antibiotics.
His INR eventually stablized to 2.0 on discharge and we
restarted his regular coumadin dose with plans to continue his
routine INR checks at his outpatient ___ clinic. Next check
___, dose adjustment per rehab doctors.
# DM2, controlled without complications: blood sugars ran low in
60-70's AM, so we decreased NPH dose from 25 units BID to 22
units BID. Diabetic diet.
# Hypothyroidism: This was also stable, and we continued
Levothyroxine at her regular home dose
# Code status: Full code
# Emergency Contact: ___ (Wife/HCP) ___ home
Wife cell # ___
TRANSITIONAL ISSUES
# Continue receiving antibiotics through your ___ line till
___ for a total 2 week course till you see the infectious
disease team as scheduled. ID may continue the total course of
antibiotics when they see you on ___. Consider re-imaging of
pocket.
# If he gets ___ need iodine contrast allergy
prevention, per ___ PPGD guideline
# INR and chem 7 to be checked on ___. Coumadin to be
managed by rehab physicians.
# Please have the staples in your back removed on ___,
___, by rehab
# TLSO brace at all times when out of bed, until follow-up with
Neurosurgery
# Restart diuretics as needed in the outpatient setting |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Concerta / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
EGD ___
Diagnostic Paracentesis ___
TIPS ___
History of Present Illness:
___ with history of hepatitis C status post Harvoni,
with cirrhosis and varices presenting with palpitations x3 days.
The patient reports that 3 days ago he developed palpitations
and shortness of breath on exertion. He denies any chest or
abdominal pain. Denies any blood in the stool or melena. He felt
more short of breath than usual yesterday when walking around.
He was seen at ___ ED today, where he was found to
have a hematocrit of 18 and a troponin I of 0.___epressions. He was transferred to ___ for further management.
He received only partially 1 unit pRBCs upon arrival to ___
ED, so repeat CBC showed Hgb of 5.4.
Denies any fevers, chills, cough.
In the ED, initial vitals: 98.3 84 117/74 95% RA
Rectal exam revealed guaiac positive brown stool.
EKG - SR, NA, QTC 500, lateral STD c/w prior from this morning
but no earlier prior available. Cardiology was consulted and
felt the changes were due to anemia.
He received protonix 40mg x1, ceftriaxone 1g, and octreotide
gtt.
Hepatology was consulted and recommend transfusion and trending
CBC.
He remained hemodynamically stable but was admitted to MICU for
profound anemia, NSTEMI, and possible variceal bleed.
On arrival to the MICU, he has no complaints. He reports he was
just admitted to the ___ ICU in ___ and required intubation
there for CHF exacerbation. His nadolol was stopped due to a
"slow heart rate" by his report. He was discharged without any
diuretics.
Past Medical History:
HCV Cirrhosis s/p Harvoni with sustained response complicated by
varices and ascites
Iron-deficiency anemia
Hyperaldosteronism
Hypogonadism
CVA ___ s/p R craniotomy with L sided weakness
CHF (EF 68% on TTE at ___ in ___
Social History:
___
Family History:
Younger sister passed away from MI at age ___, another younger
sister passed away from ruptured brain aneurysm at ___, two other
siblings have peripheral vascular disease.
Physical Exam:
=============================
PHYSICAL EXAM ON ADMISSION
=============================
Vitals: T: Afebrile BP: 134/66 P: 83 R: 18 O2: 98% on 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP 11cm, no LAD
LUNGS: Bibasilar crackles, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, II/VI systolic murmur
ABD: soft, non-tender, obese, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, 2+ peripheral edema
NEURO: Mild left facial droop, LUE contracted, LLE weaker than
RLE (chronic).
=============================
PHYSICAL EXAM ON DISCHARGE
=============================
VS: T 98 HR ___ BP 110s-140s/40s-60s RR 18 97 RA
Weight on discharge: 77.3
General: Sitting up in chair, in no acute distress
HEENT: NCAT, sclera anicteric, dry MM
CV: RRR, S1 and S2 appreciated, ___ systolic murmur best
appreciated at base
Lungs: + mildly decreased breath sounds at bases, no wheezes.
Abdomen: + BS, distended, non tender, no rebound or guarding
GU: No foley
Ext: wwp, 1+ left lower extremity edema, trace right
Neuro: Alert, oriented, neg asterixis, fluent speech, left sided
weakness ___ prior CVA
Skin: anicteric, scattered spider angiomas
Pertinent Results:
========================
LABS ON ADMISSION
========================
___ 12:25PM BLOOD WBC-3.7* RBC-2.01*# Hgb-5.4*# Hct-18.4*#
MCV-92 MCH-26.9 MCHC-29.3* RDW-17.1* RDWSD-57.6* Plt ___
___ 12:25PM BLOOD Neuts-61.8 ___ Monos-8.6 Eos-2.7
Baso-0.3 NRBC-0.5* Im ___ AbsNeut-2.29 AbsLymp-0.97*
AbsMono-0.32 AbsEos-0.10 AbsBaso-0.01
___ 12:25PM BLOOD ___ PTT-34.0 ___
___ 12:25PM BLOOD ___ 12:25PM BLOOD Ret Aut-3.7* Abs Ret-0.08
___ 12:25PM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-144
K-3.5 Cl-108 HCO3-25 AnGap-15
___ 12:25PM BLOOD ALT-26 AST-36 LD(LDH)-165 AlkPhos-172*
TotBili-0.5
___ 10:00PM BLOOD CK(CPK)-38*
___ 12:25PM BLOOD cTropnT-0.14*
___ 10:00PM BLOOD CK-MB-3 cTropnT-0.24*
___ 12:25PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.8 Mg-1.7
___ 12:43PM BLOOD Lactate-1.4
========================
PERTINENT INTERVAL LABS
========================
Cardiac Enzymes
___ 12:25PM BLOOD cTropnT-0.14*
___ 10:00PM BLOOD CK-MB-3 cTropnT-0.24*
___ 02:59AM BLOOD CK-MB-2 cTropnT-0.38*
___ 07:30AM BLOOD CK-MB-2 cTropnT-0.31* proBNP-1873*
___ 03:00PM BLOOD cTropnT-0.32*
___ 06:17AM BLOOD CK-MB-1 cTropnT-0.05*
___ 03:10PM BLOOD CK-MB-<1 cTropnT-0.05*
Metabolic
___ 07:45AM BLOOD %HbA1c-4.4* eAG-80*
___ 07:30AM BLOOD Triglyc-121 HDL-44 CHOL/HD-3.4 LDLcalc-82
___ 03:25AM BLOOD Osmolal-289
Blood Gas
___ 03:09AM BLOOD ___ pH-7.31* Comment-GREEN TOP
___ 07:37AM BLOOD ___ Temp-36.7 pO2-54* pCO2-53*
pH-7.31* calTCO2-28 Base XS-0
___ 03:07PM BLOOD ___ pH-7.34*
Ascitic Studies
___ 12:00PM ASCITES WBC-82* RBC-2473* Polys-7* Lymphs-81*
Monos-12*
___ 12:00PM ASCITES TotPro-0.9 Glucose-136 Creat-1.3
LD(LDH)-43 Amylase-29 TotBili-0.2 Albumin-0.7
Urine Studies
___ 09:49AM URINE Color-Straw Appear-Clear Sp ___
___ 09:49AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:49AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 09:49AM URINE CastHy-16*
___ 09:49AM URINE Mucous-RARE
___ 09:49AM URINE Hours-RANDOM UreaN-187 Creat-39 Na-33
K-59 Cl-89
___ 09:49AM URINE Osmolal-297
___ 09:10AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:10AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 09:10AM URINE RBC-9* WBC-12* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-1
___ 09:10AM URINE CastHy-1*
___ 09:10AM URINE Mucous-RARE
___ 05:24PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:24PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:24PM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:24PM URINE CastHy-12*
========================
LABS ON DISCHARGE
========================
___ 04:34AM BLOOD WBC-4.3 RBC-2.56* Hgb-7.2* Hct-23.7*
MCV-93 MCH-28.1 MCHC-30.4* RDW-16.2* RDWSD-55.0* Plt ___
___ 06:31AM BLOOD ___ PTT-34.8 ___
___ 04:34AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-139
K-3.8 Cl-103 HCO3-26 AnGap-14
___ 04:34AM BLOOD ALT-20 AST-53* AlkPhos-257* TotBili-0.3
___ 04:34AM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.8 Mg-1.9
========================
MICROBIOLOGY
========================
___ - Blood Culture x 2 - No growth
___ - Peritoneal Fluid - No growth
___ - Peritoneal Fluid - STAPHYLOCOCCUS, COAGULASE NEGATIVE.
OF TWO COLONIAL MORPHOLOGIES.
___ - Urine Culture - No Growth
___ - HCV VL - HCV RNA not detected
___ - Urine Culture
STENOTROPHOMONAS MALTOPHILIA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
========================
ENDOSCOPY
========================
___ - EGD
Findings:
Esophagus:
Protruding Lesions 3 cords of grade I varices were seen in the
esophagus. The varices were not bleeding.
Stomach:
Mucosa: Granularity, congestion and mosaic appearance of the
mucosa were noted in the whole stomach. These findings are
compatible with portal hypertensive gastropathy.
Protruding Lesions Protruding GOV-1 varices, without stigmata
of recent bleeding were seen in the cardia. Protuding GOV-2
varices, with stigmata of recent bleeding were seen in the
fundus.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Esophageal varices
Varices at the cardia
Varices at the fundus
Granularity, congestion and mosaic appearance in the whole
stomach compatible with portal hypertensive gastropathy
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
========================
IMAGING/STUDIES
========================
___ - ECG
Sinus rhythm. Non-specific ST segment depressions in the lateral
leads may
reflect myocardial ischemia. Clinical correlation is suggested.
Compared to
the previous tracing of ___ ST segment depressions are
noted.
QTc (___) 462/500
___ - ECG
Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization
abnormalities. Variation in precordial lead placement, in
particular
leads V4-V6 which show a less prominent ST-T wave change related
to left
ventricular hypertrophy. No diagnostic interim change.
QTc (___) 467
___ - RUQ US
1. Patent hepatic vasculature.
2. Cirrhotic liver with moderate ascites, moderate right pleural
effusion, andsplenomegaly. No suspicious focal liver lesion.
___ - TTE
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with moderate
mitral regurgitation. Mild aortic regurgitation. Moderate
pulmonary hypertension
___ - CXR
Opacities, which are seen predominantly in the right mid and
lower zones and,densely, in the left lower lobe. While this
could represent asymmetric
pulmonary edema, the possibility of a superimposed infectious
consolidation
cannot be excluded.
Upper zone redistribution on the left is noted. On the right,
the vessels areobscured by surrounding opacities.
Possible small bilateral pleural effusions.
___ - TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
___ - CT Abdomen Pelvis W and WO contrast
1. Cirrhosis, splenomegaly, and mild ascites. Esophageal and
gastric varices.No suspicious lesion.
2. Cardiomegaly.
3. Bibasilar atelectasis. Moderate right and small left pleural
effusions.
___ - KUB
1. Hazy appearance of the abdomen with centrally located
air-filled bowel
loops suggestive ascites. No evidence of obstruction.
2. Left basilar opacity could represent atelectasis and
effusion, however,
underlying airspace disease cannot be excluded.
3. Postsurgical changes from prior TIPS, coiling, and IVC
filter.
4. Stable cardiomegaly.
___ - RUQ US
1. Evaluation of the TIPS is limited in the postoperative day 2
setting.
Color flow is seen in the main and proximal portions of the
TIPS, but
velocities are 8.04 and 55.6 cm/sec, respectively. The distal
TIPS is not
evaluated, as it is obscured by shadowing.
2. Small echogenic focus in the posterior right portal vein may
indicate a
small thrombus (see series 1 a, image 3435).
3. Trace ascites an a small right pleural effusion.
RECOMMENDATION(S): Close interval imaging follow-up is
recommended.
___ - LLE US
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ - CXR
As compared to ___ chest radiograph, cardiac silhouette
has decreased in size and pulmonary edema has nearly resolved.
A nonspecific left lower lobe opacity has partially cleared and
bilateral pleural effusions have decreased in size.
___ - RUQ US
Elevated velocities within the visualized portions of the TIPS.
Directionality of flow in the right and left portal veins has
changed and is noted to be away from the TIPS. Increased
ascites. These findings are
concerning for a distal TIPS stenosis.
========================
PROCEDURES
========================
___ - TIPS
1. Pre-TIPS right atrial pressure of 19 mmHg and portal
pressure measurement of 33 mmHg, resulting in portosystemic
gradient of 14 mmHg.
2. Pre-TIPS right heart catheterization with cardiac output of
8.4 and
pressures as follows: Right atrium 19, right ventricle 24,
pulmonary artery 31, pulmonary artery wedge pressure 22.
3. Initial portal venogram demonstrating patent portal
vasculature with
retrograde filling of the coronary vein, posterior gastric vein,
and inferior mesenteric vein. Massive gastroesophageal varices
are seen to be supplied by the coronary vein and posterior
gastric vein. Portosystemic shunting is noted via inferior
phrenic veins and the left gonadal vein.
4. Sclerosis and embolization performed of the posterior
gastric vein and
coronary vein.
5. Successful creation of an intrahepatic portosystemic shunt
using 10 mm x 6 mm x 2 cm Viatorr stent and 12 mm x 4 cm Luminex
stent, both underdilated to 7mm.
6. Post-TIPS portal venogram showing significantly decreased
filling of
gastroesophageal varices with complete cessation of flow in the
left gastric vein and near complete cessation of flow in the
posterior gastric vein. Patent TIPS stent with wall to wall
flow.
7. Post TIPS right atrial pressure of 26 and portal pressure of
32, resulting in a portosystemic gradient of 6 mmHg.
8. Post TIPS right heart catheterization with cardiac output of
10 and
pressures as follows: Right atrium 19, right ventricle 30,
pulmonary artery35, pulmonary wedge pressure 27 .
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement and variceal
sclerosis/embolization with
decrease in porto-systemic pressure gradient from 14 mmHg to 6
mmHg.
========================
CYTOLOGY
========================
___ - Peritoneal Fluid
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes,
and lymphocytes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. ammonium lactate 12 % topical BID
3. Eplerenone ___ mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. HydrALAZINE 25 mg PO TID
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. LamoTRIgine 100 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Modafinil 200 mg PO BID
10. Ranitidine 150 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Eplerenone ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. HydrALAZINE 25 mg PO TID
5. LamoTRIgine 100 mg PO BID
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. Modafinil 200 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
10. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
11. ammonium lactate 12 % topical BID
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Outpatient Lab Work
ICD 10 K74.60
___ Labs: Please obtain Chem 10, LFTS, ___, PTT, CBC and Fax
to: PCP ___ ___ (P ___ Liver
Center Dr. ___ ___ (P ___
15. Outpatient Lab Work
ICD 10 K74.60
___ Labs: Please obtain Chem 10, LFTS, ___, PTT, CBC and Fax
to: PCP ___ ___ (P ___ Liver
Center Dr. ___ ___ (P ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=====================
Anemia
Variceal Bleeding s/p TIPS
NSTEMI
Acute on chronic diastolic heart failure
HCV Cirrhosis
Acute kidney injury
Sinus bradycardia
Secondary Diagnoses
=====================
Hypertension
Hyperaldosteronism
History of CVA c/b seizures
Vitamin D deficiency
Prolonged QTc
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 HCV cirrhosis, diastolic heart failure, s/p
TIPS ___ with abdominal distention // eval for obstruction, ileus, free
airplease do portable
TECHNIQUE: Upright and supine views of the abdomen.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There is a hazy appearance of the abdomen with bowel loops seen centrally.
Air-filled loops of large and small bowel is seen within the mid abdomen. No
evidence of obstruction. No free air under the diaphragms. There is stable
cardiomegaly. There suggestion of left basilar atelectasis and underlying
effusion or consolidation cannot be excluded. There is a right-sided PICC
likely terminating in the lower SVC. Partially visualized stent there seen
overlying the liver related to prior TIPS procedure. Multiple coils are seen
overlying the mid and right upper abdomen. There is an IVC filter seen
overlying the spine. No acute osseous abnormality.
IMPRESSION:
1. Hazy appearance of the abdomen with centrally located air-filled bowel
loops suggestive ascites. No evidence of obstruction.
2. Left basilar opacity could represent atelectasis and effusion, however,
underlying airspace disease cannot be excluded.
3. Postsurgical changes from prior TIPS, coiling, and IVC filter.
4. Stable cardiomegaly.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with HCV cirrhosis, diastolic heart failure, s/p
TIPS ___ with abdominal distention. Eval for TIPS patency, ascites,
thrombosis.
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: None.
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is trace ascites. A
small right pleural effusion is incidentally noted. There is splenomegaly,
with the spleen measuring 15.2 cm. There is no intrahepatic biliary dilation.
The CHD measures 4 mm. There is sludge in the gallbladder with wall edema,
likely due to third spacing in the setting of liver disease.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates flow in the proximal and midportions,
although evaluation is limited in the postop day 2 setting.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 9.16 cm/sec
Proximal TIPS: 8.04 cm/sec
Mid TIPS: 55.6 cm/sec
Distal TIPS: Not evaluated, as it is obscured by shadowing.
A small echogenic focus in the posterior right portal vein may indicate a
small thrombus (series 1a, image 34-35).
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior and right posterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
PANCREAS: The pancreas is not well visualized, largely 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. Evaluation of the TIPS is limited in the postoperative day 2 setting.
Color flow is seen in the main and proximal portions of the TIPS, but
velocities are 8.04 and 55.6 cm/sec, respectively. The distal TIPS is not
evaluated, as it is obscured by shadowing.
2. Small echogenic focus in the posterior right portal vein may indicate a
small thrombus (see series 1 a, image 3435).
3. Trace ascites an a small right pleural effusion.
RECOMMENDATION(S): Close interval imaging follow-up is recommended.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 09:44 on ___, 5 min after discovery.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with HCV Cirrhosis, dCHF, L hemiparesis s/p CVA
with L lower extremity edema. Eval for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the 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 left lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with diastolic CHF and SOB with low grade fever
// evaluate for pneumonia, effusion, pulmonary edema
IMPRESSION:
As compared to ___ chest radiograph, cardiac silhouette has decreased
in size and pulmonary edema has nearly resolved. A nonspecific left lower
lobe opacity has partially cleared and bilateral pleural effusions have
decreased in size.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with HCV cirrhosis and h/o variceal bleeding,
dCHF, s/p TIPS // please evaluate for TIPS patency/measurement of velocities,
evidence of thrombusPlease assess all four quadrants as well, evaluation of
acsites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Doppler ultrasound ___, TIPS ___
FINDINGS:
LIVER: The hepatic parenchyma is noted to be coarse. The contour of the liver
is nodular. There is no focal liver mass. There is mild ascites which is
noted to be increased since the prior ultrasound of ___. A right
pleural effusion is also incidentally noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures for
mm.
GALLBLADDER: No gallstones are visualized. Mild gallbladder wall edema is
noted which can be seen in the setting of third spacing.
DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow and
a velocity of 34 cm/sec. Flow within the right and left portal veins is away
from the TIPS. This is a change from the prior ultrasound of ___.
The proximal and distal portions of the TIPS appear patent with velocities
measuring up to 192 cm/sec. The distal portion of the TIPS cannot be
visualized due to persistent air in the new TIPS stent. This limited
visualization is likely still reflective of the postoperative setting. Also
of note, there is an echogenic line within the mid portion of the TIPS shunt
seen on grayscale imaging which is of uncertain significance.
IMPRESSION:
Elevated velocities within the visualized portions of the TIPS.
Directionality of flow in the right and left portal veins has changed and is
noted to be away from the TIPS. Increased ascites. These findings are
concerning for a distal TIPS stenosis.
NOTIFICATION: Findings concerning for TIPS stenosis were discovered at 09:05
on ___ and were conveyed by telephone to Dr. ___ by Dr.
___ approximately 10 min after discovery.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL PORT
INDICATION: ___ male with hep C cirrhosis and possible variceal
bleeding, evaluate for portal vein thrombosis or splenic vein thrombosis.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: None appear
FINDINGS:
Liver: The hepatic parenchyma is coarsened. No focal liver lesions are
identified. There is moderate ascites and a moderate right pleural effusion.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct is borderline enlarged, measuring 6 to 7 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 17.5 cm.
Kidneys: The right kidney measures 10.6 cm. The left kidney measures 11.7
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 19 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.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhotic liver with moderate ascites, moderate right pleural effusion, and
splenomegaly. No suspicious focal liver lesion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF, dyspnea after blood transfusion //
Evaluate for edema, worsening pleural effusion
COMPARISON: None.
FINDINGS:
All there is alveolar opacity throughout much of the right lung, most
pronounced in the mid and lower zones, with apparent air bronchograms and
maturation of a right costophrenic angle and without aeration of right
hemidiaphragm and its extreme lateral edge. There is increased retrocardiac
density, with obscuration left hemidiaphragm and probable air bronchograms,
consistent with left lower lobe collapse and consolidation. There is relative
sparing of the left upper and mid zones. Mild upper zone redistribution is
noted on the left.
IMPRESSION:
Opacities, which are seen predominantly in the right mid and lower zones and,
densely, in the left lower lobe. While this could represent asymmetric
pulmonary edema, the possibility of a superimposed infectious consolidation
cannot be excluded.
Upper zone redistribution on the left is noted. On the right, the vessels are
obscured by surrounding opacities.
Possible small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis, GI bleed, edema, complaining of
chest pain // volume overload
COMPARISON: Chest x-ray examination from ___
FINDINGS:
Again seen is cardiomegaly as well as prominence of the superior mediastinum.
This appears more pronounced than on the prior examination, but is also
accentuated by lordotic positioning.
There is upper zone redistribution with alveolar opacities at both lung bases,
including retrocardiac opacity that obscures the left hemidiaphragm. A tiny
left effusion would be difficult to exclude. The degree of opacity at the
right base is very slightly improved.
IMPRESSION:
Cardiomediastinal silhouette appears larger, but is likely accentuated by
lordotic positioning.
Findings compatible with pulmonary edema, including bibasilar alveolar
opacities. Possible minimal interval improvement at the right base. As
before, the presence of superimposed infectious consolidation at the lung
bases, particularly on the left, would be difficult to exclude.
Radiology Report
INDICATION: ___ year old man with CHF, new PICC line placement, 40cm right
brachial // Evaluate new PICC line
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ 08:19
FINDINGS:
Right PICC terminates in the region of the the cavoatrial junction, possibly
overlying the upper right atrium.
Bibasilar opacities are similar to before which may reflect atelectasis,
however pneumonia is difficult to exclude. There is near complete obscuration
of the left hemidiaphragm. Small left pleural effusion is similar to before.
There is no large right pleural effusion. There is no pneumothorax. Lung
slightly volume is low the film is obtained in lordotic position. The cardiac
silhouette is probably enlarged, but somewhat exaggerated by these technical
factors. Mildly enlarged cardiac silhouette is exaggerated by the low lung
volumes.
There is mild upper zone redistribution and mild vascular plethora improved
compared with ___. .
IMPRESSION:
Right PICC terminates in the region of the cavoatrial junction -- please see
comment above. No pneumothorax detected.
Bibasilar opacities are similar to before which may reflect atelectasis,
however pneumonia is difficult to exclude.
Radiology Report
EXAMINATION: CT abdomen pelvis without and with contrast
INDICATION: ___ year old man with HCV cirrhosis with variceal bleed and portal
hypertensive gastropathy // Discussed with Dr. ___ requests ___
contrast given renal failure, multiphasic liver for evaluation of varices and
porto-mesenteric system, pre-op for TIPS or BRTO
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done without and with IV contrast. Initially the abdomen was scanned without
IV contrast. Subsequently a single bolus of IV contrast was injected and the
abdomen and pelvis were scanned in the portal venous phase, followed by a scan
of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 2,677 mGy-cm.
COMPARISON: Ultrasound ___.
FINDINGS:
LOWER CHEST: Bibasilar atelectasis. Moderate right and small left pleural
effusions. Cardiomegaly.
ABDOMEN:
HEPATOBILIARY: Nodular liver surface consistent with cirrhosis. No large mass
in this single phase study. No ductal dilation. Unremarkable gallbladder.
PANCREAS: No discrete lesion or ductal dilation.
SPLEEN: 18.5 cm splenomegaly.
ADRENALS: Fullness of the left adrenal gland without nodules. Unremarkable
right adrenal.
URINARY: No nephrolithiasis or hydronephrosis.No discrete lesion.
GASTROINTESTINAL: No intestinal obstruction. No pneumoperitoneum. Mild
ascites.
PELVIS: Unremarkable rectum and seminal vesicles. Prostate hypertrophy.
Foley catheter within a decompressed bladder.Small fat and fluid containing
left inguinal hernia, indirect.
LYMPH NODES: No adenopathy.
VASCULAR: Mild arteriosclerosis. Patent aorta and major branches. Patent
hepatic vasculature. Accessory segment 6 hepatic vein. Patent splenic vein,
SMV and IMV. Prominent IMV.
Multiple esophageal, paraesophageal, gastric, and perigastric varices.
Submucosal esophageal and gastric varices are noted. No hemodynamically
significant splenorenal shunt.
Patent IVC and iliac veins. Infrarenal IVC filter in situ; filter legs tips
are outside of the IVC, not uncommon. .
BONES AND SOFT TISSUES: Moderate anasarca. Right anterior acetabulum bone
island. No acute fracture.
IMPRESSION:
1. Cirrhosis, splenomegaly, and mild ascites. Esophageal and gastric varices.
No suspicious lesion.
2. Cardiomegaly.
3. Bibasilar atelectasis. Moderate right and small left pleural effusions.
Radiology Report
INDICATION: ___ year old man with recurrent upper GI bleed in the setting of
liver cirrhosis. // Please perform TIPS for relief of portal hypertension.
COMPARISON: ___ CT abdomen pelvis.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
personally supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: General anesthesia.
MEDICATIONS: 1 g ceftriaxone.
CONTRAST: 280 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 61.1 min, 1190 mGy
PROCEDURE: 1. Right internal jugular venous access using ultrasound.
2. Pre TIPS right heart catheterization with pressure measurements (per study
protocol).
3. Portal venogram (from the proximal splenic vein) with pressure
measurements.
4. Venogram of posterior gastric vein.
5. Sclerosis / embolization of posterior gastric vein and gastroesophageal
varices using STS foam, ethanol, 8 mm x 3 cm coils (x 4), 8 mm x 5 cm coil
(x1), and 12 mm Amplatzer plug.
6. Venogram of coronary vein.
7. Sclerosis / embolization of coronary vein and gastroesophageal varices
using ethanol and 10 mm Amplatzer plug.
8. Placement of 10 mm x 6 mm x 2 cm Viatorr stent, followed by 7 mm balloon
angioplasty of the stent.
9. Post stenting portal venogram (from the proximal splenic vein) with
pressure measurements.
10. Extension of the TIPS stent (towards the hepatic confluence) using 12 mm
x 4 cm Luminex stent, followed by 7 mm balloon angioplasty of the stent.
11. Post TIPS right heart catheterization with pressure measurements (per
study protocol)
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 neck and abdomen were prepped and draped in the usual sterile
fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a TIPS sheath was advanced over
the wire into the right atrium. The wire was removed and a ___ catheter
was advanced and used to perform a pre TIPS right heart catheterization per
study protocol with pressure measurements obtained of the right atrium, right
ventricle, pulmonary artery, and pulmonary artery wedge pressure, as well as
cardiac output.
Next, the ___ catheter was removed, and the right hepatic vein was
selected using a combination of the ___ wire and an MPA catheter.
Appropriate position was confirmed with contrast injection and fluoroscopy in
AP and lateral views. Following this, the TIPS cannula was advanced over the
wire into the right hepatic vein, and the wire was exchanged for ___
needle. Several passes were made with the ___ needle anteriorly to
attempt selection of the right portal vein from the right hepatic vein. These
were unsuccessful. The TIPS cannula was repositioned into the middle hepatic
vein, the angled sheath was turned posteriorly, and the needle was then
advanced through liver parenchyma and the needle was withdrawn over its
sheath. The sheath was slowly withdrawn while gentle suction was applied.
Upon blood return, injection of contrast confirmed intraportal position and a
Glidewire was introduced into the catheter to pass into the portal vein. The
glidewire were initially passed into the intrahepatic portal veins, but was
directed towards the splenic vein using ___ 1 glide cath. The wire was
removed and injection of contrast confirmed intra portal position. An Amplatz
was advanced into the splenic vein and the TIPS sheath was advanced into the
portal vein.
A straight flush catheter was advanced into the proximal splenic vein,
pressure measurement was obtained, and a portal venogram was performed,
findings below. Based on results of this portal venogram, decision was made
to perform variceal sclerosis and embolization as well as placement of a TIPS.
An angled glidecath was advanced into the posterior gastric vein over a
Glidewire. Injection of contrast confirmed position. The glide cath was
exchanged over ___ wire for an occlusion balloon, which was inflated in
the posterior gastric vein. A venogram was performed of the posterior gastric
vein, findings below. Sclerosis of the posterior gastric vein and
gastroesophageal varices was performed using 10 cc STS foam (4 cc 3% STS, 2 cc
Lipiodol, 4 cc air mixture), which was allowed to indwell for 10 min.
Following this, venogram of the posterior gastric vein demonstrated reduced
but persistent filling of the gastroesophageal varices. Additional sclerosis
was performed using 10 cc STS foam (2:1:3 3% STS : Lipiodol : air). Following
this, coil embolization was performed of the posterior gastric vein using four
8 mm x 3 cm Hilal coils and two 8 mm x 5 cm Hilal coil. Upon withdrawal of
the occlusion balloon, migration of one of the 8 mm x 5 cm Hilal coils was
noted. This coil was successfully retrieved using a 7 ___ Ensnare device.
Next, a repeat portal venogram was performed from the proximal splenic vein,
demonstrating persistent patency of the posterior gastric vein. The occlusion
balloon was readvanced over a wire into the posterior gastric vein and further
sclerosis was performed using 10 cc of ethanol, which was allowed to indwell
for 10 min. Following this, the occlusion balloon was exchanged for a ___ Fr
RDC guidecath, which was advanced over ___ wire into the posterior gastric
vein, and embolization was performed of the posterior gastric vein using a 12
mm Amplatzer plug.
Next, attention was turned to embolization of the left gastric vein. The
___ wire was advanced into the left gastric vein using the RDC guidecath,
which was exchanged for an occlusion balloon. A venogram was performed of the
left gastric vein, findings below. The balloon was inflated and sclerosis was
performed of the left gastric vein using ethanol. Following this, the
occlusion balloon was exchanged for an RDC guidecath and embolization of the
left gastric vein was performed using a 10 mm Amplatzer plug.
Next, attention was turned to placement of a TIPS stent. An Amplatz wire was
advanced into the proximal splenic vein. The TIPS sheath was advanced using
its dilator into the main portal vein. A 10 mm x 6 cm x 2 cm Viatorr stent
was advanced into appropriate position and deployed. Following stent
deployment, the stent was dilated using a 7 mm balloon.
The straight flush catheter was advanced over the wire into the proximal
splenic vein and the wire was removed. Repeat proximal splenic vein and right
atrium pressure measurements were performed. Portal venograms were then
performed from the proximal splenic vein and the mid splenic vein, findings
below. The TIPS stent was extended towards hepatic confluence using a 12 mm x
4 cm Luminex stent, which was then dilated using a 7 mm balloon.
The wire was removed and a Swan-Ganz catheter was advanced and used to perform
a post TIPS right heart catheterization per study protocol with pressure
measurements obtained of the right atrium, right ventricle, pulmonary artery,
and pulmonary artery wedge pressure, as well as cardiac output.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. Sterile dressings were
applied.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the ICU in stable
condition.
FINDINGS:
1. Pre-TIPS right atrial pressure of 19 mmHg and portal pressure measurement
of 33 mmHg, resulting in portosystemic gradient of 14 mmHg.
2. Pre-TIPS right heart catheterization with cardiac output of 8.4 and
pressures as follows: Right atrium 19, right ventricle 24, pulmonary artery
31, pulmonary artery wedge pressure 22.
3. Initial portal venogram demonstrating patent portal vasculature with
retrograde filling of the coronary vein, posterior gastric vein, and inferior
mesenteric vein. Massive gastroesophageal varices are seen to be supplied by
the coronary vein and posterior gastric vein. Portosystemic shunting is noted
via inferior phrenic veins and the left gonadal vein.
4. Sclerosis and embolization performed of the posterior gastric vein and
coronary vein.
5. Successful creation of an intrahepatic portosystemic shunt using 10 mm x 6
mm x 2 cm Viatorr stent and 12 mm x 4 cm Luminex stent, both underdilated to 7
mm.
6. Post-TIPS portal venogram showing significantly decreased filling of
gastroesophageal varices with complete cessation of flow in the left gastric
vein and near complete cessation of flow in the posterior gastric vein.
Patent TIPS stent with wall to wall flow.
7. Post TIPS right atrial pressure of 26 and portal pressure of 32, resulting
in a portosystemic gradient of 6 mmHg.
8. Post TIPS right heart catheterization with cardiac output of 10 and
pressures as follows: Right atrium 19, right ventricle 30, pulmonary artery
35, pulmonary wedge pressure 27 .
IMPRESSION:
Successful right internal jugular access with transjugular intrahepatic
portosystemic shunt placement and variceal sclerosis/embolization with
decrease in porto-systemic pressure gradient from 14 mmHg to 6 mmHg.
RECOMMENDATION(S): The patient will need an outpatient TIPS venogram in 1
month to assess for any residual varices and further embolization.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: NSTEMI
Diagnosed with Gastrointestinal hemorrhage, unspecified, Non-ST elevation (NSTEMI) myocardial infarction, Unspecified cirrhosis of liver
temperature: 98.3
heartrate: 84.0
resprate: nan
o2sat: 95.0
sbp: 117.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with history of Hep C cirrhosis c/b varices s/p
Harvoni, diastolic heart failure with recent admission at OSH
requiring intubation, presenting with symptomatic anemia ___
variceal bleeding now s/p TIPS, course complicated by demand
NSTEMI, bradycardia, and ___.
#HCV cirrhosis s/p sustained virologic response complicated by
variceal bleeding:
Pt had a prior known history of esophageal varices s/p banding.
He presented with dyspnea and chest discomfort and was found to
have Hgb of 5 at ___ on ___. He was transferred
to ___ for further evaluation, and EGD revealed extensive
gastric varices with signs of recent bleeding. He received a
total of 4 units pRBCs. He was unable to tolerate beta blocker
for bleeding prophylaxis (see below). The patient was treated
with PPI BID, and received IV Ceftriaxone for SBP prophylaxis.
Diagnostic paracentesis fluid cultures grew coagulase negative
staph in only 1 bottle, and this was thought to be a contaminant
and treatment was discontinued. The patient underwent TIPS via R
IJ approach on ___ with improvement with improvement in
portosystemic gradient from 14 to 6 mmHg. Additionally during
the procedure the patient had sclerosis/embolization of varices.
His Hgb remained stable for the duration of his remaining
hospitalization. The patient developed some abdominal pain post
TIPS, and serial RUQ US revealed findings concerning for
possible TIPS stenosis, however imaging of TIPS limited in the
immediate post procedural follow up. The interventional
radiology team who performed the TIPS procedure evaluated the
images, and recommended repeat venogram in 1 month for follow
up, and that there were not concerning findings requiring
immediate intervention. An HCV VL was sent during the admission
which was negative.
#Symptomatic bradycardia: Pt received a dose of 20mg nadolol and
developed sinus bradycardia with rate of 30. He was also
relatively hypotensive to SBPs ___ and felt nauseated. He
required dopamine support to maintain HR and BP for nearly 48hrs
after nadolol was discontinued. Pt reported having similar
symptoms with propranolol in the past. EP was consulted for
consideration of PPM, and they felt this would be a possibility
if there was a strong indication for beta-blockers for his
varices. Hepatology did not recommend beta blockers for this
current hospitalization. Beta-blockers were added to his allergy
list. Ocreotide was also held due to concern for bradycardia as
a potential side effect. Off beta blockers, the patient had no
further episodes of bradycardia on the Liver floor.
#NSTEMI: Likely type 2 due to demand ischemia and severe anemia.
Troponin peaked at 0.35 and downtrended after transfusions. He
was started on high dose atorvastatin but aspirin was held due
to bleeding risk and beta blocker held as above. Low dose
lisinopril was started prior to discharge. Outpatient cardiology
follow up was set up prior to discharge, and the patient will
need CAD evaluation.
#Low grade fever: While on the Liver floor the patient developed
a low grade fever 10 100.1. CXR unremarkable, recent ___ US
negative for DVT. UA with pyuria though initial culture
negative. There was not evidence of leukocytosis or hemodynamic
instability, and the patient remained afebrile for the remainder
of the hospitalization. The patient was asymptomatic. A repeat
urine culture was sent one day subsequent to the prior negative
culture and returned positive for ___ stenotrophomonas
maltophila after the patient had been discharged from the
hospital.
#Acute on chronic diastolic CHF: Volume overloaded on exam at
admission. He was diuresed with furosemide IV boluses and
metolazone. The patient had not been on any diuretics prior to
admission, but was transitioned to PO torsemide prior to
discharge. He was continued on hydralazine for afterload
reduction, and low dose lisinopril was started with improvement
in ___. Home imdur was held, and the patient was not discharged
on a beta blocker due to above symptomatic bradycardia.
___: Cr increased from 0.9 to 1.7. Improved with blood
transfusion and urine studies were consistent with pre-renal
azotemia. Thought most likely in setting of hyperperfusion given
low BP and venous/portal hypertension in volume overloaded
state. Improved with diuresis in the MICU. The patient had a
slight bump in creatinine with re initiation of diuresis on the
Liver floor that resolved.
# LLE swelling and pain: Patient reported left lower extremity
swelling and pain over patella and to palpation of shin. ___
negative for DVT. No clinical evidence of infection. Pain
resolved, and asymmetric edema appears chronic secondary to
prior CVA.
=======================
CHRONIC ISSUES
=======================
#Hyperaldosteronism: Home epleronone restarted s/p EGD with
improvement in ___, electrolytes.
#History of CVA c/b seizures: The patient was continued on home
lamotrigine.
#Psych: The patient was continued on home escitalopram.
#Vitamin D deficiency: Patient continued on home vitamin D.
#Prolonged QTc: QTc trended and improved prior to discharge.
=======================
TRANSITIONAL ISSUES
=======================
# Weight on discharge: 77.3
[ ] Will need TIPS venogram in 1 month to assess for pressures
studies and evaluation of varices
[ ] Please obtain electrolytes on ___ and ___ -
Na, K, HCO3, Cl, BUN, Cr, Ca, Mg, Phosphate - ensure results
faxed to PCP ___ at ___ at ___
[ ] Consider titration of diuresis pending electrolytes and
weights
[ ] Consider starting Aspirin at cardiology follow up
[ ] Consider uptitration of lisinopril at PCP/cardiology follow
up pending electrolytes
[ ] Consider restarting Imdur at next PCP/Cardiology visit
pending blood pressures
[ ] No beta blockers or ocretotide given bradycardia
[ ] Care with QTc prolonging medications, would obtain EKG for
QTc monitoring prior to starting any new QTc prolonging
medications
[ ] Outpatient workup for CAD
[ ] Ensure follow-up with PCP, ___, ___, and cardiology
[ ] A repeat urine culture was sent one day subsequent to the
prior negative culture and returned positive for ___
stenotrophomonas maltophila after the patient had been
discharged from the hospital. If symptomatic, please treat
appropriately.
CODE STATUS: FULL CODE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p
silent MI, c/b LV thrombus on warfarin), splenic infarction,
HFrEF (LVEF=35%), COPD, recently discharged from ___
on ___, who re-presents with persistent SOB. She reports at
least one week of dyspnea with intermittent wheezing. She was
seen at ___ and was thought to have pneumonia, heart
failure exacerbation, and COPD exacerbation. She reports that
she received three days of steroids and antibiotics at the
hospital. She was discharged with a course of steroids, which
completed today. She reports that since then, her symptoms have
persisted. She reports a cough and feels as though there is
phlegm in her chest that she is unable to bring up. She has been
taking her Lasix, 20 mg once a day, without missing any doses.
She denies fevers but does endorse chills. She reports dyspnea
on exertion, without orthopnea or PND. She denies chest pain.
She endorses RUQ abdominal pain with one dark bowel movement,
without hematochezia. She denies dysuria, hematuria,
constipation, or diarrhea.
Past Medical History:
Depression
HL
C-section
Social History:
___
Family History:
Father died of an MI, sister has A-fib. Her mother's siblings
had cancers, she is unsure of what kind.
Physical Exam:
ADMISSION EXAM:
===============
Admission Weight: 91.1 kg
VS: T 97.6F BP 123/85 mmHg P 85 RR 16 O2 99% RA
General: Comfortable, NAD.
HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear.
Neck: Supple; JVD elevated to midneck at 15 degrees.
CV: RRR, soft II/VI systolic murmur best heard over LUSB. No
rubs or gallops.
Pulm: Diminished airflow throughout with prolonged expiratory
phase. No wheezes, rhonchi, or rales. No increased work of
breathing.
Abd: Soft, mild tenderness to palpation over RUQ and LLQ without
rebound or guarding. NABS.
Ext: Warm and well-perfused. 2+ DP pulses. Trace edema.
Neuro: A&Ox3. CNs II-XII grossly intact.
DISCHARGE EXAM:
===============
VITALS: Temp: 97.6 BP: 118/79 HR: 71 RR: 18 O2 sat: 93% RA
DRY WEIGHT: 95.2kg
WEIGHT: 91.1 kg on admission --> 90.5kg --> 90.7kg today
GENERAL: Well-appearing woman, sitting comfortably in bed in NAD
HEENT: NC/AT, EOMI, anicteric sclera, MMM
NECK:: Supple, no appreciable JVD
HEAR: RRR, soft II/VI systolic murmur best heard over LUSB, no
rubs or gallops.
LUNGS: CTAB, no wheezes, rhonchi, or rales. No increased work of
breathing.
ABDOMEN: Soft, mild tenderness to palpation in RUQ/RLQ, no
rebound or guarding, non-distended, active bowel sounds
EXTREMITIES: Warm and well-perfused, 2+ DP pulses, no edema
NEURO: Alert, oriented, moving all extremities with purpose, no
facial asymmetry
Pertinent Results:
ADMISSION LABS:
===============
___ 08:40AM ___ PTT-40.7* ___
___ 08:40AM PLT COUNT-433*
___ 08:40AM NEUTS-61.2 ___ MONOS-6.1 EOS-0.9*
BASOS-0.2 NUC RBCS-1.4* IM ___ AbsNeut-7.36*#
AbsLymp-3.71* AbsMono-0.73 AbsEos-0.11 AbsBaso-0.03
___ 08:40AM WBC-12.0*# RBC-4.88 HGB-10.9* HCT-34.9
MCV-72* MCH-22.3* MCHC-31.2* RDW-21.6* RDWSD-48.2*
___ 08:40AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-4.3
MAGNESIUM-1.9
___ 08:40AM proBNP-3660*
___ 08:40AM cTropnT-<0.01
___ 08:40AM LIPASE-53
___ 08:40AM estGFR-Using this
___ 08:40AM estGFR-Using this
___ 08:40AM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-146
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
___ 10:52AM URINE MUCOUS-OCC*
___ 10:52AM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 10:52AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD*
___ 10:52AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:52AM URINE UHOLD-HOLD
___ 10:52AM URINE HOURS-RANDOM
___ 04:09PM calTIBC-360 FERRITIN-166* TRF-277
___ 04:09PM MAGNESIUM-1.9 IRON-66
___ 04:09PM CK-MB-3 cTropnT-<0.01
___ 04:09PM GLUCOSE-115* UREA N-19 CREAT-1.1 SODIUM-147
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-19* ANION GAP-21*
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-13.6* RBC-5.43* Hgb-12.1 Hct-38.6
MCV-71* MCH-22.3* MCHC-31.3* RDW-22.5* RDWSD-49.2* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-41.1* ___
___ 07:15AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-141
K-4.3 Cl-105 HCO3-25 AnGap-11
___ 07:15AM BLOOD ALT-64* AST-24 AlkPhos-96 TotBili-0.4
___ 07:15AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3
MICROBIOLOGY:
=============
___ BLOOD CX: Pending
___ URINE CX: Negative
IMAGING/DIAGNOSTICS:
====================
___ CXR:
Bilateral hilar engorgement with hazy bilateral diffuse
opacities concerning for pulmonary edema. Small bilateral
pleural effusions. No definite focal consolidations are seen,
however post diuresis views could be obtained as clinically
indicated.
___ ECHO:
The left atrial volume index is moderately increased. A small
secundum atrial septal defect is present. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with inferior/inferolateral/lateral hypokinesis. The
remaining segments contract normally (LVEF = 35-40%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to
severe (3+), posteriorly-directed mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate to severe functional mitral
regurgitation. Mild aortic regurgitation. Small ASD.
Compared with the prior study (images reviewed) of ___,
left ventricle has dilated. ASD is seen. The other findings are
similar.
___ RUQUS:
Gravel-like cholelithiasis without evidence of cholecystitis or
biliary
dilatation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Aspirin 81 mg PO DAILY
5. Warfarin 7.5 mg PO 2X/WEEK (MO,FR)
6. Warfarin 5 mg PO 5X/WEEK (___)
7. Furosemide 20 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Warfarin 7.5 mg PO 2X/WEEK (MO,FR)
9. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
- Acute heart failure with reduced ejection fraction
- LV thrombus
- Cholelithiasis
SECONDARY DIAGNOSIS:
====================
- CAD
- Tobacco use
- COPD
- Microcytic anemia
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: ___ with cough and shortness of breath. Study performed to
evaluate for pneumonia.
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
There is bilateral hilar engorgement with hazy bilateral diffuse opacities
concerning for pulmonary edema. Fluid is seen within the horizontal fissure
on the right. There are small bilateral pleural effusions. No definite focal
consolidations are seen. There is no pneumothorax. Heart size is top-normal.
The mediastinal silhouette is unremarkable. Osseous structures are
unremarkable.
IMPRESSION:
Bilateral hilar engorgement with hazy bilateral diffuse opacities concerning
for pulmonary edema. Small bilateral pleural effusions. No definite focal
consolidations are seen, however post diuresis views could be obtained as
clinically indicated.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with HFrEF, now with RUQ pain and mild
elevation in LFTs// Gall bladder pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: The report from the CT abdomen and pelvis ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: Gravel-like cholelithiasis without gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 9.1 cm.
KIDNEYS: The right kidney measures 10.5 cm. The left kidney measures 11.1 cm.
Limited views of the bilateral kidneys show no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Gravel-like cholelithiasis without evidence of cholecystitis or biliary
dilatation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified, Dyspnea, unspecified
temperature: 96.9
heartrate: 86.0
resprate: 18.0
o2sat: 96.0
sbp: 135.0
dbp: 95.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p
silent MI, c/b LV thrombus on warfarin), splenic infarction,
HFrEF (LVEF=35%), COPD, recently discharged from ___
on ___, who re-presents with persistent SOB.
#CORONARIES: multivessel disease, no stenting or PCI
#PUMP: LVEF=35%
#RHYTHM: Normal sinus rhythm |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Quinine
Attending: ___.
Chief Complaint:
weakness, low-grade fever
Major Surgical or Invasive Procedure:
___ Laparoscopic to open cholecystectomy
History of Present Illness:
This patient is a ___ year old male who complains of
___ male who is here for one
week of intermittent fatigue, fevers. They had a 20 minute
episode of discomfort across the chest that was associated
with a fever to 102. The discomfort lasted for about 20
minutes and has not recurred. He denies having any abdominal
pain, vomiting, reports no bowel movement for 5 days but is
passing gas. Also feels like he has been a little bit
unsteady on his feet, contrary to resident note the patient
denies any mumbling speech just says his mouth has been dry.
Past Medical History:
-Diabetes Mellitus
-HTN
-Prostate cancer s/p radical retropubic prostatectomy
-Heart murmur
-h/o Irregular HR in ___, seen by dr ___ - notable for
episodes on NSVT and ATach; was felt to be at risk for AFib
-H/O Mild stress incontinence
-Nephrolithiasis
-Benign L Renal Mass
-Elevated Cholesterol
Social History:
___
Family History:
father had ___ disease
Physical Exam:
ON ADMISSION
Vitals: T:98.1 BP:112/62 P:84 R:20 O2:96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tender to palpation in RUQ, rebound tenderness present,
soft, non-distended,
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No slurred speech. No focal weakness. Wide based,
shuffling gait, cerebellar testing (finger to nose and Romberg)
normal.
ON DISCHARGE ___:
vital signs: t=98.2, hr=53, bp=157/83, oxygen saturation 93%
room air
general: NAD
CV: irregular, ns1, s2, -s3, -s4
LUNGS: clear, no adventitious BS bil
ABDOMEN: soft, mild tenderness, erythematous staple line, no
induration
EXT: no ankle edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 05:09AM BLOOD WBC-15.2* RBC-4.97 Hgb-13.2* Hct-42.4
MCV-85 MCH-26.6* MCHC-31.2 RDW-13.3 Plt ___
___ 05:30AM BLOOD WBC-13.9* RBC-4.64 Hgb-12.8* Hct-39.8*
MCV-86 MCH-27.5 MCHC-32.1 RDW-13.4 Plt ___
___ 06:10AM BLOOD WBC-10.5 RBC-4.21* Hgb-11.9* Hct-35.7*
MCV-85 MCH-28.2 MCHC-33.3 RDW-13.5 Plt ___
___ 11:01PM BLOOD WBC-9.8 RBC-4.93 Hgb-13.6* Hct-41.5
MCV-84 MCH-27.5 MCHC-32.7 RDW-13.3 Plt ___
___ 11:01PM BLOOD Neuts-82.6* Lymphs-7.5* Monos-9.3 Eos-0.5
Baso-0.2
___ 05:09AM BLOOD Plt ___
___ 05:09AM BLOOD ___
___ 07:00AM BLOOD ___ PTT-36.9* ___
___ 11:01PM BLOOD ___ PTT-42.8* ___
___ 06:10AM BLOOD Glucose-153* UreaN-12 Creat-1.2 Na-138
K-3.9 Cl-103 HCO3-26 AnGap-13
___ 07:00AM BLOOD ALT-27 AST-38 AlkPhos-119 TotBili-0.5
___ 05:30AM BLOOD ALT-29 AST-39 AlkPhos-134* TotBili-0.6
DirBili-0.3 IndBili-0.3
___ 11:01PM BLOOD ALT-61* AST-63* CK(CPK)-33* AlkPhos-134*
TotBili-1.5
___ 08:45AM BLOOD Lipase-19
___ 11:01PM BLOOD Lipase-23
___ 07:35PM BLOOD cTropnT-<0.01
___ 08:45AM BLOOD cTropnT-<0.01
___ 11:01PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Albumin-2.9*
___ 06:10AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.2
___ 11:16PM BLOOD Lactate-1.7
___: EKG:
Atrial fibrillation with moderate ventricular response.
Occasionalventricular premature contractions. Left axis
deviation. Inferior wall myocardial infarction of indeterminate
age. Poor R wave progression. Compared to the previous tracing
of ___ atrial fibrillation is new. Premature ventricular
contractions are also new.
___: chest x-ray:
IMPRESSION: Linear left basal opacities most likely atelectasis.
Interval
increase in size of cardiac silhouette over the past few days
could reflect pericardial effusion.
___: gallbladder scan:
Normal morphine sulphate hepatobiliary scan. No evidence of
acute
cholecystitis
___: liver/gallbladder US:
IMPRESSION:
1. Distended gallbladder with mural thickening, sludge and
gallstones. There is no apparent pericholecystic fluid or
sonographic ___ sign. While mural edema is nonspecific and
can also be present with cardiac dysfunction, hypoalbuminemia
and hepatic dysfunction, in the appropriate clinical setting,
this appearance can also be consistent with acute cholecystitis.
HIDA can be obtained for further assessment if indicated.
2. Trace perihepatic free fluid.
___ 9:15 am SWAB
ABCESS/RUPTURED GALLBLADDER PERICHOLECYSTIC ABCESS..
GRAM STAIN (Final ___:
Reported to and read back by ___, R.___. ON ___ AT
1250.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. MODERATE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. MetFORMIN (Glucophage) 425 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. MetFORMIN (Glucophage) 425 mg PO BID
3. Rivaroxaban 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Acetaminophen ___ mg PO Q8H:PRN pain
6. Amlodipine 10 mg PO DAILY
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Calcium Carbonate 500 mg PO QID:PRN heart burn
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO BID:PRN constipation
12. Valsartan 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
acalculus cholecystitis
Secondary diagnosis:
A-fib
Diabetes Mellitus 2
Coronary artery disease
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right upper quadrant pain and fever. Assess for cholecystitis.
COMPARISON: ___ MRI abdomen.
FINDINGS: The liver is normal in echotexture without focal lesion, intra or
extrahepatic biliary ductal dilatation. The common bile duct is normal
measuring 4 mm. The main portal vein is patent with hepatopetal flow. The
gallbladder is distended with sludge and possible intraluminal non shadowing
stones with mural thickening. There is no pericholecystic fluid or
sonographic ___ sign to suggest cholecystitis. The pancreas is not well
seen due to overlying bowel gas nor is the aorta. The imaged IVC is
unremarkable. Trace amount of perihepatic free fluid is noted.
IMPRESSION:
1. Distended gallbladder with mural thickening, sludge and gallstones. There
is no apparent pericholecystic fluid or sonographic ___ sign. While
mural edema is nonspecific and can also be present with cardiac dysfunction,
hypoalbuminemia and hepatic dysfunction, in the appropriate clinical setting,
this appearance can also be consistent with acute cholecystitis. HIDA can be
obtained for further assessment if indicated.
2. Trace perihepatic free fluid.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERALIZED WEAKNESS
Diagnosed with FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.5
heartrate: 82.0
resprate: 18.0
o2sat: 98.0
sbp: 160.0
dbp: 88.0
level of pain: 2
level of acuity: 2.0 | ___ with history of afibrillation presented with sudden-onset
chest pain, increasing right upper quadrant tenderness, and
generalized weakness for the last 8 days. Clinical picture
concerning for acute cholecystitis. Since there was concern for
acute coronary syndrome, troponins were cycled x 3 which were
normal. The patient underwent a ultrasound which showed
gallstones and slugde which could be consistent with acute
cholecystitis. On blood work, he was noted to have an elevated
alkaline phosphatase. He underwent serial abdominal
examinations which remained stable. He then underwent a HIDA
scan which was normal and showed no cholecystitis. However, his
white blood cell count continued to rise with reported increased
in right upper quadrant pain. He was started on intravenous
ciprofloxacin and flagyl.
Because of these findings, he was evaluated by the acute care
service. On HD # 4, he was taken to the operating room where he
underwent a cholecystectomy. He was reported to have acute
gangrenous cholecystitis with a pericholecystic abscess.At the
close of the procedure, he had ___ drain placed into the
galbladder fossa. His operative course was stable with minimal
blood loss. He was extubated after the procedure and monitored
in the recovery room.
His post-operative course has been stable. THe swab from the
gallbladder grew E.coli. The patient remainded afebrile and his
white blood cell count normalized. After bowel function
returned, he was started on clears and advanced to a diabetic
diet. His incisional pain was controlled with intravenous
analgesia with a conversion to oral agents. He was voiding
without difficulty. He was evaulated by physical therapy and
they determined that no acute needs were evident and that when
medically stable, the patient could be discharged home. The
___ drain was removed on ___ and the patient was discharged
home in stable condition. Follow-up appointments were made with
the acute care service and with the primary care provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a pleasant ___ F with a history of
hyperparathyroidism (s/p 3.5 gland parathyroidectomy in 2000s at
___), obesity s/p bariatric surgery presents transferred
from ___ for work-up of presumed first seizure.
She was in her usual state of good health and was walking her
dogs on the beach around 4:30pm on ___. The next thing she
remembers is being in the ambulance going to ___. She reports
people told her she was confused, but she denies incontinence.
She denies having any numbness, tingling, or weakness following
the event. She denies any palpitations or chest pain or
lightheadedness preceding it.
In the ___ ED, vitals were T 98.4 BP 131/62 HR 90 SpO2 99% on
RA. FSBG was 78. She was reportedly "witnessed seizuing by
bystanders."
There, she was given 2mg IV hydromorphone, NaPhosphate 63ml of
0.25mmol/ml solution, IV ondansetron
- Labs were notable for phos 0.8, mg 1.6, K 3.2, Cr 0.6, normal
LFTs, Calcium 8.8
- CT head was without pathology
- CT facial bones showed "Nondisplaced fractures of the right
orbital floor. Righ tmaxillary wall fracutres and hematoma
within the right maxillary sinus"
In The ___ ED initial vitals were: 7 98.7 84 118/50 20 100% 2L
NC
- Received 2.5mg iv diazepam, IV apap, IV fentanyl, 75mg
ketamine, 30mg keterolac
- Her mandible was reduced and follow-up CT showed better
anatomic location of mandible
- OMFS was consulted and recommended supportive care and no
surgical intervention
- Neurology was consulted and recommended MRI and EEG and no
AEDs at this time
- Labs significant for negative serum & urine tox screen, normal
chem-10 (including Mg and Phos), WBC 6.4, Hgb 11.5, Plt 242
Prior to transfer, vitals were: 5 98.1 70 127/76 16 98% RA
Currently, she reports feeling relatively well but endorses mild
headache.
ROS:
Positive for headache and back pain
Negative for chest pain, neck pain, photophobia, fever/chills,
nausea, vomiting, chest pain, palpitations,
numbness/tingling/weakness, dysuria.
Past Medical History:
- Jaw dislocation
* ___ while at dentist, manually reduced
- Bariatric surgery: 2000s. Patient does not recall details
- Hyperparathyroidism
* Removed ___ parathyroid glands
- Anxiety
- Depression
- Chronic low back pain
Social History:
___
Family History:
- Mother died of astrocytoma at age ___
- Father died of multiple myeloma at age ___
- No history of seizures, sudden cardiac death, or cardiac
arrhythmia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.4 BP 132/63 HR 77 RR 12 SpO2 100% on RA
GENERAL: Well appearing
HEENT: EOMI, PERRLA, jaw wrapped
NECK: No JVP. Surgical scar. Thyroid not easily discernible
RESP: CTAB
CV: RRR, no m/r/g
ABD: Surgical scare present, obese, nontender, no masses
EXT: WWP, no edema
NEURO: CNs2-12 intact, motor function grossly normal, PERRLA,
Finger-nose-finger intact, eyes track. No nystagmus appreciated
as previously described
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS: T 97.8 BP 154/80 HR 71 RR 18 SpO2 99% on RA
GENERAL: Well appearing
HEENT: EOMI, PERRLA, jaw wrapped. Ecchymosis below right eye.
Swollen right face. Numbness in infra-orbital nerve
distribution
NECK: No JVP.
RESP: CTAB
CV: RRR, no m/r/g
ABD: Surgical scar present, obese, nontender, no masses
EXT: WWP, no edema
NEURO: Anesthesia in right V2 infraorbital nerve distribution,
otherwise CNs2-12 intact, motor function grossly normal, PERRLA,
Finger-nose-finger intact, eyes track. No nystagmus.
Pertinent Results:
___ 03:40AM BLOOD WBC-6.4 RBC-4.31 Hgb-11.5* Hct-34.3*
MCV-80* MCH-26.7* MCHC-33.5 RDW-14.3 Plt ___
___ 06:33AM BLOOD WBC-4.5 RBC-4.30 Hgb-11.2* Hct-34.9*
MCV-81* MCH-26.2* MCHC-32.2 RDW-14.4 Plt ___
___ 04:58AM BLOOD WBC-4.7 RBC-4.40 Hgb-11.3* Hct-35.4*
MCV-81* MCH-25.7* MCHC-31.9 RDW-14.1 Plt ___
___ 03:40AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 06:33AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-143
K-3.5 Cl-105 HCO3-30 AnGap-12
___ 04:58AM BLOOD Glucose-82 UreaN-8 Creat-0.7 Na-142 K-4.0
Cl-103 HCO3-31 AnGap-12
___ 03:40PM BLOOD ALT-11 AST-15 CK(CPK)-120 AlkPhos-75
TotBili-0.4
___ 03:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.8
___ 03:40PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0
___ 08:55PM BLOOD Calcium-8.8 Phos-3.2 Mg-2.5
___ 06:33AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.4
___ 04:58AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
___ 03:40PM BLOOD 25VitD-16*
___ 03:40PM BLOOD PTH-49
___ 03:40PM BLOOD Prolact-13 TSH-0.80
___ 03:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:00AM URINE Hours-RANDOM UreaN-634 Creat-113 Na-149
K-69 Cl-139 Calcium-14.6 Phos-127.3 Mg-6.7
___ 12:58PM URINE Hours-RANDOM UreaN-168 Creat-63 Na-65
K-15 Cl-58 Calcium-7.0 Phos-18.2 Mg-4.3 HCO3-8
___ 06:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
IMAGING
=======
MRI BRAIN (___)
Axial T2 and MP-RAGE sequences are suboptimal secondary to
patient motion.
There is no intra or extra-axial mass, acute hemorrhage or
infarct. No
abnormal enhancement is noted. Sulci, ventricles and cisterns
are within
expected limits for the patient's age. The dural venous sinuses
are patent.
The major intracranial flow voids are preserved.
Although the subtle abnormalities may not be detected secondary
to patient
motion artifact, there is no clear evidence of gray matter
heterotopia and the
bilateral mesial temporal cortices are unremarkable.
Air-fluid level is seen in the right maxillary sinus. Partial
opacification of
the ethmoid air cells is noted. The orbits are unremarkable. The
mastoid air
cells are essentially clear.
IMPRESSION:
1. The examination is suboptimal secondary to patient motion
artifact.
2. Allowing for this limitation, there is no evidence of
intracranial mass,
acute hemorrhage or infarct.
3. No gross evidence of gray matter heterotopia or abnormalities
of the mesial
temporal cortex.
4. If remains high clinical concern, dedicated seizure protocol
MRI with
contrast may be performed.
5. Air-fluid level in the right maxillary sinus. This may be
seen in acute
inflammatory process such as acute sinusitis. Clinical
correlation is
recommended.
CT FACIAL BONES ___ @ ___
- CT head was without pathology
- CT facial bones showed "Nondisplaced fractures of the right
orbital floor. Right maxillary wall fractures and hematoma
within the right maxillary sinus"
EEG (___)
===
ABNORMALITY #1: During hyperventilation mild generalized theta
slowing is seen
but this resolves within 90 seconds post-HV.
BACKGROUND: Waking background is characterized by a 10 Hz
posterior dominant
rhythm, which attenuates symmetrically with eye opening.
HYPERVENTILATION: See Abnormality #1.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation is
not performed.
SLEEP: During drowsiness, the background slows to central theta
activity,
frontal beta activity becomes more prominent, and the alpha
rhythm attenuates
and becomes intermittent. There is no evidence of stage 2 sleep.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an
average rate of 60-70 bpm.
IMPRESSION: This is a mildly abnormal awake and drowsy EEG given
mild
generalized slowing during hyperventilation, which is a
nonspecific finding.
There are no epileptiform discharges or electrographic seizures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 75 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Celebrex ___ mg oral DAILY
4. Lorazepam 0.5 mg PO QHS:PRN Insomnia
5. Zolpidem Tartrate 5 mg PO QHS Insomnia
6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain
7. Fentanyl Patch 50 mcg/h TD Q48H Back pain
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Fentanyl Patch 50 mcg/h TD Q48H Back pain
3. Lorazepam 0.5 mg PO QHS:PRN Insomnia
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain
5. Venlafaxine XR 75 mg PO DAILY
6. Zolpidem Tartrate 5 mg PO QHS Insomnia
7. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit ___ tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
8. Celecoxib 100 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Syncope
- Right inferior orbital fracture
- Hypophosphatemia
- Hypomagnesemia
- Hypovitaminosis D
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MANDIBLE (PA, ___ AND ___ OBLS)
INDICATION: ___ year old woman with mandible dislocation status post
reduction.
TECHNIQUE: Frontal and lateral views of the mandible were obtained.
COMPARISON: CT from ___
FINDINGS:
The mandible appears to be in improved anatomic alignment following reduction.
Fractures of the right maxillary sinus are better seen on the dedicated CT.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ woman with family history of astrocytoma, presenting
with first seizure. Evaluate for anatomic seizure focus.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: No priors available for comparison on PACS.
FINDINGS:
Axial T2 and MP-RAGE sequences are suboptimal secondary to patient motion.
There is no intra or extra-axial mass, acute hemorrhage or infarct. No
abnormal enhancement is noted. Sulci, ventricles and cisterns are within
expected limits for the patient's age. The dural venous sinuses are patent.
The major intracranial flow voids are preserved.
Although the subtle abnormalities may not be detected secondary to patient
motion artifact, there is no clear evidence of gray matter heterotopia and the
bilateral mesial temporal cortices are unremarkable.
Air-fluid level is seen in the right maxillary sinus. Partial opacification of
the ethmoid air cells is noted. The orbits are unremarkable. The mastoid air
cells are essentially clear.
IMPRESSION:
1. The examination is suboptimal secondary to patient motion artifact.
2. Allowing for this limitation, there is no evidence of intracranial mass,
acute hemorrhage or infarct.
3. No gross evidence of gray matter heterotopia or abnormalities of the mesial
temporal cortex.
4. If remains high clinical concern, dedicated seizure protocol MRI with
contrast may be performed.
5. Air-fluid level in the right maxillary sinus. This may be seen in acute
inflammatory process such as acute sinusitis. Clinical correlation is
recommended.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Jaw pain
Diagnosed with JAW PAIN
temperature: 98.7
heartrate: 84.0
resprate: 20.0
o2sat: 100.0
sbp: 118.0
dbp: 50.0
level of pain: 7
level of acuity: 2.0 | ___ F with history of hyperparathyroidism (s/p
parathyroidectomy), obesity s/p bariactric surgery who presents
after being found down with bystander report of convulsions
concerning for first seizurea.
#) SYNCOPE: Sudden syncopal event without prodrome and
subsequent confusion is suggestive of seizure activity with
post-ictal period; this was considered a provoked seizure in the
setting of hypophosphatemia. However, it appears ___ record of
low phosphate was likely inaccurate (see below) and thus if this
truly was a seizure it was not a "provoked" seizure. Further,
second/third-hand report of convulsions by non-medical observers
may be unreliable. No evidence of cardiac cause of syncope
(EKG/tele normal), or dysautonomia (orthostatics negative.) MRI
head negative for pathology ___ (although not "seizure
protocol" so should have this repeated as an outpatient.) EEG
without epileptiform activity. Neurology was consulted and did
not recommend anti-epileptics. A follow-up appointment was
arranged with Neurologists of ___ to consider further
work-up. She was advised that she cannot drive for 6 months.
#) HYPOPHOSPHATEMIA: Documented value at ___ was 0.8 and she
received IV repletion there. Did not recur at BI in absence of
repletion, bringing into question accuracy of this lab value at
___. Further, there were no other stigmata of hypophosphatemia
(ex. elevated CK from rhabdo which you would expect at a level
that low.) Upon arrival, urine phosphate was high (FEPhos 27%
on ___. Serial measurements of phosphate and magnesium where
normal at ___ without any supplementation whatsoever. Repeat
urinary phosphate on ___ was normal (FEPhos 5%) A normal
FEPhos is ___. Thus her initial phos-wasting urine studies
may have been physiologic if she received an inappropriate load
of IV phosphate at ___ when she was believed to be truly
hypophosphatemic. Her PTH was normal at 45 and calcium was
normal. Vitamin D was low but in isolation this does not
explain a reported phosphate of 0.8. Repeat electrolytes should
be checked as an outpatient.
#) HYPOMAGNESEMIA: Reported mag at ___ was 1.1. Similar story
as with phosphate as above; No evidence of hypmagnesemia at
___ on serial measurements. EKG with normal QTc. Likely a
lab error at ___. Should be re-checked as an outpatient.
#) MANDIBULAR DISLOCATION: Reduced in ED with MAC (ketamine)
#) FACIAL FRACTURES: Nondisplaced fractures of the right orbital
floor. Right maxillary wall fractures and hematoma within the
right maxillary sinus. OMFS was consulted in the ED, who
recommended non-surgical management with pain control and ice
packs. She had anesthesia in the right infra-orbital nerve
distribution likely representing nerve damage from the above
injuries. She was given the outpatient follow-up information.
#) DEPRESSION: Continued home venlafaxine and escitalopram.
#) LOW BACK PAIN: Continued home oxycodone and fentanyl patch.
Held celecoxib since non-formulary
#) INSOMNIA: Continued home zolpidem, lorazepam.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (husband) ___, ___
(sister/HCP) ___
TRANSITIONAL ISSUES
===================
[] F/U with outpatient neurology and consideration of MRI with
seizure protocol
[] Repeat electrolytes including Ca, Mg, Phos as outpatient
- No driving x 6 months |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with a history of
recurrent/advanced ___ s/p chemo/XRT, cardiomyopathy (unclear
etiology, maybe from chemo, EF 40%), DVT s/p IVC filter, CVA,
COPD, HTN, DM who woke up at 2 AM with chest discomfort that
started in abdomen and moved up to his chest. This is associated
with shortness of breath and dizziness. The episode lasted about
a couple hours and was not relieved with TUMS. Patient reports
cough and progressively worsening dyspnea but denies fevers,
chills, chest pain, abdominal pain, dysuria, syncope. Patient
has history of DVTs and has an IVC filter in place.
He takes baby aspirin each day but is not on any other
anticoagulation.
He otherwise reports good exercise tolerance. Takes daily walks
around a park. Denies exertional chest discomfort or shortness
of breath. No orthopnea, sleeps on one pillow. No lower
extremity edema. No recent changes in weight.
In regards to ___, his last cycle of palliative chemo was on
___. According to most recent heme/onc note, he has signs of
disease progression and further options are limited and appears
that an approach of supportive measures is being initiated. He
has a chest CT scheduled for tomorrow.
In the ED initial vitals were: 98.2 108 111/66 16 95% RA
EKG: read as HR 103, low voltage,
CXR- unchanged from prior, BNP 4515
trop- 0.3
guaiac- neg
CTA was performed which was negative for PE. Head CT was
negative for hemorrhagic mets and he was started on a heparin
drip.
On arrival to the floor, patient is feeling well with no
complaints. He wants to know when he can go home.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- ___, on cycle 14 of pemetrexed. diagnosed ___ with stage
IIIB disease. started on etoposide, cisplatin, XRT on ___
-DVT status post filter placement in ___.
-Hypertension
-Macular degeneration
-H/O CVA ___, TIA ___
-COPD
-AAA s/p endovascular repair
Social History:
___
Family History:
No family history of early MI, does have a brother with a "bad
heart" that also beats slow
Physical Exam:
Initial Physical Exam
================
VS: T=98.3 BP=102/64 HR=95 RR=22 O2 sat= 97RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: inspiratory crackles and wheezes heard in all lung
fields, no using as accessory muscles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No ulcers, scars, or xanthomas.
PULSES: 1+ DP pulses b/l
Discharge Physical Exam
================
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: inspiratory crackles and wheezes heard in all lung
fields, no using as accessory muscles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No ulcers, scars, or xanthomas.
PULSES: 1+ DP pulses b/l
Pertinent Results:
INITIAL LAB RESULTS
===============
___ 12:07PM BLOOD WBC-9.4 RBC-3.85* Hgb-12.5* Hct-38.4*
MCV-100* MCH-32.4* MCHC-32.4 RDW-14.6 Plt ___
___ 12:07PM BLOOD Glucose-139* UreaN-28* Creat-1.3* Na-143
K-4.4 Cl-105 HCO3-28 AnGap-14
___ 12:07PM BLOOD CK-MB-12* MB Indx-14.8* proBNP-4515*
___ 12:07PM BLOOD cTropnT-0.35*
___ 07:00PM BLOOD CK-MB-8 cTropnT-0.30*
___ 06:05AM BLOOD CK-MB-5 cTropnT-0.21*
___ 06:05AM BLOOD Calcium-9.6 Phos-2.8 Mg-2.1
IMAGING
=================
___ CXR
IMPRESSION:
Right hilar mass and paramediastinal post treatment changes are
unchanged
since ___. A small to moderate subpulmonic right pleural
effusion has
increased since ___.
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Unchanged right hilar and paramediastinal post-treatment
changes.
3. Slight interval decrease in size of right upper paratracheal
mass compared
to the prior study.
4. Mucoid impaction in the left lower lobe airways, with an
8-mm endoluminal
filling defect in the left lower lobe bronchus which could be a
chronic mucus
plug; however, attention on followup imaging is recommended to
exclude
malignancy.
5. Extensive venous collateralization along the left chest wall
and
paravertebral regions due to narrowing of the left
brachiocephalic vein,
advanced since the prior study.
6. 2.8 cm left supraclavicular soft tissue nodule is concerning
for
metastasis.
7. Stable appearance of aortic arch pseudoaneurysm, as described
above.
___ CT Head
IMPRESSION:
1. No acute intracranial abnormality.
2. Small metastases are better assessed with MRI.
3. Chronic left basal ganglia infarct is unchanged.
___ Cardiac Echo
The estimated right atrial pressure is ___ mmHg. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Images were
not amenable to quantitatively assess LV function. Right
ventricular function is normal. The aortic valve is not well
seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is a small to moderate
sized pericardial effusion (1.1-1.3 cm adjacent to the right
heart chambers). There are no echocardiographic signs of
tamponade (no chamber collapse, IVC plethora; respiratory
inflows not assessed).
IMPRESSION: Suboptimal image quality. Estimated LVEF is 50-55%.
Valves are suboptimally visualized. A small to moderate sized
effusion is seen without echocardiographic evidence of
hemdynamic compromise.
Compared with the prior study (images reviewed) of ___,
tecnically limited images on both exams limits comparison.
However, LV function appears better than on prior study. The
size of the effusion is not appreciably changed.
Discharge Lab Results
===============
___ 09:40AM BLOOD WBC-6.4 RBC-3.99* Hgb-13.3* Hct-39.5*
MCV-99* MCH-33.2* MCHC-33.6 RDW-14.8 Plt ___
___ 09:40AM BLOOD Glucose-100 UreaN-27* Creat-1.3* Na-144
K-4.2 Cl-106 HCO3-31 AnGap-11
___ 09:40AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY:PRN swelling
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Mirtazapine 7.5 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
11. Pravastatin 20 mg PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Tiotropium Bromide 1 CAP IH DAILY
14. Aspirin 81 mg PO DAILY
15. garlic 1,000 mg oral daily
16. Balanced Nutritional (food supplement, lactose-free) one can
oral TID
17. Ocutabs (vitamin A-vitamin C-vit E-min) 1 tab oral daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS
6. Ocutabs (vitamin A-vitamin C-vit E-min) 1 tab oral daily
7. Omeprazole 20 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Tiotropium Bromide 1 CAP IH DAILY
11. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Balanced Nutritional (food supplement, lactose-free) 0 can
ORAL TID
13. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS
14. Furosemide 20 mg PO DAILY:PRN swelling
15. garlic 1,000 mg oral daily
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Nitroglycerin SL 0.4 mg SL PRN chest pain
1 tablet under the tongue every five minutes, Maximum of 3
(three) tablets total, for chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually as needed for
chest pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: non-ST-elevation myocardial infarction, Non-small cell
lung cancer
SECONDARY: Chronic systolic heart failure, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with shortness of breath, intermittent cough //
evaluate for pna
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: CT chest ___.
FINDINGS:
A right hilar mass and right paramediastinal post treatment changes are
unchanged since ___. A small to moderate subpulmonic right pleural
effusion has increased since ___. The left lung is clear. There is no
pneumothorax. The cardiac are normal. There is no free air beneath the right
hemidiaphragm.
IMPRESSION:
Right hilar mass and paramediastinal post treatment changes are unchanged
since ___. A small to moderate subpulmonic right pleural effusion has
increased since ___.
Radiology Report
HISTORY: ___ male with chest pain, hypoxia and elevated troponin.
Evaluation for pulmonary embolism and right heart strain. Further history
denotes the patient has a known history of non-small cell lung cancer, as well
as a tender nodule or lymph node above the left clavicle.
COMPARISON: Comparison is made to multiple prior studies, including most
recent from ___, dating back to ___.
TECHNIQUE: Axial MDCT images were obtained through the thorax after the
dynamic administration of Omnipaque intravenous contrast material.
Reformatted coronal and sagittal images were also reviewed.
DLP: 584.9 mGy-cm.
FINDINGS: There is no evidence of filling defect within the main, right, left,
lobar, segmental or subsegmental pulmonary arteries. The main and right
pulmonary arteries are of normal caliber.
There is redemonstration of mural outpouching along the undersurface of the
aortic arch (2:54), compatible with known pseudoaneurysm, unchanged since
___. There is no evidence of intramural hematoma or aortic dissection.
Extensive collateralization of vessels along the left anterior and posterior
chest wall, as well as in the paravertebral regions has progressed since prior
studies, likely owing to focal narrowing of the left brachiocephalic vein
(2:26), which may be partially occluded, although intravenous contrast is
identified throughout its course. A moderate right pleural effusion has
increased in size since the prior study, and a small pericardial effusion
appears relatively stable. The overall heart size is unchanged. The
esophagus is unremarkable.
Extensive post-treatment changes along the bilateral paramediastinal regions,
particularly in the right upper lobe, at the site of previously treated lung
mass appear overall similar in comparison to the prior study. No new
pulmonary mass or concerning nodules are identified. Stable scattered
pulmonary nodules, some of which are ground-glass, and other solid measure
less than 4 mm, and are unchanged compared to the prior study (2:54, 2:39). A
right upper paratracheal lymph node measures 2.1 x 2.1 cm, slightly decreased
since the prior study when it measured 2.7 x 2.5 cm (2:36).
Moderate centrilobular background emphysema is overall unchanged, and areas of
mucus plugging in the left lower lobe airways appear similar compared to prior
studies.
A soft tissue endobronchial nodule in the left lower lobe bronchus (2:84)
measures approximately 8 mm, and is similar in appearance compared to numerous
prior studies, possibly a mucus plug; however, attention on followup imaging
is recommended to exclude endobronchial malignancy.
No significant mediastinal or hilar lymphadenopathy is noted. No
supraclavicular lymphadenopathy is noted on the right. A 2.8 x 2.0 cm soft
tissue nodule in the left supraclavicular fat pad is concerning for metastasis
(2:11).
Incidental note is made of aberrant right subclavian artery, which is not
dilated. A small hiatal hernia is present.
Although this study is not designed for evaluation of subdiaphragmatic
structures, there is no focal hepatic lesion, and a cystic lesion arising from
the superior pole of the left kidney is unchanged. No lytic or blastic lesion
suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Unchanged right hilar and paramediastinal post-treatment changes.
3. Slight interval decrease in size of right upper paratracheal mass compared
to the prior study.
4. Mucoid impaction in the left lower lobe airways, with an 8-mm endoluminal
filling defect in the left lower lobe bronchus which could be a chronic mucus
plug; however, attention on followup imaging is recommended to exclude
malignancy.
5. Extensive venous collateralization along the left chest wall and
paravertebral regions due to narrowing of the left brachiocephalic vein,
advanced since the prior study.
6. 2.8 cm left supraclavicular soft tissue nodule is concerning for
metastasis.
7. Stable appearance of aortic arch pseudoaneurysm, as described above.
Radiology Report
HISTORY: ___ man with advanced nonsmall cell lung cancer, presenting
with altered mental status. Evaluation for hemorrhagic metastasis, prior to
administering heparin.
COMPARISON: Comparison is made to MRI of the brain from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast. Reformatted coronal,
sagittal and thin slice bone images were also reviewed.
DLP: 1003.4 mGy-cm.
CTDIvol: 53.0 mGy.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or large vascular territorial infarction. The ventricles and sulci
are unchanged in size or configuration, slightly prominent, in keeping with
age-related atrophic changes. Chronic infarct involving the left basal
ganglia (3A:13) is unchanged. The gray-white matter differentiation is
preserved, and the basal cisterns appear patent. There is no shift of the
normally midline structures.
The cranial and facial soft tissues are unremarkable. The orbits are normal
in appearance. There is no evidence of fracture. Mucosal thickening in the
ethmoid air cells is noted, otherwise, the visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are grossly clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Small metastases are better assessed with MRI.
3. Chronic left basal ganglia infarct is unchanged.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC, TACHYCARDIA NOS, HYPOXEMIA
temperature: 98.2
heartrate: 108.0
resprate: 16.0
o2sat: 95.0
sbp: 111.0
dbp: 66.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with advanced NSCLC and
cardiomyopathy of unclear etiology with EF 40%, who presents
with chest pain and dyspnea, found to have an NSTEMI.
ACUTE ISSUES
# NSTEMI:
The patient received medical management of his NSTEMI given his
life-limiting illness and poor prognosis with advanced
malignancy. He was started on a heparin drip and received
Enoxaparin to complete 48 hours of anti-coagulation. He was also
started on metoprolol for a heart rate goal <70, and SL nitro
PRN chest pain. His home statin was switched to Atorvastatin
80mg. He was also further evaluated with a cardiac echo which
revealed an improved left ventricular function from prior and a
stable pericardial effusion. By morning of admission, the
patient was chest pain free and denied chest pain throughout his
hospital stay.
# Pericardial effusion:
The patient was noted to have a small pericardial effusion on CT
imaging. A cardiac echo revealed a small to moderate sized
pericardial effusion without echocardiographic signs of
collapse.
# Cardiomyopathy
The patient has a known cardiomyopathy with an EF of 40% on echo
from ___. He was euvolemic on exam despite an elevated BNP.
His chest CT did not show evidence of pulmonary edema, and a
repeat cardiac echo showed an improved EF of 50-55%. He was
maintained on his home Lisinopril 2.5mg daily, and his home
furosemide was initially held and then restarted on discharge.
# R pleural effusion:
The patient was noted to have a right pleural effusion,
increased in size from prior imaging. His dyspnea improved with
resolution of his chest pain, and he was satting well on RA.
Thus further work up of his right pleural effusion was deferred.
CHRONIC ISSUES
# NSCLC:
The patient's CTA demonstrated stable appearing paratracheal and
paramediastinal masses. He was continued on his home inhalers
and should follow up with his out-patient oncologists. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen / ___ pig
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with poorly controlled asthma, bronchiectasis, history
of positive PPD and tobacco use presents with shortness of
breath.
The patient has had a complicated course over the last couple of
years with exacerbations requiring frequent steroid tapers,
antibiotics and hospital admissions. She has at least two ICU
stays with one intubation and one bipap. Over the last few
weeks, she reports worsening shortness of breath again. She was
prescribed a steroid taper that started around ___. She
reports improving on the 40mg dose, but by the time she tapered
to 10mg, the symptoms has started again. She increased herself
back to 30mg prednisone for 2 days on ___ and ___ but then
stopped completely because she was out of medication and did not
have any refills. So she has been without steroids since ___.
She reports increased dyspnea, especially on exertion. SHe is
unable to walk across the room to get to her bathroom. She has
chest tightness and wheezing. She has been using her home
nebulizers and inhalers with increased frequency, with nebs up
to four times a day (previously only once a day), which provide
some relief. She denies any fevers or chills.
Patient was seen in outpatient ___ clinic and was
referred to ___ for respiratory distress. At the outside
office, her FEV1 fell to 30% from 90% at baseline. Her work-up
through the outpatient clinic has included negative ANCA, but
there was still a concern that patient has ANCA-negative
___. She received 125mg IV solumedrol, 2 duonebs and
750mg levaquin. She had a flu swab taken and labs including IgE,
ESR, CRP, ANCA were all drawn in clinic, as well as a sputum
culture.
In the ED intial vitals were: 98.0 95 130/88 30 95% RA
- Labs were significant for WBC 11
- Patient was given duonebs, levoflox and methylpred
- CT scan showed some improvement from previous scans of tree in
___ pattern
Vitals prior to transfer were: 98 77 126/87 18 98% RA
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Asthma (diagnosed in ___
- Brochiectasis
- Pulmonary nodules (detected in ___, follow-up CT in ___
showed no progression)
- positive PPD
Social History:
___
Family History:
FAMILY HISTORY: Grandmother had asthma. Father had ___,
HTN, and died of Stomach cancer. Mother had HTN and uterine
cancer. Daughter has ___.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=============================
Vitals- 98.6 1074/81 93 20 96% RA
General- NAD, but becomes dyspneic with speech
HEENT- PERRL, no scleral icterus, no OP erythema or exudates
Neck- supple, no cervical LAD
Lungs- poor air movement bilaterally and diffuse wheezes
CV- RRR, no m/r/g
Abdomen- soft, NT, ND
Ext- no peripheral edema
Neuro- nonfocal
PHYSICAL EXAM ON DISCHARGE:
============================
Vitals: 98.3 ___ 98%
General: Alert, oriented, no acute distress, no conversational
dyspnea, can speak in full sentences but coughs with deep
breathing on lung exam
HEENT: Sclera anicteric, MMM, a few white lesions in the hard
palate
Neck: supple, JVP not elevated, no LAD
Lungs: mild wheezes with good air entry
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: non-focal
Pertinent Results:
LABS ON ADMISSION:
==================
___ 09:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 09:35PM URINE RBC-7* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-1
___ 06:53PM ___ PO2-62* PCO2-40 PH-7.41 TOTAL CO2-26
BASE XS-0
___ 06:53PM LACTATE-1.8
___ 06:53PM O2 SAT-90
___ 06:45PM GLUCOSE-171* UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 06:45PM WBC-11.8* RBC-5.22 HGB-14.3 HCT-45.0 MCV-86
MCH-27.4 MCHC-31.8 RDW-14.0
___ 06:45PM NEUTS-92.4* LYMPHS-6.0* MONOS-0.8* EOS-0.4
BASOS-0.5
___ 06:45PM PLT COUNT-316
PERTINENT LABS:
==============
___ 06:50AM BLOOD ALT-27 AST-21 LD(LDH)-198 AlkPhos-81
TotBili-0.2
___ 06:50AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.7 Mg-2.0
___ 06:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:15AM BLOOD HCG-<5
___ 06:50AM BLOOD HCV Ab-NEGATIVE
LABS ON DISCHARGE:
===================
___ 06:15AM BLOOD WBC-15.1* RBC-4.62 Hgb-12.5 Hct-39.8
MCV-86 MCH-27.1 MCHC-31.5 RDW-14.2 Plt ___
___ 06:15AM BLOOD Glucose-211* UreaN-20 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-25 AnGap-16
___ 06:15AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.3
MICROBIOLOGY:
===============
DFA ___:
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
BLOOD CULTURE ___: NO GROWTH.
STUDIES:
=========
CT CHEST ___:
1. Overall improvement of bronchial wall thickening and mucous
plugging. Marginally more prominent ___ opacities in
right upper lobe suggestive of small airways disease in light of
other findings.
2. Pulmonary nodule in the left lower lobe laterally, similar
to prior exam. Recommend follow-up CT chest in one year if she
has risk factors.
CXR ___:
Frontal and lateral views of the chest. Heart size and
cardiomediastinal
contours are normal. Lungs are clear without focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
No focal consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. PredniSONE 10 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
6. Tiotropium Bromide 1 CAP IH DAILY
7. Omeprazole 40 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Montelukast Sodium 10 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
6. Tiotropium Bromide 1 CAP IH DAILY
7. Nystatin Oral Suspension 5 mL PO QID thrush
RX *nystatin 100,000 unit/mL 5 cc by mouth four times a day Disp
#*1 Bottle Refills:*0
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg One tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
9. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg One tablet(s) by mouth daily Disp #*80
Tablet Refills:*0
10. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
11. Azathioprine 50 mg PO DAILY
RX *azathioprine 50 mg One tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath, history of likely and ANCA-negative
___, concerning for infection.
TECHNIQUE: MDCT imaging of the chest without intravenous contrast was
performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT chest from ___.
FINDINGS: Overall improvement of bronchial wall thickening and mucous
plugging, with ___ opacities marginally more prominent now in the
right upper lobe compared to prior. The atelectasis previously seen in the
right lung base has improved. A granuloma is seen in the right lung base. A
nodule is seen along the major fissure in the right lobe, which appears
unchanged from prior exam (4:128). The previously seen nodule in the left
lung base is no longer appreciated on this exam. A nodule is seen in the left
lower lobe laterally, unchanged from prior exam (4:132). No pathologically
enlarged axillary, mediastinal, or hilar lymph nodes are identified. There is
no pleural or pericardial effusion. The heart, pericardium, and great vessels
are within normal limits. The thyroid gland is unremarkable.
This study is not tailored for subdiaphragmatic evaluation, but the visualized
intra-abdominal organs are unremarkable.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen.
IMPRESSION:
1. Overall improvement of bronchial wall thickening and mucous plugging.
Marginally more prominent ___ opacities in right upper lobe suggestive
of small airways disease in light of other findings.
2. Pulmonary nodule in the left lower lobe laterally, similar to prior exam.
Recommend follow-up CT chest in one year if she has risk factors.
Updated findings from wet read were communicated to Dr. ___ at 11:05 p.m.
on ___ by phone.
Radiology Report
HISTORY: Asthma vs Churg ___ presenting with shortness of breath.
COMPARISON: Multiple prior exams, most recently of ___.
FINDINGS:
Frontal and lateral views of the chest. Heart size and cardiomediastinal
contours are normal. Lungs are clear without focal consolidation, pleural
effusion, or pneumothorax.
IMPRESSION:
No focal consolidation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: WHEEZING
Diagnosed with SHORTNESS OF BREATH
temperature: 98.0
heartrate: 95.0
resprate: 30.0
o2sat: 95.0
sbp: 130.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with poorly controlled asthma, bronchiectasis, history
of positive PPD and tobacco use presents with shortness of
breath.
# Asthma exacerbation - Most likely due to discontinuing home
prednisone and non-compliance with medications. We initially
placed pt on solumedrol 125mg Q6hr x2 days and further
transitioned her to prednisone 40mg. However, patient's symptoms
and lung exam worsened upon transitioning to prednisone and
thus, taper may have been too quick for her. We resumed
solumedrol 125mg Q6hr x2 days, then tapered to 80mg Q8 x1 day
and then to prednisone 60mg daily with the following taper: 60mg
x5 days, 50mg x3 days, 40mg x3 day, 30mg x3 days, 20mg x3 days,
10mg until f/u with Dr. ___. We also treated her with
levofloxacin for total of 7 days, last dose on ___. Per
pulmonogy recommendation, we initiated azathioprine 50mg daily
upon discharge upon normal LFT's, negative hepatitis serology,
and negative serum HCG. Given concern for EGPA on behalf of
primary pulmonologist, we consulted rheumatology who believed
that current presentation is unlikely to be due to EGPA given
lack of symptoms suggestive of vasculitis and other systemic
involvement. We also initiated bactrim for PCP ___.
There was evidence of thrush due to chronic steroid use and
patient was started on nystatin mouth wash. The following were
found on outside hospital records: IgE 181 and ESR 34.
# hand and leg pain/numbness - Peripheral neuropathy is a common
presentation in EGPA but usually presents as mononeuritis
multiplex, or as peripheral neuropathy in "stocking and glove"
distribution. Her presentation is more c/w radicular vs.
vasculitic.
- outpatient f/u w/ neurology as previous work-up suggestive of
cervical stenosis, had recommended MRI.
- Rheum consult as above
# pulmonary nodules - unclear significance
- radiology recommends f/u study with CT in ___ year.
TRANSITIONAL ISSUES:
[] neuropathy of ___ - has appointment scheduled with
neurology as there is concern for radicular neuropathy
[] hypertension: pt hypertensive to 150's/100's throughout
hospital course. Currently, on no antihypertensives. Renal
function normal.
[] attention to follow-up regarding LLL pulmonary nodule noted
on
chest CT dated ___
[] please schedule close follow-up (within ___ weeks) with Dr.
___ pulmonary) and with PCP
[] drug monitoring as above
[] follow-up pending studies as above
[] follow-up blood glucose level as outpatient while on steroid
therapy
[] Has received pneumonia vaccine in ___ at ___ and flu vaccine
on ___. Will need prevnar at clinic follow-up when on lower
dose of steroids |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with recently diagnosed metastatic
pancreatic cancer c/b biliary obstruction s/p CBD stent ___ and
chole tube ___ who is admitted from ED with fever. Patient
with recent hospitalizations for recurrent fevers and hx
cholecystitis requiring biliary stent w/ revisions and long term
abx for meropenem resistant pseudomonal bacteremia (+bile ___,
blood and bile ___. Admit ___ for fever and abx changed to
ceftolazone/tazobactam, as bile from ___ again + pseudomonas.
Readmitted ___ w/ fever. he was found to have RUE DVT.
Chole
tube and CBD stent in good position w/ no drainable fluid
collection. MRCP showed progression of liver mets. There was no
other cause of fever found and was attributed to DVT, PICC
removed. He was discharged off abx, last ___. chole tube was
also
capped w/ plan for removal in 4 days. tube removed ___.
His partner called to report low grade temp last evening, he was
reluctant to present to ED. agreed to not take tylenol in case
masking fever. of note his partner check his temp every ___
hours
at home. when he check again at 2am was 101. Denies any chills
or rigors, pt did not notice fever. He has been having some
nights sweats lately but not every night. Pt denies cough,
shortness of breath, worsening abdominal pain, diarrhea,
dysuria,
urethral discharge, headache, sinus congestion or pressure, sore
throat, skin lesions, mouth sores. No sick contacts. Ab pain is
mainly in epigastric area, not worse w/ eating, no RUQ pain.
He does have chronic constipation related to narcotics. Had BM
___ after doing enema at home. Per partner he is sleeping more.
Initial VS 03:50 0 99.8 104 124/77 20 94%.
Liver U/S did not show intrahepatic bili dilatation
In ED was given 4L LR, vancomycin, tobramycin, tylenol, his
scheduled lovenox and oxycodone
HR imiproved to ___. BP stable 110/80s.
Past Medical History:
PAST ONCOLOGIC HISTORY:
per OMR
Pt reports that his symptoms began on ___, at which time he
noted nonradiating RUQ pressure when he lay down to sleep. He
took tums without relief. RUQ discomfort was intermittent, worse
at night, with associated darkening of urine
and yellowing of his sclera. He also noted onset of light yellow
loose stools on ___. Denies history of similar symptoms. He
presented to HIV provider, Dr. ___, at ___ for
consideration of ART initiation on ___. Given his RUQ pain
and jaundice, LFTs and CT abdomen were ordered, which revealed
cholestasis and a pancreatic head mass, with possible
pulmonary/pleural and hepatic metastases. In light of these
results, urgent ERCP was arranged. CEA 54. Biopsy from ___ ___ile duct stricture showed poorly differentiated
carcinoma, consistent with adenocarcinoma of a biliary or
pancreatic origin.
Also He had a CT chest with contrast at ___ on ___
demonstrated innumerable pleural-based nodules in both lungs
measuring up to 9 mm. These are indeterminate and metastases
cannot be excluded.
Admitted ___ to ___ to ___. CBD stent changed to metal
stent on ___. Blood culture with pseudomonas, intermediate
resistant to meropenem. Biliary culture with pseudomonas,
resistant to meropenem. Infectious disease consulted and he was
treated with tobramycin and extended infusion cefepime. MRCP
revealed lesions that could be early abscesses vs mets, so he
was
kept on the beta-lactam, although the pseudomonas had
intermediate sensitivity. He had a PICC placed and will continue
IV antibiotics for at least 4 weeks and will require eventual
reimaging to evaluate for abscesses. MRCP also showed possible
partial portal vein thrombosis, however, RUQ doppler showed no
thrombosis.
Admitted to the ___ from ___ after several days of
fever following an ___ procedure on ___. His bile grew out
MDR
pseudomonas. on ___ he was started on ceftolozane-tazobactam
1.5 gm IV every 8 hr through a ___ line
PAST MEDICAL HISTORY:
Cholangitis
Cholecystitis s/p cholecystostomy placement
HIV-1 infection - diagnosed in ___ in setting of other STDs,
treatment naive. Last CD4 ___,000 on ___.
Eczema
Syphilis
s/p appendectomy
Social History:
___
Family History:
Father diagnosed with gastric cancer in his ___. No FH
pancreatic cancer. Mother with asthma.
Physical Exam:
DISCHARGE EXAM
General: NAD, thin
VITAL SIGNS: 98.1 110/70 95 18 95%RA
HEENT: MMM, no OP lesions, no scleral icterus
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, L chole
site well healed no erythema or drainge
EXT: warm well perfused, no edema
SKIN: No rashes or bruising, depigmented plaques over L
face/neck and posterior scalp
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
Pertinent Results:
ADMISSION LABS:
___ 04:47AM BLOOD WBC-6.5 RBC-2.61* Hgb-7.2* Hct-22.3*
MCV-85 MCH-27.6 MCHC-32.3 RDW-18.2* Plt ___
___ 04:47AM BLOOD Glucose-110* UreaN-16 Creat-1.5* Na-130*
K-4.4 Cl-94* HCO3-25 AnGap-15
___ 04:47AM BLOOD ALT-49* AST-47* AlkPhos-341* TotBili-0.3
___ 04:47AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.4 Mg-1.7
___ 04:52AM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.3* Hct-27.1*
MCV-84 MCH-28.6 MCHC-34.1 RDW-18.4* Plt ___
___ 06:50AM BLOOD Glucose-95 UreaN-9 Creat-1.2 Na-137 K-3.9
Cl-101 HCO3-26 AnGap-14
___ 06:50AM BLOOD ALT-37 AST-34 AlkPhos-287* TotBili-0.4
MICRO:
blood cultures x 2 ___ - negative to date
urine culture negative
IMAGING:
MRCP ___:
IMPRESSION:
No significant intraabdominal change status post removal of
percutaneous cholecystostomy tube. No evidence of recurrent
acute cholecystitis or collection.
Pancreatic head tumor with local vascular involvement, and
diffuse hepatic and nodal metastases, unchanged from recent
priors.
Slight increase in bilateral pleural effusions. Subpleural
parenchymal
nodules are visualized in regions of prior consolidation. These
could
represent residual consolidation or metastases.
RUQ U/S ___
IMPRESSION:
1. No intrahepatic biliary duct dilation. Unchanged appearance
of the common
bile duct stent, with pneumobilia suggesting the stent is
patent.
2. Collapsed gallbladder with wall thickening, which is
nonspecific. There
is a small amount of curvilinear foci of fluid around the
gallbladder but no
discrete drainable fluid collection. Residual inflammatory
change in this
region is not excluded.
3. Pancreatic head mass and liver metastases, which were better
characterized
on the prior MRI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC DAILY
2. Acetaminophen 650 mg PO Q6H:PRN fever
3. Docusate Sodium 100 mg PO BID
4. Lorazepam 0.5 mg PO BID:PRN nausea/anxiety
5. Multivitamins 1 TAB PO DAILY
6. Nystatin Oral Suspension 5 mL PO QID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Senna 8.6 mg PO BID
9. Temazepam 15 mg PO QHS:PRN sleep
10. Polyethylene Glycol 17 g PO DAILY
11. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 100 mg SC DAILY
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
3. Lorazepam 0.5 mg PO BID:PRN nausea/anxiety
4. Multivitamins 1 TAB PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Temazepam 15 mg PO QHS:PRN sleep
9. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
10. Acetaminophen 650 mg PO Q6H:PRN fever
11. Nystatin Oral Suspension 5 mL PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic cancer
Fever
History of biliary obstruction s/p bile duct stenting and
percutaneous cholecystostomy tube now removed
History of multi-drug resistant pseudomonas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: Metastatic pancreatic cancer and fever. Assess for biliary
dilation.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the right upper
quadrant were obtained.
COMPARISON: T-Tube cholangiogram from ___. MRI of the abdomen and
pelvis from ___. Right upper quadrant ultrasound from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits.The contour of the
liver is smooth. There are several ill-defined hypoechoic masses in the
liver, which are compatible with the known metastases. These are better
evaluated on the recent MRI. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. A common bile duct
stent is in place, obscuring evaluation of the common bile duct. This is
similar to the prior exam. Pneumobilia is present, suggesting the stent is
patent.
GALLBLADDER: Since the prior exam, the cholecystostomy tube has been removed.
The gallbladder appears collapsed and thick walled. There are some
curvilinear areas of fluid around the gallbladder, but no discrete drainable
fluid collection.
PANCREAS: There is an unchanged hypodense mass in the head of the pancreas,
better assessed on the prior MRI. There is pancreatic duct dilation.
KIDNEYS: Limited views of the right kidney demonstrate no hydronephrosis or
large mass.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
Small right basal pleural effusion with mild atelectasis is noted.
IMPRESSION:
1. No intrahepatic biliary duct dilation. Unchanged appearance of the common
bile duct stent, with pneumobilia suggesting the stent is patent.
2. Collapsed gallbladder with wall thickening, which is nonspecific. There
is a small amount of curvilinear foci of fluid around the gallbladder but no
discrete drainable fluid collection. Residual inflammatory change in this
region is not excluded.
3. Pancreatic head mass and liver metastases, which were better characterized
on the prior MRI.
Radiology Report
INDICATION: Fevers of uncertain etiology. Evaluate for pneumonia.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph from ___. CT of the chest from ___.
FINDINGS:
The lung volumes are low and linear opacities at the bases most likely
represent atelectasis. Otherwise there is little change. There is no focal
consolidation to suggest pneumonia. There is no pulmonary edema. The small
subpleural nodule seen on the prior CT of the chest are not well visualized on
today's exam. There are small bilateral pleural effusions. No pneumothorax is
identified. The cardiomediastinal silhouette is normal. A metallic biliary
stent is present in the right upper quadrant.
IMPRESSION:
Small bilateral pleural effusions and bibasilar atelectasis. No definite
pneumonia.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with hx recurrent MDR pseudomonas, recurrent
fever after perc chole tube removal
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 T magnet, including 3D dynamic sequences obtained prior to,
during, and following the administration of 6 cc of Gadavist intravenous
contrast. The patient also received oral contrast of 1 cc of Gadavist diluted
in 50 cc of water.
COMPARISON: The abdominal CT dating ___. MRCP dating ___
and ___.
FINDINGS:
There is been slight interval increase in size of bilateral pleural effusions,
left greater than right. Mild adjacent airspace opacity is noted at both lung
bases. There also nodular foci of enhancement previously obscured by airspace
opacity such as within the subpleural, anterior right lung base (10:15).
These may relate to residual consolidation, although metastases should be
considered.
Innumerable hepatic lesions are again seen scattered throughout the liver
parenchyma. These are T2 hyperintense with indistinct and hazy margins. Each
demonstrates markedly restricted diffusion, and T1 hypointensity. Each is
hypoenhancing compared with the surrounding parenchyma. During the arterial
phase of imaging there is transient parenchymal hyperenhancement of the left
lobe, accounted for by asymmetric left portal vein narrowing, unchanged from
prior (1403: 73).
The gallbladder continues to be decompressed status post recent removal of the
percutaneous cholecystostomy tube. There is residual gallbladder wall
thickening and mucosal hyperemia. The cystic duct is dilated, similar to
prior, appearing truncated at the level of the metallic stent within the
common bile duct. Maximum diameter of the cystic duct is 1.2 cm (11:3).
There is re- demonstration of a large pancreatic head mass with approximate
axial ___ of 2.1 x 3.7 cm. The upstream pancreatic parenchyma is
atrophied with main duct dilation to 5 mm. This mass abuts the anterior aspect
of the distal common bile duct, which contains a metallic stent. The distal
proper hepatic artery and proximal common hepatic artery course along the
superior margin of the tumor, and gastroduodenal artery traverses the tumor.
There is marked focal narrowing of the portal vein/SMV confluence which
appears to remain patent.
Lymphadenopathy is seen within the porta hepatis and gastrohepatic ligament,
unchanged from prior.
The spleen, adrenal glands and kidneys are unremarkable.
There is a trace amount of abdominal ascites, not significantly changed from
prior
Note is made of dilated vessels within the right axilla.
Arterial vascular anatomy is notable for a replaced left hepatic artery.
No focal osseous lesion of concern is identified.
IMPRESSION:
No significant intraabdominal change status post removal of percutaneous
cholecystostomy tube. No evidence of recurrent acute cholecystitis or
collection.
Pancreatic head tumor with local vascular involvement, and diffuse hepatic and
nodal metastases, unchanged from recent priors.
Slight increase in bilateral pleural effusions. Subpleural parenchymal
nodules are visualized in regions of prior consolidation. These could
represent residual consolidation or metastases.
Gender: M
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, MALIG NEO PANCREAS NOS
temperature: 99.8
heartrate: 104.0
resprate: 20.0
o2sat: 94.0
sbp: 124.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | ___ hx HIV recently started on HAART, recently dx metastatic
panc CA c/b biliary obstruction s/p CBD stent and recently
removed perc chole tube, who presents from ED w/ recurrent
fever.
# Fever with SIRS: Remained HD stable since IVF bolus in ED.
Given pt hx concerning for recurrent cholangitis/cholecystitis
or liver abscess although no WBC elevation, GB not thickened on
U/S and no RUQ pain. Also possible recurrent pseudomonas
bacteremia but no signs of sepsis since admission.
- given vanco/tobra in ED but did not cont as tobra led to renal
insufficiency in recent past and no hx MRSA or other indication
for vanco at this time
- pt was resumed on ceftolazone/tazobactam to cover prior MDR
pseudomonas (had been stopped on ___ however cx neg for 48 hrs,
stopped am ___
- no further fevers off antibiotics. Liver U/S and MRI without
signs of cholecystitis/cholangitis.
- discussed w/ ___, no plans for replacement of drain given
stable imaging
During his admission was noted to have nightly temp elevation
___, reports some night sweats at home. suspect fevers prior to
admission may have been related to underlying malignancy
#Anemia - symptomatic w/ fatigue. possible chronic blood loss w/
iron def as there was some invasion of duodenum by panc mass on
last ERCP in ___ but no ulceration or bleeding at that time.
iron studies this admission more c/w ACD, is able to mount some
reticulocytosis.
- hapto/LD normal
- mod low iron, elevated ferritin, low TIBC more c/w ACD than
true iron def
- hgb declined to 6.7 after IVF on admission, pt received total
2U PRBCs ___ and ___
- guiac stools x 3 negative
#Renal insufficiency - timing c/w prior tobra nephrotoxicity,
has been slowly improving, Cr 1.2 on discharge (prev up to 1.9)
# Right PICC-assocd DVT: RUE U/S positive for DVT on ___. PICC
removed, swelling has resolved. Cont on daily lovenox.
# Pancreatic adenocarcinoma: Followed by Dr ___ w/ ___.
Chemotherapy has been delayed due to mult prior infectious
complications. per Dr ___ like him to be off antibiotics
for 2 weeks prior to starting therapy. Other than 48 hrs
antibiotics this admission, last antibiotic course ended ___.
He will f/u w/ Dr ___ week
# HIV: recently initiated HAART w/ triumeq. Per ID notes is long
term nonprogressor. Last known CD4 313 & viral load 20K on
___, recently started receiving HIV care by Dr ___
at ___. triumeq continued while inpt
PAIN: cont home oxycodone
BOWEL REGIMEN: cont home regimen senna/docusate increase miralax
to daily (was prn) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
Arm pain
Major Surgical or Invasive Procedure:
POC placement ___
History of Present Illness:
___ is a ___ year old man with recently diagnosed
high-grade soft tissue sarcoma of the right upper arm who was
transferred to ___ with bleeding from his tumor and plan to
urgently initiate radiation treatment.
Patient initially presented to ___ in ___ with
several
months of relatively painless enlarging mass of upper right arm.
He underwent US guided biopsy on ___ which confirmed
diagnosis of high grade sarcoma. He established in our
___ clinic on ___ with plans for
neo-adjuvant radiation therapy followed by limb preserving
surgery.
However, on ___ he developed spontaneous hemorrhage from his
right arm mass. He presented to OSH before transfer to ___. He
was initially admitted to the orthopedics service, and there was
at least some thought regarding embolization to control the
hemorrhage. Fortunately, the bleeding resolved and he remained
HDS. He started XRT treatment today and is being transferred to
the oncology service.
On interview, patients main concern is right arm pain. It has
been slowly progressive over the last few months as his tumor
has
grown, and has now become a constant ___ aching pain with
tingling in his right bicep. He gets moderate relief with
oxycodone 10mg for about two hours. He was started on oxycontin
10mg q12 hours prior to transfer. He denies fevers or chills. No
recent URTI. No headache or visual changes. No dysphagia or
odynophagia. No CP, SOB or cough. No N/V/D. Large normal BM this
am. Denies hematochezia or melena. No dysuria. He has some mild
bilateral leg edema, which he reports is due to missing his home
HCTZ. No new rashes. No leg pain.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. ___ is a ___ man
with a history of chronic lower back pain who in ___
fell down the stairs in his house suffering multiple bruises.
He
did not seek evaluation at the time however several weeks later
he noticed a bump appearing in his right arm in the area of the
lower biceps muscle which he initially thought was a persistent
bruise related to his fall. The mass was painless but
uncomfortable with deep palpation, and over the subsequent
months
grew steadily. The skin over the mass also began to become
erythematous prompting him to seek evaluation. MRI of the right
arm on ___ showed an enhancing and infiltrative
mass measuring up to 10 cm with involvement of the
brachioradialis and biceps muscles. There was also noted to be
abnormal heterogeneous marrow pattern concerning for involvement
of the humerus; however, plain films on ___ showed
no evidence of bone erosion or periostitis in the adjacent
humerus. Ultrasound-guided core biopsy on ___ showed
high-grade pleomorphic sarcoma. CT chest on ___
showed no evidence of pulmonary metastases or enlarged regional
lymph nodes.
- ___: Established care with ___ Radiation oncology
PAST MEDICAL HISTORY:
- Anemia
- Hypertension
- Chronic low back pain
Social History:
___
Family History:
Mother with cervical cancer. No other known family history of
cancer.
Physical Exam:
PHYSICAL EXAM:
___ 1133 Temp: 99.5 PO BP: 136/82 L Sitting HR: 109 RR: 18
O2 sat: 97% O2 delivery: RA
GENERAL: Pleasant, anxious man sitting up in bedside chair in
NAD.l
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 1+ radial pulses bilaterally. 1+ peripheral edema in
bilateral lower extremities.
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding
MUSKULOSKELATAL: Right arm with large subcutaneous swelling over
anterior bicep is dressed and wrapped. He has 1+edema distally
but intact strength and sensation with equal 1+ radial pulses
bilaterally. He has limited ROM in elbow flexion and supination
due to the mass with associate pain. Otherwise, prominent
subcutaneous fullness over bilateral supraclaviular without
frank
lymphadenopathy and 1+ edema bilaterally; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
___ 0400 Temp: 99.5 PO BP: 104/66 L Lying HR: 95 RR: 18 O2
sat: 96% O2 delivery: RA
GENERAL: Pleasant, man in no distress, standing up at bedside
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 1+ radial pulses bilaterally. trace peripheral edema in
bilateral lower extremities.
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding
MUSKULOSKELATAL: Right arm with large subcutaneous swelling over
anterior bicep with gauze dressing c/d/I. No edema distal to the
tumor and he has 1+ radial pulses bilaterally. He has limited
ROM
in elbow flexion and supination due to the mass with associated
pain. Otherwise, subcutaneous fullness over bilateral
supraclaviular without frank lymphadenopathy; Normal bulk
NEURO: Alert, oriented, motor and sensory
function grossly intact. Gait normal
SKIN: No significant rashes
ACCESS: Right POC dressing c/d/i
Pertinent Results:
ADMISSION LABS:
===============
___ 10:12PM BLOOD WBC-5.3 RBC-2.85* Hgb-9.8* Hct-31.1*
MCV-109* MCH-34.4* MCHC-31.5* RDW-14.6 RDWSD-59.1* Plt ___
___ 10:12PM BLOOD ___ PTT-31.6 ___
___ 10:12PM BLOOD Glucose-121* UreaN-3* Creat-0.6 Na-138
K-4.7 Cl-97 HCO3-25 AnGap-16
___ 09:20AM BLOOD ALT-9 AST-19 LD(LDH)-172 AlkPhos-150*
TotBili-0.8
___ 07:20AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9
___ 04:40PM BLOOD calTIBC-321 VitB12-<150* Folate-3
___ Ferritn-69 TRF-247
___ 06:55AM BLOOD METHYLMALONIC ACID-PND
DISCHARGE LABS:
===============
___ 05:31AM BLOOD WBC-5.6 RBC-2.28* Hgb-7.9* Hct-24.2*
MCV-106* MCH-34.6* MCHC-32.6 RDW-15.5 RDWSD-60.2* Plt ___
___ 06:55AM BLOOD ___ PTT-31.6 ___
___ 05:31AM BLOOD Glucose-95 UreaN-10 Creat-1.0 Na-137
K-4.4 Cl-96 HCO3-23 AnGap-18
___ 06:55AM BLOOD ALT-8 AST-18 LD(LDH)-182 AlkPhos-123
TotBili-0.7
___ 05:31AM BLOOD Calcium-8.1* Phos-6.3* Mg-2.5
IMAGING:
========
___ Imaging PORT PLACEMENT ___
Successful placement of a double lumen chest power Port-a-cath
via the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
___ Imaging MR ARM W&W/O CONTRAST R
In the distal right upper extremity, there is a predominantly
solid, heterogeneously enhancing mass with mixed cystic
components currently measuring 13.1 x 11.3 x 16.4 cm. It is
similar in size to the prior CT from 2 days prior. However,
there
has been marked enlargement in size of the mass since ___ when it measured 10.0 x 6.5 x 9.5 cm. Some of the cystic
components demonstrate fluid fluid levels with areas that are T1
hyperintense which is new from the study from ___
likely representing components of hemorrhage within the mass.
There is mass effect on the adjacent musculature. However, no
significant signal abnormality or enhancement is noted within
this musculature to suggest invasion. Nonspecific subcutaneous
edema is noted the region of the elbow that is partially
visualized
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ Imaging BILAT UP EXT VEINS US
1. Patent deep veins of the bilateral upper extremities without
evidence of deep vein thrombosis identified.
2. Bilateral supraclavicular soft tissue edema without focal
abnormalities.
___ Cardiovascular ECHO
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function. No definite pathologic
valvular flow identified.
___ Imaging CTA UPPER EXT W&W/O C &
Interval increase in size of a highly vascular right upper arm
mass. Multiple presumed necrotic cystic spaces within the mass
contain hematocrit levels compatible with prior hemorrhage - one
with a couple locules of subcutaneous emphysema suggesting
recent
laceration/abrasion. No evidence of extravasation of
intravascular contrast material. There are preserved muscle and
fat planes between the mass and the brachial artery and vein.
___HEST W/CONTRAST
- The only suggestion malignancy in the chest is a pair of deep
right axillary subcentimeter peripherally enhancing lymph
nodes.
Alternatively these could be benign. There are no pulmonary
nodules or any intrathoracic adenopathy.
- Proximal LAD atherosclerotic calcification could be
hemodynamically significant.
___ Tissue: SOFT TISSUE, CORE BIOPSY FOR TUMOR
High grade pleomorphic sarcoma
___ Imaging HUMERUS (AP & LAT) RIGH
- Large soft tissue mass is seen in the lower portion of the
right upper arm adjacent to the right humerus. No obvious soft
tissue calcification is identified.
- No definite bone erosion or periostitis. Although there is a
segment of slightly ill-defined cortex along the lateral aspect
of the distal left humeral metadiaphysis, this is unlikely to
reflect bone erosion by the mass, as there was no direct
abutment of the soft tissue mass against humerus in this area on
the outside scanned-in MRI from ___.
- Otherwise, the right humerus is within normal limits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain - Moderate
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth q8 hours Disp #*42
Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone 30 mg 1 tablet(s) by mouth q12 hours Disp #*60
Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth q4 hours Disp #*84
Tablet Refills:*0
10. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Lisinopril 20 mg PO BID
RX *lisinopril 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# High grade sarcoma
# Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI right arm with and without contrast
INDICATION: ___ year old man with a right arm soft tissue sarcoma// evaluate
tumor progression. Biopsy-proven high-grade pleomorphic sarcoma.
TECHNIQUE: Multisequence multiplanar MRI of the right humerus was performed
before and after the administration of intravenous gadolinium.
COMPARISON: Targeted review of CTA of the right upper extremity dated ___. MRI of the humerus dated ___.
FINDINGS:
At the level of the distal humeral diaphysis, there is a large heterogeneously
enhancing, predominantly solid mass with mixed cystic components currently
measuring 13.1 x 11.3 x 16.4 cm. It is similar in size to the recent prior CT.
However, there has been marked enlargement in size of the mass since ___ when it measured 10.0 x 6.5 x 9.5 cm. Some of the cystic
components demonstrate fluid-fluid levels with areas that are T1 hyperintense
which is new since ___ likely representing components of hemorrhage
and/or proteinaceous content within the mass.
There is mass effect on the adjacent musculature. However, no significant
signal abnormality or enhancement is noted within this musculature to suggest
invasion. Nonspecific subcutaneous edema is noted the region of the elbow that
is partially visualized
Evaluation of the bones demonstrates heterogeneous marrow signal that remains
higher signal intensity on T1 weighted images when compared to the adjacent
skeletal muscle compatible with red marrow changes.
IMPRESSION:
Since ___, there has been marked increase in size of the large,
predominantly solid mass in the anterior soft tissues at the level of the
distal humerus compatible biopsy-proven high-grade pleomorphic sarcoma.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with new diagnosis of sarcoma undergoing XRT.
bilateral leg edema// eval 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: BILAT UP EXT VEINS US
INDICATION: ___ year old man with new diagnosis of sarcoma in proximal right
arm. Needs POC placement with prominence of bilateral supraclavicular areas//
Eval soft tissue promienence bilateral supraclaviulcar and evaluate for
possible permantent central access options
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins. Separate grayscale images were obtained of the
bilateral supraclavicular soft tissues.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The bilateral internal jugular and axillary veins are patent, show normal
color flow and compressibility.
The bilateral brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation.
Imaging of the bilateral supraclavicular soft tissues demonstrates soft tissue
edema without focal abnormalities.
IMPRESSION:
1. Patent deep veins of the bilateral upper extremities without evidence of
deep vein thrombosis identified.
2. Bilateral supraclavicular soft tissue edema without focal abnormalities.
Radiology Report
INDICATION: ___ year old man with proximal right arm sarcoma. Plan to start
Adriamycin chemotherapy.// please place double lumen chest port and leave both
accessed. ___ aware.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: OPERATORS: Dr. ___ and
Dr. ___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 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: 1 g IV Ancef.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.0 min, 8 mGy
PROCEDURE
1. Right internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. An Amplatz
wire was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 4.0 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The double lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the Amplatz wire through which the port was threaded
into the right side of the heart with the tip in the right atrium. The sheath
was then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The po
Rt was accessed using non coring ___ needles and could be aspirated and
flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Arm pain
Diagnosed with Malig neoplm of conn and soft tiss of l upr limb, inc shldr
temperature: 98.7
heartrate: 101.0
resprate: 15.0
o2sat: 96.0
sbp: 160.0
dbp: 83.0
level of pain: 9
level of acuity: 3.0 | PRINCIPLE REASON FOR ADMISSION:
===============================
___ is a ___ year old man with recently diagnosed
high-grade soft tissue sarcoma of the right upper arm who was
transferred to ___ with bleeding from his tumor and plan to
urgently initiate radiation treatment.
# High grade sarcoma: His external bleeding has stopped, and he
initiated his first session of radiation on ___, which he
continued daily through ___. We prepared to start concurrent
doxorubicin next week with TTE and obtained POC access. Ultimate
plan for 4 additional weeks of neoadjuvant chemoradiation prior
to surgical evaluation. He will return to 11R on ___ morning
to resume concurrent chemoradiation.
# Hemorrhage:
# Anemia
# B12 deficiency: Superficial hemorrhage of fungating tumor
resolved. He also has areas of internal hemorrhage in the tumor.
CTA showed no active extravasation, and HCT stayed generally
stable. Also found to be B12 deficient, likely nutritional. We
started 1000mcg B12 daily with MVI and folate. MMA is pending on
discharge.
# Cancer associated pain: Due to severe cancer associated pain,
with high oxycodone requirement, he was started on Oxycontin. We
titrated the dose to 30mg q12 hours along with 10mg po
oxyocodone q4 hours as needed. ___ benefit from palliative care
consult in future admissions.
# Edema: Doppler US negative for clots. Improved after
restarting home HCTZ.
# HTN: Restarted home HCTZ and home lisinopril 20mg bid
# Coronary artery disesea: No known clinical CAD, but CT on ___
noted proximal LAD atherosclerotic calcification. TTE was
normal. Consider outpatient stress testing.
# Billing> >30 minute spent coordinating and executing this
discharge plan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
HIDA scan
History of Present Illness:
Mr. ___ is a ___ yo M with a h/o HIV (CD4 1270, Viral Load <75
on ___ here with acute onset RUQ abdominal pain with
radiation to the epigastrium. Patient states that this 'gnawing'
pain woke him out of his sleep at 2am this morning and was
constant ___ severity. Tried naproxen with no relief. No
alleviating/aggrevating factors. Pain was associated with severe
nausea, but no vomitting. Denies recent fevers or illnesses,
cp/sob, diarrhea, change in appetite, urinary symptoms. Last BM
yesterday morning. No bloody or dark stools. Reports 2 prior
episodes of same pain, 3wks ago and 6months ago. Similar in
nature, waking him from sleep, but resolved with NSAIDs. Pain
episodes are not associated with food.
Patient reports HIDA scan in ___ for abdominal pain before
initiating HAART therapy and it was unremarkable. Has never had
an EGD.
In the ED, initial VS were 98.3 85 157/92 18 99% RA. Labs
including WBC, chem10, LFTs were wnl. RUQ u/s showed a distended
gallbladder without definitive evidence of stones or
cholecystitis. However, sonographic ___ was positive.
Surgery was consulted and recommended admission to medicine for
HIDA scan. Kept NPO and given IVF, 10mg of Morphine and 4mg
Zofran. Transfer VS were 98 82 118/78 18 98% RA.
On arrival to the floor, patient reports that his pain improved
from ___ to ___ after receiving morphine. Denies nausea. ROS
otherwise negative as below.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
HIV- last CD4 1270, viral load <75 on ___ on HAART
Obesity
Lumbar disc disease
Condyloma acuminata
Internal hemorrhoids/Recurrent rectal abscesses
Aphthous ulcer
H/o syphilis-treated
Social History:
___
Family History:
No h/o Crohns, IBD in family
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 135/79 70 16 98RA pain: ___
General - NAD, AOx3
HEENT - mucuouse membranes moist. no thrush. no tonsillar
enlargement.
Neck - supple. full ROM.
CV - RRR, no m/r/g
Lungs - CTAB, no wheezes, rales, or crackles
Abdomen - +bowel sounds, soft, non-distended. TTP in RUQ,
epigastric and mildly in the LUQ. Mild voluntary guarding. No
rebound. No organomegaly.
GU - no CVA tenderness.
Ext - full ROM of all joints. strength/sensation intact.
Neuro - no focal neurologic deficits.
Skin - no rashes noted. no edema of the extremities
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS - 98.1 135/79 70 16 98RA pain: ___
General - NAD, AOx3
HEENT - mucuouse membranes moist. no thrush. no tonsillar
enlargement.
Neck - supple. full ROM.
CV - RRR, no m/r/g
Lungs - CTAB, no wheezes, rales, or crackles
Abdomen - +bowel sounds, soft, non-distended. TTP in RUQ,
epigastric and mildly in the LUQ. Mild voluntary guarding. No
rebound. No organomegaly.
GU - no CVA tenderness.
Ext - full ROM of all joints. strength/sensation intact.
Neuro - no focal neurologic deficits.
Skin - no rashes noted. no edema of the extremities
Pertinent Results:
Admission labs:
___ 07:00AM BLOOD WBC-5.8 RBC-4.43* Hgb-14.3 Hct-43.2
MCV-98 MCH-32.4* MCHC-33.2 RDW-12.9 Plt ___
___ 07:00AM BLOOD Neuts-59.0 ___ Monos-7.1 Eos-1.9
Baso-0.8
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-30.8 ___
___ 07:00AM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-139
K-4.1 Cl-104 HCO3-27 AnGap-12
___ 07:00AM BLOOD ALT-27 AST-18 AlkPhos-62 TotBili-0.3
___ 07:00AM BLOOD Lipase-29
___ 07:00AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.6*# Mg-2.0
___ 07:00AM BLOOD LtGrnHD-HOLD
___ 07:00AM BLOOD GreenHd-HOLD
Imaging:
___ HIDA scan:
IMPRESSION:
1. No evidence of cholecystitis. 2. Small bowel tracer
activity not visualized at 60 minutes. This is likely due to
recent morphine administration just prior to the exam, but
common bile duct obstruction is not excluded.
___ Gallbladder ultrasound:
IMPRESSION:
1. Distended gallbladder with positive sonographic ___
sign, but no
definite stones, wall edema, or pericholecystic fluid. Findings
were
equivocal for acute cholecystitis. HIDA scan may be obtained
for further
evaluation.
2. Hepatic steatosis. More severe forms of liver disease,
including cirrhosis, cannot be excluded.
Discharge Labs:
___ 07:10AM BLOOD WBC-5.8 RBC-4.46* Hgb-14.5 Hct-43.4
MCV-97 MCH-32.6* MCHC-33.5 RDW-12.4 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-91 UreaN-14 Creat-1.2 Na-138
K-4.0 Cl-101 HCO3-30 AnGap-11
___ 07:10AM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.0 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Multivitamins 1 TAB PO DAILY
3. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg Oral
QD
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg Oral
QD
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right upper quadrant pain.
COMPARISON: None.
TECHNIQUE: Grayscale and Doppler ultrasound images of the right upper
quadrant were obtained.
FINDINGS: Increased echogenicity of the liver is consistent with hepatic
steatosis. The main portal vein is patent with antegrade flow. There is no
intra- or extra-hepatic biliary ductal dilatation. The common bile duct
measures 4 mm. The gallbladder is distended without wall edema,
pericholecystic fluid or definite stones. The neck of the gallbladder and the
pancreas were not well assessed due to overlying bowel gas. Sonographic
___ sign was positive. Limited views of the aorta, IVC, and right kidney
are unremarkable.
IMPRESSION:
1. Distended gallbladder with positive sonographic ___ sign, but no
definite stones, wall edema, or pericholecystic fluid. Findings were
equivocal for acute cholecystitis. HIDA scan may be obtained for further
evaluation.
2. Hepatic steatosis. More severe forms of liver disease, including cirrhosis,
cannot be excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ PAIN
Diagnosed with ABDOMINAL PAIN RUQ, ASYMPTOMATIC HIV INFECTION
temperature: nan
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 155.0
dbp: 97.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ yo M with HIV presenting with acute onset
severe RUQ abdominal pain radiating to the epigastric region
initially concerning for cholecystitis but more likely
gastritis, after having normal labs and negative HIDA scan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark stools
Major Surgical or Invasive Procedure:
___ EGD
___ EGD
History of Present Illness:
___ year old gentleman with history of CAD s/p 4 vessel CABG,
dyslipidemia and ?diverticulosis who presented to the ___ dark
stools x 2 days and lightheadedness x ___ days. He reported that
he initially believed that his dark stools were due to changes
in diet (eating brownies). Associated symptoms included
appearing pale to his co-workers. This morning he felt dizzy
when he woke up and then had a completely black bowel movement.
No BRBPR, hematochezia or maroon colored stools. No recent
consumption of iron supplements or pepto bismol, however he has
taken a full dose aspirin for many years. He went to work as a
___ and felt persisent lightheadness so
he called his supervisor and was given a ride to the ED. He
presented to the ___ ED where his initial vitals were 97.8 78
141/78 18 100% RA. His hematocrit was 32.3 from a baseline of
~40 (in ___. He stools in the ED were noted to be melanotic
and guaiac positive. He was seen by GI who were concerned about
a possible upper EGD. GI recommending starting the patient on
PPI bolus and PPI gtt. 2 peripheral IVs were placed prior to
transfer to Medicine floor.
On the floor, he reports some ongoing lightheadness with
ambulation.
He reports that his last bowel movement was this morning. He
continues to deny BRBPR and hematochezia. The patient has no
history of upper or lower GIB. He has a questionable h/o
diverticulosis -- he reports that he was never told he has
diverticulosis by a MD, but believes he may have this because he
has a lot of pain with peanut ingestion.
Past Medical History:
MYOCARDIAL INFARCTION
CORONARY ARTERY DISEASE s/p CABG ___
FAMILY PLANNING
ANEMIA
CORONARY ARTERY BYPASS SURGERY
Hypercholesterolemia
DIVERTICULOSIS -- unclear if patient carries this diagnosis, he
reports that he was never told he has diverticulosis by a
physician, but he presumes he has because he has a lot of pain
with peanut ingestion.
OBESITY UNSPEC
Hypertension
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father had CABG at age ___
Physical Exam:
ADMISSION:
Vitals: 98.2 72 106/60 16 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Well healed mid-line incision; regular rate and rhythm,
normal S1 + S2
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
DISCHARGE:
Vitals: 97.7 ___ ___ 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Well healed mid-line incision; regular rate and rhythm,
normal S1 + S2
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
MSk: R shoulder joint ROM limited to pain -- cannot abduct
beyond 40 degrees; no point tenderness in R shoulder; joint is
not warmer compared to L side; no appreciable fluid or effusion
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-9.2 RBC-3.44* Hgb-10.8* Hct-32.1*
MCV-94 MCH-31.6 MCHC-33.7 RDW-12.6 Plt ___
___ 01:00PM BLOOD Neuts-86.6* Lymphs-10.0* Monos-3.0
Eos-0.1 Baso-0.3
___ 01:00PM BLOOD Glucose-108* UreaN-30* Creat-0.8 Na-137
K-4.8 Cl-104 HCO3-22 AnGap-16
___ 01:00PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
___ 01:08PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 05:14PM BLOOD WBC-8.9 RBC-3.13* Hgb-9.8* Hct-28.0*
MCV-90 MCH-31.2 MCHC-34.9 RDW-15.6* Plt ___
___ 06:30AM BLOOD Glucose-102* UreaN-11 Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-27 AnGap-11
___ 06:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
IMAGING:
EGD ___:
Impression:
-Small hiatal hernia
-Erythema and petechiae in the antrum compatible with gastritis
-Granularity and erythema in the duodenal bulb compatible with
duodenitis
-The antrum and duodenal bulb were deformed, likely related to
duodenal diverticulum
-Diverticula in the proximal bulb and third part of the duodenum
-Blood was seen in the duodenum but this was washed away with
normal mucosa underneath. No new blood was seen during the
procedure.
-Otherwise normal EGD to third part of the duodenum
Recommendations:
-Continue BID PPI: Omeprazole 40mg or equivalent
No ulcer was seen. Its possible that a small ulcer in the
duodenal sweep was missed as the duodenal diverticula ___
___ antrum and sweep. However this area was examined multiple
times and there was certainly no new bleeding over the
procedure.
-Source of bleeding may have been from gastritis/duodenitis, now
treated with PPI
-Possible dieulafoy lesion that was missed because not bleeding.
If re-bleeds would repeat endoscopy.
EGD ___:
Impression: Small hiatal hernia
Patchy erythema and edema was seen in the stomach, consistent
with gastritis.
Patchy erythema, edema, and congestion was seen in the duodenum
consistent with duodenitis.
Duodenal diverticulum
Otherwise normal EGD to third part of the duodenum
Recommendations:
-Continue BID PPI x 8 week course
-Check H pylori
Shoulder Film ___:
FINDINGS: The AC joint is essentially within normal limits.
There is
narrowing of the glenohumeral joint, consistent with some
degenerative
changes. There is a large amount of opacification extending
upward from the level of the greater tuberosity. This is most
consistent with calcific tendinosis in the rotator cuff.
___ ___: IMPRESSION: No evidence of deep venous thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Diltiazem 120 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Diltiazem 120 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth every 12 hours Disp #*60 Capsule Refills:*1
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
Daily Disp #*30 Tablet Refills:*0
7. Acetaminophen 1000 mg PO Q8H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed for shoulder pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Upper gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with gastrointestinal hemorrhage. Evaluate for
pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: The patient is status post median sternotomy with surgical clip
seen in the anterior mediastinum. The lungs are clear. The hilar and
cardiomediastinal contours are normal. There is no pneumothorax or pleural
effusion. Pulmonary vascularity is normal.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Right shoulder pain.
FINDINGS: The AC joint is essentially within normal limits. There is
narrowing of the glenohumeral joint, consistent with some degenerative
changes. There is a large amount of opacification extending upward from the
level of the greater tuberosity. This is most consistent with calcific
tendinosis in the rotator cuff.
Radiology Report
HISTORY: Left flank pain, evaluate for deep venous thrombosis.
COMPARISON: None
FINDINGS:
The there is normal grayscale and color Doppler appearance, pulsed Doppler
waveform, compressibility, and augmentation of the veins of the left lower
extremity from the left common femoral vein through the mid calf.
No adenopathy or other incidental abnormality identified.
IMPRESSION:
No evidence of deep venous thrombosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DIZZINESS
Diagnosed with GASTROINTEST HEMORR NOS, AORTOCORONARY BYPASS
temperature: 97.8
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 78.0
level of pain: 3
level of acuity: 2.0 | ___ year old gentleman with h/o CAD and diverticulosis who
presented with dark stools and drop in hematocrit concering for
a upper GI bleed.
# Upper GI bleed: At admission the patient reported dark stools,
associated with dizzyness. He Hct in the ED was 32 from a
baseline of Hct ~40. His stools in the ED were noted to be
melanotic and guaiac positive. He was seen by GI who were
concerned about a possible upper GI bleed. He was started on a
PPI gtt and home beta blocker and diltiazem were held. On the
floor his hematocrit was trending down 32 -> 29 -> 27 so the
patient was transfused 1 unit overnight on ___ . His
hematocrit increased to 29 after the transfusion. GI performed
an EGD on ___ which was notable for erythema and petechiae in
the antrum compatible with gastritis, granularity and erythema
in the duodenal bulb compatible with duodenitis, and blood was
seen in the duodenum -- however there did not appear to be any
sites of active bleeding. He was transitioned to PO BID high
dose PPI. He was dizzy with ambulation and noted to have a
hematocrit of 26 on ___ so he was transfused 2 units. Post
transfusion hematocrit was 31. GI repeated EGD on ___, which
again did not identify a source of active bleeding. Serial
hematocrits were checked and were noted to be stable (___) in
the day prior to discharge and on the day of discharge. The
patient will f/u with PCP to have another CBC checked in the
coming days. Patient will be seen by ___.
# Right shoulder pain, likely muscle sprain: The patient
developed new right shoulder pain overnight on ___. His exam was
not concerning for a septic joint or acute monoarticular
process. He denied any trauma. His shoulder pain did not radiate
or appear to be neuropathic. Shoulder x-ray was negative for
acute process. Pain improved with tylenol. The patient also
reported some mild lower extremity pain on the day of discharge.
He was able to ambulate and was not significantly limited by the
pain. ___ was negative for DVT.
# CAD s/p CABG ___: Continued home dose of statin. Full dose
aspirin was changed to 81mg aspirin given risk for bleeding.
Initially held beta blocker and diltiazem in setting of acute
bleed -- these medications were restarted prior to discharge.
# Hypercholesterolemia: Continued home dose of statin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Imitrex / shellfish derived
Attending: ___.
Chief Complaint:
Right flank pain / fevers
Major Surgical or Invasive Procedure:
___: Placement of an 8 ___ percutaneous right-sided
nephrostomy tube.
___: Right ureteroscopy with laser lithotripsy, and
placement of double-J stent, and basket extraction of stone.
___: Right nephrostomy catheter left in situ given a small
stone in the lower calyx and no passage of contrast beyond the
mid ureter. The tube was capped.
History of Present Illness:
PRIMARY CARE PHYSICIAN: ___
HISTORY OF PRESENT ILLNESS:
___ w/ h/o obstructive nephrolithiasis who is one week
post-partum presents with worsening right flank pain and fever
that began this morning. Mrs. ___ awoke with ___ right flank
pain that radiated through to the back. She states that the pain
is similar to kidney stones in the past. At home, she was
febrile to 102.4. She describes some nausea without vomiting.
She denies any hematochezia, melena, hematuria, or dysuria. Mrs.
___ had 3 kidney stones identified in ___ of this year, for
which she recieved lithotrypsy and had a ureteral stent placed.
The stent was removed one month later. She was subsequently
evaluated with monthly ultrasounds. Most recent U/S from ___
showed worsening right-sided hydronephrosis. Invasive therapy
was not pursued at this time since she was relatively
asymptomatic and late in pregnancy. She delivered her daughter
one week ago via vaginal delivery and had no complications. She
also had no complications during her pregnancy. CT of the
abdomen in the ED showed severe right hydroureteronephrosis with
3 stones in the right distal ureter, largest measuring 1.1 cm.
Given the severity of obstruction and patient's presentation
with fevers, urology recommended percutaneous nephrostomy tube
w/ ___ for rapid decompression of hydronephrosis. Right perc
nephrostomy tube was placed in ___. Shortly after the procedure,
patient spiked a fever to 105.5 and became tachycardic to 140s.
She was started on ampicillin and ceftriaxone. Shortly
thereafter, she defervesced and her tachycardia improved. She
was admitted to the MICU for close monitoring.
On arrival to the MICU, patient continues to have ___ right
flank pain. Overall, feels much better. Denies any recent
hematuria/dysuria, diarrhea, nausea/vomiting.
REVIEW OF SYSTEMS:
(+) Per HPI. 10-point ROS conducted and otherwise negative.
Past Medical History:
Past medical history:
Nephrolithiasis
-calcium oxalate stones
-s/p lithotripsy and ureteral stent in ___
-recurrent obstructive stones seen on u/s from ___
Past surgical histories:
Deviated septum repair
MNT both ears.
Obstetric History:
Three pregnancies, two live births, both vaginal deliveries.
Social History:
___
Family History:
Denies any family history of significant medical conditions.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.9 88 113/66 98% 2Lnc
General: Well appearing in no acute distress
HEENT: Moist mucous membranes
Neck: JVP non elevated
CV: Regular rate and rhythm, normal S1 S2, no murmurs
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
Abdomen: Soft, normoactive bowel sounds, nontender,
nondistended, no rebound or guarding. Right percutaneous
nephrostomy tube in place draining clear/yellow urine. Mild
right CVA tenderness present.
GU: no Foley in place
Ext: Warm, no peripheral edema peripheral pulses 2+ ___
Neuro: alert and oriented to person, hospital, and date. No
focal deficits.
Discharge Physical Exam:
AVSS
Abdomen soft, nt/nd
R PCN clamped. Dressing over wound. c/d/i.
Ext w/out edema, pitting, calf pain to deep palpation bilateral.
Pertinent Results:
Admission Labs:
___ 10:45AM BLOOD WBC-10.1 RBC-3.92* Hgb-13.0 Hct-34.4*
MCV-88 MCH-33.1* MCHC-37.8* RDW-12.6 Plt ___
___ 10:45AM BLOOD Neuts-89.8* Lymphs-6.3* Monos-3.3 Eos-0.4
Baso-0.2
___ 01:08PM BLOOD ___ PTT-31.1 ___
___ 10:45AM BLOOD Glucose-79 UreaN-23* Creat-1.4* Na-139
K-4.0 Cl-104 HCO3-20* AnGap-19
___ 10:45AM BLOOD Calcium-8.1*
___ 05:45PM BLOOD Lactate-2.1*
Interim Labs:
Discharge Labs:
Microbiology:
___ MRSA SCREEN-PENDING
___ URINE,KIDNEY FLUID CULTURE-PENDING
___ Blood Culture-PENDING
___ URINE CULTURE-PENDING
___ BLOOD CULTURE-PENDING
Imaging:
CT abdomen and pelvis ___:
1. Severe right hydroureteronephrosis with 3 stones in the right
distal
ureter, largest measuring 1.1 cm.
2. New non-obstructive 5-mm left renal calculus.
___ 01:15PM BLOOD WBC-9.8 RBC-4.21 Hgb-13.5 Hct-37.7 MCV-90
MCH-32.1* MCHC-35.9* RDW-13.2 Plt ___
___ 06:05AM BLOOD WBC-7.8 RBC-3.52* Hgb-11.1* Hct-30.7*
MCV-87 MCH-31.5 MCHC-36.2* RDW-12.8 Plt ___
___ 02:37AM BLOOD WBC-11.9* RBC-3.73* Hgb-12.4 Hct-34.0*
MCV-91 MCH-33.1* MCHC-36.5* RDW-13.2 Plt ___
___ 01:15PM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-137
K-4.4 Cl-103 HCO3-21* AnGap-17
___ 06:05AM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-137
K-3.0* Cl-104 HCO3-20* AnGap-16
___ 02:37AM BLOOD Glucose-112* UreaN-22* Creat-1.3* Na-140
K-4.3 Cl-110* HCO3-18* AnGap-16
___ 11:13 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 3:17 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 4:00 pm URINE,KIDNEY RIGHT KIDNEY.
**FINAL REPORT ___
FLUID CULTURE (Final ___:
PRESUMPTIVE GARDNERELLA VAGINALIS. >10,000 CFU/ML.
___ 12:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Medications on Admission:
Allergies: Sulfa, Imitrex and shellfish.
Medications: Prenatal vitamins and zantac
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
2. Senna 1 TAB PO BID constipation
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*40 Tablet
Refills:*0
4. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin [Keflex] 500 mg ONE capsule(s) by mouth four
times a day Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___: SEVERE RIGHT HYDRONEPHROSIS
PREOPERATIVE DIAGNOSIS: Right multiple ureteral stones and
right renal calculus, history possible urosepsis.
POSTOPERATIVE DIAGNOSIS: Right multiple ureteral stones and
right renal calculus, history possible urosepsis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Followup Instructions:
___
Radiology Report
INDICATION: History of nephrolithiasis with right flank pain and fever,
please evaluate.
COMPARISON: CTU from ___ and renal ultrasound from ___.
TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes were generated and reviewed.
FINDINGS: The bases of the lungs are clear.
CT ABDOMEN: The evaluation of the intra-abdominal structures is limited by the
lack of IV contrast. The liver appears unremarkable without evidence of focal
lesions concerning for malignancy. There is no evidence of intrahepatic
biliary ductal dilatation. The gallbladder is normal without evidence of wall
thickening or stones. The spleen appears homogenous and normal in size. The
adrenal glands bilaterally are normal. The pancreas is normal without
evidence of focal lesions or peripancreatic stranding. The left kidney
contains a new left lower pole caliceal stone measuring 5 mm; however, there
is no hydronephrosis.
There is severe right kidney hydroureteronephrosis with 3 discrete stones in
the right distal ureter. The largest calculus measures 1.1 cm. There is mild
right perinephric stranding.
The stomach, duodenum and small bowel are unremarkable without evidence of
obstruction or wall thickening. The colon is normal. The appendix is
visualized and is unremarkable. There is no intra-abdominal free air. No
retroperitoneal or mesenteric lymphadenopathy is identified.
CT PELVIS: There is an enlarged, post-partum uterus. There is no pelvic or
inguinal lymphadenopathy. There is no evidence of pelvic free fluid.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are
identified.
IMPRESSION:
1. Severe right hydroureteronephrosis with 3 stones in the right distal
ureter, largest measuring 1.1 cm.
2. New non-obstructive 5-mm left renal calculus.
Radiology Report
HISTORY: ___ female with kidney stones and right-sided
hydroureteronephrosis.
COMPARISON: Same day CT abdomen
OPERATORS: Dr. ___ (attending) and Dr. ___ (fellow). The
attending was present and supervising throughout the entire procedure.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intra-service time of 40 min. The
patient's hemodynamic parameters were continuously monitored. A total dose of
125 mcg of fentanyl and 2 mg of Versed were used. 1% local lidocaine was also
used subcutaneously.
FINDINGS:
The procedure was discussed in detail with the patient. The risks and
benefits were emphasized. Informed written consent was obtained.
When the patient arrived in the angiography suite they were placed prone on
the procedure table. A pre-procedure ultrasound imaged the kidney and lower
costal margin. The region was prepped and draped in usual sterile fashion. A
preprocedural time out was performed per ___ protocol.
Under sonographic guidance a posterior mid pole calyx was identified within
the right kidney. A 21 gauge cook needle was then advanced into the
collecting system. Clear urine was obtained. Under fluoroscopic guidance an
0.018 Nitinol wire was advanced into the renal pelvis. The needle was then
exchanged for an Accustick system. The wire was removed and clear urine
drained from the catheter. A sample was sent to microbiology. A small volume
of contrast was administered into the collecting system demonstrating severe
right -sided hydronephrosis and a moderately dilated right ureter.
A dedicated antegrade nephrostogram was not performed given urosepsis.
A ___ wire was advanced through the Accustick sheath and coiled within the
renal pelvis. The Accustick sheath was removed and 8 and 9 ___ dilators
were used to open the tract over the Amplatz wire. This was followed by
successful placement of an 8 ___ nephrostomy tube with the pigtail locked
within the renal pelvis. Nephrostogram confirmed the location of the
nephrostomy tube.
The catheter was secured to the skin using a suture and flexi track. The
catheter was placed to external bag drainage and bandaged according to
protocol. The patient left the department in stable condition. No
complications.
IMPRESSION:
Severe right sided hydronephrosis.
Successful placement of an 8 ___ percutaneous right-sided nephrostomy tube.
Radiology Report
INDICATION: ___ female with obstructing renal stone status post right
nephrostomy placed on ___. Now status post ureteroscopy, laser
lithotripsy and nephroureteral stent placement. Nephrostomy removal
requested.
COMPARISON: ___.
PHYSICIAN: Dr. ___ (fellow) and Dr. ___ (attending), present
and supervising throughout.
FLUOROSCOPY TIME: 2.1 minutes.
CONTRAST: 10 mL Optiray 320.
PROCEDURE: Right nephrostogram.
PROCEDURE DETAIL: After explanation of the procedure, the patient was brought
to the angiography suite and placed prone on the imaging table. A
preprocedure timeout was performed. The right flank was prepped with
chlorhexidine.
Initial scout fluoroscopic image demonstrates an indwelling right nephrostomy
tube with a slightly tortuous course, a double J stent and a calculus in the
lower calyx. Approximately 10 mL of contrast was injected under fluoroscopic
visualization via the indwelling nephrostomy catheter. Contrast did not pass
beyond the mid ureter. The catheter was flushed and secured to the skin with a
0-silk suture and Stat-Lock device. The patient tolerated the procedure well
without immediate complication.
IMPRESSION: Right nephrostomy catheter left in situ given a small stone in
the lower calyx and no passage of contrast beyond the mid ureter. The tube
was capped. Findings and recommendations discussed between Dr. ___ Dr.
___ at the time of the exam on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with CALCULUS OF KIDNEY
temperature: 98.0
heartrate: 99.0
resprate: 18.0
o2sat: 98.0
sbp: 131.0
dbp: 88.0
level of pain: 6
level of acuity: 3.0 | Hospital course prior to transfer to urology service:
___ w/ h/o obstructive nephrolithiasis presents with right flank
pain and fevers, found to have severe hydronephrosis ___ large
ureteral stone, now s/p percutaneous nephrostomy.
# Pyelonephritis / Obstructive nephrolithiasis:
Patient's presentation with right flank pain, fevers, and pyuria
is consistent with pyelonephritis. Evidence of severe
obstructive nephrolithiasis qualifies this as complicated
pyelonephritis. She received right percutaneous nephrostomy,
spiked fever to 105.5 shortly after her procedure, likely
representing an episode of transient bacteremia. Treated
complicated pyelonephritis with IV ampicillin/sulbactam. She was
admitted to the MICU for monitoring given her fever and
tachycardia. Remained hemodynamically stable although with mild
orthostasis by heart rate. Overnight febrile to 101. Pain at
nephrostomy site treated with oxycodone. She was sent to the
floors where she remained febrile and was started on
ceftriaxone.
# ___: Patient presents with an elevated creatinine of 1.4 (bl
of 1.0). This may be related to her obstructive nephrolithiasis,
though this is unlikely because the obstruction is unilateral. A
more likely explanation is pre-renal azotemia in combination
with recent NSAID use. She received 4L NS in the ED, a further
1L NS in the MICU given asymptomatic orthostasis. Her creatinine
returned to normal.
# Postpartum: The patient was one week post-partum, recovering
well with scant vaginal bleeding. She was pumping breast milk,
advised to discard after antibiotic administration.
# Glucose management: check daily FSGs
# FEN: regular diet, IVF as above, replete electrolytes
# Prophylaxis:
- DVT: heparin SC
- GI: none required
# Access: 2 PIVs
# Restraints: not needed
# Communication: Patient
# Code: Full
# Disposition: ICU pending clinical improvement
Ms. ___ was transferred to the general urology service on
___ morning, ___, where she remained until discharge. She
was prepped for operative intervention and taken to the OR on
___ where she underwent right ureteroscopy with laser
lithotripsy, and placement of double-J stent, and basket
extraction of stone. She tolerated the procedure well; see
dictated note for full details. The right percutaneous
nephrostomy was open to gravity drainage until she arrived back
on the general surgical floor when it was capped. On POD1 she
was takne to the ___ suite where they attempted PCN removal but
because of a stone/blockage, this was terminated and she was
sent back to the general surgical floor. She was voiding
independently and pain was well controlled. She was therefore
set up with visiting nurse services to facilitate care of the
PCN and her transition home. She will follow up with Dr. ___
definitive management in the next ___ days. She was given a
course of Keflex and additional pain medications with
instructions to check in with her pediatrician and OBGYN
clinicians. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of multiple sclerosis is presenting with BRBPR.
1 day prior to admission patient passed a normal bowel movement
followed by large amount of bright red blood with clots. During
this time she had severe abdominal pain. She continued to have
BMs that were mostly blood and clots so she came to the ED. The
BRBPR started suddenly, she rates it as severe, it is not
getting
better, it has been going on for 1 day.
In the ED:
VS: T 97.3, HR 94, BP 114/54, RR 17, 100% RA
Labs: WBC 11.8, Hgb 13, plts 265, bicarb 21, Cr 0.9.
Imaging: CT abd: colitis involving entire descending colon from
the splenic flexure to junction of sigmoid colon. Either
infectious or inflammatory in etiology with ischemia not
included.
Meds: CTX, flagyl, LR 1L, morphine 4mg x2.
On hospital floor patient is still having moderate abdominal
pain. Last BM was in the ED and was liquid blood.
Past Medical History:
Multiple Sclerosis
Acne
Social History:
___
Family History:
no family history of IBD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, moderate tenderness to
palpation
throughout. 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: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
VITALS: 97.9 PO BP133/78 HR62 RR17 100%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, 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, no TTP. 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: Alert, oriented, face symmetric, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS ON ADMISSION:
___ 01:20PM WBC-11.8* RBC-4.46 HGB-13.4 HCT-40.1 MCV-90
MCH-30.0 MCHC-33.4 RDW-13.5 RDWSD-44.3
___ 01:20PM NEUTS-72.9* LYMPHS-17.5* MONOS-8.5 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-8.58* AbsLymp-2.06 AbsMono-1.00*
AbsEos-0.04 AbsBaso-0.05
___ 01:20PM PLT COUNT-265
___ 01:20PM ALT(SGPT)-14 AST(SGOT)-33 ALK PHOS-52 TOT
BILI-0.9
___ 01:20PM ALBUMIN-4.4
___ 01:20PM GLUCOSE-99 UREA N-8 CREAT-0.9 SODIUM-136
POTASSIUM-7.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-14
___ 01:58PM URINE COLOR-Straw APPEAR-CLEAR SP ___
___ 01:58PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0
LEUK-NEG
___ 01:58PM URINE RBC-4* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-1
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL
INPATIENT (NO GROWTH)
___ URINE URINE CULTURE-FINAL (NO GROWTH)
IMAGING:
Colitis involving the entire descending colon from the splenic
flexure to its
junction with the sigmoid colon, either infectious or
inflammatory in etiology
with ischemia not excluded. No evidence of pneumatosis, free
intraperitoneal
air, or drainable fluid collection.
LABS ON DISCHARGE:
___ 06:22AM BLOOD WBC-6.7 RBC-4.28 Hgb-12.8 Hct-39.1 MCV-91
MCH-29.9 MCHC-32.7 RDW-13.4 RDWSD-45.0 Plt ___
___ 06:22AM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-140
K-3.9 Cl-101 HCO3-25 AnGap-14
___ 06:22AM BLOOD CRP-29.4*
___ 06:22AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. glatiramer 20 mg/mL subcutaneous five days a week
3. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days
2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. glatiramer 20 mg/mL subcutaneous five days a week
4. Spironolactone 50 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis
Multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with 2 days of left lower quadrant
pain, multiple episodes of bloody diarrheaNO_PO contrast // Diverticulitis,
stricturing, other abnormally?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8
mGy-cm.
2) Spiral Acquisition 5.7 s, 44.6 cm; CTDIvol = 8.6 mGy (Body) DLP = 384.5
mGy-cm.
Total DLP (Body) = 389 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Minimal bibasilar atelectasis. No pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is diffuse,
circumferential wall thickening and adjacent fat stranding of the entire
descending colon, extending from the splenic flexure to its junction with the
proximal sigmoid colon. No evidence of pneumatosis, free intraperitoneal air,
or drainable fluid collection. Appendix is normal.
PELVIS: The bladder and distal ureters are unremarkable. Trace pelvic free
fluid.
REPRODUCTIVE ORGANS: A tampon is in situ. The uterus otherwise appears
unremarkable. 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: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Tiny, fat containing umbilical hernia.
IMPRESSION:
Colitis involving the entire descending colon from the splenic flexure to its
junction with the sigmoid colon, either infectious or inflammatory in etiology
with ischemia not excluded. No evidence of pneumatosis, free intraperitoneal
air, or drainable fluid collection.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Hemorrhage of anus and rectum
temperature: 97.3
heartrate: 94.0
resprate: 17.0
o2sat: 100.0
sbp: 114.0
dbp: 54.0
level of pain: 4
level of acuity: 2.0 | Ms ___ is a ___ with PMH of multiple sclerosis who presented
to the ED with BRBPR and was found to have colitis, thought to
be most likely infectious in etiology.
Patient presented initially with 1 day of BRBPR. She reportedly
passed a normal stool which was then followed by a large amount
of red blood and clots and subsequent frequent bleeding. In the
ED she was found to be hemodynamically stable, with stable Hgb,
and CT consistent with colitis of the entire descending colon
from the splenic flexure to the junction of the sigmoid colon.
She had mild leukocytosis, normal lactate and CRP 42. Cdiff,
Ecoli O157, Shigella, Campylobacter all negative. She improved
with ceftriaxone and flagyl, had no further bleeding, and was
switched to ciprofloxacin (trialed off flagyl and monitored
overnight as she reported intolerance of the medication with
severe nausea) with plan for a 7d course. She was afebrile
during her hospitalization. Patient reported a history of a very
similar episode in the past during a trip to ___, the
etiology of which was never discovered which reportedly also
involved the left colon. In discussion with GI, she was set up
with close outpatient GI follow-up with Dr. ___ at ___ for
re-evaluation and consideration of outpatient colonoscopy.
With regards to her MS, her copaxone was held initially in the
setting of her infection, but was restarted after patient
improved clinically. Patient's Neurologist Dr. ___ was
notified of admission per patient's request and agreed current
symptoms are unrelated to her MS.
___, spironolactone was held in house but restarted on
discharge due to improved po intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
Ms. ___ is a ___ female with the past medical of
cholelithiasis s/p CCY who presents with abdominal pain. Patient
notes onset of severe, cramping and pressure-like abdominal pain
starting ___. Pain was associated with food, sometimes
relieved with belching and defecation. Pain was ___, no
associated n/v, diarrhea. Patient does endorse chills. She tried
tums and Prilosec for the pain however this did not help.
Patient presented to her PCP due to the pain and labs were
notable for elevated LFTs. US revealed dilated CBD. Pain became
very severe today, prompting patient to come to ED due to
concern
for recurrent stones. Labs again revealed elevated LFTs, US
again
with dilated CBD concerning for CBD stone.
She was taken for ERCP on afternoon of ___ - sphincterotomy
performed, sludge noted but no stones. Post procedure patient
has
no complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Cholelithiasis s/p CCY
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: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. 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: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mild TTP in epigastric area.
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: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
___ 11:00AM BLOOD WBC-6.6 RBC-4.68 Hgb-13.6 Hct-41.5 MCV-89
MCH-29.1 MCHC-32.8 RDW-12.4 RDWSD-40.7 Plt ___
___ 11:00AM BLOOD Glucose-68* UreaN-9 Creat-0.6 Na-138
K-4.1 Cl-98 HCO3-23 AnGap-17*
___ 11:00AM BLOOD ALT-451* AST-251* AlkPhos-241*
TotBili-5.1* DirBili-3.9* IndBili-1.2
Discharge labs
___ 06:55AM BLOOD WBC-6.3 RBC-3.89* Hgb-11.5 Hct-34.2
MCV-88 MCH-29.6 MCHC-33.6 RDW-12.3 RDWSD-39.4 Plt ___
___ 06:55AM BLOOD Glucose-70 UreaN-6 Creat-0.6 Na-141 K-4.3
Cl-104 HCO3-24 AnGap-13
RUQ US ___
IMPRESSION:
Intrahepatic and extrahepatic biliary ductal dilation with CBD
measuring 12 mm. Findings are concerning for distal CBD
obstruction and ERCP is recommended to further assess.
ERCP ___
The scout film showed surgical clips in the RUQ.
The major papilla was bulging.
The CBD was successfully cannulated using a Rx sphincterotome
preloaded with 0.035in guidewire.
Contrast injection revealed small filling defects in the lower
CBD consistent with sludge. The CBD was dilated up to
approximately 10mm in diameter.
A biliary sphincterotomy was successfully performed at the 12
o'clock position. There was mild post-sphincterotomy oozing.
Large amounts of dark thick bile was draining from the major
papilla after sphincterotomy.
The bile duct was swept multiple times using a biliary balloon
catheter. Moderate amount of sludge material was successfully
removed.
Occlusion cholangiogram revealed no more filling defects. There
was excellent contrast and bile drainage at the end of the
procedure.
It was noted that the post-sphincterotomy oozing has stopped by
the end of the procedure
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
Take through morning of ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Elevated liver enzymes
Abdominal pain
Dilated common bile duct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with RUQ pain s/p cholecystectomy, had oSH US that showed ?
crytals in CBD// eval CBD
TECHNIQUE: Ultrasound.
COMPARISON: None.
FINDINGS:
The liver appears normal in grayscale appearance, size, without focal lesion.
Mild intrahepatic biliary ductal dilation is noted with the common bile duct
measuring up to 12 mm at the level of the porta hepatis. Difficult to exclude
distal CBD obstruction including retained stone. The pancreas is grossly
unremarkable. No ascites. Gallbladder surgically absent. Right kidney
appears normal in grayscale appearance and size. The spleen is normal in
size. Left kidney is also normal in grayscale appearance and size.
IMPRESSION:
Intrahepatic and extrahepatic biliary ductal dilation with CBD measuring 12
mm. Findings are concerning for distal CBD obstruction and ERCP is
recommended to further assess.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Abd pain, Abnormal labs
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.6
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 102.0
dbp: 57.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ female with the past medical of
cholelithiasis s/p CCY who presents with abdominal pain.
#Abdominal pain
#elevated LFTs
#dilated CBD concerning for choledocolithiasis
#s/p ERCP - initially there was concern for choledocolithiasis
given constellation of findings included elevated LFTs and
dilated CBD however patient underwent ERCP with no stones
visualized, sludge removed. Patient was placed on ciprofloxacin
after the procedure per ERCP recs. Patient will be on cipro for
5 days total. She was maintained on IVF overnight. Patient
denied further abdominal pain the following day and tolerated a
regular diet. LFTs improved. She was discharged home in stable
condition.
Transitional issues
-LFTs down-trending on day of discharge although not full
normalized, will need repeat labs with PCP
___ than 30 minutes were spent coordinating and providing
care for this patient on day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion, hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH notable for A fib on coumadin, intermittend
hematuria for years presenting with lightheadedness and dyspnea
on exertion for three days. Patient has had intermittent
hematuria for ___ years with known cystoprostatic bleeding and
bladder calculi. Of note he was recently diagnosed with E. coli
UTI last week (culture from ___, completed 3-day
course of a quinolone this morning. Still intermittent hematuria
and rust-colored urine, passing some clots in ED. Denies chest
pain/pressure, orthopnea, extremity swelling, fevers/chills,
back pain, syncope or presyncope, vertigo, HA, or visual
changes.
In the ED, initial vital signs were: 98.0 78 123/73 20 100% RA.
Labs were notable for Hgb 8.5 down from 13.9 on ___, INR 2.2,
BNP 1787 (similar to prior), trop <0.01. Urine: rust-colored
with clots, >182 RBC/WBC, nitrite neg, many bacteria. Heme
negative on rectal exam. CXR with no acute cardiopulmonary
processes. Patient was transfused one unit of pRBCs. Patients
urologist was contacted who recommended not puting in a catheter
for now as long as patient still voiding, r/o other causes of
anemia and await cultures for antibiotics if needed with formal
urology consult as inpatient. Patient admitted for transfusion
and hematuria. Vitals on transfer: 98.8 62 100/55 16 100% RA.
Past Medical History:
-Hypertension
- Seborrheic keratosis
-Atrial fibrillation, rate controlled.
-Atrial flutter ablation in ___ with development of atrial
fibrillation requiring cardioversions and now permament Afib.
-Non-ischemic dilated cardiomyopathy with LVEF ___ in ___,
improved to 50% ___
-PPM
-Right carotid stenosis, left carotid occlusion s/p CEA ___
--Anticoagulation (Patient adjusts coumadin for hematuria).
Social History:
___
Family History:
No history of sudden cardiac death, premature coronary disease,
or arrhythmias.
Physical Exam:
ADMISSION:
Vitals: 98.2 147/89 80 18 98%RA
General: Elderly man laying comfortably in bed w/ no accessory
muscle use
HEENT: NCAT EOMI MMM. Mild tenderness along right jaw. No
palpable tmeporal artery.
Neck: Supple, full ROM
CV: irregularly irregular rate S1/S2
Lungs: CTAB without w/r/r
Abdomen: +BS soft NT/ND well healed midline surgical scar below
umbilicus
Back: No CVA tenderness, no midline spine tenderness or step
offs
Ext: No c/c/e
Neuro: AAOx3, no gross focal neuro deficits noted
Skin: warm and dry
DISCHARGE:
Vitals: 98.3 114/62 (107-147/57-89) 71 (60-80) 20 99%RA
General: Elderly man laying comfortably in bed w/ no accessory
muscle use
HEENT: NCAT EOMI MMM. Mild tenderness along right jaw. No
palpable tmeporal artery.
Neck: Supple, full ROM
CV: irregularly irregular rate S1/S2
Lungs: CTAB without w/r/r
Abdomen: +BS soft NT/ND well healed midline surgical scar below
umbilicus
Back: No CVA tenderness, no midline spine tenderness or step
offs
Ext: No c/c/e
Neuro: AAOx3, no gross focal neuro deficits noted
Skin: warm and dry
Pertinent Results:
ADMISSION:
___ 01:15PM BLOOD WBC-5.4 RBC-2.75*# Hgb-8.5*# Hct-26.5*#
MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* Plt ___
___ 01:15PM BLOOD Neuts-74.8* Lymphs-16.6* Monos-6.1
Eos-2.3 Baso-0.2
___ 01:15PM BLOOD Plt ___
___ 01:22PM BLOOD ___ PTT-35.4 ___
___ 01:15PM BLOOD Ret Aut-3.3*
___ 01:15PM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-138
K-4.8 Cl-105 HCO3-23 AnGap-15
___ 01:15PM BLOOD cTropnT-<0.01 proBNP-1787*
___ 01:15PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 Iron-36*
___ 01:15PM BLOOD calTIBC-393 ___ Ferritn-22* TRF-302
DISCHARGE:
___ 09:12AM BLOOD WBC-5.8 RBC-3.31* Hgb-10.1* Hct-31.8*
MCV-96 MCH-30.6 MCHC-31.8 RDW-16.9* Plt ___
___ 11:12AM BLOOD ___
___ 09:12AM BLOOD Plt ___
___ 03:44AM BLOOD Glucose-88 UreaN-17 Creat-0.9 Na-139
K-3.9 Cl-107 HCO3-21* AnGap-15
IMAGING:
___ CXR IMPRESSION:
No acute cardiopulmonary abnormality.
___ EKG:
Ventricularly paced rhythm. Underlying rhythm is atrial
fibrillation.
Compared to the previous tracing of ___ pacemaker rhythm is
new.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Desonide 0.05% Cream 1 Appl TP DAILY
3. Doxazosin 4 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Warfarin 2.5 mg PO DAILY16
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Doxazosin 4 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Warfarin 2.5 mg PO DAILY16
7. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Desonide 0.05% Cream 1 Appl TP DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN jaw
pain Duration: 7 Days
before meals as needed, no driving or operating heavy machinery
while taking med
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every eight (8) hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: chronic iron deficiency anemia, hematuria
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 atrial fibrillation/pacemaker, now with
shortness of breath and lightheadedness.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided AICD/pacemaker device is re- demonstrated with leads in unchanged
positions. Mild enlargement of the cardiac silhouette is similar. Mediastinal
and hilar contours are unremarkable and unchanged. Pulmonary vasculature is
normal. Lungs are clear without focal consolidation. No pleural effusion,
pneumothorax, or pulmonary edema is present. Moderate hypertrophic changes
seen throughout the thoracic spine
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with ANEMIA NOS, HEMATURIA, UNSPECIFIED, CARDIAC PACEMAKER STATUS, LONG TERM USE ANTIGOAGULANT
temperature: 98.0
heartrate: 78.0
resprate: 20.0
o2sat: 100.0
sbp: 123.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Admitted with iron deficiency anemia. No evidence of GI losses
so this may be due to chronic urinary blood loss. He was
transfused one unit and improved symptomatically with this, but
will need further urological work up and potentially colonoscopy
as oupatient. Physical therapy evaluated patient and recommended
___ rehabilitation, however, patient was not agreeable and
wished to go home with rehabilitative services. He was
discharged in stable condition to outpatient follow-up with his
outpatient providers. Discharged on percocet for 7 days(Q8H) for
jaw pain, likely TMJ.
#. Dyspnea on exertion: Pt. c/o dyspnea on exertion. CXR with
no acute cardiopulmonary process to suggest pneumonia. Also no
pulmonary edema on CXR, BNP elevated similar to prior value. PE
unlikely in setting of normal oxygen saturation and another
explanation. Etiology most likely anemia due to urinary blood
loss. Repeat H+H stable and symptoms resolved post-transfusion.
Pt worked with patient and recommended rehabiliation but patient
deferred in preference of home with services. He will follow-up
continued resolution of symptoms with his PCP as outpatient.
#. Anemia: Normochromic normocytic anemia. Differential
includes anemia of chronic disease or multifactorial anemia
(mixed microcytic and macrocytic) given that patient has been
macrocytic in the past. Guaic negative in the ED and on repeat
on floor. Given normocytic anemia with low ___ represent
mixed dx given history of macrocytosis. Maintained active type
and screen. Monitored for s/s bleeding. Held on CBI given
continud voiding. Urologicy plan per below.
#. Hematuria: Intermittent for many years. Outpatient
urologist called how did not recommend CBI unless stops
urinating and inpatient urology consult. Hematuria had grossly
resolved on hospital day #2. After discussion with outpatient
urologist, Dr. ___, decided to defer further evaluation to
outpatient setting given stability of symptoms. Will likely
undergo cystoscopy with Dr. ___.
# UTI
UA floridly positive but difficult to interpret given hematuria.
No leukocytosis, fever, dysuria. UCx grew yeast.
# Jaw discomfort
New onset, mild, day of admission. No sign of local infection
(no erythema, LAD, leukocytosis). Has not tried pain reliever.
Trop negative x1. Sx improved with acetaminophen. Improved
hospital day #2. Patient prescribed percocet and will follow-up
with his PCP as outpatient for further work-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
___: Upper endoscopy
History of Present Illness:
___ male with a history of alcohol abuse presenting
today for evaluation of an upper GI bleed. He was brought into
the outside hospital today at request of his girlfriend as
patient looked more lethargic than normal. He also had episodes
of coffee-ground emesis earlier today. This was also witnessed
while at the outside hospital. Lab tests there were notable for
a bilirubin of 6 and platelets of 64. Patient was then
transferred here for continuous evaluation of upper GI bleed.
Recent sick contact at home with his girlfriend ___ daughter,
and URI symptoms since ___ with new cough. On arrival states
that he has relapsed into alcohol since last ___. Last drink
this AM, drinks ~1 bottle vodka daily. Has no diagnosis of
cirrhosis but has been told in the past that his lab tests
looking at his liver have been concerning.
BP 117/78 at OSH. He was treated with Protonix and IV Rocephin
prior to transfer.
In ED initial VS: 100.3 125 100/80 24 98% Non-Rebreather , BP
eventually as low as 84/45
Labs significant for:
ALT 26, AST 56, Tbili 6.2, D bili 3.2 WBC 16.8 (bands 16), HGB
13.6-> 12.9, Plt 53, INR 1.7, BUN 9, Cre 1.1, WBC 16.8. Lactate
7.8, VBG 7.25/48
Serum ETOH 111
Patient was given: Ocrtreotide gtt, Levophed gtt, Zosyn, vanc,
Ativan 0.5 IV, 2L NS, 50mg Albumin 25%
Imaging notable for:
CXR:
Large area of right mid to lower lung opacity, concerning for
consolidation,possibly due to pneumonia and/or aspiration.
Right internal jugular central venous catheter terminates in the
mid SVC without evidence of pneumothorax.
Left costophrenic angle not well seen, may be due to overlying
soft tissue, but a pleural effusion is not excluded.
Liver US:
Probable cirrhosis with evidence of portal hypertension
including hepatofugal portal venous flow and splenomegaly.
Gallbladder wall edema is likely third spacing related to
primary liver disease.
Consults: Liver
On arrival to the MICU, patient is alert, somewhat inattentive,
reasonable historian. Reports that he came to the hospital
because he could not stay conscious and had dark vomiting. He
reports a new cough that started 2 days ago. Also reports having
blood around his mouth when he wakes up for the last week. Has
been drinking on and off for years. Says his boss told him he
"looked yellow" starting about a month ago. Denies chest pain,
SOB, fever/chills, abdominal pain.
Past Medical History:
Obesity
Alcohol use disorder
Social History:
___
Family History:
Unknown because adopted
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in metavision
GENERAL: Sleepy but arousable, mildly inattentive, Alert,
oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP difficult to assess due to body habitus
LUNGS: Decreased breath sounds diffusely, possible ___/ to body
habitus. No respiratory distress.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Large, 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: Mild jaundice
NEURO: AAOX3, grossly intact. Mild asterixis.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 802)
Temp: 98.6 (Tm 99.6), BP: 112/72 (87-116/54-79), HR: 81
(81-91), RR: 20 (___), O2 sat: 93% (90-95), O2 delivery: RA,
Wt: 345.46 lb/156.7 kg
Fluid Balance (last updated ___ @ 044)
Last 8 hours No data found
Last 24 hours Total cumulative 1621ml
IN: Total 1621ml, PO Amt 1505ml, IV Amt Infused 116ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: Sleepy but arousable, Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
NECK: supple, JVP difficult to assess due to body habitus
LUNGS: Decreased breath sounds diffusely, possible ___/ to body
habitus. No respiratory distress.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Large, 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: Mild jaundice
NEURO: AAOX3, grossly intact. No Asterixis or tremor
Pertinent Results:
===============
ADMISSION LABS
===============
___ 05:00PM BLOOD WBC-16.8* RBC-3.87* Hgb-13.6* Hct-40.9
MCV-106* MCH-35.1* MCHC-33.3 RDW-14.6 RDWSD-57.1* Plt Ct-53*
___ 05:00PM BLOOD Neuts-83* Bands-16* ___ Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-16.63*
AbsLymp-0.00* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00*
___ 05:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-2+* Microcy-NORMAL Polychr-NORMAL
___ 05:00PM BLOOD ___ PTT-38.4* ___
___ 05:00PM BLOOD Plt Smr-VERY LOW* Plt Ct-53*
___ 05:00PM BLOOD Glucose-52* UreaN-9 Creat-1.1 Na-142
K-3.9 Cl-98 HCO3-23 AnGap-21*
___ 05:00PM BLOOD ALT-26 AST-56* AlkPhos-107 TotBili-6.2*
DirBili-3.2* IndBili-3.0
___ 08:15PM BLOOD Lipase-52
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Albumin-2.8*
___ 02:05AM BLOOD Calcium-7.3* Phos-4.6* Mg-0.9*
___ 05:00PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
===============
PERTINENT LABS
===============
___ 05:35AM BLOOD AMA-NEGATIVE
___ 05:35AM BLOOD ___
___ 05:35AM BLOOD IgG-1713* IgA-564* IgM-139
___ 02:09AM BLOOD HIV Ab-NEG
___ 05:35AM BLOOD tTG-IgA-16
___ 02:09AM BLOOD HCV Ab-NEG
===============
DISCHARGE LABS
===============
___ 06:56AM BLOOD WBC-5.0 RBC-3.06* Hgb-10.9* Hct-33.6*
MCV-110* MCH-35.6* MCHC-32.4 RDW-15.6* RDWSD-62.1* Plt Ct-62*
___ 06:56AM BLOOD Plt Ct-62*
___ 06:56AM BLOOD ___ PTT-41.3* ___
___ 06:56AM BLOOD Glucose-92 UreaN-4* Creat-0.7 Na-139
K-4.5 Cl-100 HCO3-31 AnGap-8*
___ 06:56AM BLOOD ALT-19 AST-37 LD(LDH)-227 AlkPhos-82
TotBili-8.1*
___ 06:56AM BLOOD Albumin-2.1* Calcium-7.7* Phos-3.2 Mg-1.7
==================
STUDIES/PATHOLOGY
==================
___: RUQ US
Probable cirrhosis with evidence of portal hypertension
including hepatofugal
portal venous flow and splenomegaly. Gallbladder wall edema is
likely third
spacing related to primary liver disease.
___ CXR:
Large area of right mid to lower lung opacity, concerning for
consolidation,
possibly due to pneumonia and/or aspiration.
Right internal jugular central venous catheter terminates in the
mid SVC
without evidence of pneumothorax.
Left costophrenic angle not well seen, may be due to overlying
soft tissue,
but a pleural effusion is not excluded.
___ EGD
Mosaic appearance in the stomach body and fundus compatible with
portal hypertensive gastropathy
No varices
Otherwise normal EGD to third part of the duodenum
___: TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. No right-to-left flow of intravenous
agitated saline injection. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
mild-moderate pulmonary artery systolic hypertension. There is
an anterior fat pad.
IMPRESSION: Suboptimal image quality. Mild-moderate pulmonary
artery systolic hypertension. Normal biventricular cavity sizes
with preserved global biventricular systolic function. No
valvular pathology or pathologic flow identified. No
right-to-left shunt identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
============
MICROBIOLOGY
============
__________________________________________________________
___ 1:52 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 3:05 am 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.
__________________________________________________________
___ 11:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 10:05 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine: No growth
__________________________________________________________
___ 9:00 pm BLOOD CULTURE
Blood Culture, Routine: No growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lactulose 30 mL PO TID:PRN confusion
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*90 Package Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Septic shock
Pneumonia
Secondary diagnoses:
Obstructive sleep apnea
Upper GI bleed
Macrocytic anemia
Alcoholic hepatitis
Alcohol use disorder
Coagulopathy
Cirrhosis
Thrombocytopenia
Anisocoria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with history of alcohol abuse and bilirubin of 6//
Evaluate for cirrhosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is probably
slightly nodular. There is no focal liver mass. The main portal and right
portal veins are patent with hepatofugal (reversed) flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: Gallbladder wall edema without cholelithiasis.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 18.0 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Probable cirrhosis with evidence of portal hypertension including hepatofugal
portal venous flow and splenomegaly. Gallbladder wall edema is likely third
spacing related to primary liver disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypertension now a central line placed//
Evaluate central line placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Right internal jugular central venous catheter terminates in the mid SVC
without evidence of pneumothorax. Large area of right mid to lower lung
opacity could be due to consolidation due to pneumonia and/or aspiration. The
left costophrenic angle is not well seen, which may be due to overlying soft
tissue, but a pleural effusion is not excluded. Cardiac silhouette size is
top-normal. Mediastinal contours are unremarkable.
IMPRESSION:
Large area of right mid to lower lung opacity, concerning for consolidation,
possibly due to pneumonia and/or aspiration.
Right internal jugular central venous catheter terminates in the mid SVC
without evidence of pneumothorax.
Left costophrenic angle not well seen, may be due to overlying soft tissue,
but a pleural effusion is not excluded.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Sepsis, unspecified organism, Granuloma faciale [eosinophilic granuloma of skin], Hypotension, unspecified, Pneumonia, unspecified organism, Alcohol dependence with withdrawal, unspecified, Acute and subacute hepatic failure without coma
temperature: 100.3
heartrate: 125.0
resprate: 24.0
o2sat: 98.0
sbp: 100.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male with alcohol abuse who presented
with upper GI bleed and concern for septic shock.
# Septic shock secondary to pneumonia:
Patient presented with cough, leukocytosis, and CXR with
consolidation concerning for pneumonia. No ascites for
spontaneous bacterial peritonitis and hemoglobin relatively
stable so unlikely blood loss. There was some initial concern
for blood loss contributing to his shock, but his hemoglobin
remained stable. He briefly required pressor support and was
given volume resusictation for hypotension. He was treated with
ceftriaxone and azithromycin for a total of 5 days.
# Upper GI bleed:
Patient had episodes of coffee ground emesis before
presentation. His stool was noted to be brown on exam. Upper
endoscopy performed on ___ showed evidence of portal
hypertensive gastropathy but no varices. He was briefly treated
with IV PPI and octreotide drip and later transitioned to PO
PPI.
# EtOH use disorder:
Patient with significant drinking history at home, drinking up
to 1 bottle of vodka per day. He was given a phenobarbital load
and taper. He was also started on high-dose thiamine, folate,
and multivitamin. Social work was consulted.
# Nighttime desaturations:
# OSA:
Patient with nighttime desaturationa. Given body habitus and
nighttime occurrences, most likely sleep apnea, but it has never
been diagnosed formally. Sleep medicine consulted and
recommended empiric CPAP while inpatient. Given persistent
hypoxia (especially with ambulation), patient underwent ECHO
with bubble study that showed moderately increased PASP with no
evidence of right to left shunt. Given persistent hypoxia,
patient discharged on home oxygen with plan for outpatient sleep
study. Until he has CPAP at home, he should wear 4 LPM of O2 at
night. He can also use supplemental oxygen if desaturating with
ambulation activity; this can be titrated and weaned by a
visiting nurse.
# Alcohol hepatitis:
Patient presented with elevated t.bili and coagulopathy with
___ Discriminant Function of 34 on admission, concerning for
alcoholic hepatitis. He was not given steroids in the setting of
active infection. Total bilirubin downtrended throughout
admission.
# Coagulopathy:
INR elevation likely due to cirrhosis and poor nutrition. His
labs were monitored daily without need for vitamin K.
# Cirrhosis:
No formal diagnosis but evidence of cirrhosis on RUQUS with
splenomegaly, mild jaundice, and consistent history of alcoholic
cirrhosis. MELD-Na 20. AST>ALT 2:1 so likely alcoholic. Workup
for other causes of cirrhosis including elevated IgG, IgA as
well as normal IgM. ___, AMSA, AMA, tTGA anti-tissue
transglutaminase pending at time of discharge. Right upper
quadrant ultrasound showed evidence of portal hypertension
including hepatofugal portal venous flow and splenomegaly. Upper
endoscopy on admission without varices but with portal
hypertensive gastropathy. He will need outpatient Hepatology
follow up with ___ screening and varices screening.
# Thrombocytopenia:
Most likely due to underlying liver disease. Blood smear without
shistocytes and hemodynamically stable so DIC/TTP unlikely. Low
fibrinogen likely in the setting of liver disease. Subcutaneous
heparin was held given his low platelets but restarted once
platelets were over 50.
# anisocoria:
Patient with dilated left pupil>right but no diplopia, eye pain,
or other neuro symptoms. Left pupil sluggish to react. Rest of
neurologic exam unremarkable so less concern for
aneurysm/intracranial process. Patient was on ipatroprium which
can cause anisocoria so it was discontinued with resolution of
anisocoria.
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ ___ placed Percutaneous Cholecystostomy
___ Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ history of chronic pneumobilia of
unclear etiology, seizure disorder, GERD, gout, presenting with
worsening abdominal pain to ___, found to be febrile with CT A/P
showing pneumobilia with cholelithiaisis, RUQUS without
definitive evidence of cholecystitis transferred here for ERCP
evaluation.
Patient states that he has had several months of epigastric and
RUQ abdominal pain that is intermittent, worse with PO intake. 2
days prior he had acute worsening epigastric abdominal pain
worse
at night when lying down. Pain is located on bilateral sides,
epigastrium, and back. Associated with several days fevers and
chills. Also with nausea and 2 episodes of non-bloody emesis.
With very poor PO intake due to pain and nausea over last week.
Endorsing dry cough, no diarrhea, no burning on urination or
pain
on urination.
At ___ initial VS 98.2 P 72 BP 160/90 RR 22 O2 99% RA. Found to
have WBC 12.6. CT A/P with IV contrast showing mildly dilated
and
thickening of GB wall with air in GB and biliary tree presumably
reflecting prior sphincterotomy present in ___. Had RUQUS
showing gallstones, pneumobilia in intrahepatic ducts, cBD, and
gall bladder. Was given CTX 1gm, morphine, and protonix and
transferred for ERCP evaluation.
In the ED,
Initial Vitals: T 99 HR 74 BP 154/64 RR 16 O2 98%RA
During ED course, was febrile to 103 with worsening tachycardia
to 121 and hypotension to 79/49. WBC 4, lactate was 8. Given
worsening septic shock with presumed intra-abdominal source was
started on vanc/zosyn and got 4L NS. Had R IJ placed and was
started on levophed 0.15 prior to transfer to MICU. Had repeat
RUQUS showing sonographic findings equivocal for possible
cholecystitis. With sludge and gallstones, however with minimal
gallbladder wall thickening. ___ reat CT A/P at OSH showing no
evidence of perforated duodenal diverticulum. CBD with air
however without dilatation no obstructing mass or calculus.
Exam:
Gen: Comfortable, No Acute Distress
HEENT: NC/AT. EOMI.
Neck: No swelling. Trachea is midline. No JVD
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Mild epigastric tenderness.
Ext: No edema, cyanosis, or clubbing.
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
Labs:
- WBC 4, Hb 16.5, PLT 146
- Na 139, K 4.6, bicarb 15, BUN 13, Cr 1.1
- Ca 9.4, Mg 2.2, P 4.7
- Lactate 8 --> 6 --> 2.7
- ALT 25, AST 24, ALP 93, T. bili 0.5, lipase 18
Imaging:
CXR: No acute intrathoracic abnormality.
RUQUS:
1. Sonographic findings are equivocal for possible
cholecystitis.
The gallbladder is filled with sludge and gallstones, however
there is minimal gallbladder wall thickening, and the
gallbladder
is not distended. Further
evaluation with HIDA scan may be performed if clinically
indicated.
2. Pneumobilia as seen on recent outside hospital CT abdomen
pelvis.
CT A/P WO Contrast OSH films:
1. There is no evidence of a perforated duodenal diverticulum.
Distortion and hyperenhancement of the wall of a short segment
of
the duodenum in its second portion in the periampullary region
is
likely related to chronic ulcer disease or recent passage of
sludge/gallstones, especially given the presence of unexplained
pneumobilia.
2. Air within the gallbladder and pneumobilia noted. The CBD
also
demonstrates presence of air within it, however tapers normally
towards the ampulla without visualization of an obstructing mass
or calculus at the ampulla.
3. No other acute process seen in the abdomen or pelvis to
explain patient's symptoms.
RECOMMENDATION(S): Additional evaluation for cause of
pneumobilia
and evaluation of the second portion of the duodenum by ERCP is
recommended.
Consults: Both ACS and ERCP consulted in ED. Per ERCP, no
indication for ERCP at this time. Per ACS, given duodenal
ulceration and pnuemobilia, concern for possible duodenal
perforation. In discussion with GI, decision initially made to
order UGIS. However after further discussion with radiology, OSH
CT WO contrast did not show evidence of duodenal ulceration.
Decision was made per ACS recommendations ultimately to repeat
CT
A/P with PO contrast to definitively rule out duodenal
perforation given prior CT was without PO contrast.
Interventions:
___ 00:58 IVF NS
___ 00:58 IV Morphine Sulfate 4 mg
___ 00:58 IV Ondansetron 4 mg
___ 01:51 IV Piperacillin-Tazobactam
___ 02:15 IV Morphine Sulfate 4 mg
___ 02:15 IV Ondansetron 4 mg
___ 02:15 PO/NG PHENObarbital 64.8 mg
___ 02:15 IVF NS
___ 03:24 IV Vancomycin ___
___ 04:43 IV Acetaminophen IV 1000 mg
___ 05:32 IV DRIP NORepinephrine
___ 05:41 IVF NS
___ 08:11 PO/NG Allopurinol ___ mg
___ 08:11 PO Omeprazole 20 mg
___ 08:11 PO/NG PHENObarbital 64.8 mg
___ 12:45 IV Piperacillin-Tazobactam
___ 13:06 IV Acetaminophen IV 1000 mg
___ 13:20 IV Piperacillin-Tazobactam 4.5 g
___ 13:47 IVF NS ___
Past Medical History:
- PUD
- Gout
- Seizure disorder
- Pneumobilia
Social History:
___
Family History:
No history of hepatobiliary problems
Physical Exam:
ADMISSION EXAM
VS: Reviewed in metavision
GEN: Uncomfortable appearing, grimacing in pain
HENNT: HEENT, NC/AT, PERRL, EOMI
CV: Regular rate and rhythm, no m/r/g
RESP: Lungs clear to auscultation bilaterally, no wheezes,
rales,
or rhonchi
GI: Non-distended. Normoactive bowel sounds. Diffusely tender.
No
rebound or guarding.
MSK: 2+ peripheral pulses, no c/c/e
NEURO: CN II-XII grossly intact. No focal neurological deficits.
DISCHARGE EXAM
VS: 24 HR Data (last updated ___ @ 420)
Temp: 98.1 (Tm 99.7), BP: 113/77 (102-115/67-77), HR: 102
(99-113), RR: 20 (___), O2 sat: 93% (93-94), O2 delivery: RA
General: Lying in bed asleep, in no acute distress
CV: Normal rate and rhythm. Normal S1 and S2. No murmurs, rubs,
or gallops.
Lungs: Clear to auscultation bilaterally without wheezes, rales,
or rhonchi.
Abdomen: Mildly distended. Tender to palpation in RUQ and
epigastrium without rebound or guarding.
Ext: Warm, well perfused. 2+ pulses. No clubbing, cyanosis or
edema.
MSK: No glenohumeral or AC joint effusions appreciated,
nontender
to palpation, ROM intact but limited by pain
Neuro: AAOx3. Motor and sensory function grossly intact
throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 03:33AM BLOOD WBC-16.7* RBC-3.91* Hgb-11.9* Hct-36.4*
MCV-93 MCH-30.4 MCHC-32.7 RDW-14.6 RDWSD-50.0* Plt ___
___ 01:41AM BLOOD ___ PTT-24.3* ___
___ 01:15AM BLOOD Glucose-135* UreaN-13 Creat-1.1 Na-139
K-4.6 Cl-97 HCO3-15* AnGap-27*
___ 08:22PM BLOOD ALT-46* AST-48* AlkPhos-59 TotBili-0.8
___ 01:15AM BLOOD Lipase-18
___ 03:33AM BLOOD Calcium-7.6* Phos-1.5* Mg-1.8
___ 01:39AM BLOOD Lactate-8.0*
PERTINENT LABS
==============
___ 04:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:38AM BLOOD Lipase-18
___ 03:00PM BLOOD VitB12-517
___ 03:00PM BLOOD TSH-1.8
DISCHARGE LABS
==============
___ 05:12AM BLOOD WBC-7.3 RBC-3.98* Hgb-12.1* Hct-35.5*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.1 RDWSD-46.2 Plt ___
___ 05:12AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-135
K-4.4 Cl-97 HCO3-23 AnGap-15
___ 05:12AM BLOOD ALT-27 AST-25 LD(LDH)-163 AlkPhos-110
TotBili-0.4
MICROBIOLOGY
============
___ 1:13 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ 10:47 am BILE BILE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
IMAGING
=======
CXR ___: No acute intrathoracic abnormality.
RUQUS ___:
1. Sonographic findings are equivocal for acute cholecystitis.
The
gallbladder is only partially distended and filled with sludge
and air however with minimal wall thickening without a positive
sonographic ___ sign or pericholecystic fluid. Further
evaluation with HIDA scan may be performed if clinically
indicated.
2. Pneumobilia as seen on recent outside hospital CT abdomen
pelvis.
CT A/P WC ___ opinion ___:
1. There is no evidence of a perforated duodenal diverticulum.
Distortion and hyperenhancement of the wall of a short segment
of the duodenum in its second portion in the periampullary
region is likely related to chronic ulcer disease or recent
passage of sludge/gallstones, especially given the presence of
unexplained pneumobilia.
2. Air within the gallbladder and pneumobilia noted. The CBD
also
demonstrates presence of air within it, however tapers normally
towards the ampulla without visualization of an obstructing mass
or calculus at the ampulla.
3. No other acute process seen in the abdomen or pelvis to
explain patient's symptoms.
HIDA ___: Abnormal hepatobiliary scan with
non-visualization of the
gallbladder including non-visualization after morphine
administration. Findings compatible with acute cholecystitis.
GB Drainage ___: Successful US-guided placement of ___
pigtail catheter into the gallbladder. Samples was sent for
microbiology evaluation.
MRCP (MR ABD ___ Date of ___
IMPRESSION:
1. No evidence of a bile leak or biloma.
2. Pneumobilia, without evidence choledocholithiasis.
3. 3.0 x 2.1 cm ill-defined focus of heterogeneous T2
hyperintense signal
intensity in the gallbladder fossa with inflammation of the
surrounding
hepatic parenchyma, likely containing some fluid which may be
postsurgical.
Superimposed infection/phlegmon cannot be excluded, but there is
no drainable collection.
4. Trace right pleural effusion.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PHENObarbital 64.8 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 (One) capsule(s) by mouth every four (4)
hours Disp #*18 Capsule Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. PHENObarbital 64.8 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
-Septic Shock
-E. Coli Bacteremia
-Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic
cholecystectomy
SECONDARY DIAGNOSES:
====================
-Chronic Pneumobilia
-Herpes re-activation
-Gout
-GERD
-Seizure disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT) PORT
INDICATION: ___ male with right upper quadrant pain, fever, and
cough. Evaluate for pneumonia in the right lower lobe.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lungs are moderately well aerated. No focal consolidation is seen. No large
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. No free subdiaphragmatic gas or mass effect.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with c/f pneumobilia. Evaluate for cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT abdomen pelvis performed ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. Mild pneumobilia is
noted.
CHD: 5 mm
GALLBLADDER: The gallbladder is filled with sludge and gallstones. There is
minimal gallbladder wall thickening and possible focal edema however, the
gallbladder is not distended or hydropic in appearance.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.0
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Sonographic findings are equivocal for acute cholecystitis. The
gallbladder is only partially distended and filled with sludge and air however
with minimal wall thickening without a positive sonographic ___ sign or
pericholecystic fluid. Further evaluation with HIDA scan may be performed if
clinically indicated.
2. Pneumobilia as seen on recent outside hospital CT abdomen pelvis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:58 am, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male with CVL line placement. Evaluate
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph performed 4 hours prior.
FINDINGS:
Interval placement of a right central venous catheter, with the tip projecting
over the mid SVC. Otherwise, the lungs are clear without evidence of focal
consolidation. No large pleural effusion or pneumothorax is identified. The
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
1. Interval placement of a right central venous catheter line which projects
over the low SVC.
2. No complications.
Radiology Report
EXAMINATION: SECOND OPINION CT TORSO
INDICATION: History: ___ with ?pnuemobilia on OSH CT A/P, reqesting second
read to eval ? duodenal diverticulum that could be inflamed and or
perforated// ? duodenal diverticulum that could be inflamed and or perforated
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was NOT administered.
IV contrast: 130ml Omnipaque
DOSE: DLP: 520 mGy cm
COMPARISON: None.
FINDINGS:
LOWER CHEST:
The visualized lung bases are clear.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: There is left-sided pneumobilia. The background hepatic
parenchyma enhances homogeneously with no focal liver lesions.
The gallbladder is distended and demonstrates air-fluid level within it.
There is minimal gallbladder wall edema. No radiopaque calculi noted within
the gallbladder. No pericholecystic stranding of fat seen..
There is air and fluid within the CHD and CBD. The CBD tapers normally
towards the ampulla. No obstructing mass or calculi seen on this exam.
PANCREAS: There is homogeneous enhancement of the pancreatic parenchyma
without main duct dilation.
SPLEEN: No splenomegaly or focal splenic lesions noted..
ADRENALS: There are no adrenal nodules.
URINARY: No hydronephrosis or solid enhancing renal masses noted.
GASTROINTESTINAL: There is no bowel obstruction. No duodenal diverticulum
noted. No evidence of a perforated diverticulum mass suggested on the outside
read. There is mild hyper enhancement in the wall of the duodenum, just
distal to the bulb (best visualized on the sagittal reformats, series 4, image
45) that may be related to chronic ulcer disease
Scattered colonic diverticuli without acute diverticulitis seen. Appendix.
LYMPH NODES: There are no enlarged lymph nodes in the abdomen or pelvis..
VASCULAR: Abdominal aorta is normal in caliber.
PELVIS:
The bladder is moderately distended and appears normal. The prostate is not
enlarged.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
1. There is no evidence of a perforated duodenal diverticulum. Distortion and
hyperenhancement of the wall of a short segment of the duodenum in its second
portion in the periampullary region is likely related to chronic ulcer disease
or recent passage of sludge/gallstones, especially given the presence of
unexplained pneumobilia.
2. Air within the gallbladder and pneumobilia noted. The CBD also
demonstrates presence of air within it, however tapers normally towards the
ampulla without visualization of an obstructing mass or calculus at the
ampulla.
3. No other acute process seen in the abdomen or pelvis to explain patient's
symptoms.
RECOMMENDATION(S): Additional evaluation for cause of pneumobilia and
evaluation of the second portion of the duodenum by ERCP is recommended.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with history of chronic pneumobilia, duodenal
ulcers, presenting as a transfer from ___ with worsening abdominal pain,
pneumobilia, with septic shock found to have GNR bacteremia likely from
biliary source// Please perform CT A/P with PO contrast to eval for extrav and
possible duodenal perforation per ACS requesting repeat CT A/P with PO
contrast
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) = 577 mGy-cm.
COMPARISON: CT abdomen pelvis ___ from outside institution.
Similar ultrasound ___.
FINDINGS:
LOWER CHEST: Partially imaged lung bases demonstrate bibasilar atelectasis.
There is no evidence of pleural effusion. There is a trace pericardial
effusion within physiologic range.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates heterogeneous attenuation throughout
with regional areas of enhancement at the hepatic dome and surrounding the
gallbladder fossa/segment 4 (02:10, 02:19). However, there is no evidence of
focal lesions. There is similar extent of left pneumobilia with air tracking
into the common bile duct and gallbladder fundus. There is extrahepatic
biliary dilatation measuring up to 10 mm. There is layering hyperdense
material in the distal CBD consistent with retrograde oral contrast from the
duodenum. This suggests a sphincter of Oddi dysfunction/incompetence,
possibly due to a recently passed gallstone. No evidence of obstructing mass
or calculus at the level of the ampulla. Gallbladder layering sludge is
better assessed on ultrasound from same day.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. Pneumobilia, extrahepatic biliary dilatation and oral contrast filling the
CBD in a retrograde fashion suggests sphincter of Oddi
dysfunction/incompetence, possibly due to recently passed gallstone.
2. No evidence of bowel perforation. No free intraperitoneal air.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with history of chronic pnuemobilia presenting
with fevers, abdominal pain, found to have GNR bacteremia s/p IVF
resuscitation, now with worsening hypoxemia to 2L O2// Eval for underlying
etiology of worsening hypoxemia, volume status Eval for underlying etiology
of worsening hypoxemia, volume status
IMPRESSION:
Compared to chest radiographs ___.
New ring shadows in the right mid and lower lung zone are due to bronchial
wall thickening or extra bronchial cuffing. Differential diagnosis includes
early edema or new widespread bronchial inflammation. There are no findings
of edema elsewhere or any consolidation in the lungs. Heart size top-normal.
No appreciable pleural effusion or pneumothorax.
Right jugular line ends in the low SVC, as before.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement.
INDICATION: ___ year old man with chronic pneumobilia, duodenal ulcers
complicated by strictures presents with GNR bacteremia and sepsis, HIDA scan
consistent with acute cholecystitis.// Drainage
COMPARISON: Ultrasound liver dated ___.
PROCEDURE: Ultrasound-guided drainage of the gallbladder.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the gallbladder demonstrated
distended gallbladder containing sludge. Based on the ultrasound findings an
appropriate skin entry site percutaneous cholecystostomy was chosen. The site
was marked. Local anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the gallbladder. The pigtail
was deployed. The position of the pigtail was confirmed within the
gallbladder via ultrasound.
Approximately 40 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure ultrasound was performed demonstrated a distended gall bladder
containing sludge as seen on prior ultrasound ___.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with perc chole tube in placeme// Concern for ___
perc chole drain being mal positioned causing irritation
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___
FINDINGS:
Sole expanded. Cardiomediastinal silhouette is top normal. Hilar contours
are unremarkable. Interval removal of right internal jugular central venous
catheter. No pneumothorax or pleural effusion. No pneumonia or pulmonary
edema. Pigtail catheter projects over the right upper abdomen.
IMPRESSION:
Interval removal of right internal jugular central venous catheter with no
evidence of pneumothorax.
No evidence of pneumonia or pleural effusion.
Pigtail catheter projects over the right upper abdomen.
Radiology Report
EXAMINATION: GI fluoroscopy
INDICATION: ___ year old man s/p perc chole with right sided pleuritc pain//
repo of perc chole. please page Dr. ___ patient arrives.
TECHNIQUE: The percutaneous cholecystostomy tube was examined under
fluoroscopic guidance. No intervention was found to be necessary.
DOSE: Dose information not available at time of reporting. 2 images were
saved.
COMPARISON: Correlation with chest radiographs from today.
FINDINGS:
Apparent redundancy in the cholecystostomy tubing seen on the chest
radiographs from today was determined to be outside the patient's skin upon
manipulation under fluoroscopy. The tube appears in good position and there
is no kinking or redundancy around the diaphragm. No adjustment was made to
the tube position and no contrast was injected. There is a moderate amount of
bilious fluid in the bag. The patient reports mild discomfort with coughing.
IMPRESSION:
Cholecystostomy tube is in satisfactory position.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year s/p lap chole, POD 2, increased abdominal RUQ pain,//
concern for bile leak, retained stone?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Eovist.
Oral contrast: Not administered.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Lower Thorax: Limited evaluation of the lung bases shows trace right pleural
effusion. There is bibasilar subsegmental atelectasis.
Liver: There is no significant drop in signal on opposed phase imaging to
suggest hepatic steatosis. No focal hepatic lesions are identified. There is
a surgical drain, extending from the right lower abdomen towards the inferior
surface of the liver.
Biliary: Since the prior CT performed on ___, the patient has
undergone interval cholecystectomy. Within the gallbladder fossa, there is an
area of heterogeneous signal intensity measuring 3.0 x 2.1 cm (22:24). It is
largely hyperintense on T2 weighted imaging. There is no appreciable
postcontrast enhancement within this region. Findings are suggestive of a
small amount of fluid, with inflammation of the surrounding hepatic parenchyma
as evidence by heterogeneous arterial hyperenhancement (14:44). Developing
phlegmon/infection cannot be excluded.
On the delayed hepatobiliary phase, there is expected excretion through the
common bile duct, without evidence of a biliary leak. Filling defect in the
anti dependent portion of the CBD is consistent with air (22:28). There is no
evidence of choledocholithiasis. CBD measures up to 1 cm, which is not
significantly changed from the preoperative study.
Pancreas: There is normal intrinsic T1 hyperintense signal throughout the
pancreas. No focal parenchymal lesions or ductal dilation.
Spleen: Spleen is normal in size, without focal lesions.
Adrenal Glands: Normal in size and shape.
Kidneys: Kidneys are normal in size and shape. No solid parenchymal lesions
are identified. There is no hydronephrosis.
Gastrointestinal Tract: Stomach is unremarkable. There is no bowel
obstruction or ascites.
Lymph Nodes: Retroperitoneal and mesenteric lymph nodes are not enlarged by
size criteria.
Vasculature: Abdominal aorta is not aneurysmal. Celiac artery, superior
mesenteric artery, and bilateral renal arteries are patent.
Osseous and Soft Tissue Structures: No worrisome osseous lesions are
identified. Soft tissues are unremarkable.
IMPRESSION:
1. No evidence of a bile leak or biloma.
2. Pneumobilia, without evidence choledocholithiasis.
3. 3.0 x 2.1 cm ill-defined focus of heterogeneous T2 hyperintense signal
intensity in the gallbladder fossa with inflammation of the surrounding
hepatic parenchyma, likely containing some fluid which may be postsurgical.
Superimposed infection/phlegmon cannot be excluded, but there is no drainable
collection.
4. Trace right pleural effusion.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Sepsis, unspecified organism, Acidosis, Unspecified abdominal pain
temperature: 99.0
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 154.0
dbp: 64.0
level of pain: sleep
level of acuity: 3.0 | Mr. ___ is a ___ history of chronic pneumobilia
thought to be secondary to sphincter of Oddi incompetence,
seizure disorder, GERD, gout, who initially presented with
worsening abdominal pain to ___, found to have pneumobilia
transferred here for consideration of ERCP. Underwent HIDA found
to have acute cholecystitis with E. Coli bacteremia. Underwent
percutaneous cholecystostomy and narrowed to ciprofloxacin and
flagyl. Then underwent laparoscopic cholecystectomy.
ACUTE ISSUES
====================
#E. Coli bacteremia
#Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic
cholecystectomy
#Septic Shock
Patient initially presented with acute on subacute worsening
abdominal pain, fevers, chills to ___. There with normal LFTs,
however on CT A/P WO contrast found to have pneumobilia,
cholelithiaisis, with RUQ U/S equivocal for cholecystitis. Given
pneumobilia was transferred to ___ for consideration of ERCP.
Found to have septic shock with E. coli bacteremia requiring
pressors. Ultimately underwent HIDA confirming acute
cholecystitis. In consultation with both ACS and ___, underwent
percutaneous cholecystostomy. Was initially started on
vancomycin for enterococcus coverage, cefepime, flagyl however
narrowed to IV cipro based on sensitivities. Was weaned off of
vasoactive support prior to transfer to floor. Transitioned to
oral cipro, but given continued abd pain and borderline fevers,
flagyl was added back on ___. Patient underwent uncomplicated
laparoscopic cholecystectomy on ___. Patient had significant
pain secondary to the drain and the procedure, and was
controlled with oxycodone and lidocaine patch.
#Pneumobilia
With chronic pneumobilia for which patient underwent ERCP in
___ for work-up of pneumobilia. Showed duodenal ulceration
however without evidence of enteric-biliary fistula. Also found
to have duodenal stenosis on ERCP in ___ for which was unable
to pass duodenoscope past stricture. Given known stricture, per
ERCP during this admission deferred ERCP given would be unlikely
to pass scope past the stricture. Underwent CT A/P WC which
ruled out duodenal diverticulum perforation as cause of his
pnuemobilia. Found to have contrast reflux into CBD suggestive
of sphincter of oddi dysfunction/incompetence which is likely
the cause of patient's known chronic pneumobilia.
#Herpes re-activation
Post percutaneous cholecystostomy, had oral HSV re-activation.
Was treated with five day course of Valtrex.
CHRONIC ISSUES
====================
#Gout
Continued home allopurinol ___ PO QD
#GERD
Continued home omeprazole 20mg PO QD
#Seizure disorder
Continued home phenobarbital 64.8mg PO BID
TRANSITIONAL ISSUES
===================
[ ] Patient evaluated by occupational therapy as inpatient,
complete MOCA evaluation with score of ___ suggestive of
cognitive impairment. Arranged for neurocognitive follow up as
outpatient
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
non functioning J tube and redness at site
Major Surgical or Invasive Procedure:
___
Jejunostomy tube replacement
History of Present Illness:
Ms. ___ is a ___ woman with T3N0M0 poorly
differentiated squamous cell carcinoma of the esophagus s/p
neoadjuvant chemoradiation therapy followed by minimally
invasive
esophagectomy with Dr. ___ ___, now with local
recurrence/lymph node metastasis undergoing salvage
chemoradiation therapy. She underwent a laparoscopic feeding
jejunostomy tube placement on ___ with Dr. ___. She
tolerated this without complications and went home the same day.
She used her J-tube for feeding with no issues last night; she
has been cycling her tube feeds. When she showered this morning,
she dressed the J-tube site as usual, but noticed that the tube
may have appeared loose although all the sutures were in place.
She then noted when she tried to flush the tube later on, the
water came out through the J-tube site. She then called into the
office and was sent to the ED.
Of note, she has noticed increasing irritation/redness around
the
J-tube site, as well as surrounding the sutures. She has not had
any temperatures at home, but has felt some chills. She
continues
with chemoRT and has been tolerating that well with some nausea.
She is still able to eat soft foods with careful chewing as she
does have some dysphagia, and as previously mentioned, cycles
her
tube feeds at night. She moves her bowel regularly with the help
of miralax. She is scheduled for her next radiation treatment
this morning at 8:45AM on ___.
Past Medical History:
-GERD
-Hyperlipidemia
-H/o tobacco use
-Osteoarthritis
-R rotator cuff injury
-S/P MIE ___
Social History:
___
Family History:
The patient's father died at age ___ from aortic
aneurysm; her mother's age is ___ and healthy and was previously
treated for breast cancer in her ___ a half brother had
lymphoma
and a half sister had breast cancer.
Physical Exam:
T97.5, HR97, BP127/62, RR16, Sat100%RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Trachea midline [ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [] NT [x] ND [x] No mass/HSM [x] No hernia
[x] Abnormal findings: tender to palpation around J-tube site
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[] No rashes/lesions/ulcers
[] No induration/nodules/tightening
[x] Abnormal findings: The skin around the jejunostomy was noted
to be erythematous and indurated, without fluctuance. In
addition, all of the suture sites were also noted to be
erythematous and indurated. Altogether, about a 3cm diameter
area
around the jejunostomy site was warm, indurated and
erythematous.
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 01:25AM WBC-6.3 RBC-3.10* HGB-9.0* HCT-28.4* MCV-92
MCH-29.0 MCHC-31.7* RDW-12.9 RDWSD-42.4
___ 01:25AM NEUTS-85.3* LYMPHS-4.0* MONOS-8.1 EOS-1.7
BASOS-0.3 IM ___ AbsNeut-5.37 AbsLymp-0.25* AbsMono-0.51
AbsEos-0.11 AbsBaso-0.02
___ 01:25AM PLT COUNT-267
___ 01:25AM ___ PTT-31.2 ___
___ 01:25AM GLUCOSE-111* UREA N-9 CREAT-0.4 SODIUM-135
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
___ Abdomen:
Appropriately placed jejunal tube.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Dexamethasone 8 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Mirtazapine 30 mg PO QHS
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
7. ALPRAZolam 0.5 mg PO Q6H:PRN anxiaty
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Atorvastatin 20 mg PO QPM
11. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
13. Pantoprazole 40 mg PO Q12H
14. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
15. Morphine SR (MS ___ 15 mg PO Q12H
Discharge Medications:
1. Sulfameth/Trimethoprim Suspension 20 mL PO BID
RX *sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL 20 mls by
mouth twice a day Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
4. ALPRAZolam 0.5 mg PO Q6H:PRN anxiaty
5. Atorvastatin 20 mg PO QPM
6. Dexamethasone 8 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
9. Mirtazapine 30 mg PO QHS
10. Morphine SR (MS ___ 15 mg PO Q12H
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Wound cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: G/GJ/GI TUBE CHECK
INDICATION: ___ year old woman with j-tube and concerns for displacement.
Evaluate J-tube placement.
TECHNIQUE: Supine radiograph were obtained before and after administration of
contrast via the G-tube.
DOSE: DAP: 2.227
COMPARISON: CT abdomen pelvis of ___.
FINDINGS:
Initial scout view demonstrates a left-sided to projecting in the region of
the left mid abdomen. After administration of contrast through the tube, the
jejunum is opacified, indicating appropriate placement of the known J-tube.
Bowel loops are not dilated. There is no evidence of free intraperitoneal air
on limited supine views. Surgical clips overlie the spine in the midline.
Mild lower lumbar degenerative changes are present.
IMPRESSION:
Appropriately placed jejunal tube.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: gtube eval
Diagnosed with Enterostomy infection, Cellulitis of abdominal wall, Form of external stoma cause abn react/compl, w/o misadvnt
temperature: 97.5
heartrate: 97.0
resprate: 16.0
o2sat: 100.0
sbp: 127.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | Mrs. ___ was evaluated by the Thoracic surgery service in
the Emergency Room and admitted to the hospital for obcervation
of her abdominal cellulitis. She remained afebrile and had a
normal WBC. An attempt was made to drain an area adjacent to the
J tube but the entire area was hard and erythematous. There was
no fluctuant area. The J tube was replaced with an ___ Fr tube
and placement was confirmed by xray. The tube was taped
securely to an area that had no skin breakdown. Bactrim was
started and the plan is for her to continue a 10 day course of
oral Bacrtim. She will be seen tomorrow by Dr. ___ to assess
the area and potentially suture the tube in place tomorrow in
the Thoracic Clinic. She was discharged on ___ prior to
her radiation appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
heparin
Attending: ___.
Chief Complaint:
Abdominal aortic aneurysm rupture with hemodynamic instability
Major Surgical or Invasive Procedure:
___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR
WASHOUT OF HEMATOMA
___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT
___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN
History of Present Illness:
HPI:
Mr. ___ is a ___, former smoker, with PVD s/p
aortobifemoral bypass (___ ___ vs ___ per wife), who presented
to the OSH with sudden onset abdominal pain this morning. He
underwent a CTA which showed a disrupted proximal anastomosis of
the aorto-femoral graft with rupture. Additionally he has a
right groin pseudoaneurysm between the right limb of the
aort-bifemoral
graft with the native artery which appears contained. He was
therefore transferred to ___ for further management. On
Medflight, he became hypotensive with worsening abdominal
distention and was given a total of 4u pRBC and ___ FFP. He was
taken directly to the OR for definitive treatment.
Past Medical History:
PMH:
afib, stroke (no neuro deficits ___, PVD, HTN
PSH:
- aortobifemoral bypass ___ vs ___
- >___nd endovascular procedures
including left iliac artery stent, fem-fem bypass, ultimately
resulting in R BKA
Social History:
___
Family History:
FH:
unknown
Physical Exam:
Physical Exam: ON ARRIVAL
Vitals: HR 112 BP 135/110
GEN: in acute distress, conversant
CV: tachycardic
PULM: no respiratory distreess
ABD: tense, distended abdomen, tender to palpation
Ext: No ___ edema, ___ warm and well perfused
Pulses: R: p/d/BKA L: p/d/d/d
ON DISCHARGE
***************
Pertinent Results:
___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4*
MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___
___ 05:37AM BLOOD ___ PTT-33.4 ___
___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138
K-5.0 Cl-97 HCO3-27 AnGap-14
___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2
___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255
Medications on Admission:
Lisinopril
Lovastatin
Gabapentin
Prilosec
Warfarin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN
dry eyes
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Captopril 37.5 mg PO TID
RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day
Disp #*135 Tablet Refills:*0
7. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
9. Docusate Sodium (Liquid) 100 mg PO BID
10. Fondaparinux 7.5 mg SC DAILY
RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe
Refills:*0
11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
12. Metoclopramide 10 mg PO Q6H
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. QUEtiapine Fumarate 12.5 mg PO QHS agitation
15. Senna 8.6 mg PO BID
16. Divalproex (DELayed Release) 500 mg PO BID
17. Gabapentin 800 mg PO TID
18. Lovastatin 40 mg oral DAILY
19. Memantine 10 mg PO DAILY ___
20. Memantine 5 mg PO DAILY AM
21. Omeprazole 20 mg PO DAILY
22. Warfarin 2 mg PO 5X/WEEK (___)
23. Warfarin 4 mg PO 2X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal Aortic Aneurysm Rupture
Peripheral Vascular Disease
Anemia secondary to rupture requiring transfusion
Oliguria
Pleural effusions with pulmonary edema requiring diuresis
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
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change// ___ year old man with
ruptured aortobifem now intubated w/ evolving RLL consolidation please eval
for change ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change
IMPRESSION:
Comparison to ___. The monitoring and support devices are stable.
Moderate cardiomegaly persists. Minimal bilateral pleural effusions. Signs
of mild pulmonary edema. No new focal parenchymal changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic respiratory failure, two episodes
of desaturation this afternoon.// Atelactasis, new consolidation
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 05:37.
IMPRESSION:
The support lines and tubes are in stable position. Low lung volumes are
noted. Small bilateral pleural effusions and bibasilar opacities are
unchanged. There is no overt pulmonary edema. The cardiomediastinal
silhouette is stable in appearance. No acute osseous abnormalities are
identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change// ___ year old man with
ruptured aortobifem now intubated w/ evolving RLL consolidation please eval
for change ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left lower lobe collapse unchanged. Mild pulmonary edema more pronounced in
the right lung, moderate right pleural effusion is small left pleural effusion
unchanged. No pneumothorax. Heart size normal.
Cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man who presented with ruptured aorta bifem
anastomosis s/p proximal aortic cuff x4. Currently intubated.// assess for
lung volumes
TECHNIQUE: Chest AP film
COMPARISON: ___
FINDINGS:
In comparison to study completed on ___, there is increased vascular
congestion bilaterally. Low lung volumes bilaterally with bilateral
atelectasis. Moderate layering pleural effusion on the right and small
pleural effusion on the left. Borderline cardiomediastinal silhouette.
Trachea is patent, midline. No pneumothorax. ET tube is about 5.6 cm above
the carina. Right IJ catheter extends to the upper to mid SVC. Enteric tube
is seen extending past the mid-body, tip is out of view.
IMPRESSION:
Low lung volumes bilaterally, with increased vascular congestion. Moderate
pleural effusion on the right and small pleural effusion on the left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man who presented with ruptured proximal anastomosis
s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes
assess lung volumes
IMPRESSION:
Compared to chest radiographs ___ through ___.
Patient is rotated to his left, obscuring the left lower lobe which is
probably still collapsed. Basal atelectasis is also persistent in the right
lower lobe, severity indeterminate. The right upper lobe is clear. The heart
is not enlarged. There is no pneumothorax.
ET tube in standard placement. Transesophageal drainage tube passes into the
stomach and out of view. Left jugular line ends in the low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man who presented with ruptured proximal anastomosis
s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes
assess lung volumes
IMPRESSION:
Compared to chest radiographs ___ through ___.
There is no longer pulmonary edema. Severe left lower lobe atelectasis and
small pleural effusions persist. Heart size top-normal. No pneumothorax.
Cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man who presented with ruptured proximal anastomosis
s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes.
Monitoring and support devices are stable. Cardiac silhouette is enlarged and
there is increased engorgement of ill defined pulmonary vessels consistent
with elevated pulmonary venous pressure. Bilateral pleural effusions with
compressive atelectasis is seen.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with anastamotic rupture// New Left IJ Central
line Contact name: ___, Phone: ___
IMPRESSION:
In comparison with the study of 6 hours previously, there has been placement
of a left IJ catheter that extends to the lower SVC. No evidence of post
procedure pneumothorax. Cardiomediastinal silhouette is less prominent and
there is substantial decrease in the bilateral pulmonary opacifications that
most likely represented pulmonary edema. There again are bilateral pleural
effusions with compressive basilar atelectasis, more prominent on the right.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with APLAS, now with LUE swelling and petechial
rash// ?LUE DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian veins.
The left internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The left basilic,
and cephalic veins are patent, compressible and show normal color flow.
There is moderate subcutaneous edema over the dorsum of the hand.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic respiratory failure// worsening
tachypnea
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with small bilateral effusions right greater than left.
Cardiomediastinal silhouette is stable. There is mild pulmonary vascular
congestion. The ETT, NG tube and left-sided central line are unchanged. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with hypoxic respiratory failure// worsened
hypoxemia worsened hypoxemia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Pulmonary vascular congestion persists. Large area of consolidation right
lower lobe in smaller regions of peribronchial opacification suggest
widespread pneumonia. Heart size normal. Small pleural effusions are likely.
No pneumothorax.
Cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old man s/p repair of ruptured aortobifemoral bypass, now
with persistent leukocytosis also Hgb drop overnight (unknown source).
suspected VAP. Evaluation for bleeding, VAP, abdominal source of
leukocytosis/fevers.
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 4.7 s, 74.7 cm; CTDIvol = 4.3 mGy (Body) DLP = 317.2
mGy-cm.
2) Spiral Acquisition 5.6 s, 74.7 cm; CTDIvol = 14.9 mGy (Body) DLP =
1,112.0 mGy-cm.
3) Spiral Acquisition 5.6 s, 74.7 cm; CTDIvol = 14.9 mGy (Body) DLP =
1,110.8 mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP =
6.6 mGy-cm.
Total DLP (Body) = 2,548 mGy-cm.
COMPARISON: Comparison to CT abdomen/pelvis performed at outside hospital
from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Moderate atherosclerotic calcification along the aortic
arch and descending thoracic aorta. The heart, pericardium, and great vessels
are within normal limits. Moderate coronary artery calcifications. No
pericardial effusion is seen. Left-sided central venous line with tip
extending to the mid SVC.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. A mildly enlarged right hilar lymph node measures 1.3 cm in short
axis (301:54), presumably reactive.
PLEURAL SPACES: No pneumothorax. Stable small left pleural effusion and new
small right pleural effusion, with adjacent compressive atelectasis.
LUNGS/AIRWAYS: Focal ground-glass opacities in the right upper lobe (301:34),
possibly infectious or asymmetric edema. Mild upper lobe predominant
emphysema. Compressive atelectasis at the bilateral lung bases. The airways
are patent to the level of the segmental bronchi bilaterally. Patient is
intubated with endotracheal tube in appropriate position at the midthoracic
trachea.
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. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. The left
adrenal gland contains a 1.9 cm nodule (303:125).
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: Enteric tube courses beyond the gastroesophageal junction
and into the stomach. The stomach is unremarkable. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy. A mildly prominent left external
iliac lymph node measures 1.3 cm in short axis (303:213), however demonstrates
a normal fatty hilum.
VASCULAR: Interval repair of a ruptured infrarenal abdominal aortic aneurysm
with aortobifemoral graft placement. Expected interval evolution of the large
hematoma in the right hemiabdomen, measuring 11.5 x 7.6 x 17.0 cm (303:173,
601:69), which appears to be involuting. No evidence of active extravasation
identified. Persistent occlusion of the aortobifemoral bypass is again
demonstrated. Persistent occlusion of the fem-fem graft is also noted. There
is stable appearance of a chronic bilobed fluid collection in the left
inguinal region, measuring 6.0 x 4.8 x 6.8 cm (303:259, 601:74). Stable
appearance of a right common femoral pseudoaneurysm measuring approximately
2.2 x 1.8 cm (301:252).
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Right hip hardware appears intact. Mild multilevel
degenerative change of the thoracolumbar spine, including mild wedging of few
midthoracic vertebral bodies, unchanged. Postsurgical changes in the anterior
abdominal midline, including superficial skin staples.
IMPRESSION:
1. Interval repair of a ruptured infrarenal abdominal aortic aneurysm with
aortobifemoral graft placement.
2. Expected interval evolution of the large hematoma in the right hemiabdomen,
which appears to be involuting and measures up to 17.0 cm. No evidence of
active extravasation identified.
3. Stable right common femoral pseudoaneurysm measuring approximately 2.2 x
1.8 cm.
4. Unchanged appearance of a chronic bilobed fluid collection in the left
inguinal region, measuring up to 6.8 cm.
5. Nonspecific 1.9 cm left adrenal nodule, indeterminately characterized but
most commonly adenoma. A dedicated CT/MRI with adrenal protocol on a
nonemergent basis as an outpatient may be performed if needed for better
characterization.
6. Focal ground-glass opacities in the right upper lung, possibly representing
infection or asymmetric edema.
7. Persistent small left pleural effusion and new small right pleural
effusion, with adjacent compressive atelectasis.
8. Mildly enlarged right hilar lymph node measuring 13 mm, presumably
reactive.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p ruptured aortic graft w/ concern for fluid
overload and possible PNA. Please eval for interval changes// Please eval for
interval changes
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged and in satisfactory position. Improved, though still relatively
low lung volumes. Cardiomediastinal silhouette is stable and there is
indistinctness of engorged pulmonary vessels consistent with the clinical
concern for volume overload. Opacification at the left base silhouetting
hemidiaphragm is consistent with pleural fluid and volume loss in left lower
lobe. Band of atelectasis at the right base is now seen instead of the more
amorphous opacification previously noted. Nevertheless, the possibility of
superimposed pneumonia would have to be considered in the appropriate clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic resp failure// hypoxemia
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs since ___, most recent
___, and chest CTA from ___.
FINDINGS:
Right lower lobe band atelectasis is stable. Left basilar opacification
silhouetting the hemidiaphragm and suggesting left lower lobe collapse and
mild pleural effusion is unchanged, however a superimposed focal consolidation
cannot be excluded in the proper clinical setting. Monitoring and support
devices are in stable position.
IMPRESSION:
Right atelectatic band in left lower lobe collapse are unchanged. However, in
the appropriate clinical setting, it would be difficult to exclude
superimposed consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with vap// ? vap
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest radiographs since ___, most recent on ___, and chest CTA from ___.
FINDINGS:
Right lower lobe band atelectasis is stable. Left basilar opacification
silhouetting the hemidiaphragm and suggesting left lower lobe collapse and
mild pleural effusion is unchanged, however, a superimposed focal
consolidation cannot be excluded in the proper clinical setting. Monitoring
and support devices are in stable position.
IMPRESSION:
Right atelectatic band and left lower lobe collapse are unchanged. However,
in the appropriate clinical setting, it would be difficult to exclude
superimposed consolidation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with ruptured aortobifem now intubated and with
new CVL// evaluate Contact name: ___: ___ evaluate
IMPRESSION:
No comparison. The patient is intubated. The tip of the endotracheal tube
projects approximately 3 cm above the carinal. The course of the feeding tube
is normal. Right internal jugular vein catheter, left internal jugular vein
catheter, both in correct position. Lung volumes are low. There is mild
cardiomegaly and mild to moderate pulmonary edema, combines to a small left
pleural effusion as well as a relatively extensive right basilar atelectasis.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increased O2 requirement, poor left breath
sounds// please eval for ?PTX
TECHNIQUE: Chest AP film
COMPARISON: ___ through ___
FINDINGS:
In comparison to the study completed on ___, patient has been
extubated. There is a nasogastric tube seen past the midbody, distal tip out
of view. Left IJ catheter terminating in the distal SVC.
Lower lung volumes today compared to the prior study. Stable
cardiomediastinal silhouette. Mildly improved engorgement of pulmonary
vascular congestion. Ill-defined opacity seen in the right lower lung that
may be represent aspiration/pneumonia in the correct clinical setting. Small
to moderate left pleural effusion with volume loss in the left lower lobe.
Stable right base atelectasis. No pneumothorax.
IMPRESSION:
1. No evidence of pneumothorax.
2. Improved pulmonary vascular congestion.
3. Possible aspiration/pneumonia in the right lower lung in the correct
clinical setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with VAP// VAP
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Patient is rotated to the right. The left IJ line projects at the junction of
the left brachiocephalic and SVC. The NG tubes are unchanged. Lungs are low
volume with patchy parenchymal opacity in the right lower lobe and left lower
lobe, unchanged. Small bilateral effusions left greater than right are
unchanged. No pneumothorax. Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: Radiographs with limited views of chest and abdomen.
INDICATION: ___ year old man with dobhoff placement// dobhoff placement
TECHNIQUE: 4 portable upright images with limited views of the chest and
abdomen.
COMPARISON: CT scan dated ___, dedicated chest radiograph dated ___.
FINDINGS:
CHEST:
Limited visualization of the chest due to patient being outside the field of
view.
Right basilar lung opacities previously seen have resolved, there is
persistent left basilar opacity and pleural effusion.
ABDOMEN:
Dobhoff tube is seen coursing through the esophagus, below the diaphragm and
eventually coiling in the antrum of the stomach. There is another NG tube
also in the stomach.. Central line terminates in the azygos vein.
Endotracheal tube terminates 5-6 cm above the carina.
IMPRESSION:
1. Dobhoff tube successfully placed in the stomach.
2. Central line terminates in the azygos vein.
3. Interval resolution of right-sided basilar lung opacities, persistence of
left-sided basilar opacities and pleural effusion.
NOTIFICATION: Findings communicated to ___, MD by ___
___, MD at 16:33 on ___ 20 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic resp failure// hypoxemia
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable. Continued low lung volumes with enlargement of the cardiac
silhouette and elevation of pulmonary venous pressure. Retrocardiac
opacification with obscuration of the hemidiaphragm is consistent with volume
loss in left lower lobe and pleural effusion. The opacification at the right
base has substantially decreased.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with intubation// intubation
IMPRESSION:
In comparison with the study of ___, the patient has taken a much better
inspiration. The tip of the endotracheal tube is approximately 5 cm above the
carina. Other monitoring and support devices are stable.
Continued relatively low lung volumes with enlargement of the cardiac
silhouette and moderate pulmonary edema. Opacification in the retrocardiac
region with obscuration hemidiaphragm is again consistent with volume loss in
left lower lobe and pleural effusion.
There is an area of increased opacification above the right hemidiaphragmatic
contour. This most likely represents merely atelectatic changes. However, in
the appropriate clinical setting, superimposed aspiration/pneumonia would have
to be considered.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with AMS. Evaluation for etiology of AMS.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
There is no evidence of intracranial hemorrhage, acute large territorial
infarction, edema,or mass. Extensive encephalomalacia within the posterior
right parietal lobe is consistent with prior infarct. Chronic infarction is
also noted of the adjacent to the right caudate nucleus. There is prominence
of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical hypodensities are nonspecific, though likely
sequela of chronic small vessel ischemic disease.
There is no evidence of fracture. Partial opacification of the bilateral
ethmoid air cells. Mild mucosal thickening of the bilateral sphenoid sinuses
and maxillary sinuses with small amount of layering fluid. Complete
opacification of the bilateral mastoid air cells. The middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial abnormality or hemorrhage.
2. Chronic right caudate nucleus infarct, and chronic posterior right parietal
lobe infarct as described above.
3. Moderate paranasal sinus disease with complete opacification of the
bilateral mastoid air cells and layering fluid within the bilateral sphenoid
sinuses and maxillary sinuses, possibly sequela of intubation.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old man with pmh significant for anti-phospholipid
anitbiody syndrome, hypercoagulable state, PAD s/p R BKA, multiple strokes due
to clotting disorder now has LUE swelling, persistent fevers despite extensive
infectious work up, concern for venous thrombus.// Please eval for DVT or
etiology of upper extremity swelling and persistent fevers.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: Left upper extremity venous ultrasound from ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular vein is noncompressible with an intraluminal linear
echogenicity, attached to the vessel wall cranially, compatible with an
nonocclusive thrombus. Left internal jugular, and bilateral axillary, and
brachial veins are patent, show normal color flow, spectral doppler, and
compressibility.
The bilateral basilic, and cephalic veins are patent, compressible and show
normal color flow.
IMPRESSION:
Nonocclusive venous thrombosis in the right internal jugular vein. Remainder
of the right upper extremity veins and left extremity veins are without
thrombus.
Radiology Report
EXAMINATION: GO TO NOTIFICATION CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with intubation// acute process acute
process
IMPRESSION:
Compared to chest radiographs ___ through ___.
Although lung volumes are still relatively low, previous left lower lobe
atelectasis has improved substantially. Pulmonary edema is mild. Mild
cardiomegaly has improved since ___. Small left pleural effusion
unchanged. No pneumothorax.
No endotracheal tube is seen. Transesophageal drainage tube ends at the
thoracic inlet either in the airway or upper esophagus. Transesophageal
feeding tube ends in the proximal duodenum. Left jugular line tip in the low
SVC.
NOTIFICATION:
The findings were discussed with ___, RN, by ___, M.D. on the
telephone at 12:49, IMMEDIATELY following discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic respiratory failure, now s/p
extubation// hypoxemia
IMPRESSION:
In comparison with the study of ___, there are slightly improved lung
volumes. The endotracheal tube is been removed. What appears to of been a
transesophageal drainage tube has been removed. The other monitoring and
support devices appear stable.
Cardiomediastinal silhouette is unchanged. Mild engorgement of ill defined
pulmonary vessels is consistent with elevated pulmonary venous pressure.
Basilar opacification on the left is consistent with pleural fluid and
atelectatic changes.
Radiology Report
INDICATION: ___ year old man with increased O2 requirements// Eval for pulm
edema, effusion
COMPARISON: Radiographs from ___
IMPRESSION:
There has been improvement of the pulmonary edema. The left IJ central line
has been removed. There is a feeding tube with distal tip is below the edge
of the film, past the GE junction.. There remains bibasilar opacities at the
lung bases, left greater than right. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ruptured aortobifem now intubated, please
eval for interval change// ___ year old man with ruptured aortobifem now
intubated, please eval for interval change ___ year old man with ruptured
aortobifem now intubated, please eval for interval change
IMPRESSION:
Comparison to ___. Stable correct position of the monitoring and
support devices. New small to moderate bilateral pleural effusions, with
subsequent areas of basilar atelectasis, in addition to the pre-existing right
perihilar and basal opacity and consolidation. There also is a new
retrocardiac atelectasis. No pulmonary edema. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change// ___ year old man with
ruptured aortobifem now intubated w/ evolving RLL consolidation please eval
for change
IMPRESSION:
In comparison with the study of ___, there is little change in the
monitoring and support devices. The cardiac silhouette is again mildly
enlarged with elevated pulmonary venous pressure that appears less prominent
than on the prior study. The layering pleural effusions with compressive
basilar atelectasis also are less prominent, though much of this could merely
reflect a more upright position of the patient.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man post-op vent dependence still with open abdomen.
Bronch'd this morning for ?mucus plugging in RLL.// worsening hypoxemia s/p
bronch/BAL worsening hypoxemia s/p bronch/BAL
IMPRESSION:
Comparison to ___. Stable monitoring and support devices. Minimal
increase in extent of the moderate right and small left pleural effusion.
Stable basal areas of atelectasis. On the current image, signs of mild
pulmonary edema present. Mild cardiomegaly persists. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change// ___ year old man with
ruptured aortobifem now intubated w/ evolving RLL consolidation please eval
for change ___ year old man with ruptured aortobifem now intubated w/
evolving RLL consolidation please eval for change
IMPRESSION:
ET tube tip is 6 cm above the carina. NG tube tip is in the stomach. Right
internal jugular line tip is at the level of mid SVC.
Heart size and mediastinum are stable. Bibasal consolidations and bilateral
pleural effusions are unchanged. There is interval improvement in pulmonary
edema with only pulmonary vascular congestion currently present.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NGT// ? NGT
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 03:59.
IMPRESSION:
The nasogastric tube terminates in the body of the stomach. The remaining
support lines and tubes are in stable position. No other significant interval
change compared to study from earlier today.
Gender: M
Race: UNKNOWN
Arrive by HELICOPTER
Chief complaint: Transfer
Diagnosed with Abdominal aortic aneurysm, without rupture
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who
presented to the OSH with sudden onset of abdominal pain with
CTA confirming p/w ruptured ___ anastomosis. He was transfused
4u rPBC 2uFFP in medflight with worsening hypotension. He was
taken immediately to the OR where he underwent infrarenal ___
aortic cuff x4 w open abdomen (see op note for further
details). He was transferred to the ICU in critical condition.
He was started on fondaparinux prophylaxis due to his history of
HIT. His respiratory status was tenuous and he frequently
desatted and required increasing FiO2 while he remained
intubated. Pulmonology was consulted and he was started on
Lasix. During this initial post-op period his antibiotic
coverage was adjusted as appropriate and he was started on tube
feeds. He had a TTE that showed a PFO, but cardiology did not
feel that any intervention was necessary at this time. He
returned to the OR on POD4 for an abdominal washout, lysis of
adhesions, and abthera placement. Following his second trip to
the OR he had continued PRN Lasix requirements in the ICU. Two
days following this he became febrile and his R IJ line had
evidence of pus when it was removed, so a L IJ was placed. His
fevers continued and he was taken back to the OR again for
another washout and at this time his abdomen was closed. After
this third trip to the OR he was persistently hypertensive and
required nicardipine for BP control. In the following days the
ICU team attempted to wean him from the vent but it was not well
tolerated. He also went into Afib and was started on metoprolol.
He continued to be febrile so a CTA of his torso was obtained,
but it showed no obvious source of infection that would explain
his fevers. On POD12 from his original operation he was
extubated, but developed respiratory distress and needed to be
reintubated. The following day he continued to be febrile so ID
was consulted. The following day he went into Afib with RVR
again and was started on a dilt drip. He had an echo for
unexplained hypotension which didn't show a cardiac cause, but
revealed a thrombus in his IJ. At this time he was also
transitioned to bivalirudin for a short period before being
restarted on fondaparinux. On POD16 from his original operation
he was successfully extubated and his oxygen requirements were
subsequently weaned down. His mental status then became one of
his chief issues, as he would only occasionally follow commands
and would not communicate in any meaningful manner. His fevers
subsided and on POD18 he was transferred to the VICU.
While on the floor in the VICU his blood pressure and mental
status were his main issues. Vascular medicine provided
assistance with his anti-hypertensive regimen, which needed to
be adjusted multiple times for adequate control. Neurology was
consulted for his altered mental status, which they attributed
to delirium secondary to an extended ICU stay. Additionally, ACS
was consulted for placement of a PEG tube as he would likely
need long term feeding access due to his mental status.
Ultimately, his family opted not to go through with the PEG so
that they could avoid reintubation, so his feedings were
continued with the Dobhoff. Neurology attributed his mental
status to delirium related to his prolonged ICU stay, so
delirium precautions were put in place. His mental status began
to improve and he became more conversant and oriented as time
progressed. Vascular medicine continued to be involved in his
care and he was diuresed as necessary. On hospital day ___ he had
a brief run of afib that was seen on telemetry, but had no
further issues with afib afterwards. On hospital day ___ he was
hemodynamically stable and his mental status continued to
improve so he was determined to be fit for discharge. His
discharge was ultimately delayed due to difficulties with
finding rehab placement, but by hospital day 27 case management
had found a rehab facility and he was transferred there with
plans to follow up with vascular surgery clinic for re-imaging
of his abdomen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / carboplatin
Attending: ___.
Chief Complaint:
C3-C5 Spinal Stenosis s/p Surgical Decompression
Major Surgical or Invasive Procedure:
C3-6 Laminectomy, C3-7 Posterior Fusion,
Autografts/Allografts/Instrumentation on ___ ___
___
History of Present Illness:
Mr. ___ is a ___ year old man with lung ___ on chemo who
presents to ED after transfer from ___. Pt had an
unwitnessed syncopal episode at 2:30 a.m. Pt's wife states she
heard a fall while he was walking to the bathroom and found him
after he struck the left anterior aspect of his face on the
floor, laying on his bilateral hands. He presented to ___
where he reported B/L hand numbness on radial aspect and pain
and L foot numbness s/p fall. At ___ head was negative,
and CT Cspine revealed no fracture but narrowing at C3-C5. EKG
showed multifocal PVCs.
Pt is ambulatory at baseline. Since the fall, he stood to
transfer to a wheelchair but has otherwise not walked. He has
recently diagnosed afib but is not on Coumadin, takes aspirin
81mg daily. Currently on weekly chemo for lung ___.
Previously had two bilateral lower lung resections, unknown when
date. Got 5 sessions of pemetrexed ___ to first week
of ___. Tumor regressed by only half, then started vinorelbine,
had 2 sessions, ___.
Admit to medicine for medical clearance/syncope workup, then
spine op
In the ED, initial VS were temp: 98.4 HR: 100 BP: 128/76 RR:
20O2 SaO2 98%. Exam notable for decreased sensation in bilateral
hands and left foot. Alert, oriented x3. Labs showed trop neg,
otherwise unremarkable. MRI spine showed significant cervical
stenosis at C3-C5. Hand x-ray showed no evidence of fracture.
Received morphine, NS. Transfer VS were 98 °F (36.7 °C), Pulse:
87, RR: 19, BP: 107/68, O2 sat: 93. Ortho spine was consulted
and the patient will likely have surgery following synocope
workup/OR clearance, but no need for urgent surgery. Spine will
continue to follow on the floor. Patient OK to eat.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient denies numbness and tingling
currently and his main complaint is bilateral dorsal hand pain
to the mid forearm. He denies a history of neuropathy in the
past. No CP/SOB/palp. No NV.
Past Medical History:
COPD
HLD
Renal ___ (transitional cell carcinoma of the left renal
pelvis and a papillary tumor--dx ___
lung ___ (Likely non small cell lung ___. Previously had
two bilateral lower lung resections, does not know date. Found
to have a new uppe0r lobe lesion in ___. Startd chemo--got 5
qweek sessions of pemetrexed with carboplatin ___ to
first week of ___. Was unable to tolerate carboplatin. Tumor
regressed by only half, so started on vinorelbine, had 2
sessions, ___
HTN
DM
C3-C7 Cord Compression post-syncope s/p surgical decompression
___
Social History:
___
Family History:
Does not report any family history.
Physical Exam:
Admission physical exam:
VS - 98.2 128/73 94 20 93% on RA
General: thin, older gentleman, lying comfortably in bed, with
cervical. responding appropriatley to quesitons, aox3.
HEENT: mucous membranes dry. Echymosis/hematoma to L orbit.
PERRLA. EOMI.
Neck: cervical collar
CV: regular rate, rhythm. normal s2, s2. could not appreciate
murmurs--exam limited by cervical collar extending down.
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender, nondistended, +BS
GU: deferred
Ext: Right axillae with steri strips over a 2cm incision. ___
strength in bilateral hands. Tender to palpation over bilateral
hands, wrists- worse in right ___ and ___ digits. No deformity
appreciated. No pain with PROM of shoulders, elbows. Pain w/
passive ROM of bilateral wrists/digits. 2+ radial pulses.
Small abrasion on left knee, no tenderness in bilateral legs.
Painless arom/prom hip, knees and ankles. 1+ ___ and DP pulses.
No edema, cyanosis. Warm, well-perfused.
Neuro: AOx3. Speech fluent. He has decreased sensation and in
fingers of both hands and left foot. Strength normal. He does
have slightly decreased motor strength bilateral upper
extremities.
Skin: bruising around left orbit. no rashes noted.
Discharge physical exam:
Vitals 97.9, 90-95, 128-139/75-87, 18, 95% on 2L
GENERAL: Lying in bed, NAD, cervical collar in place, A+Ox3
HEENT: Anicteric sclera, pink conjunctiva, patent nares, dry
mucous membrances, ecchymosis over left eye
NECK: Cervical collar in place, could not evaluate JVD
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: Diffus upper airway noise transmission, intermittent
wheeze
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing or edema, 2+ DP pulses
bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Arm flexor/extensors ___ bilaterally, finger
flexors/extensors ___ bilaterally, ___ in lower extremities.
Sensory intact to light touch bilaterally throughout
Pertinent Results:
___ 09:40AM BLOOD WBC-2.8*# RBC-3.36* Hgb-10.8* Hct-34.1*
MCV-101* MCH-32.1* MCHC-31.6 RDW-14.1 Plt ___
___ 09:40AM BLOOD Glucose-178* UreaN-26* Creat-1.0 Na-137
K-4.5 Cl-104 HCO3-25 AnGap-13
___ 05:40AM BLOOD WBC-4.4 RBC-3.08* Hgb-9.8* Hct-29.6*
MCV-96 MCH-31.9 MCHC-33.2 RDW-15.0 Plt ___
___ 10:32AM BLOOD ___ PTT-28.4 ___
___ 05:40AM BLOOD Glucose-132* UreaN-12 Creat-0.8 Na-138
K-4.0 Cl-99 HCO3-28 AnGap-15
___ 05:40AM BLOOD ALT-33 AST-32 LD(LDH)-204 AlkPhos-56
TotBili-0.6
___ 09:40AM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2*
Mg-1.4*
___ 05:40AM BLOOD VitB12-1680*
___ 05:40AM BLOOD %HbA1c-7.0* eAG-154*
___ 05:40AM BLOOD TSH-2.7
IMAGING:
___ MRI Spine
1. No definite evidence of bony metastatic disease although
marrow signal is heterogeneous.
2. Severe changes of cervical spondylosis are seen at C3-4 C5-6
and C6-7 extrinsic indentation and deformity of the spinal cord
with subtle increased signal within the spinal cord at C5 and C6
levels indicating cord edema or myelomalacia.
3. Multilevel degenerative changes in the thoracic and lumbar
region without spinal stenosis at these levels. No evidence of
fracture.
4. Right upper lobe lung mass which can be further evaluated
with chest CT.
___ Hand, wrist x-ray:
No acute fracture or dislocation in either hand or wrist.
ECHOCARDIOGRAM ___
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a small circumferential pericardial
effusion most prominent around the right ventricle and apex.
There are no echocardiographic signs of tamponade.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Small pericardial effusion
without evidence for hemodynamic compromise. Mildly dilated
ascending aorta. No valvular pathology or pathologic flow
identified. No structural cardiac cause of syncope identified.
CAROTID ULTRASOUND ___ =
Mild heterogenous plaque bilaterally. Flow velocities are
indicative of less than 40% stenosis.
OPERATIVE REPORT
___.
Signed Electronically by ___ on MON ___ 1:57
AM
Name: ___ ___ No: ___
Service: Orthopaedic Surgery Date: ___
Date of Birth: ___ Sex: M
Surgeon: ___, ___
SERVICE: Orthopedic Surgery.
___ ASSISTANT: ___, MD
PREOPERATIVE DIAGNOSES:
1. Cervical stenosis.
2. Cervical spinal cord injury.
3. Myelopathy.
POSTOPERATIVE DIAGNOSES:
1. Cervical stenosis.
2. Cervical spinal cord injury.
3. Myelopathy.
PROCEDURES PERFORMED:
1. Laminectomy, C3, C4, C5, C6.
2. Posterior fusion, C3-C4, C4-C5, C5-C6, C6-C7.
3. Posterior instrumentation, C3-C7.
4. Autograft, same incision.
5. Allograft.
IMPLANTS:
1. Globus Ellipse posterior instrumentation.
2. Corticocancellous allograft.
ESTIMATED BLOOD LOSS: 200 cc.
SPECIMEN TO PATHOLOGY: None.
INDICATIONS: The patient is a ___ man who presented
to ___ emergency department after a fall walking to the
bathroom. He struck the anterior aspect of his face, and had
subsequent tingling in both hands, as well as lower extremity
symptoms including difficulty walking. He has found on
imaging to have severe spinal cord compression at C3-C4, C4-
C5, C5-C6, and C6-C7, including myelomalacia within the
spinal cord. Because of the ongoing severe stenosis, the
nature of his symptoms, and the severity of the symptoms, he
elected to undergo surgical treatment, with the goal of
halting the progression of his spinal cord injury and
myelopathy.
Prior to surgery I explained in detail to the patient the
possible risks of surgery which included the risk of
nerve injury, persistent and or worsening pain, spinal fluid
leak, infection or meningitis, excessive bleeding, paralysis,
death, blindness, sexual dysfunction, retrograde ejaculation,
blood vessel injury, injury to neighboring organs, need for
further surgery, bowel and bladder dysfunction, instability, and
autonomic nervous system dysfunction as well as unforeseen
medical and surgical complications. An understanding that in
general spinal surgery is more predictive in improving extremity
discomfort than axial spine pain and arresting the progression
of
spinal cord dysfunction rather than improving it was stressed.
The risks of junctional degeneration, bone graft donor
morbidity,
the differences in efficacy between local bone graft,
autologous iliac crest bone graft and allograft, the FDA status
of the instrumentation, the possible need for further surgery,
the risk of nonhealing and instrumentation failure, and chronic
pain were also explained.
The patient was taken to the Operating Room and after
identification of the patient and the operative site,
administration of antibiotics, and completion of anesthesia, the
patient was prepped and draped in the prone position on
laminectomy rolls. During this time and the entire operation,
care was taken to maintain appropriate perfusion pressures
during
anesthesia. All bony protuberances and soft tissues were well
padded in the standard fashion. Pre- and intra-operatively
prophylactic antibiotics were administered according to the
appropriate timing schedule. A Foley catheter was placed.
Sequential compressive boots were applied and maintained
throughout the procedure. A time out was completed before
beginning the surgical procedure.
Posterior Spinal Exposure:
An incision was made in the skin over the intended surgical
levels and dissection was carried down through the subcutaneous
tissue down to the level of the deep fascia. The deep fascia was
divided and elevated off the posterior elements in a
subperiosteal manner. An intra-operative radiograph was taken
to
confirm the appropriate spinal level.
Cervical lateral mass screw placement:
The anatomic landmarks were identified for lateral mass and
pedicular fixation. A pilot hole was initiated in the correct
anatomic location with a 2 mm burr. Lateral mass fixation was
performed at the C3 to C6 levels. Lateral mass screw
trajectory was drilled in an upward and outward direction
according to the modified Magerl technique. Each of the holes
was tapped if necessary and palpated with a small ball tipped
feeler probe to insure proper integrity of the bony tunnel.
Pedicle fixation was performed at C7 by directly palpating the
borders of the pedicle following a laminoforaminotomy to allow
proper placement and trajectory of the pedicle screw. The
pedicular holes were tapped if necessary and palpated to ensure
integrity of the pedicle screw path. Appropriate length screws
were then selected and placed into the properly prepared bone
holes. In all cases, satisfactory purchase of the screws was
noted.
Spinal rods were then contoured and applied to the spinal
anchors
followed by the appropriate locking vector forces.
Intraoperative
imaging confirmed the appropriate placement of the spinal
anchors
and alignment of the spinal fixation.
Laminectomy C3, C4, C5, C6:
Using sub-periosteal dissection, the laminas of the C3 to C7
vertebrae were exposed. The cervical laminas of C3 to C6 were
secured with towel clips for stabilization. The interspinous
ligament was carefully removed between the laminectomy levels
and
the bordering caudal and cranial spinous processes. A high-speed
drill was then used to create two lateral gutters at
the laminar border. The outer bony cortex and inner cancellous
bone was removed down to the level of the inner cortical bone. A
small curette and ___ ___ was then used to remove this
layer
of bone allowing exposure of the ligamentum flavum and dural
sac.
A ___ ___ rongeur was then used to detach the remaining
intervening ligaments. By carefully elevating the lamina through
the attached towel clips, the spinous processes and lamina were
removed as one unit. A ___ rongeur was then used to widen the
laminectomy as necessary. Foraminotomies were next performed at
each level of decompression to ensure absence of foraminal
compression. Complete hemostasis was obtained in the lateral
recesses with bipolar cautery and hemostatic agents. The dura
was seen to expand and dural pulsations were evident.
Posterolateral fusion C3 to C7 with bone grafting:
The remaining posterior elements of the C3 to C7
vertebral bodies were gently decorticarted with a high speed
drill to expose bleeding trabecular bone. Autograft prepared
from the laminectomy harvest was packed within the decorticated
facet joints as well as allograft was packed over the
decorticated posterior elements.
After the wound was thoroughly irrigated with antibiotic
impregnated fluid and all bleeding was stopped, closure was
completed with interrupted 0 Vicryl suture ligatures in the
fascia, ___ Vicryl suture ligatures in the subcutaneous tissues
and a running ___ Monocryl suture ligature in the subcuticular
layer. The drain was left in the wound exiting through the
wound
closure site which was a small Hemovac.
All sponge, needle and instrument counts are correct at the
end of the case. The patient tolerated the anesthesia and
the procedure well and is brought to the postanesthesia care
unit in stable condition.
___, MD ___
I was physically present during all critical and key portions of
the procedure and immediately available to furnish services
during
the entire procedure, in compliance with CMS regulations.
Dictated By: ___, MD
Radiology Report
EXAMINATION: MRI CERVICAL SPINE, THORACIC AND LUMBAR SPINES
INDICATION: History: ___ with fall on face, BUE tingling, weakness //
presence of cord edema, impingement
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
cervical, thoracic and lumbar spine were obtained.
COMPARISON: Cervical spine CT EXAMINATION of ___.
FINDINGS:
There is a right upper lung mass identified. The patient is known to have lung
cancer
There is heterogeneous bone marrow identified in the cervical, thoracic and
lumbar but there are no focal bony abnormalities identified. The T4 vertebra
demonstrates mild chronic appearing compression.
In the cervical region no evidence of fracture identified. Degenerative
changes seen with moderate to severe spinal stenosis at C3-4 level with
deformity of the spinal cord. Additionally at the C5-6 there is
moderate-to-severe spinal stenosis seen with deformity of the spinal cord. All
there is mild to moderate spinal stenosis seen at this C6-7 level. At other
levels in the cervical region degenerative changes are identified. At C3-4
C5-6 and C6-7 severe bilateral foraminal narrowing is seen.
At the C5-6 and C6-7 levels. There is deformity of the spinal cord. There is
subtle increased signal appreciated within the spinal cord which could be
secondary to myelomalacia or cord edema. There are no signs of intramedullary
hemorrhage is seen.
In the thoracic and lumbar region multilevel mild degenerative changes are
identified. There is no spinal stenosis seen. At L4-5 mild disc bulging
identified with mild narrowing. The remaining spinal cord in the thoracic and
upper lumbar region appears normal without extrinsic compression or intrinsic
signal abnormalities
IMPRESSION:
1. No definite evidence of bony metastatic disease although marrow signal is
heterogeneous.
2. Severe changes of cervical spondylosis are seen at C3-4 C5-6 and C6-7
extrinsic indentation and deformity of the spinal cord with subtle increased
signal within the spinal cord at C5 and C6 levels indicating cord edema or
myelomalacia.
3. Multilevel degenerative changes in the thoracic and lumbar region without
spinal stenosis at these levels. No evidence of fracture.
4. Right upper lobe lung mass which can be further evaluated with chest CT.
Radiology Report
INDICATION: Fall onto hands with bilateral hand numbness and pain
TECHNIQUE: Bilateral hands, three views each and bilateral wrists, four views
each
COMPARISON: None.
FINDINGS:
Within the left hand and wrist, there is no acute fracture or dislocation
identified. A pulse oximeter device slightly obscures assessment of the middle
and distal phalanges of the long finger. No concerning lytic or sclerotic
osseous abnormalities seen. Minimal degenerative changes are noted within the
carpal bones.
Within the right hand and wrist, tubing from a intravenous device is seen
projecting over the carpal bones. No acute fracture dislocation is seen. Mild
degenerative changes are noted at the first CMC joint with osteophytic
spurring. No suspicious lytic or sclerotic osseous abnormality is seen.
IMPRESSION:
No acute fracture or dislocation in either hand or wrist.
Radiology Report
HISTORY: Cervical fusion.
FINDINGS: Images from the operating suite show posterior fusion spanning what
appears to be C3 through C7. Further information can be gathered from the
operative report.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: ___.
FINDINGS: Tip of endotracheal tube terminates 9 cm above the carina and could
be advanced approximately 4 to 5 centimeters for standard positioning. Tip of
nasogastric tube terminates in proximal stomach with side port above GE
junction and could also be advanced.
Exam is otherwise remarkable for a large mass-like area of opacification above
the right hilum with adjacent surgical sutures, as well as right upper lobe
volume loss and asymmetrical right apical thickening. Although similar to
recent radiographs, this is a change from baseline radiograph of ___. Surgical sutures are also present in the left mid lung.
Further evaluation with dedicated chest CT is suggested when the patient's
clinical status permits, in order to assess for possible lung malignancy. Dr.
___ was successfully paged to discuss these findings at 8:15 a.m. on
___ at time of discovery.
Radiology Report
EXAMINATION: Duplex Doppler evaluation of the extracranial carotid arteries.
TECHNIQUE: Grayscale, color and spectral Doppler were used to evaluate the
extracranial carotid arteries.
HISTORY: ___ male with history of lung cancer and syncope. Request
is to evaluate for carotid atherosclerosis.
FINDINGS:
RIGHT SIDE:
There is mild heterogenous plaque involving the right ICA.
Peak systolic velocities in the proximal, mid and distal ICA are 68 cm/sec, 62
cm/sec and 54 cm/sec respectively. Peak systolic velocities in the right
common and external carotid arteries are 67 cm/sec and 110 cm/sec
respectively. Peak systolic antegrade velocities in the right vertebral
artery of 62 cm/sec are recorded. This yields a right-sided internal to
common carotid ratio of 1.0, predictive of less than 40% stenosis.
LEFT SIDE: Again, there is mild heterogenous plaque involving the left
internal carotid artery ostium. Peak systolic velocities in the left
proximal, mid and distal ICA are 53 cm/sec, 60 cm/sec and 48 cm/sec. Left
common and external carotid artery peak systolic velocities of 54 cm/sec and
101 cm/sec are recorded. Again, there is normal antegrade flow in the left
vertebral artery with a peak systolic velocity of 79 cm/sec. This yields a
left-sided internal to common carotid ratio of 1.1, again predictive of less
than 40% stenosis.
IMPRESSION: Mild heterogenous plaque bilaterally. Flow velocities are
indicative of less than 40% stenosis.
Radiology Report
INDICATION: ___ year old man with COPD with cough and poor secretion
mobilization // ?Aspiration
TECHNIQUE: PA and lateral images of the chest.
COMPARISON: Comparison made with chest radiographs from ___, and ___ and MR cervical, thoracic, and lumbar spine
from ___.
FINDINGS:
A right-sided central line terminates in the superior cavoatrial junction.
The lungs are well expanded. There is a mass in the right upper lobe,
partially imaged on recent MR and similar to recent prior radiographs but new
since radiographs from ___. There are small bilateral pleural effusions. No
definite focal consolidation is seen, however cannot exclude a small opacity
in the posterior lungs, which could be obscured by the pleural effusions.
There is no pneumothorax. The cardiomediastinal silhouette is unremarkable.
A compression deformity is noted in an upper thoracic vertebra.
IMPRESSION:
1. No definite focal consolidation, however cannot exclude a small opacity in
the posterior lung, which could be obscured by the pleural effusions.
2. Right upper lobe mass, partially imaged on recent MR and similar to recent
prior radiographs but new since radiographs from ___. Further evaluation by
CT is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O CORD INJURY
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 98.4
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 128.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old man with h/o lung ___, currently
on chemo, who is transferred from ___ after a syncopal event
and subsequent paresthesias. His MRI revealed narrowing of C3-C5
with cord edema and compression, now s/p decompression surgery
by ortho spine for ___. His delirium and post-syncope
workup were managed and he was discharged to ___
rehabilitation.
# Syncope: Patient had unwitnessed fall immediately prior to
going to bathroom. The differential includes vasovagal syncope,
carotid artery stenosis, orthostatic hypotension, arrhythmia,
and structural heart disease. Echocardiogram and carotid
ultraound did not reveal significant disease, orthostasis
improved with IV fluids, and the patient had no further
presyncopal episodes. Discharged to ___ rehab.
# Cervical stenosis and paresthesias: Patient had multiple
compression fractures status-post syncope with cervical cord
compression. Orthopedic Spine surgery performed an operative
decompression, he was maintained on C-spine collar. He had
residual arm weakness and moderate to severe hand weakness.
Patient was discharged to ___ rehab and outpatient
orthopedic followup.
# Urinary Retention: No spontaneous void in hospital and initial
concern for urinary retention and so a Foley was placed.
Patient had difficulty spontaneously voiding post-Foley being
pulled. Unclear if purely delirium, spinal cord injury, or
medication-related. Patient had intermittent straight
catheterization, tamsulosin dosing was altered, and ultimately
he was voiding spontaneously on the day of discharge without
difficulty.
# Lung ___: Was on weekly chemotherapy. He will follow-up
with oncologist Dr. ___ ___. ___
___.
# Delirum: AM ___ noted disorientation to time and visual
hallucinations. Remainder of neuro exam essentially unchanged,
has not had BM in 3 days. Normal LFTs aside from albumin 2.6.
Per wife ___, he does not have much to drink, maybe ___
drinks/week or 1 case of beer per month. Had 25 WBC and
moderate leukocytes on UA. B12/TSH within normal limits.
Ultimately, patient had bowel movements, void spontaneously, was
maintained on delirium precautions, and his mental status
improved. No antipsychotics were needed for agitation.
# COPD: Currently presenting with rhonchi and wheezing on exam,
requiring 3L of 02, though is not on 02 at home, though
currently having difficulty bringing up sputum while in
C-Collar. On spiriva at home and albuterol nebs Q4H PRN here.
Denies increased cough or sputum production. Chest X-ray was
negative. Patient given incentive spirometry ___/hour, counseled
on smoking cessation, given oxygen therapy, and chest
physiotherapy was performed to optimize pulmonary status.
# Anemia: Labs notable for Hct drop from 34 on admission to 27
today. Hgb 10.8 to 9.2. No evidence of acute bleed in the ICU.
___ be secondary to post-operative losses combined with IVF. He
is now s/p 2 units pRBC transfusion in the ICU. By the time of
discharge, his H/H was improving, stool guaiac was negative, and
pRBCs were never utilized.
# Sinus tachycardia: Likely secondary to volume depletion,
particularly in the setting of positive orthostatics this
morning. Currently denying pain or pleurisy. He has been
progressively more net negative in the ICU throughout the day
with progressive increase in HR. Thus the most likely etiology
is hypovolemia. Less likely secondary to PE, though he does have
an 02 requirement now (see above). Patient was repleted with IV
NS several liters and his heart rate improved.
# Atrial fibrillation: Chronic stable issue in sinus during this
hospital stay. Patient received no rhythm control and no rate
control (sinus tachycardia felt to be physiologic). Maintained
on home aspirin 81mg (held prior to surgery).
# HLD: Chronic stable condition continued on home atorvastatin
# T2DM: HbA1c 7% , needs repeat draw in 3 months.
# Small Bilateral Pleural Effusions: Patient has no known
metastatic disease. A CXR may be done to document resolution
and should require further diagnostics/interventions if no
resolution.
# Code Status: Full Code confirmed. Emergency contact is wife
___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Macrobid / codeine
Attending: ___
Chief Complaint:
bil flank tenderness
Major Surgical or Invasive Procedure:
L PCN exchange (___)
History of Present Illness:
___ with lumbar spinal injury with marked b/l ___ weakness,
multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive
uropathy w/ chronic Foley, L ureteral stricture s/p L PCN,
recent admission to ___ ___ for UTI (ESBL E.coli and
Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting
with b/l flank tenderness.
Mr. ___ was recently admitted ___ for likely UTI in
setting of chills, nausea, and moderate L flank tenderness. UCx
grew ESBL E.coli and Stenotrophomonas, for which he was treated
with Ceftaz/Bactrim x 10d. Foley was exchanged. In discussion
with ___, the decision was made to not exchange his L PCN, as it
was draining well. Repeat UCx from ___ again grew ESBL
E.coli and Stenotrophomonas, and he was subsequently seen by ID
on ___. These organisms were thought to represent colonizers
in the absence of fevers/chills/malaise, and he was not treated
with additional antibiotics. ID recommended discussing
replacement of his L PCN with an internal stent with his
outpatient providers.
Of note, Mr. ___ was previously followed by ___ urology but
is in the process of transitioning his urology care to ___ (he
does not appear to have a urologist yet). He has a benign L
ureteral stricture, for which his L PCN was placed about a year
ago, exchanged q3 months (last about 3 months ago). ___
urology was reportedly unable to pass a ureteral stent
anterograde or retrograde. His Foley was placed for BPH/urethral
obstruction and is exchanged by his ___ monthly (last about a
month ago).
Mr. ___ reports that over the last 1.5 weeks he has had
worsening L flank pain, with some drainage around the L PCN and
malodorous urine. The pain has been getting worse, and yesterday
he noticed mild R-sided flank tenderness as well with some
nausea and two episodes of NBNB emesis. He endorses chills and
fatigue, but denies fevers or rigors. He has chronic lower
extremity pain
from a prior crush injury, for which he takes oxycontin and
oxycodone PRN. His mobility is limited secondary to his injury;
he ambulates with a walker with difficulty and has a wheelchair.
Transport to and from his home is by ambulance.
ED:
VS AF, BP 136/65, HR 46, RR 18, 99% RA
Exam: Not documented
Labs: WBC 9.4, Hgb 11.9, Plt 201, Cr 2.6, Lactate 1.8, UA
w/pyuria (see below)
Imaging: CT A/P with L PCN in place, no hydro, b/l perinephric
stranding, thickened bladder
Consults: urology; no recommendations made
Interventions: Cefepime 2g x 1, oxycodone 5mg
ROS: Denies CP, SOB, cough, abdominal pain,
diarrhea/constipation, melena/hematochezia, headaches, new
rashes.
Past Medical History:
# Spinal crush injury -> ___ weakness, mult spinal surgeries.
# Hardware L hip, L femur, R ankle, R shoulder
# HTN/HLD
# Hypothyroidism.
# Afib w/junctional bradycardia, on anticoagulation.
# CKD stage IV
# AIN ___ indomethacin ___ years ago)
# IgA nephropathy on low dose prednisone
# Obstructive nephropathy, L ureter obstruction
- chronic foley (q1 mos), L PCN (q3mo)
- ureter brushings, bx (___) neg
- urology at ___ reportedly unable to pass ureteral
stent
# Recurrent UTIs
# BPH.
# ACD
# OSA, on CPAP.
# B12 deficiency.
# Gout, without recent episodes.
Social History:
___
Family History:
No family history of kidney disease.
Physical Exam:
ADMISSION:
----------
24 HR Data (last updated ___ @ ___)
Temp: 98.5 (Tm 98.5), BP: 153/76, HR: 45 (baseline), RR: 18, O2
sat: 98%, O2 delivery: Ra
GENERAL: NAD, sitting comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: regular, bradycardic, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: L PCN in place draining yellow urine without clear purulent
drainage; Foley in place draining yellow urine; b/l CVA
tenderness
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm with trace, non-pitting edema b/l
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
DISCHARGE:
----------
24 HR Data (last updated ___ @ 1219)
Temp: 97.6 (Tm 98.4), BP: 178/81 (130-178/58-81), HR: 44
(37-45),
RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: RA
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: regular, bradycardic, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: L PCN in place draining yellow urine without clear purulent
drainage; Foley in place draining yellow urine; no significant L
CVA tenderness
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm without edema; RUE midline c/d/i
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities
(limited by pain), sensation grossly intact throughout, gait
testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
----------
___ 11:40AM BLOOD WBC-9.4 RBC-3.97* Hgb-11.9* Hct-37.7*
MCV-95 MCH-30.0 MCHC-31.6* RDW-15.1 RDWSD-52.9* Plt ___
___ 06:25AM BLOOD ___
___ 11:40AM BLOOD Glucose-103* UreaN-63* Creat-2.6* Na-138
K-4.9 Cl-100 HCO3-22 AnGap-16
___ 06:25AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.1
___ 06:25AM BLOOD CRP-54.9*
DISCHARGE:
----------
___ 06:00AM BLOOD WBC-7.1 RBC-3.46* Hgb-10.2* Hct-33.6*
MCV-97 MCH-29.5 MCHC-30.4* RDW-15.1 RDWSD-54.4* Plt ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-104* UreaN-78* Creat-2.3* Na-142
K-5.2 Cl-106 HCO3-19* AnGap-17
___ 06:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.0
UA ___, ___): mod blood, neg nit, lg ___, 600 prot, 70 gluc,
38
RBCs, >182 WBCs, few bact, 0 epis
UA ___, PCN): sm blood, neg nit, lg ___, 100 prot, tr gluc, 8
RBCs, 49 WBCs, few bact, 0 epis
UCx (___): mixed flora
BCx (___): pending x 2
UCx (___): Pseudomonas aeruginosa (>100,000); Corynebacterium
(10,000-100,000); not urealyiticum per lab
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
IMAGING:
========
EKG (___):
Poor baseline, but appears to be a regular rhythm at 46 bpm with
no clear P waves and narrow QRS complex; QRS 94, QTC 504 (manual
is 495), no clear ischemic changes (similar to ___
Perc nephrostomy (___):
FINDINGS:
Moderate left hydronephrosis
IMPRESSION:
Successful exchange of a 8.5 ___ nephrostomy on the left.
CT A/p w/o cont (___):
1. Percutaneous nephrostomy tube is seen in the left renal
pelvis.
2. Punctate nonobstructing left renal stones. No
hydronephrosis.
3. Bilateral perinephric stranding is nonspecific, but can be
seen in the setting of infection recommend correlation with
urinalysis.
4. Thickened urinary bladder, may be due to underdistention,
however recommend correlation with urinalysis.
5. Cholelithiasis without evidence of acute cholecystitis.
6. 1.5 cm cystic lesion in the uncinate process of the pancreas.
Recommend nonemergent MRCP if previous workup has not been
performed.
7. Small pericardial effusion.
RECOMMENDATION(S):
1.5 cm cystic lesion in the uncinate process of the pancreas.
Recommend nonemergent MRCP if previous workup has not been
performed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Cerovite Advanced Formula (multivitamin-iron-folic acid)
___ mg-mcg oral daily
5. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 500 mg oral daily
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. PredniSONE 2.5 mg PO DAILY
11. Sertraline 150 mg PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 3.75 mg PO DAILY16
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
16. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
17. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
18. LORazepam 0.5 mg PO Q6H:PRN anxiety
19. Oxybutynin 5 mg PO BID PRN bladder spasms
20. Epoetin ___ ___ u SC WEEKLY
Discharge Medications:
1. Daptomycin 300 mg IV Q24H urinary tract infection Duration:
7 Days
RX *daptomycin 350 mg 300 mg IV q24h Disp #*7 Vial Refills:*0
2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
3. Piperacillin-Tazobactam 4.5 g IV Q12H
RX *piperacillin-tazobactam 4.5 gram 4.5 grams IV every 12 hours
Disp #*15 Vial Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Allopurinol ___ mg PO DAILY
8. Cerovite Advanced Formula (multivitamin-iron-folic acid)
___ mg-mcg oral daily
9. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 500 mg oral daily
10. Cyanocobalamin 500 mcg PO DAILY
11. Epoetin ___ ___ u SC WEEKLY
12. Finasteride 5 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Hydrochlorothiazide 25 mg PO DAILY
15. Levothyroxine Sodium 50 mcg PO DAILY
16. LORazepam 0.5 mg PO Q6H:PRN anxiety
17. Oxybutynin 5 mg PO BID PRN bladder spasms
18. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
19. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
20. PredniSONE 2.5 mg PO DAILY
21. Sertraline 150 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until you have completed daptomycin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pyelonephritis, Catheter associated 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: ___ year old man with h/o chronic L PCN admitted with bil
pyelonephritis (L>R)// replacement of L PCN
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 9 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:
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.7 min, 10 mGy
PROCEDURE: 1. Left diagnostic nephrostogram.
2. 8.5 ___ nephrostomy 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
lateral decubitus on the exam table. A pre-procedure time-out was performed
per ___ protocol. The tube site was prepped and draped in the usual sterile
fashion.
Diluted contrast was injected into the nephrostomy on the left to confirm
catheter position. The image was stored on PACS. Local anesthesia was
administered with instillation of lidocaine jelly and 1% subcutaneous
lidocaine injection. The catheter was cut. A ___ wire was advanced into
the left nephrostomy and advanced into the distal ureter. The stay sutures
were cut and the catheter was removed over the wire. A new 8.5 ___
nephrostomy was flushed and advanced with its plastic stiffener over the wire
into appropriate position. The wire and stiffener were removed and the pigtail
was formed. Contrast injection confirmed appropriate positioning. The final
image was saved. The catheter was then flushed, stay sutures applied and the
catheter was secured with a Stat Lock device and sterile dressings. The
nephrostomy was attached to a bag for drainage. The patient tolerated the
procedure well and there were no immediate post-procedure complications.
FINDINGS:
Moderate left hydronephrosis
IMPRESSION:
Successful exchange of a 8.5 ___ nephrostomy on the left.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ with L PCN placement? PCN placement ? nephrolithiasis
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) = 1,279 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is trace dependent atelectasis bilaterally. Otherwise,
visualized lung fields are within normal limits. There is a small pericardial
effusion. Aortic annulus and coronary artery calcifications are noted. There
is no evidence of pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of concerning focal lesions within the limitations of an
unenhanced scan. A subcentimeter hypodensities seen in the peripheral right
hepatic lobe, likely a hepatic cyst or biliary hamartoma (2; 35). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
contains gallstones without wall thickening or evidence of inflammation.
PANCREAS: The pancreas is mildly atrophic. A 1.5 x 1.4 cm cystic lesion is
seen in the uncinate process and is not fully characterized on this exam (2;
44). 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 left kidney is atrophic. There is no evidence of focal renal
lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. Punctate renal stones are seen in the left kidney. A
percutaneous nephrostomy tube is seen within the renal pelvis. There is
bilateral perinephric stranding, which extends to surround bilateral proximal
ureters.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding. There
is distal constipation with perirectal fat stranding. The appendix is normal.
Calcified peritoneal mice are seen in the abdomen (2; 67).
PELVIS: The urinary bladder wall appears thickened which may be secondary to
underdistention. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions. The patient is
status post posterior spinal fusion extending from L3-L5. Degenerative
changes are seen throughout the thoracolumbar spine. A fixation rod is seen
within the left femur stabilizing a femoral neck fracture. A chronic
appearing right rib deformity is seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Percutaneous nephrostomy tube is seen in the left renal pelvis.
2. Punctate nonobstructing left renal stones. No hydronephrosis.
3. Bilateral perinephric stranding is nonspecific, but can be seen in the
setting of infection recommend correlation with urinalysis.
4. Thickened urinary bladder, may be due to underdistention, however recommend
correlation with urinalysis.
5. Cholelithiasis without evidence of acute cholecystitis.
6. 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend
nonemergent MRCP if previous workup has not been performed.
7. Small pericardial effusion.
RECOMMENDATION(S): 1.5 cm cystic lesion in the uncinate process of the
pancreas. Recommend nonemergent MRCP if previous workup has not been
performed.
Gender: M
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Dysuria
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 97.4
heartrate: 46.0
resprate: 18.0
o2sat: 99.0
sbp: 163.0
dbp: 65.0
level of pain: 7
level of acuity: 3.0 | ___ h/o lumbar spinal injury, marked b/l ___ weakness,
multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive
uropathy w/ chronic Foley, L ureteral stricture s/p L PCN,
recent
admission to ___ ___ for UTI (ESBL E.coli and
Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting
with b/l flank tenderness, imaging suggestive of b/l
pyelonephritis and cystitis. UCx grew Pseudomonas and
Corynebacterium, for which he will complete two week course of
Daptomycin/Zosyn. S/p Foley and L PCN exchange.
# Bilateral pyelonephritis:
# Urinary retention (with chronic Foley):
# L ureteral stricture s/p L PCN:
Mr. ___ was recently admitted ___ with
E.coli/Stenotrophomonas UTI, treated with Bactrim/Ceftaz, with
subsequent UCx in ___ again positive for those organisms (for
which he was evaluated by ID, with decision not to treat given
presumed colonization). He presented this admission with b/l
flank tenderness, malaise, WBC 9.4, and a CT scan with fat
stranding c/w cystitis and b/l pyelonephritis with no
hydronephrosis. He underwent a Foley exchange and a L PCN
exchange ___. He was initially restarted on Bactrim/Ceftaz and
ID
was consulted. When UCx from admission grew MDR Pseudomonas and
Corynebacterium (not urealyiticum per micro lab), he was
transitioned to Vanc/Cefepime (despite Pseudomonas with only
intermediate sensitivity to cefepime). Subsequent sensitivity
testing showed sensitivity with Zosyn and Ciprofloxacin; given
prolonged QTC, Cefepime was transitioned to Zosyn. A midline was
placed on ___ for access. Given inability to administer
Vancomycin through a midline, ID recommended transitioning
Vancomycin to Daptomycin (rather than replacing midline with
PICC). He will continue a 2 week course of Daptomycin 300mg IV
q24h and Zosyn 4.5g IV q12h (per ID pharmacy recommendations
given urinary source and infeasibility of home q6 or q8h
dosing),
___. He was discharged home with home infusion services;
daughter ___ (a ___) will administer antibiotics. ID ___ is
scheduled for ___. In addition, patient will transfer urology
care to ___ for consideration of L ureteral stenting
(appointment scheduled for this month). L PCN exchanged
scheduled
for ___ with ___. Of note, suppressive UTI therapy has been
considered by ID and thought suboptimal (oral B-lactams
inadequate, fosfomycin resistance on ___ cultures, suspected
nitrofurantoin ___, inability to use methenamine given CKD,
TMP/SMX wouldn't cover known organisms and would risk
nephrotoxicity).
# Acute on chronic CKD stage IV:
# Non-gap metabolic acidosis:
Followed by Dr. ___ for multifactorial CKD
stage
IV (thought due to AIN, obstructive uropathy, IgA nephropathy).
Baseline Cr appears to be 2.1-2.3, 2.6 on admission, likely
pre-renal, and improved to 2.3 at discharge. Home prednisone
2.5mg daily was continued. HCO3 19 on discharge; initiation of
sodium bicarbonate deferred to outpatient nephrologist, Dr.
___ scheduled for ___.
# Afib:
# Possible CHB with junctional bradycardia:
Patient with hx of afib on Coumadin with EKG suggestive of
possible complete heart block with narrow junctional escape in
the ___. I spoke with the patient's former cardiologist (Dr.
___ at ___, who last saw patient in ___ while the
patient was hospitalized. Dr. ___ that this rhythm
dates back to ___. Given stability, Dr. ___ PPM
placement. ___ EP was consulted this admission and recommended
outpatient ___ given stability. Patient remained asymptomatic
and
HD stable. Coumadin was held initially for procedures and
subsequently resumed. Given CHADs2=1, he was not bridged. He
received Coumadin 5mg on ___, 5mg on ___, 5mg on ___, and 3.5mg
on ___. He was discharged on Coumadin 5mg daily and will resume
Coumadin monitoring through the ___ Anticoagulation Management
Clinic (___) after discharge. Next INR should be
checked
on ___ (1.6 on discharge) by ___. Patient requested that
cardiology care be transitioned to ___ he was scheduled for
___ with Dr. ___ on ___.
# Normocytic anemia:
Hgb 11.9 on admission. Patient has chronic anemia dating back to
___ (b/l appears to be ~8), for which he has intermittently
required transfusions and was recently seen by hematology (Dr.
___ on ___. Thought secondary to CKD and low Epo vs MDS.
___ was deferred, and Procrit 40,000u weekly was initiated
(held in-house). Hgb stable while hospitalized, 10.2 on
discharge.
# Hyperkalemia:
K peaked at 5.4 on ___, likely in setting of captopril
initiation
for hypertension (see below). Captopril was discontinued, and K
improved to 5.2 on discharge. Would benefit from repeat BMP at
PCP ___.
# HTN:
Intermittently hypertensive this hospitalization to SBPs 180s
(without evidence of end organ damage) in absence of clear pain
or anxiety. Home HCTZ was continued. Home amlodipine was
uptitrated to 10mg daily, continued at discharge. Captopril was
briefly trialed with plan to transition to long-acting ACE-I,
discontinued for hyperkalemia as above. BPs improved,
particularly on manual rechecks, and further titration of
anti-hypertensives was deferred to patient's PCP and
nephrologist. Of note, B-blockers should be avoided going
forward
given bradycardia.
# Hypothyroidism:
Continued home levothyroxine.
# HLD:
Held home statin on discharge pending completion of daptomycin
course. To be resumed by PCP.
# Anxiety:
Continued home sertraline and lorazepam.
# Gout:
Continued home allopurinol.
# Pain ___ prior crush injury
Continued home oxycodone 10mg q6h PRN and oxycontin 10mg BID
with hold parameters.
# Pancreatic cyst:
Incidental 1.5 cm cystic lesion in the uncinate process of the
pancreas seen on CT. ___ as outpatient with non-emergent MRCP.
** TRANSITIONAL **
[ ] Daptomycin 300mg IV q24h and Zosyn 4.5g IV q12h, ___.
[ ] INR on ___ call results to ___ Clinic
___
[ ] repeat BMP to monitor K at PCP ___
[ ] consider sodium bicarb initiation if metabolic acidosis
persists
[ ] resume statin after completion of daptomycin course
[ ] trend BPs; adjust anti-hypertensives as needed
[ ] MRCP for incidentally seen cystic lesion in uncinate process
[ ] consideration of PPM |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Codeine
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and deployment of a drug-eluting stent
in the high ___ diagonal branch
History of Present Illness:
___ with Type 2 diabetes mellitus complicated by neuropathy,
prior strokes and ___ transferred from ___ with
troponin 0.04, ? evolving ST changes in V2-V3 increasing in the
setting of increasing chest pain with concern for NSTEMI.
Patient's outside labs were significant for Hct 21, hypokalemia
and hypocalcemia. Patient was given ASA and pRBCs and was guaiac
negative. Patient is wheelchair bound at baseline with many
prior strokes. The patient's most recent coronary angiography
was at ___ which was done after a negative ETT. He had only one
50% LAD lesion. Patient presented with intermittent chest pain
since the night before Qunicy admission, which became persistent
in AM, so he was brought to QH by EMS. There was no report of
dyspnea or cough. Initial troponin was 0.048, Ca 5.5, alb 1.9,
Hct 21.1. CXR was unremarkable. Per QH notes, he had minimal EKG
changes compared with prior and was pain free in their ED. It
was decided to transfer the patient to ___ for possible
coronary angiography.
In the ___ ED, initial VS were pain scale 6 T 97.8 HR 67 BP
138/114 RR 17 SaO2 100%. CXR showed new perihilar fullness with
Kerley B lines. Labs were significant for Hct 34 here (was 20 at
___). His troponin-T was 0.08 and he was guaiac negative. He was
started on a nitro drip but per ED, was "pain free when no one
in room". VS on transfer: T 98.2 HR 73 BP 147/79 RR 16 SaO2
100%. On transfer from ED, patient noted to still have ___
chest pain.
Past Medical History:
# Diabetes mellitus, type II with Peripheral Neuropathy
# Hypertension
# Hypercholesterolemia
# HCV
# Sleep apnea
# Erectile dysfunction
# Anxiety
# Depression
# Multiple strokes (4 per fiance)
Social History:
___
Family History:
# Mother died age ___: No known illnesses
# Father die age ___: Possible homicide
# 6 Sisters, 3 Brothers: DM2, cancer of unknown primary
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: uncomfortable appearing middle aged ___
man
VS: T 98 BP 144/91 HR 77 RR 20 SaO2 98% on 2 Lpm
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: anterior lung exam unremarkable
HEART: RRR; nl S1-S2; no murmurs, rubs or gallops
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and DP
NEURO: awake, speech pressured, A&Ox3, CNs II-XII grossly
intact, muscle strength ___ throughout, sensation grossly intact
throughout, DTRs 2+ and symmetric
DISCHARGE PHYSICAL EXAM:
VS: T 98.0, BP 145/79, HR 63, RR 18, SaO2 99% on RA
I/O: 2263/725+
Wt: wt not recorded <-70.5 <-71.8<-72.6
GENERAL: NAD, awake, alert
HEENT: NC/AT, sclerae anicteric
NECK: supple, no JVD
LUNGS: CTAB
HEART: RRR, nl S1-S2; no murmurs, rubs or gallops
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema
Pertinent Results:
ADMISSION LABS:
___ 07:45PM WBC-7.8 RBC-4.03* HGB-11.5* HCT-34.7* MCV-86
MCH-28.7 MCHC-33.2 RDW-14.0
___ 07:45PM GLUCOSE-113* UREA N-20 CREAT-1.5* SODIUM-139
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
___ 07:45PM CK-MB-6 cTropnT-0.08*
ECG ___ 6:31:04 ___
Normal sinus rhythm. Intra-atrial conduction defect. Diffuse T
wave flattening. Since the previous tracing of ___ T waves
are slightly more flat.
IMAGING STUDIES:
- CXR (___)
The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is new perihilar fullness
with indistinct pulmonary vascularity and an interstitial
abnormality, including ___ B lines at the lung bases, most
consistent with mild to moderate pulmonary vascular congestion.
No discrete focal opacity is otherwise identified.
- Echocardiogram (___)
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). 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 no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild mitral regurgitation with normal valve morphology.
Pulmonary artery hypertension.
Cardiac catheterization (___):
- Hemodynamics: Mild-moderate elevated left-sided filling
pressures (LVEDP ___ mmHg)
- Coronary angiography: right dominant
- LMCA: Large vessel with distal plaque (30%) extending into
the LAD origin.
- LAD: Mild luminal irregularities. The origin has a 30%
lesion (an extension of the distal LM plaque) and the mid
segment is tortuous with ___ plaque at the takeoff of the
diseased high D1. The high D1 is a large bifurcating vessel
(functionally ramus) with 90% ostial lesion. The LAD gives
several small distal diagonal branches that are patent.
- LCX: Retroflexed with mild luminal irregularities and focal
30% mid vessel lesion. The "high" OM1 a small diameter but
bifurcating vessel. The OM2 and OM3 are patent.
- RCA: Difficult to engage selectively. Subselective injection
with AR1 diagnostic catheter showed a dominant vessel with
tortuous mid segment with tubular 50% lesion.
- Interventional details
- Change for ___ R radial sheath. AC with UFH and several
boluses were administered. ___ XB LAD 3.5 guide provided good
support throughout the case. Crossed with Prowater with ease and
predilated with 2.0x12 mm RX Sprinter balloon. We then decided
to pass another wire into the LAD given the presence of disease
at the diag takeoff. At this point, a 2.75x12 mm Resolute
drug-eluting stent was deployed at 9 ATM with complete balloon
expansion. Final angiography showed excellent result with 0%
residual stenosis and no angiographically-apparent impingement
on the LAD whatsoever.
- CT HEAD W/O CONTRAST (___)
Small foci of encephalomalacia noted in the right cerebellum,
pons and the right basal ganglia indicative of prior infarct.
There is no hemorrhage, edema, mass effect or acute large
territory infarct. Significant prominence of the ventricles and
sulci is suggestive of global atrophy. Periventricular and
subcortical white matter hypodensities are compatible with
chronic small vessel ischemic disease. The basal cisterns are
patent and there is preservation of gray-white matter
differentiation. No fracture is identified. The visualized
paranasal sinuses, middle ear cavities and mastoid air cells are
clear. The globes are intact. Atherosclerotic mural
calcifications are noted in the carotid siphons.
IMPRESSION: No acute intracranial process.
DISCHARGE LABS:
___ 06:00AM BLOOD ___-7.3 RBC-3.90* Hgb-11.0* Hct-33.8*
MCV-87 MCH-28.2 MCHC-32.6 RDW-13.6 Plt ___
___ 06:00AM BLOOD Glucose-96 UreaN-20 Creat-1.8* Na-141
K-3.9 Cl-114* HCO3-20* AnGap-11
___ 06:00AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9
___ 06:00AM BLOOD cTropnT-0.38*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. CloniDINE 0.1 mg PO TID
5. Carvedilol 12.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. HydrALAzine 50 mg PO TID
10. Glargine 23 Units Bedtime
novolog 5 Units Breakfast
novolog 5 Units Lunch
Insulin SC Sliding Scale using Lispro Insulin
11. LeVETiracetam Oral Solution 750 mg PO BID
12. Lisinopril 40 mg PO DAILY
13. Enoxaparin Sodium 40 mg SC DAILY
14. Paroxetine 10 mg PO DAILY
15. Potassium Chloride 10 mEq PO DAILY
16. traZODONE 25 mg PO QAM; Please give at 8am
17. traZODONE 25 mg PO QPM; PLease give at 2pm
18. traZODONE 50 mg PO HS; Please give at 8:30pm
19. Prazosin 1 mg PO BID
20. Ranitidine 150 mg PO BID
21. Simvastatin 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. CloniDINE 0.1 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. HydrALAzine 50 mg PO TID
10. LeVETiracetam Oral Solution 750 mg PO BID
11. Lisinopril 40 mg PO DAILY
12. Paroxetine 10 mg PO DAILY
13. Prazosin 1 mg PO BID
14. Ranitidine 150 mg PO BID
15. traZODONE 25 mg PO QAM
16. traZODONE 25 mg PO QPM
17. traZODONE 50 mg PO HS
18. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
19. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
20. Glargine 23 Units Bedtime
novolog 5 Units Breakfast
novolog 5 Units Lunch
Insulin SC Sliding Scale using Lispro Insulin
21. Potassium Chloride 10 mEq PO DAILY
22. Loperamide 4 mg PO QID:PRN diarrhea
23. Psyllium 1 PKT PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Non-ST segment myocardial infarction
Secondary:
Coronary artery disease
Hypertension
Diabetes mellitus, type II, with neuropathy
Prior cerebrovascular accidents
Gastroesophageal reflux disorder
Anxiety
Depression
Seizure disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Chest pain.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP upright.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is new perihilar fullness with indistinct
pulmonary vascularity and an interstitial abnormality, including ___ B
lines at the lung bases, most consistent with mild to moderate pulmonary
vascular congestion. No discrete focal opacity is otherwise identified.
IMPRESSION: Findings suggesting vascular congestion.
Radiology Report
HISTORY: Multiple CVAs. Here for NSTEMI with unwitnessed fall last night.
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: 891.93 mGy-cm.
COMPARISON: MR head ___.
FINDINGS:
Small foci of encephalomalacia noted in the right cerebellum, pons and the
right basal ganglia indicative of prior infarct. There is no hemorrhage,
edema, mass effect or acute large territory infarct. Significant prominence
of the ventricles and sulci is suggestive of global atrophy. Periventricular
and subcortical white matter hypodensities are compatible with chronic small
vessel ischemic disease. The basal cisterns are patent and there is
preservation of gray-white matter differentiation. No fracture is identified.
The visualized paranasal sinuses, middle ear cavities and mastoid air cells
are clear. The globes are intact. Atherosclerotic mural calcifications are
noted in the carotid siphons.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CP, +NSTEMI
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ with Type 2 diabetes mellitus complicated by neuropathy,
multiple prior strokes and HCV who was transferred from ___
___ with chest pain, EKG changes and biomarker elevations
consistent with NSTEMI.
# NSTEMI/CAD: Patient presented with chest pain, troponin
elevation, and some EKG changes, all consistent with NSTEMI. He
was treated with heparin gtt, nitro gtt, morphine, beta-blocker,
ACE-I, aspirin, and statin (changed from simvastatin to
atorvastatin) and was rendered pain free after arrival to the
___. He underwent echocardiography, which showed mild left
ventricular hypertrophy, but no regional wall motion
abnormalities. Since the patient occasionally became somewhat
agitated and there was concern about his ability to cooperate by
lying still during a prolonged procedure, cardiac
catheterization was deferred for several days until the
procedure could be performed under MAC coverage by anesthesia.
Cardiac catheterization on ___ showed LVEDP 18-20 mm Hg,
diffuse mild disease (including a 50% stenosis in the mid RCA),
with a 90% ostial stenosis of the ___ diagonal branch. A DES was
placed in this location, and he was discharged on full-dose
aspirin and Plavix.
# Fall: He had an unwitnessed fall on the morning of discharge.
Head CT performed shortly thereafter was negative for any acute
intracranial process.
# Laboratory artifact: In retrospect, the initial laboratory
values from ___ were likely artifactual, possibly
diluted. The patient's Hct recovered too well and too quickly
after 1 unit of pRBCs, and his hypokalemia and hypocalcemia also
normalized very quickly. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of HTN, newly diagnosed
with a T9 compression fracture that was biopsied on ___,
revealing plasma cell neoplasm CD138+ and kappa LC restricted.
He started XRT to T9 on ___, and saw Dr. ___ primary
oncologist at ___, where he had a bone marrow on ___ that
revealted 10% plasma cells. He was started on Zometa, and
referred to ___ for a ___ opinion for systemic treatment.
Since his XRT, he has had increasing abdominal pain. He was
admitted to Mr. ___ on ___, where EGD revealed mild
gastritis and mild edema of the GE junction. He was treated with
Dilaudid, and his Fentanyl patch ws increased. He was discharged
on ___, and presented for his initial visit with Dr. ___ &
Dr. ___ that day. Due to severe stress and pain, he was
admitted for further evaluation.
In the ED, he continued to have bad epigastric pain. U/S
appendix was concerning for appendicitis, and CT abdomen/pelvis
showed dilated appendix without surrounding inflammation.
General surgery was consulted, and determined there was no role
for surgical intervention. Labs showed normal white count, Hgb
13.3, platelets 146. Chem 7 wnl. AST 41, ALT 77, otherwise LFTs
also wnl.
On arrival to the floor, he reports worsening epigastric pain.
Pain is worse after eating, and better after taking pain
medications. He had some abdominal pain since starting XRT, but
this has intensified over the past 2 weeks, and greatly
increased within the past 2 days. He has also had decreased
appetite, but denies nausea, vomiting, fevers, chills, or
diarrhea. Last bowel movement was 2 days ago.
ROS
+ weight loss 40 lbs since ___ point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: biopsy of T9 compresion fracture revealed plasma cell
neoplasm CD138+ and kappa LC restricted
- ___: started XRT to T9
- ___: bone marrow biopsy showed 10% plasma cells, started
on Zometa
- ___: initial appointment with Dr. ___ & Dr. ___,
admitted to ___ for epigastric pain
PAST MEDICAL HISTORY:
HTN
PAST SURGICAL HISTORY:
cholecystectomy ___ years ago
Social History:
___
Family History:
Brother with type 2 diabetes. maternal ___ cousin: breast
cancer.
Brother with prostate cancer. Sister with uterine cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: Tc 99.2 Tm 99.2 BP 125/65 HR 91 RR 16 SaO2 97% ra
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, mildly distended, epigastric tenderness, no r/g
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
LABORATORY ANALYSIS: Reviewed in EMR
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: Tm 99 Tc 97.5 HR 92 BP ___ RR 18 SaO2 98% ra
General: NAD, lying down comfortably
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: regular rate and rhythm, S1S2 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, mildly distended, mild tenderness on epigastric region
SPINE:tender to palpation along T9 dermatome from spine,
LIMBS: no lower extremity edema
SKIN: No rashes noted
NEURO: CN grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 03:05PM BLOOD WBC-8.3 RBC-4.22* Hgb-13.3* Hct-39.3*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.3 RDWSD-45.2 Plt ___
___ 03:05PM BLOOD Neuts-74.3* Lymphs-9.5* Monos-13.3*
Eos-1.9 Baso-0.5 Im ___ AbsNeut-6.16* AbsLymp-0.79*
AbsMono-1.10* AbsEos-0.16 AbsBaso-0.04
___ 03:05PM BLOOD ___ PTT-34.6 ___
___ 03:05PM BLOOD UreaN-14 Creat-0.8 Na-138 K-4.8 Cl-102
HCO3-26 AnGap-15
___ 03:05PM BLOOD estGFR-Using this
___ 03:05PM BLOOD ALT-77* AST-41* LD(LDH)-177 AlkPhos-84
TotBili-0.5
___ 09:45PM BLOOD Lipase-45
___ 03:05PM BLOOD TotProt-7.4 Albumin-4.1 Globuln-3.3
Calcium-9.2 Mg-2.4
___ 03:05PM BLOOD PEP-AWAITING F ___ FreeLam-13.3
Fr K/L-1.41 b2micro-1.6 IgG-1280 IgA-240 IgM-58 IFE-PND
___ 09:50PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-3.8* RBC-3.90* Hgb-12.1* Hct-34.9*
MCV-90 MCH-31.0 MCHC-34.7 RDW-12.7 RDWSD-41.9 Plt ___
___ 07:45AM BLOOD Neuts-61.1 Lymphs-17.6* Monos-15.2*
Eos-4.5 Baso-0.8 Im ___ AbsNeut-2.33 AbsLymp-0.67*
AbsMono-0.58 AbsEos-0.17 AbsBaso-0.03
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-137
K-4.3 Cl-101 HCO3-28 AnGap-12
___ 07:45AM BLOOD ALT-50* AST-31 LD(LDH)-131 AlkPhos-92
TotBili-0.4
___ 07:45AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3
IMAGING:
___ CT Chest:
1. Nonspecific ill-defined perigastric fat stranding posterior
to the left liver lobe at the level of the GE junction appears
unchanged from ___. Again, this may reflect
gastritis. Proximally the esophagus appears unremarkable.
2. Relative regional hypodensity of the left hepatic lobe is
unchanged, and may reflect sequela of prior radiation treatment.
Multiple hepatic hypodensities measuring up to 1.3 cm are
stable, and likely represents cyst or biliary hamartomas.
3. Vertebral plana of T9 and lytic lesion in the inferior
endplate of T8 again seen.
___ MRI T spine:
Multiple osseous lesions, likely secondary to multiple myeloma.
2. Pathologic fracture at T9 leading to vertebra plana and
associated spinal
canal and neural foramen stenosis causing impingement of T10
nerve root.
3. Postradiation changes involving T6- T11 vertebral bodies with
fatty infiltration.
US APPENDIX ___
Dilated 11 mm, noncompressible appendix in the right lower
quadrant. In the correct clinical setting, findings suggest
appendicitis.
CT ABD/PELVIS ___
1. Fat stranding at the level of the GE junction likely
reflects gastritis seen on the EGD from the outside hospital.
This could also be non-specific change from prior radiation
therapy. The stomach itself is not well distended, limiting
evaluation.
2. The appendix is dilated to 10 mm, although without adjacent
fat stranding or fluid collection. Oral contrast fills the
cecum, but not the appendix. While outside hospital images are
not available for review, based on the outside hospital report,
today's appearance of the appendix is presumed to be similar to
the scan from 3 days prior.
3. Known multifocal lytic lesions of T8, L4, and the left iliac
bone, compatible with known history of multiple myeloma. Near
complete collapse of the T9 vertebral body was also identified
on the prior study.
MRI T-SPINE ___. Multiple osseous lesions, likely secondary to multiple
myeloma.
2. Pathologic fracture at T9 leading to vertebra plana and
associated spinal
canal and neural foramen stenosis causing impingement of T10
nerve root.
3. Postradiation changes involving T6- T11 vertebral bodies with
fatty
infiltration.
CT CHEST ___. Nonspecific ill-defined perigastric fat stranding posterior
to the left liver lobe at the level of the GE junction appears
unchanged from ___. Again, this may reflect
gastritis but appears to be within the radiation treatment
field. Proximally the esophagus appears unremarkable.
2. Relative regional hypodensity of the left hepatic lobe is
unchanged, and likely reflects sequela of radiation treatment.
Multiple hepatic
hypodensities measuring up to 1.3 cm are stable, and likely
represents cyst or biliary hamartomas.
3. Vertebral plana of T9 and lytic lesion in the inferior
endplate of T8
again seen
OSH IMAGING
CT ABD/PELVIS ___
1. Apparent appendiceal wall thickening with an appendiceal
diameter of up to 8 mm. No evidence of periappendiceal
stranding, abscess, or fluid collection. These findings are new
when compared to the PET/CT of ___ and could be seen in
chronic inflammation of the appendix but equivocal for acute
appendicitis. If the patient has continue pain or develops sign
of infection, consider a repeat abdominal CT to reassess.
2. Distal and sigmoid colon diverticulosis. No evidence of
enteritis or colitis.
3. Multifocal lucent lytic lesions involving T8, T9, L4, and
left
iliac bone, unchanged from a PET/CT study of ___,
___ PET
Impression: Moderately hypermetabolic lytic lesion in the T9
vertebra, known to represent a plasma cell neoplasm. Lucent 1.2
cm lesion in the right L4 vertebral body and a 0.3 cm focus in
the left iliac crest are suspicious but do not demonstrate
striking hypermetabolism, possibly due to their small size.
Mottled, mildly increased hypermetabolism is present in the
lumbar vertebrae and in the proximal more so than distal femurs
without corresponding lytic lesions is of uncertain significance
but could represent low grade disease or hyperplastic marrow.
___ MRI spine:
1) ___ compression fracture of T9.
2) Nondisplaced vertical fracture through the right lamina of
T9-T10.
3) Focal ____ at T8-T9 which is superimposed on the posterior
buckling of T9.
PATHOLOGY:
___. CT guided core bx T9 mass:
*** CONSISTENT WITH INVOLVEMENT BY A PLASMA CELL NEOPLASM,
CORE BIOPSY REVEALS ABUNDANT PLASMA CELLS STAINING POSITIVELY
FOR CD138 AND KAPPA LIGHT-CHAIN RESTRICTED.
___
BONE MARROW ASPIRATE SMEAR PREPARATIONS ARE DILUTE WITH
PERIPHERAL BLOOD BUT SHOW MATURING HEMATOPOIETIC ELEMENTS AND
SOME SCATTERED PLASMA CELLS.
BONE MARROWS CORE BIOPSY AND CLOT SECTIONS (H/E AND PAS):
HYPERCELLULAR FOR AGE MARROW,65-75%.
PATCHY INFILTRATE OF PLASMA CELLS, SINGLE AND FOCALLY IN
CLUSTERS
OF UP TO ___ CELLS, ARE ESTIMATED AT APPROXIMATELY 10%
CELLULARITY; ATYPICAL NUCLEOLATED FORMS ARE
PRESENT (CD138; BIOPSY AND CLOT SECTIONS);
BOTH KAPPA AND LAMBDA EXPRESSING PLASMA CELLS ARE PRESENT WITH
PREDOMINANCE OF KAPPA POSITIVE CELLS (KAPPA AND LAMBDA).
LYMPHOCYTES ARE LESS THAN 5-8% CELLULARITY WITH
PREDOMINANCE OF T OVER B CELLS (CD3, CD20).
-FLOW CYTOMETRY PROVIDED THE FOLLOWING RESULTS: (SEE ATTACHED
REPORT FROM AMERIPATH)
THE FINDINGS PROVIDE NO IMMUNOPHENOTYPIC EVIDENCE OF ACUTE
LEUKEMIA, A T-CELL OR
B-CELL NEOPLASM, OR PLASMA CELL NEOPLASIA.
NORMAL KARYOTYPE.
-FISH ANALYSIS"
NEGATIVE STUDY FOR ALL PROBES EXAMINED.
IMPRESSION:
- INVOLVEMENT BY A PLASMA CELLS NEOPLASM, PLASMA CELLS
APPROXIMATELY 10%, NUCLEOLATED
FORMS PRESENT.
STUDIES:
EGD ___ Dr. ___ at ___
Esophagus: Mild edema at the GE Junction, biopsies
obtained. Stomach: Mild gastritis characterized by faint
scattered erythema. Duodenum: The duodenum appeared to be
normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Lisinopril 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO QHS
5. Ranitidine 75 mg PO DAILY
6. Fentanyl Patch 75 mcg/h TD Q72H
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Sucralfate 1 gm PO DAILY:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Fentanyl Patch 75 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour Apply every 72 hours Disp #*10 Patch
Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
three (3) hours Disp #*90 Tablet Refills:*1
5. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl 75 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
6. Senna 8.6 mg PO QHS
7. Amoxicillin 1000 mg PO Q12H Duration: 14 Days
RX *amoxicillin 500 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*50 Tablet Refills:*0
8. Clarithromycin 500 mg PO Q12H Duration: 14 Days
RX *clarithromycin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*24 Tablet Refills:*0
9. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain due to T9 Lesion
H.pylori/gastritis
Multiple myeloma
Hypertension
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: ___ with concern for appy on US, abd pain in RUQ. Evaluate for
appendicitis.
TECHNIQUE: 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: Total DLP (Body) = 671 mGy-cm.
COMPARISON: Only the report of the outside hospital CT abdomen pelvis from ___ is available. No images from this study are available for
comparison.
FINDINGS:
LOWER CHEST: There is mild bibasilar dependent atelectasis, but no pleural
effusions.
ABDOMEN:
HEPATOBILIARY: A 1.4 cm and 0.9 cm left hepatic lobe hypodensities were
described on the outside hospital as stable, likely hepatic cysts. Multiple
other right hepatic lobe subcentimeter hypodensities are too small to
characterize, but are also unchanged. Relative regional hypodensity of the
left hepatic lobe is likely due to differential perfusion, as described on the
prior study. There is no evidence of new focal lesions. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is
surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A small accessory spleen is identified (2:22).
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: There is nonspecific ill-defined perigastric fat stranding
posterior to the left liver lobe at the level of the GE junction (___),
which may reflect gastritis seen on EGD from the outside hospital. The
stomach itself is not well distended, therefore limiting evaluation. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Diverticulosis of the sigmoid colon is noted, without evidence of
wall thickening and fat stranding. There is appendiceal wall thickening to
approximately 1.0 cm (02:59), although without periappendiceal stranding or
fluid collection. Oral contrast fills the cecum, but not the appendix.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is enlarged, with small calcifications, likely
due to prior inflammation.
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 AND SOFT TISSUES: Near complete collapse of the T9 vertebral body, as
described on the prior study, is identified. Known lytic lesions at the
inferior T8 and L4 vertebral bodies, and left iliac bone, are also seen.
Retrolisthesis of L5 on S1 is also present, with endplate sclerosis and vacuum
disc phenomenon at that level. Small amount of fat seen in the bilateral
inguinal canals.
IMPRESSION:
1. Fat stranding at the level of the GE junction likely reflects gastritis
seen on the EGD from the outside hospital. This could also be non-specific
change from prior radiation therapy. The stomach itself is not well
distended, limiting evaluation.
2. The appendix is dilated to 10 mm, although without adjacent fat stranding
or fluid collection. Oral contrast fills the cecum, but not the appendix.
While outside hospital images are not available for review, based on the
outside hospital report, today's appearance of the appendix is presumed to be
similar to the scan from 3 days prior.
3. Known multifocal lytic lesions of T8, L4, and the left iliac bone,
compatible with known history of multiple myeloma. Near complete collapse of
the T9 vertebral body was also identified on the prior study.
NOTIFICATION: The above findings were communicated in person by Dr. ___
to Dr. ___ resident) at 06:55 on ___.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with MM s/p XRT to T9 in ___, p/w 1 week
worsening epigastric pain in setting of 2 months epigastric pain // Any
changes from MM or radiation to explain acute on chronic epigastric pain?
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: Total DLP (Body) = 205 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
MEDIASTINUM: The imaged thyroid is normal. There is no supraclavicular,
axillary, mediastinal, or hilar lymphadenopathy. Partially calcified small
mediastinal and hilar lymph nodes are present. The aorta and pulmonary
arteries are normal in size. There is a bovine aortic arch (normal variant,
common origin of the innominate artery and left common carotid). The heart
size is normal and there is no pericardial effusion.
PLEURA: There is no pneumothorax. There is no pleural effusion.
LUNGS: The airways are patent. There is discoid lingular atelectasis and
lingular and mild right middle lobe atelectasis. A punctate pulmonary nodule
is seen in the right lower lobe (5:159).
BONES: There is vertebral plana of the T9 vertebral body. Unchanged
appearance of lytic lesion at the inferior T8 vertebral body. Healed left
lateral fifth and sixth rib fractures.
UPPER ABDOMEN: This study is not tailored to evaluate the abdomen. Relative
regional hypodensity of the left hepatic lobe is unchanged, and likely
reflects sequela of radiation treatment. Multiple hepatic hypodensities
measuring up to 1.3 cm appear unchanged, and likely represent cysts or biliary
hamartomas. Note is made of a small accessory spleen. Nonspecific
ill-defined perigastric fat stranding posterior to the left liver lobe at the
level of the GE junction appears unchanged from a CT abdomen pelvis dated ___. Proximally the esophagus is unremarkable.
IMPRESSION:
1. Nonspecific ill-defined perigastric fat stranding posterior to the left
liver lobe at the level of the GE junction appears unchanged from ___. Again, this may reflect gastritis but appears to be within the
radiation treatment field. Proximally the esophagus appears unremarkable.
2. Relative regional hypodensity of the left hepatic lobe is unchanged, and
likely reflects sequela of radiation treatment. Multiple hepatic
hypodensities measuring up to 1.3 cm are stable, and likely represents cyst or
biliary hamartomas.
3. Vertebral plana of T9 and lytic lesion in the inferior endplate of T8
again seen.
Radiology Report
EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with newly diagnosed MM, s/p XRT to ___, w/
epigastric pain x 2 months, worsening epigastric pain x 1 week // Any signs
of MM or radiation changes that could explain epigastric pain that radiates in
T9 distribution?
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 8 mL of
Gadavist contrast agent.
COMPARISON: CT thoracic spine from ___. CT abdomen and pelvis
from ___.
FINDINGS:
There is vertebra plana at T9, unchanged compared to the prior CT from ___ with associated focal kyphosis of the thoracic spine. This is
likely secondary to the vertebral body involvement with multiple myeloma and
superimposed pathologic fracture. There is associated retropulsion of the
fracture fragments posteriorly into the spinal canal causing severe spinal
canal stenosis and indentation of the ventral aspect of the spinal cord as
seen on image 7:11. There is associated severe narrowing of the left and
moderate narrowing of the right T9-T10 neural foramen with impingement of the
T10 nerve roots at this level. No focal cord signal abnormality is however
seen.
There are multiple other lytic lesions involving the visualized thoracic
spine, likely secondary to the involvement by multiple myeloma including a
lesion along the inferior end plate of T8, a lesion along the posterior aspect
of T1 vertebrae measuring approximately 0.9 x 1.2 cm and a lesion along the
superior endplate of T12 vertebrae.
There is fatty marrow signal involving T6 to the 11 vertebral bodies, likely
postradiation in etiology.
No cord signal abnormality is seen. No enhancing epidural soft tissue mass is
seen.
The remaining thoracic spine appears unremarkable. Neural foramen and spinal
canal are patent at all other levels.
The visualized retroperitoneal, paraspinal and paravertebral soft tissues
appear unremarkable. The visualized lung parenchyma appears clear.
IMPRESSION:
1. Multiple osseous lesions, likely secondary to multiple myeloma.
2. Pathologic fracture at T9 leading to vertebra plana and associated spinal
canal and neural foramen stenosis causing impingement of T10 nerve root.
3. Postradiation changes involving T6- T11 vertebral bodies with fatty
infiltration.
Gender: M
Race: SOUTH AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, NAUSEA
temperature: 98.1
heartrate: 88.0
resprate: 22.0
o2sat: 99.0
sbp: 132.0
dbp: 74.0
level of pain: 8
level of acuity: 2.0 | SUMMARY
___ M with new MM (diagnosed ___, s/p XRT to T9 on
___, never had chemo) who presented with 2 months of
epigastric pain, much worse in the past week. Initially, pain
was thought to be ___ gastritis because of location, and EGD at
OSH showed mild gastritis. Upon further examination, discovered
that pain followed a T9 distribution from his vertebra, along
ribs laterally, to his epigastrum. MRI on ___ showed T9
vertebral plana with canal narrowing, so pain is likely
neuropathic from cord compression. Pain was controlled with
Fentanyl patch, Gabapentin, and prn Dilaudid; patient also took
Protonix & Ranitidine for his gastritis. He was found to be
positive for H.pylori, and thus was started on triple therapy
for 14 days for treatment.
ACTIVE ISSUES
#ABDOMINAL PAIN:
Originally, the patient reported severe epigastric pain, which
was thought to be ___ gastritis. EGD at OSH showed mild
gastritis, but this did not fit with the severity of the
patient's symptoms. Radiation effect was also considered, but
the timeline didn't fit, because radiation gastritis/edema
typically occurs ___ after XRT, then improves. Patient also
received Protonix & Ranitidine for gastritis. He was found oto
be H.pylori positive, with triple therarpy started ___ in
pm:Pantoprazole 40mg po BID, Clarithromycin 500mg BID,
Amoxicillin 1 g BID for ___ (stop date ___.
#T9 Compression Fracture: Patient has tenderness along the T9
distribution, where he has known MM involvement. His was tender
along his T9 spine, around both ribs, and ending in epigastric
pain. MRI on ___ showed vertebral plana of T9 with focal
kyphosis, which is the likely cause of patient's symptoms. He
was assessed by orthopedics who saw no current indication for
spine surgery. Given minimal low back pain and that he was
ambulating well, he had no need for TLSO brace with plan to
follow up with Dr. ___ in 1 month if pain persists. He was
stated on gabapentin, continued this Gabapentin 300mg TID, which
helped the patient's pain signifcantly. He was also continued on
a Fentanyl patch and Dilaudid PO ___ mg PO/NG Q3H:PRN severe
pain.
# Multiple Myeloma: Patient was diagnosed in ___, and
received XRT to T9 lesions in ___. He has never received
chemotherapy. His lab studies shows IgG 1280, IgA 240, IgM 58.
He was scheduled for appointments with his oncologists for the
day after discharge.
#CONSTIPATION: Patient was initially consipated given
substantial narcotics needs for pain. He was given Docusate and
Senna, with Miralax and Bisacodyl as needed, and resumed having
regular BMs.
# Hypertension: Given overalln normal blood pressures, home
Lisinopril was held while in house. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
FLANK PAIN, ACUTE KIDNEY INJURY, NEPHROLITHIASIS
Major Surgical or Invasive Procedure:
Right ureteroscopy with laser lithotripsy and placement of a
double-J stent.
History of Present Illness:
___ w/ known nephrolithiasis history w/ R flank pain and nausea.
He notes stubborn pain over recent days culminating in worsening
pain today with some associated nausea. ROS demonstrates
dysuria. Vital signs within normal limits; patient
well-appearing. PE demonstrates no flank pain b/l; minimal
abdominal pain. ___ shows no leukocytosis and creatinine to
1.7 from 1.2 (most recent
baseline available in computer. ___ from several
days ago shows <10K strep species. CTU shows obstructing right
ureteral stone at ___ w/ moderate hydronephrosis and some
associated perinephric stranding.
Past Medical History:
ALLERGIC RHINITIS
PROSTATISM
SLEEP APNEA
SLEEP STUDY-DIAGNOSTIC
SCIATICA
H/O GASTROESOPHAGEAL REFLUX
H/O TENDINITIS
NEPHROLITHIASIS
INSOMNIA
HTN
HYPERCHOLESTEROLEMIA
TRANSURETHRAL PROSTATECTOMY ___
Social History:
No tobacco. Social EtOH, no other illicits. He is married and
lives at home with his wife. He works for the ___.
Married over ___ years; two children. He has one set of twin
girl grandchildren.
Nonsmoker, may be has three to four drinks a week, has started
doing more regular exercise but actually is incredibly active
doing all his own yard work
everything from mowing lawn to chopping trees and he reports
that he feels very well doing that. He actively wears his seat
belt.
Marital status: Married, # years: ___
Children: Yes: 2
Lives with: ___
Lives in: House
Work: ___
Multiple partners: ___
___ activity: Past and Present
Sexual orientation: Female
Sexual Abuse: Denies
Domestic violence: Denies
Contraception: N/A
Tobacco use: Never smoker
Alcohol use: Past and Present
drinks per week: ___
Recreational drugs Denies
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: None
Seat belt/vehicle Always
restraint use:
Family History:
Significant for hypertension and a CVA in father.
Physical Exam:
WDWN, NAD, AVSS
Abdomen soft, non-distended
Bilateral lower extremities w/out edema, pitting or pain to deep
palpation of calves
Pertinent Results:
___ 06:45AM BLOOD WBC-6.4 RBC-4.51* Hgb-12.5* Hct-36.9*
MCV-82 MCH-27.7 MCHC-33.9 RDW-13.1 Plt ___
___ 02:30PM BLOOD WBC-8.7 RBC-5.29 Hgb-14.9 Hct-43.7 MCV-83
MCH-28.2 MCHC-34.2 RDW-13.5 Plt ___
___ 02:30PM BLOOD Neuts-77.6* Lymphs-15.5* Monos-6.0
Eos-0.3 Baso-0.6
___ 06:45AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-140
K-4.5 Cl-107 HCO3-27 AnGap-11
___ 02:30PM BLOOD Glucose-122* UreaN-28* Creat-1.7* Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
___ 02:30PM BLOOD Lactate-1.2
___ 06:40PM URINE Color-DKAMB Appear-Clear Sp ___
___ 01:45PM URINE Color-DKAMB Appear-Clear Sp ___
___ 06:40PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.5 Leuks-NEG
___ 01:45PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 06:40PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
___ 01:45PM URINE RBC-9* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:45PM URINE CastGr-3*
___ 06:40PM URINE Mucous-OCC
___ 01:45PM URINE Mucous-FEW
___ 2:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending): NGTD at time of dictation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. Lorazepam 1 mg PO QHS:PRN insomnia
4. Ranitidine 75 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. pramipexole 0.25 mg oral QHS
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily
Disp #*30 Capsule Refills:*1
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*30 Tablet
Refills:*0
4. Zofran ODT (ondansetron) 4 mg oral Q8hrs prn nausea
RX *ondansetron [Zofran ODT] 4 mg ONE tablet(s) by mouth Q8hrs
Disp #*21 Tablet Refills:*0
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain
6. Amitriptyline 25 mg PO HS
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO HS
9. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*30
Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
11. Lisinopril 5 mg PO DAILY
12. Lorazepam 1 mg PO QHS:PRN insomnia
13. pramipexole 0.25 mg oral QHS
14. Ranitidine 75 mg PO DAILY
15. Gabapentin 300 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE KIDNEY INJURY (creatinine to 1.7)
Right ureteral stone with obstruction and hydronephrosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: NO65M with renal colic similar to prior episodes with bump in
creatinine// CTU. Please evaluate for kindey stones
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
without intravenous contrast administration with the patient in prone
position. Coronal and sagittal reformations were performed and reviewed on
PACS.
No oral contrast was administered.
DOSE: DLP: 573.47 mGy-cm
COMPARISON: Outside hospital CT abdomen ___, CT abdomen pelvis ___..
FINDINGS:
LOWER CHEST:
Mild atelectatic changes are present at the lung bases anteriorly. A
millimetric nodule at the left lung base is stable since ___, as is a
punctate nodule at the right lung base.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is moderate right hydronephrosis with perinephric stranding.
Right hydroureter is also present, with a 5 mm stone at the right UVJ. The
left kidney is unremarkable without hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Mild fecal loading is present. Sigmoid
diverticulosis is present without diverticulitis. Appendix contains air, has
normal caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is partly distended. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Degenerative changes are noted,
most markedly at the anterior superior endplate of L3. Abdominal and pelvic
wall is within normal limits.
IMPRESSION:
1. 5 mm obstructing stone at the right UVJ with moderate right hydronephrosis
and perinephric stranding.
2. Diverticulosis without signs of diverticulitis.
Radiology Report
EXAMINATION: RETROGRADE UROGRAPHY (FILMS ONLY) IN CYSTO
INDICATION: Right ureteral stent placement.
FINDINGS:
5 intraoperative images were acquired without a radiologist present.
Images show right retrograde urography with placement of a ureteral stent
within the nondilated right renal collecting system. Urography demonstrates a
filling defect in the mid ureter, potentially a ureteral stone or air bubble.
Final image shows a well-formed pigtail of the right renal pelvis, and
excludes the bladder pigtail from the field-of-view..
IMPRESSION:
Intraoperative images were obtained during right retrograde urography and
ureteral stent placement. Please refer to the operative note for details of
the procedure.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with CALCULUS OF KIDNEY
temperature: 98.4
heartrate: 74.0
resprate: 18.0
o2sat: 96.0
sbp: 126.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was admitted to urology service for nephrolithiasis
management with a known right ureteral stone with obstruction
and hydronephrosis causing acute kidney injury with a creatinine
to 1.7. He was admitted, given intravenous fluids and expulsive
therapy but without nephrotoxic agents like Toradol. He had
taken a Pyridium provided by outside provider from prior
hospital visit for same complaints. No stone was passed
overnight or since admission so he was made NPO and taken to the
OR where he underwent right ureteroscopy with laser lithotripsy
and
placement of a double-J stent. Mr. ___ tolerated the
procedure well and recovered in the PACU before transfer to the
general surgical floor. See the dictated operative note for full
details. He remained in observation on the general surgical
floor until voiding well and without complaint. He was
subsequently discharged home. At discharge, Mr. ___ 's pain
was controlled with oral pain medications and he was tolerating
a regular diet, ambulating without assistance, and voiding
without difficulty. He was given antibiotics and pain
medications on discharge with explicit instructions to follow up
as directed as the indwelling ureteral stent must be removed and
or exchanged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
iodine / metformin / vancomycin / Cephalosporins
Attending: ___.
Chief Complaint:
Hemorrhage from recent infarction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ R handed gentleman with a
past medical history significant for hyperlipidemia, htn, CAD,
diabetes mellitus type II, and recently diagnosed R
temporo-parietal infarct treated at ___. He presents
today as a transfer from ___ after he had an
"interval
follow up ct scan" to evaluate his stroke which revealed concern
for possible hemorrhage prompting transfer to ___.
The patient is an extremely poor historian and could not
remember
when he was admitted but thinks it was "last ___. He states
that he was told he had a blood clot leading to a stroke on the
R
side of his body. Regarding his initial symptoms that prompted
evaluation 10-days ago, he states that he remembers feeling like
he couldn't coordinate any movements on either side of his body.
He called a friend who is in the medical field who thought
something was "off" with him and brought him to ___
where he was evaluated.
He underwent an MRI on ___ which revealed an acute R
temporo-parietal infarct. The rest of his stroke work-up is
unknown as patient doesn't remember what tests were done. He was
placed on aspirin and Plavix. He reports feeling well a few
hours
after he was admitted to ___ without any focal weakness,
visual
loss or field cuts, sensory changes etc. and was symptom-free
for
the remainder of his hospitalization. He had been taking Plavix
alone up until a few months ago but lost his insurance and
stopped taking his medications for a short while. The patient
has
had a stressful summer as he reports recently divorcing from his
wife last month.
The patient denies having any TIAs or strokes in the past. He
denies a history of atrial-fibrillation but states that he went
into "cardiac arrest" many years ago and was in the ICU for a
prolonged period of time. He does not have further details on
this. He was smoking about ___ cigarettes per week until he was
admitted for this stroke last week. After discharge, he went to
live at his sister's house (___). At baseline, he lives
alone (since his divorce).
Since discharge the patient reports feeling well. He has not had
any headaches, changes or difficulty with speech, no weakness,
motor difficulties etc. He has been watching tv and using the
computer this week while at his sister's house. He has been
taking his medications as prescribed and has not started to
smoke
again. He does not have any complaints currently.
Past Medical History:
1. Recently diagnosed R temporoparietal ischemic infarct:
etiology unclear need records
2. HTN
3. HLD
4. Diabetes Mellitus
5. CAD
6. Anxiety
7. Spinal stenosis with chronic pain
Social History:
___
Family History:
Father had MI at age ___ but died at ___ from dementia. Mother
with
emphysema and diabetes died a few years ago. No FH of strokes or
other neurologic illnesses.
Physical Exam:
Admission PHYSICAL EXAMINATION
Vitals: T 97.9, HR 61, BP 139/69, RR 16
General: odd affect
HEENT: NCAT, no oropharyngeal lesions, neck supple
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x self,date,location.
Poor historian, provides vague details about medical history but
able to provide history about his life very well. Attentive,
able
to name ___ backward without difficulty. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. Mild to moderate
dysarthria, speech difficult to understand at times. Normal
prosody. No apraxia. No evidence of hemineglect. No left-right
confusion. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL 3->2 brisk on R, 4-->2 on L. 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. No drift. mild tremor with
outstretched arms
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: deferred
Discharge PHYSICAL EXAMINATION
24 HR Data (last updated ___ @ 1727)
Temp: 97.7 (Tm 98.4), BP: 123/70 (102-145/64-80), HR: 69
(63-97), RR: 16 (___), O2 sat: 91% (91-98), O2 delivery: RA
General: NAD, odd affect but very cheerful
HEENT: NCAT, no oropharyngeal lesions, neck supple
CV: Warm, well-perfused
Resp: breathing comfortably on room air
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x self, ___,
___. Attentive, able to name ___ backward but went forwards a
couple times. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. Mild dysarthria . Normal prosody. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL L 5-4mm, R 4-3mm. VF full to number
counting. EOMI, no nystagmus. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally. Palate elevation symmetric.
Trapezius
strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. mild tremor with
outstretched arms
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. .
- Gait: deferred
Pertinent Results:
___ 05:35AM BLOOD WBC-12.7* RBC-4.77 Hgb-15.0 Hct-44.8
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.3 RDWSD-48.9* Plt ___
___ 05:35AM BLOOD Glucose-117* UreaN-43* Creat-1.5* Na-140
K-5.0 Cl-99 HCO3-29 AnGap-12
___ 08:00AM BLOOD %HbA1c-9.7* eAG-232*
___ 08:00AM BLOOD Triglyc-315* HDL-30* CHOL/HD-6.6
LDLcalc-104
___ 08:00AM BLOOD TSH-0.79
Medications on Admission:
acetaminophen 325 mg capsule oral
2 capsule(s) Every ___ hrs, as needed
___ ___ 21:49)
amlodipine 5 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:49)
aspirin 81 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:49)
atorvastatin 80 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:49)
Plavix 75 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:49)
finasteride 5 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:50)
furosemide 20 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:50)
gabapentin 100 mg tablet oral
2 tablet(s) Three times daily
___ ___ 21:50)
insulin aspar prt-insulin aspart 100 unit/mL (70-30)
subcutaneous soln subcutaneous
1 solution(s) 20 Units SQ twice daily with meals
___ ___ 21:51)
metoprolol tartrate 25 mg tablet oral
1 tablet(s) Twice Daily
___ ___ 21:51)
mirtazapine 30 mg tablet oral
1 tablet(s) Once Daily
___ ___ 21:51)
nicotine 14 mg/24 hr daily transdermal patch transdermal
1 patch 24 hour(s) Once Daily
___ ___ 21:52)
nitroglycerin 0.4 mg sublingual tablet sublingual
1 tablet, sublingual(s) q5 min x3 prn for chest pain
___ ___ 21:52)
venlafaxine ER 150 mg capsule,extended release 24 hr oral
1 capsule,extended release 24hr(s) Once Daily
Discharge Medications:
1. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Finasteride 5 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. GlipiZIDE XL 10 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Mirtazapine 30 mg PO QHS
10. Nicotine Patch 14 mg TD DAILY
11. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute infarcts due to LV thrombus
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: ___ year old man with known right parietotemporal infarct
diagnosed last week at ___, on interval CT has linear hyperdensity.
Question of subarachnoid hemorrhage or laminar necrosis.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 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 without contrast dated ___ from ___
___.
FINDINGS:
Examination is minimally limited by motion artifact.
There is an evolving large subacute infarct involving the right parietal lobe,
temporal lobe, and posterior insula with extensive gyriform low signal on
gradient echo images and gyriform T1 hyperintensity, compatible with
hemorrhagic conversion plus/minus pseudolaminar necrosis. There is
superimposed gyriform contrast enhancement, as expected in a subacute infarct.
Mild partial effacement of the atrium of the right lateral ventricle is
similar to ___. No significant shift of midline structures.
There is also a smaller area of blood products and T1 hyperintensity in the
anterior temporal lobe, with gyriform contrast enhancement, but no evidence
for slow diffusion, compatible with hemorrhagic transformation of a subacute
infarct which is older than 10 days.
Within the posterior inferior right cerebellar hemisphere, there are multiple
foci of slow diffusion and patchy contrast enhancement, without evidence for
blood products, compatible with subacute infarctions. No significant
associated mass effect.
There is a punctate focus of slow diffusion with small, but slightly more
extensive area of gyriform contrast enhancement in the right posterior frontal
lobe, images 6:21 and 13:129, consistent with subacute infarction. Punctate
low signal on gradient echo image 10:20 in this area suggest petechial
hemorrhage.
Nonspecific, non masslike T2 hyperintensity in the bilateral central pons is
nonspecific but compatible with sequela of chronic small vessel ischemic
disease in this age group. Where not affected by the infarctions, the
ventricles and sulci appear age appropriate in size. Basal cisterns are not
compressed.
Right intracranial vertebral artery flow void is poorly seen, which is likely
secondary to its small caliber, as it demonstrates contrast opacification on
postcontrast MP RAGE images. The dural venous sinuses are patent on
postcontrast MP RAGE images.
There is mild mucosal thickening in the right ethmoid and frontal sinuses.
IMPRESSION:
1. Large subacute infarct involving the right parietal lobe, temporal lobe,
and posterior insula, with hemorrhagic transformation, plus/minus
pseudolaminar necrosis.
2. Additional smaller right anterior lobe infarct with hemorrhagic
transformation plus/minus pseudolaminar necrosis, also subacute, which appears
to be older than 10 days.
3. Patchy small subacute infarctions in the right posterior inferior
cerebellar hemisphere.
4. Small focus of cortical subacute infarction in the right posterior frontal
lobe.
5. Contrast enhancement associated with above described subacute infarctions
is likely physiologic, but follow-up imaging is recommended to ascertain
resolution.
6. The above described infarctions of varying ages in multiple vascular
territories suggest embolic etiology.
RECOMMENDATION(S): Follow up MRI with and without contrast in approximately 6
weeks to confirm expected resolution of contrast enhancement.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified
temperature: 97.9
heartrate: 61.0
resprate: 16.0
o2sat: 96.0
sbp: 139.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ R handed gentleman with a
past medical history significant for hyperlipidemia, htn, CAD,
diabetes mellitus type II, and recently diagnosed R
temporo-parietal infarct treated at ___. He presents
today as a transfer from ___ after he had an
"interval
follow up ct scan" to evaluate his stroke which revealed concern
for possible hemorrhage prompting transfer to ___. CT scan
showed an area of hyperdensity in a linear/ribbon-like fashion
concerning for possible SAH vs. Cortical laminar necrosis
prompting transfer to ___.
He was previously found with a large LV thrombus at ___ but he
was not discharged on anticoagulation due to concern for
hemorrhagic conversion. On this admission, his exam was mostly
nonfocal except for anisocoria and mild inattention.
MRI found "large subacute infarct involving the right parietal
lobe, temporal lobe, and posterior insula, with hemorrhagic
transformation, plus/minus pseudolaminar necrosis. Additionally,
there was smaller right anterior lobe infarct with hemorrhagic
transformation plus/minus pseudolaminar necrosis, also subacute,
which appears
to be older than 10 days. There was also patchy small subacute
infarctions in the right posterior inferior cerebellar
hemisphere. Small focus of cortical subacute infarction in the
right posterior frontal lobe."
TTE showed LVH, severe distal anterolateral hypokinesis, large
LV apical thrombus. Plavix was held but ASA continued.
Patient was started on Coumadin 5 mg daily. He understands
importance of compliance with his meds & the need to monitor
warfarin/INR closely. He also stated that his sister "keeps a
very close eye on him". Spoke with his outpatient neurologist,
Dr. ___ agreed with AC.
Transitional Issues:
[]INR checks by VNS initially and at PCP ___
[]PCP ___ on ___ at 12 pm.
[]Neurology ___ in next ___ weeks. Office will contact
patient.
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. If no, reason why:
2. DVT Prophylaxis administered? () Yes - (x) No. Hemorrhagic
transformation. If no, why not (I.e. bleeding risk, hemorrhage,
etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No. If not, why not? Hemorrhagic transformation
(I.e. bleeding risk, hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 104) - () 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 - atorvastatin
40mg () 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 - () No [reason
(x) non-smoker - recently quit, on nicotine patch () 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. If no, why not? (I.e. patient at baseline
functional status)
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: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / Niaspan Extended-Release
Attending: ___.
Chief Complaint:
nausea, vomitting, diarrhea
Major Surgical or Invasive Procedure:
___: Successful US-guided aspiration of a superficial right
lower quadrant fluid collection
History of Present Illness:
This patient is a ___ year old female who complains of
n/v/d. Hx SBO, s/p recent ventral hernia repair s/p SBO 5d
PTA, discharged yesterday, presenting with abdominal pain,
nausea, vomiting, and profuse watery diarrhea. She has
typically had diarrhea associated with her SBO. No
fever/schills. NBNB emesis. Not tolerating po. Decreased
flatus.
Past Medical History:
HTN, HLD
PSHx: open CCY, appendectomy, 3 C sections, hysterectomy,
ventral hernia repair
Allergies: bactrim, niaspan
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: ___
Temp: 98.6 HR: 90 BP: 133/74 Resp: 16 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, nontender, midline incision
c/d/i
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Physical examination upon diacharge: ___:
vital signs: 98.5, hr=75, bp=127/64, rr=18, 96% room air
CV: Ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, scattered mid-abdominal staples, mild separation
of skin after few staples removed, wound edges closed with
steri-strips
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3 speech clear
Pertinent Results:
___ 06:15AM BLOOD WBC-10.1 RBC-3.21* Hgb-11.0* Hct-32.0*
MCV-100* MCH-34.2* MCHC-34.3 RDW-12.3 Plt ___
___ 03:15PM BLOOD WBC-12.0* RBC-3.29* Hgb-11.4* Hct-33.1*
MCV-101* MCH-34.7* MCHC-34.5 RDW-12.3 Plt ___
___ 02:00AM BLOOD WBC-20.2*# RBC-3.82* Hgb-13.5 Hct-37.4
MCV-98 MCH-35.4* MCHC-36.1* RDW-12.3 Plt ___
___ 02:00AM BLOOD Neuts-84.8* Lymphs-9.8* Monos-4.4 Eos-0.6
Baso-0.4
___ 06:15AM BLOOD Plt ___
___ 02:17AM BLOOD ___ PTT-27.2 ___
___ 06:15AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-140
K-4.2 Cl-101 HCO3-29 AnGap-14
___ 02:00AM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-136
K-5.5* Cl-97 HCO3-22 AnGap-23*
___ 03:15PM BLOOD ALT-91* AST-61* AlkPhos-231* TotBili-0.6
___ 02:00AM BLOOD Lipase-194*
___ 06:15AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
___: cat scan abdomen and pelvis:
1. Intra-abdominal fluid collection posterior to the surgical
mesh measuring
13.0 x 2.4 cm, concerning for a developing abscess. Markedly
edematous, mildly
dilated loops small bowel posterior to this collection are
probably reactive
(vs enteritis or ischemia.)
2. Soft tissue fluid collection within the anterior abdominal
wall soft
tissues with surrounding stranding, is likely postsurgical
although a
superimposed infection is not excluded.
3. Fluid-filled large bowel without evidence of thickening.
___: chest x-ray:
No radiographic evidence of pneumonia.
___ drainage: ___
Successful US-guided aspiration of a superficial right lower
quadrant fluid
collection, yielding 50 cc of sanguineous fluid. Samples were
sent for
microbiology evaluation.
Medications on Admission:
Meds: lisinopril 10 (or 15, pt unsure)', atorvastatin 80',
omeprazole 20'', spironolactone 50''', vitamins
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
intra-abdominal fluid collection
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: ___ with recent surg for vent hernia repair on ___,
sbo, with return of symptoms of SBO+PO contrast
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was administered.
DLP: 943 mGy-cm
COMPARISON: Comparison is made to abdomen and pelvic CT from ___.
FINDINGS:
CHEST: The visualized lung bases are clear. The heart is normal in size and
there is no evidence of pericardial effusion.
ABDOMEN:
The liver enhances homogeneously and is without focal lesions. The portal
venous system is patent. Mild intrahepatic biliary ductal dilation is
unchanged. The gallbladder is surgically absent..
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
Focal defects in the cortex of the of right and left kidneys likely from prior
scarring. Subcentimeter hypodensity in the left kidney is too small to
characterize but likely represents a cyst. There is no hydronephrosis. The
ureters are normal in caliber and course to the bladder.
Oral contrast extends through the proximal small bowel. The stomach and
proximal small bowel are normal in caliber without wall thickening.
A mesh from prior ventral hernia repair is seen spanning the midline of the
lower abdomen. In the soft tissues anterior to the mesh there is a 8.4 x2.9 x
5.5 cm (transverse by AP by cc) collection with surrounding stranding (series
2:75). There are a few foci of air within the soft tissues. Just posterior to
the mesh within the intra-abdominal cavity is an additional fluid collection
with a hyperenhancing border crossing the midline and measuring approximately
13.0 x 2.4 cm (transverse by AP). There is no evidence of rim enhancement.
Posterior to this collection there are multiple fluid filled loops of
edematous and mildly dilated small bowel (series 2, image 76). There is no
evidence of intra-abdominal free air. The large bowel is primarily
fluid-filled and is without wall thickening.
The abdominal aorta and its major branches are patent . The aorta and iliac
branches are normal in course and caliber. There is no retroperitoneal or
mesenteric lymphadenopathy by CT size criteria.
PELVIS:
The bladder is well distended and normal. There is no pelvic side-wall or
inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is
identified.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Intra-abdominal fluid collection posterior to the surgical mesh measuring
13.0 x 2.4 cm, concerning for a developing abscess. Markedly edematous, mildly
dilated loops small bowel posterior to this collection are probably reactive
(vs enteritis or ischemia.)
2. Soft tissue fluid collection within the anterior abdominal wall soft
tissues with surrounding stranding, is likely postsurgical although a
superimposed infection is not excluded.
3. Fluid-filled large bowel without evidence of thickening.
Radiology Report
INDICATION:
___ year old woman with N/V and WBC 20 postop day 10 from ventral hernia
repair.
COMPARISON: None Available.
TECHNIQUE
Frontal lateral view of the chest.
FINDINGS:
The cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. No acute osseous
abnormality is seen.
IMPRESSION:
No radiographic evidence of pneumonia.
Radiology Report
INDICATION: ___ year old woman with SBO w/ fluid collections.
COMPARISON: CT abdomen pelvis ___.
PROCEDURE: Ultrasound-guided drainage of superficial right lower quadrant
collection.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on the
ultrasound findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, 20G spinal needle was inserted into the
collection.
Approximately 50 cc of sanguineous fluid was drained, and a sample sent for
microbiology evaluation. The needle was withdrawn, and a sterile dressing was
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: No sedation was provided.
FINDINGS:
Limited ultrasound of the right lower quadrants demonstrates a superficial
complex fluid collection.
IMPRESSION:
Successful US-guided aspiration of a superficial right lower quadrant fluid
collection, yielding 50 cc of sanguineous fluid. Samples were sent for
microbiology evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.6
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 133.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the hospital 24 hours after
discharge with nausea, vomiting, and abdominal pain. Her white
blood cell count was reported at 20. Upon admission, the
patient was made NPO, given intravenous fluids, and underwent
cat scan imaging of the abdomen which showed an intra-abdominal
fluid collection posterior to the surgical mesh measuring 13.0 x
2.4 cm. This was concerning for a developing abscess. The
patient was started on intravenous vancomycin and zosyn.
The patient then underwent ___ drainage of the fluid collection
where 50 cc of sanguineous fluid was removed and sent for
culture.
The patient's vital signs remained stable and she was afebrile.
She was tolerating a regular diet and voiding without
difficulty. Her white blood cell count decreased to 10. Because
the diarrhea persisted, a stool culture for c.diff was sent
which was negative.
The patient was discharged home with ___ services on HD #3 in
stable condition. The patient was transitioned to oral
antibiotics for 1 week. Post-operative instructions were
reviewed. A follow-up appointment was made with the acute care
clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___
Chief Complaint:
abdominal pain, fevers
Major Surgical or Invasive Procedure:
diagnostic paracentesis
History of Present Illness:
___ with history of cirrhosis secondary to alcoholic liver
disease and hep C who presents with worsening ascites and lower
extremity swelling. Pt reports that he began having cough with
subjective fevers/chills on ___, associated with pain
underneath his shoulder blades bilaterally and shortness of
breath. His cough was productive of green mucous. Pt reports a
Tmax at home of 103.3 on ___. That afternoon, he presented
to ___ for a therapeutic tap, where 3
liters of ascitic fluid was reportedly removed. Pt told staff
there that he was feeling unwell, but was told that his blood
work was normal and he was discharged home. He presented again
to the ___ ED on ___ and was reportedly
diagnosed wtih pneumonia and started on azithromycin. He reports
no improvement since starting on azithro. Since ___, he notes
worsening of his lower extremity edema and abdominal distension,
associated with diffuse abdominal tenderness. Pt called Dr.
___ for an appointment but stated that he needed to
be seen today, so presented to the ED.
.
Pt was hospitalized ___ for hematemesis with negative EGD.
Bleeding was attributed to epistaxis. No evidence of variceal
bleed. He was discharged on 7 day course of ciprofloxacin.
.
ED Course: Initial Vitals 97.7 57 ___ 99% ra. CXR showed
stable persistent patchy L basilar opacity wo acute findings. He
underwent diagnostic paracentesis which showed WBC 140, RBC 845,
tot protein 1.3, gluc 126, 7% PMN. Labs notable for lactate 1.8,
wbc 6.8 (wo L shift), Hct 40.7, Plt 70, chem 7 wnl, AST 109, ALT
45, tbili 1.3, alb 2.8. He received ceftriaxone 1g IV to broaden
for presumed pna, IV morphine, and zofran. Vitals prior to
transfer 97.8 °F (36.6 °C), Pulse: 62, RR: 18, BP: 110/79,
O2Sat: 97, O2Flow: ra, Pain: ___. Access: PIV 20g.
.
On the floor, pt reports feeling improved since getting
ceftriaxone in the ED. He states that his leg and abdominal
swelling is only mildly increased and his biggest concern has
been his cough, nasal congestion and headaches. He also note 1
day of diarrhea and vomitting last ___. Pt reports that he
has been compliant with medications, and compliant with a low
salt diet. He has been requiring therapeutic taps every 2.5
weeks.
Past Medical History:
Cirrhosis
Hepatitis C
Esophageal varices
Ascites
HTN
Myocardial infarction in setting of cocaine use (age ___
b/l hip replacement
Social History:
___
Family History:
Hypertension; Mother, father and brothers with alcoholism;
sister former drug addict, now sober
Physical Exam:
ADMISSION EXAM:
VS: 98.0 122/81 60 22 98% RA
___: Well appearing ___ yo M/F who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically, upper airway noises transmitted
throughout, mildly rhonchous, no crackles, wheezes.
ABDOMEN: soft, mild distension, diffusely tender to light touch,
worse over spleen and abdominal hernia, splenomegaly. Dullness
to percussion over dependent areas but tympanic anteriorly.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
___ ___ bilaterally to knees.
.
DISCHARGE EXAM:
VS: Tm 98.5 Tc97.9 ___ 20 97/RA
I/O: ___ overnight BM x5
___: Well appearing ___ yo M/F who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically, upper airway noises transmitted
throughout, mildly rhonchous, no crackles, wheezes.
ABDOMEN: soft, mild distension, diffusely tender to light touch,
worse over spleen and abdominal hernia, splenomegaly. Dullness
to percussion over dependent areas but tympanic anteriorly.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
___ ___ bilaterally to knees.
Pertinent Results:
ADMISSION LABS:
___ 12:02PM BLOOD WBC-6.8# RBC-4.14* Hgb-13.0* Hct-40.7
MCV-99* MCH-31.4 MCHC-31.9 RDW-17.3* Plt Ct-70*
___ 12:02PM BLOOD Neuts-67.5 ___ Monos-5.3 Eos-2.3
Baso-0.8
___ 12:02PM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-133
K-4.1 Cl-100 HCO3-26 AnGap-11
___ 12:02PM BLOOD ALT-45* AST-109* AlkPhos-91 TotBili-1.3
___ 12:02PM BLOOD Albumin-2.8*
.
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.8 RBC-4.12* Hgb-12.8* Hct-40.6
MCV-99* MCH-31.2 MCHC-31.6 RDW-17.4* Plt Ct-93*
___ 06:25AM BLOOD ___ PTT-35.7 ___
___ 06:25AM BLOOD Glucose-116* UreaN-6 Creat-0.6 Na-134
K-4.6 Cl-102 HCO3-25 AnGap-12
___ 06:25AM BLOOD ALT-45* AST-106* AlkPhos-99 TotBili-1.1
___ 06:25AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.6
.
URINALYSIS/URINE TOX:
___ 05:14PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.5 Leuks-NEG
___ 05:14PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
DIAGNOSTIC PARACENTESIS:
___ 02:54PM ASCITES WBC-140* RBC-845* Polys-7* Lymphs-32*
Monos-4* Mesothe-5* Macroph-52*
___ 02:54PM ASCITES TotPro-1.3 Glucose-126
.
MICROBIOLOGY
___ 2:54 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
Blood culture x 2 pending
.
Urine culture pending
.
CHEST (PA & LAT) Study Date of ___
FINDINGS: The heart is normal in size. The mediastinal and hilar
contours
appear within normal limits. There is a persistent patchy left
basilar opacity. Given the lack of change, the appearance may be
chronic. More
generally, there is mild interstitial prominence, perhaps due to
slight fluid overload or congestion, but not specific; other
possibilities include atypical infection, airway inflammation,
or possibly interstitial lung disease.
IMPRESSION: Mild suspected background interstitial abnormality
and unchanged focal left infrahilar opacity, accordingly
suggestive of longer chronicity. Clinical correlation is
recommended. If shortness of breath were to continue and the
possibility of an underlying interstitial process is of
potential clinical concern, dedicated chest CT could be
considered.
.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
CT ABDOMEN: There are no pleural effusions. The lung bases
appear clear.
The liver is nodular consistent with fibrosis. The caudate and
left lateral segments are markedly enlarged. The entire left
lobe is shrunken with predominantly central areas of relative
hypodensity suggesting fibrosis. Because monophasic technique
was used, screening for hepatocellular carcinoma is limited, but
there are no suspicious focal lesions identified. The spleen is
moderately enlarged, measuring up to 17.3 cm in length.
Esophageal, paraesophageal and short gastric varices are
apparent. The gallbladder shows mild wall thickening which can
be seen in cirrhosis but it does not appear distended. The
adrenal glands, pancreas and adrenal glands appear within normal
limits.
Along the anterior abdominal wall there is a fat-containing
paraumbilical
hernia with omental contents. Its neck is wide, measuring up to
nearly 26 mm in diameter; the sac measures up to 49 mm in
diameter. There is congestive change suggested by high
attenuation in the fat as well as a small amount of peripheral
fluid, which are findings that can be seen with incarceration
but which are highly nonspecific particularly in the setting of
generalized cirrhosis and ascites with portal hypertension.
The stomach, small and large bowel appear within normal limits.
The appendix appears normal.
CT PELVIS: Moderate-to-large ascites layers in the pelvis.
Streak artifact
from bilateral hip replacements makes evaluation of lower pelvic
structures such as the prostate and seminal vesicles and lower
part of the bladder difficult, but no definite abnormality is
identified. The bladder is poorly delineated and probably mostly
empty. There are patchy vascular
calcifications without any aneurysm. There are slightly
prominent celiac and periportal lymph nodes but none enlarged by
size criteria. The main portal vein and its major branches
appear patent, although segmental branches of the portal vein
are markedly attenuated in keeping with portal hypertension.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
Mild
degenerative changes are present along the lower lumbar facets.
Patient is
status post right hip hemiarthroplasty and left total hip
replacement.
IMPRESSION:
1. Cirrhosis with findings consistent with portal hypertension
including
splenomegaly and varices.
2. Moderate-to-large quantity of ascites.
3. Fat-containing ventral hernia with a fairly wide neck.
Although there is
increased attenuation of fat as well as a small quantity of
peripheral fluid,
which can be seen with incarceration, findings are highly
nonspecific in this
setting.
Medications on Admission:
# nadolol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
# sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
# hydroxyzine HCl 50 q HS
# zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO twice a
day.
# furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# spironolactone 150 mg Tablet Sig: One (1) Tablet PO once a
day.
# ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
# oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
# flovent inhaler 2 puffs BID
# flonase daily
# vitamin B complex
# MVI
# Vit D
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
12. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: Please complete 2 more doses, last
dose ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
abdominal pain
SECONDARY:
hepatitis C
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Shortness of breath and ascites.
COMPARISON: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is a persistent patchy left basilar
opacity. Given the lack of change, the appearance may be chronic. More
generally, there is mild interstitial prominence, perhaps due to slight fluid
overload or congestion, but not specific; other possibilities include atypical
infection, airway inflammation, or possibly interstitial lung disease.
IMPRESSION: Mild suspected background interstitial abnormality and unchanged
focal left infrahilar opacity, accordingly suggestive of longer chronicity.
Clinical correlation is recommended. If shortness of breath were to continue
and the possibility of an underlying interstitial process is of potential
clinical concern, dedicated chest CT could be considered.
Radiology Report
CT OF THE ABDOMEN AND PELVIS
HISTORY: Cirrhosis complicated by ascites and varices, presenting with fever
and abdominal pain. Question incarcerated hernia or other nidus for
infection.
COMPARISONS: An ultrasound is available from ___ which showed
chronic fibrotic liver disease with ascites and splenomegaly. No prior CT
imaging is available.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with oral and intravenous contrast. Sagittal and coronal reformations were
also performed.
Shortly after the study, a preliminary interpretation was provided by Dr.
___:
"1. Cirrhosis with splenomegaly to 17.3 cm in portosystemic collaterals,
suggesting portal hypertension. Main portal vein, SMV and splenic veins are
patent.
2. Moderate large ascites. Superinfection in the ascitic fluid cannot be
excluded on this study. No rim-enhancing fluid collection identified.
3. Small ventral hernia with a 2.6-cm neck containing omentum and mesenteric
vessels. A small amount of free fluid is seen within it, but is nonspecific
in the setting of ascites. It does not contain small or large bowel loops.
Correlate clinically.
4. No other infectious nidus seen."
FINDINGS:
CT ABDOMEN: There are no pleural effusions. The lung bases appear clear.
The liver is nodular consistent with fibrosis. The caudate and left lateral
segments are markedly enlarged. The entire left lobe is shrunken with
predominantly central areas of relative hypodensity suggesting fibrosis.
Because monophasic technique was used, screening for hepatocellular carcinoma
is limited, but there are no suspicious focal lesions identified. The spleen
is moderately enlarged, measuring up to 17.3 cm in length. Esophageal,
paraesophageal and short gastric varices are apparent. The gallbladder shows
mild wall thickening which can be seen in cirrhosis but it does not appear
distended. The adrenal glands, pancreas and adrenal glands appear within
normal limits.
Along the anterior abdominal wall there is a fat-containing paraumbilical
hernia with omental contents. Its neck is wide, measuring up to nearly 26 mm
in diameter; the sac measures up to 49 mm in diameter. There is congestive
change suggested by high attenuation in the fat as well as a small amount of
peripheral fluid, which are findings that can be seen with incarceration but
which are highly nonspecific particularly in the setting of generalized
cirrhosis and ascites with portal hypertension.
The stomach, small and large bowel appear within normal limits. The appendix
appears normal.
CT PELVIS: Moderate-to-large ascites layers in the pelvis. Streak artifact
from bilateral hip replacements makes evaluation of lower pelvic structures
such as the prostate and seminal vesicles and lower part of the bladder
difficult, but no definite abnormality is identified. The bladder is poorly
delineated and probably mostly empty. There are patchy vascular
calcifications without any aneurysm. There are slightly prominent celiac and
periportal lymph nodes but none enlarged by size criteria. The main portal
vein and its major branches appear patent, although segmental branches of the
portal vein are markedly attenuated in keeping with portal hypertension.
BONE WINDOWS: There are no suspicious lytic or blastic lesions. Mild
degenerative changes are present along the lower lumbar facets. Patient is
status post right hip hemiarthroplasty and left total hip replacement.
IMPRESSION:
1. Cirrhosis with findings consistent with portal hypertension including
splenomegaly and varices.
2. Moderate-to-large quantity of ascites.
3. Fat-containing ventral hernia with a fairly wide neck. Although there is
increased attenuation of fat as well as a small quantity of peripheral fluid,
which can be seen with incarceration, findings are highly nonspecific in this
setting.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LACITIES/EDEMA
Diagnosed with OTHER ASCITES, HYPERTENSION NOS, LIVER DISORDER NOS
temperature: 97.7
heartrate: 57.0
resprate: 20.0
o2sat: 99.0
sbp: 112.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | ___ man with a history of cirrhosis secondary to
hepatitis C and alcohol use who was admitted with fever and
abdominal pain. Pt remained afebrile throughout his stay and his
abdominal exam and imaging were not concerning for any acute
process.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins / Flagyl
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Whole brain radiation
History of Present Illness:
___ year old female with metastatic lung cancer with progressive
brain metastases s/p metastasis resection and craniotomy ___
for
brain met felt to be causing intractable nausea/vomiting who
started fraction 1 of 5 of whole brain radiation therapy today
___ now presenting with chief complaint of nausea, vomiting
and
headache.
Pt has been admitted previously for nausea/vomiting and right
chest/back pain; pain has improved with previous course of chest
RT and she is now down to using po dilaudid only once daily. Has
also had prior admission before this decrease for opiate related
constipation which per pt is no longer an issue. Most recently
tapered post-op steroid dose and has been tolerating food and
feeling well at home but due to progression ofnumerous brain
mets, decision was made to do WBRT rather than cyberknife and
she
initiated WBRT today (___). She went home after RT, fell
asleep
and woke up with pounding frontal headache. No visual changes or
weakness of any extremity. She also had nausea and 1 episode of
nonbloody vomiting. Rad Onc instructed her to take 4mg po dex
which she did with some relief but later developed recurrene of
nausea and headache and was referred to the ED as she was unable
to keep down PO. She also notes that she developed abdominal
pain
during this time which was mild-moderate and located in the
___ the abdomen; did not appear to be exacerbated by food,
and she continues having bowel movements that are formed and
nonbloody. She has had no diarrhea and no fevers and no sick
contacts. She has had similar pain in the setting of
constipation
in the past but does not believe she is constipated at this
time;
last formed bowel movement was fairly soft and was yesterday.
ED course:
v/s 99.1 115/87 HR ___ RR 18 98% RA. LFTs/lipase
unremarkable.
CT head noncon read as :
Patient is status post right frontal and occipital craniotomy.
Relative to CT dated ___, degree of hypodensity
surrounding known metastatic lesions particularly within the
left
frontal lobe and right temporal parietal region are slightly
more
conspicuous. There is no evidence of hemorrhage or
significant mass effect.
Pt received 10mg IV dex, 1mg IV dilaudid, 4mg IV Zofran, 1L IVF.
Labs otherwise unremarkable. She felt symptomatically improved
and was transferred to the floor.
At the time of this interview she appears comfortable and
conversant and not in extreme pain though endorses ongoing mild
gnawing abd pain, denies headache or nausea at this time. Denies
cough, sx/signs of bleeding, fever, sick contacts, dysuria.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: + n/v as sabove but no diarrhea; abd pain as above. No
recent
change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: presents to ___ with 4 days of L hand weakness
after
OSH NCHCT demonstrates R frontal lobe lesion with local edema
but
no midline shift. Keppra and dex loaded (subsequent confirmed
seizure activity). Admitted to Neuro ICU.
-___: craniotomy w/ tumor resection by Dr. ___: Metastatic adenocarcinoma, lung origin, Positive:
TTF-1, CK7, p63 (weak), Negative: Cytokeratin 20, immunoglobin,
GCDFP-15
- ___: CT chest showed 1.7 x 1.9 cm solid lesion in the
right
upper lobe, likely a primary lung tumor. Satellite 2 x 2.3
partially solid lesion suspicious for additional primary
malignancy versus organizing pneumonia. Remainder right upper
lobe ground-glass opacities are concerning for metastasis There
is extensive bilateral hilar and mediastinal lymphadenopathy,
also with involvement of the right supraclavicular space. The
latter compresses the right internal jugular vein, producing
upstream jugular vein thrombosis. Filling defect compatible with
thrombus is also in the SVC.
-___: vascular surgery consulted for R IJ/subclavian
thrombosis as well as submassive PE, initiated on therapeutic
lovenox with stable NCHCT on anticoagulation
-___: developed seizures, started on Keppra
-___: AOx3; motor exam, left upper arm flaccid
left leg IP 4+, quad ___, ham ___, at ___, ___ ___, ___ ___,
the right arm and leg were full strength. Cipro for UTI.
Discharged to rehabilitation in neurological stable condition.
-___: 3 sessions CyberKnife OTV
-___: Admitted to ___ with high fever and radiologic
evidence
of RUL PNA, initially treated for HCAP and discharged on
levofloxacin we extended to 10 days
-___: EGFR wild type, K-Ras wild type, ALK/ROS1 without
rearrangement
-___: C1D1 carboplatin/pemetrexed
-___: Admitted to ___ w/ cavitary lung lesion consistent
with abscess, BAL + MRSA, unable to safely drain, discharged on
14 days vanc/aztreonzam w/ ID followup, RUE DVT
-___: C2D1 carboplatin/pemetrexed
-___: CT chest with substantial involution since ___ in
central adenopathy in the mediastinum and right hilus with
recovered patency to right upper lobe posterior segmental
bronchus and marked decrease in size of postobstructive right
upper lobe abscess. Direct tumor extension from the hilus into
the right lung has improved, but there is a question of new RLL
implant.
-___: ID followup, discontinued vanc/aztreonam/clinda and
narrowed to PO bactrim
-___: C3D1 carboplatin/pemetrexed
-___: C4D1 carboplatin/pemetrexed (with fosaprepitant, 1L
IVF)
-___: C1 pemetrexed maintenance
-___: C2 pemetrexed maintenance
-___: C3 pemetrexed maintenance HELD
-___: RUE ultrasound: On the right there is a large
occlusive thrombus in the internal jugular vein that extends
partially into the subclavian vein. The axillary, brachial,
cephalic, and basilic veins are compressible and demonstrate
augmentation.
-___: CT venogram (chest): Occlusive thrombus in the right
internal jugular vein. Partially occlusive focal thrombus in the
superior vena cava. Known right upper lobe mass has slightly
increased in size since ___. Necrotic mediastinal
lymphadenopathy is relatively stable. This study is not designed
to evaluate for extent of disease. A hypodensity in the dome of
the liver measuring 13 mm is not fully evaluated on this study.
-___: C3 pemetrexed maintenance
-___: C4 pemetrexed maintenance
-___: CT chest w/ interval progression in the mediastinal
lymphadenopathy. There is also possible progression of right
upper lobe lesion and right internal jugular and superior vena
cava thrombi as well as narrowing up to almost occlusion of the
left subclavian vein. Cortical reaction at the lateral aspect of
the right tenth rib of uncertain significance.
-___: pemetrexed HELD for progression
-___: PET/CT FDG avid right upper lobe mass and FDG-avid
mediastinal and bilateral hilar lymphadenopathy. FDG avid
material in the right internal jugular vein and right
brachiocephalic vein is concerning for tumor thrombus.
-___: CT chest with continued progression of large scale
adenopathy from the supraclavicular regions through all all
peritracheal stations of the mediastinum in both hila. The most
serious tumor related complications are near occlusion of the
superior vena cava, chronic thrombosis of the right internal
jugular vein, and recently progressive narrowing of both
descending pulmonary arteries, and right main bronchus.
No metastatic disease in abd/pelvis.
-___: MRI brain with new 4 mm enhancing lesion within the
right cerebellar hemisphere concerning for metastatic lesion
-___ initiated crizotinib off trial
-___ CK to R cerebellar met
-___ CT chest with broad response to therapy
-___: MRI brain with slight increase edema at resection
site,
otherwise stable. CT chest with persistent excellent response.
-___ admitted with groin hematoma, lovenox
temporarily
held then restarted at slightly lower dose
-___ having orthostatic symptoms, referred to cardiology, she
had some transient bradycardia which could be related to
crizotinib but was continued on her dose as symptoms were stable
-___ saw Dr. ___ in f/u, remained off keppra. Brain MRI
showed new R occipital lesion,
-___ new R occ lesion treated by Dr. ___ with CK
-___ CT showed slight increase in size of her dominant RUL
mass, and was noted to have neutropenia attributed to
crizotinib,
ANC 740. This recovered 1150 by ___ brain MRI stable
-___ CT chest: Progressive disease with increase in size of
RUL mass from 14x19mm to 26x30mm, increase in size of a RUL
nodule, new massive mediastinal LAD and local osteolytic rib
lesion
- ___ underwent craniotomy and resection for one brain
metastasis followed by WBRT initiation on ___
PAST MEDICAL HISTORY:
Hypertension
Vitamin B12 deficiency
Social History:
___
Family History:
Her mother died at ___ with dementia and her father died at ___
when the patient was ___ years old.
Physical Exam:
VITAL SIGNS: 98.9 108/71 71 18 99% RA
General: NAD, thin, frail appearing, pale but conversant and
energetic conversationalist
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. Pt has
tenderness to palpation in one area of abdomen to right of
center
but no RUQ tenderness and appears comfortable despite palpation.
No CVA tenderness
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
Pertinent Results:
___ 11:20PM BLOOD WBC-4.3 RBC-3.38* Hgb-11.0* Hct-33.5*
MCV-99* MCH-32.5* MCHC-32.8 RDW-15.7* RDWSD-57.1* Plt ___
___ 06:45AM BLOOD WBC-4.6 RBC-3.11* Hgb-10.0* Hct-31.8*
MCV-102* MCH-32.2* MCHC-31.4* RDW-15.4 RDWSD-57.8* Plt ___
___ 11:20PM BLOOD Neuts-74.9* Lymphs-18.3* Monos-5.6
Eos-0.5* Baso-0.5 Im ___ AbsNeut-3.20# AbsLymp-0.78*
AbsMono-0.24 AbsEos-0.02* AbsBaso-0.02
___ 11:20PM BLOOD Glucose-133* UreaN-14 Creat-1.0 Na-135
K-5.4* Cl-101 HCO3-24 AnGap-15
___ 06:45AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-138
K-4.3 Cl-106 HCO3-27 AnGap-9
___ 11:20PM BLOOD ALT-16 AST-32 AlkPhos-63 TotBili-0.3
___ 11:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:20PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 11:20PM URINE CastHy-1*
___ 11:20PM URINE Mucous-RARE
CT Head ___
IMPRESSION:
1. Compared to ___, the extent of edema associated
with bilateral supratentorial and left cerebellar metastases has
increased, statistically likely secondary to radiation therapy.
There is only mild new effacement of the atrium of the right
lateral ventricle, but no other significant mass effect.
2. No evidence for acute hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ s/p whole brain radiation therapy today for lung metastases,
presenting with headache, likely secondary to cerebral edema, please evaluate
for acute intracranial process/ hemorrhage, change in brain metastases.
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: CTA head dated ___ as well as MR head dated ___.
FINDINGS:
Right frontal/parietal and right temporal craniotomies are again seen.
There are multiple areas of edema related to the known brain metastases, best
seen within the right superior frontal lobe, left inferior frontal lobe,
bilateral temporal lobes, right parietal/posterior upper lobes, and the left
cerebellar hemisphere. Compared to ___, the extent of edema at
the sites has increased. There is new mild mild effacement of the atrium of
the right lateral ventricle, but no other significant mass effect, and no
shift of midline structures. There is no evidence of acute hemorrhage. Basal
cisterns are not compressed.
Visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. Partially visualized orbits are unremarkable.
IMPRESSION:
1. Compared to ___, the extent of edema associated with bilateral
supratentorial and left cerebellar metastases has increased, statistically
likely secondary to radiation therapy. There is only mild new effacement of
the atrium of the right lateral ventricle, but no other significant mass
effect.
2. No evidence for acute hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, N/V
Diagnosed with Headache
temperature: 99.1
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 115.0
dbp: 81.0
level of pain: 8
level of acuity: 2.0 | ___ year old female with metastatic lung cancer with progressive
brain metastases s/p metastasis resection and craniotomy ___
for brain met felt to be causing intractable nausea/vomiting who
started fraction 1 of 5 of whole brain radiation therapy today
___ now presenting with chief complaint of nausea, vomiting
and
headache concerning for radiation induced edema (treatment
effect).
# nausea/vomiting/headache - Suspected sequelae of too rapid a
taper of dexamethasone. Headache improved rapidly with steroids.
Patient was discharged on an long dexamethasone taper.
# Abdominal pain - Improved with a bowel movement. Started on
ranitidine and simethicone for "fullness" with improvement in
sypmtoms. On discharge she was able to tolerate a regular diet.
# Lung cancer - plan had been to try nivolumab/immunotherapy but
currently pursuing WBRT as recently found to have progression of
intracranial mets; s/p resection of one large met earlier in
___. Received ___ days of whole brain radiation while
hospitalized. Final day will be ___. She will follow up with
oncology as an outpatient.
# H/O DVT: continued on home lovenox. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mango tree bark
Attending: ___.
Chief Complaint:
Altered Mental Status, Hypoxia
Major Surgical or Invasive Procedure:
Pericardiocentesis
Left thoracentesis
Abdominal JP drain insertion
Intubation, extubation
Right IJ line placement, removal
History of Present Illness:
___ w/ HLD, HTN, OSA, PNET s/p distal pancreatectomy/splenectomy
(___) w/ recent hospitalization (___) w/ abdominal abscess
requiring JP drain and PE (warfarin) who p/w hypoxemia and AMS.
He went from ___ rehab to ___ on ___ for
hypoxia (desatting to ___ and AMS ("baseline confused" to
"grossly altered" per records) and was started on NRB. He had
purulent drainage from his JP drains and had a CT scan that
showed large pericardial effusion. TTE concerning for large
effusion. He was transferred to ___ for further management and
possible pericardiocentesis.
In ED initial VS: T 99.2 HR 117 BP 170/98 RR 28 98% NRB
Exam: Somnolent, withdraws to pain
Labs: wbc 9.6, hgb 11.2, plt 689, K 6.4 (recheck was 4.1),
lactate 1.3, Cr 0.6, INR 2.2, VBG 7.28/80, UA w/ lg leuk, neg
nitr, but no bact.
Imaging: Bedside US w/ large effusion w/ concern for impending
tamponade clinically.
Patient was given: Zosyn, calcium gluconate, insulin 10
Imaging notable for: CXR w/ dense L bibasilar opacity likely
combination of effusion w/ atelectasis (superimposed infection
possible). Englarged cardiac silhouette and pulmonary vascular
congestion. EKG w/ AFIB, RBBB (unchanged from prior).
Consults: Surgery was consulted and said that patients JP drains
are draining purulent fluid, but CT scans are not concerning for
repeat abscess. Cardiology was consulted and urgently performed
pericardiocentesis in the cath lab w/ 500 serosanguinous, drain
placed. Opening pressure 13, closing was 3. Recommended TTE
tomorrow pm.
VS prior to transfer: T 99.0 HR 121 BP 144/72 RR 26 99% NRB
On arrival to the MICU, he is somnolent, but arousable and
answers some questions appropriately. His ABG showed ___
w/ K 4.1 and lactate 0.8, he was switched to BiPAP. His mental
status did not improve on BiPAP so he was intubated with
etomidate without complication.
Past Medical History:
Past medical history:
- Pancreatic neuroendocrine tumor s/p distal pancreatectomy and
splenectomy
- HTN
- hypercholesterolemia
- OSA
- Hepatic steatosis
- Osteoarthritis
- Hypogonadism
Past surgical history:
- ___ lap distal pancreatectomy with splenectomy
(___)
- Lap chole
- Appendectomy
- Lumbar disc surgery
- thyroid resection
- right inguinal herniorrhapy, umbilical herniorrhaphy
Social History:
___
Family History:
- Father - pancreatic CA, melanoma
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: Afebrile HR 113 BP 137/117 RR 17 93% on ___
GENERAL: Somnolent, but answering some questions appropriately
prior to intubation. BiPAP in place.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased breath sounds L > R without rales, rhonchi,
wheeze, cough
CV: Irregular tachycardia, no m,r,g. Pericardial drain w/
minimal serosanguinous fluid.
ABD: 2 JP drains w/ purulent drainage. No erythema around drain
site.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm distal extremities, no erythema or swelling
NEURO: CN ___ b/l, ___ strength bilateral wrists, finger
grasp, biceps, ankles.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.0 142/73 81 17 95RA
GENERAL - Alert, interactive, NAD
HEENT - NC/AT
HEART - ___ systolic murmur loudest in LUSB, nl ___, RRR
LUNGS - CTAB anteriorly, slightly dull in bases bilaterally
ABDOMEN - ___, + bowel sounds, not tender; 3 JP drains
in LUQ and left flank draining purulent material
EXTREMITIES - WWP, no edema
NEURO - Awake, A&Ox3, CNs ___ grossly intact
LINES/TUBES: Dobhoff
Pertinent Results:
ADMISSION LABS
==============
___ 12:30PM BLOOD ___
___ Plt ___
___ 12:30PM BLOOD ___
___ Im ___
___
___ 12:30PM BLOOD Plt ___
___ 02:22PM BLOOD ___ ___
___ 12:30PM BLOOD ___
___
___ 12:30PM BLOOD ___
___ 12:30PM BLOOD ___
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD ___
___ 03:30AM BLOOD ___
___ 12:45PM BLOOD ___
___ Base ___
NOTABLE LABS
============
___ 12:30PM BLOOD ___
___ 03:30AM BLOOD ___
___ 05:27PM BLOOD ___
___ 05:27PM BLOOD RheuFac-<10 ___
___ 04:23AM BLOOD ___
___ 05:27PM BLOOD HIV ___
___ 03:16PM PERICARDIAL FLUID ___
___
___ 03:16PM PERICARDIAL FLUID ___
LD(LDH)-924 ___
___ 05:30PM PLEURAL ___
___
___ 05:30PM PLEURAL ___
LD(___)-143 ___
MICRO
=====
___ 3:13 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___ 350PM.
WORK UP PER ___ (___) ___.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
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.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. ___
MORPHOLOGY.
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
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROCOCCUS SP.
| | ENTEROBACTER
CLOACAE COMPLE
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- 4 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING
=======
TTE (___): FOCUSED STUDY/LIMITED VIEWS. The estimated right
atrial pressure is at least 15 mmHg. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade. Compared with
the prior study (images reviewed) of ___, the pericardial
effusion is larger. The heart rate is faster and the rhythm
appears to be atrial fibrillation .
CXR (___): Dense left basilar opacity likely combination of
effusion with atelectasis noting superimposed infection would be
possible.
Enlarged cardiac silhouette potentially due to combination of
cardiomegaly and/or pericardial effusion. Pulmonary vascular
congestion. Enteric tube off the inferior field of view.
TTE (___): The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
IMPRESSION:
1) Trivial to very small pericardial effusion mostly located of
the basal inferolateral wall without signs of tamponade
physiology.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion is much smaller.
TTE (___): The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The right ventricle is
mildly dilated with low normal free wall motion. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade. A
prominent left pleural effusion is present.
IMPRESSION: Trivial pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CXR (___):
IMPRESSION:
In comparison with the study of ___, the tip of the right IJ
catheter
again extends to the level of the carina in the upper to mid
SVC.
Cardiomediastinal silhouette is stable and there again is mild
vascular
congestion. Increased opacification at the left base with
obscuration of the
hemidiaphragm is consistent with pleural fluid and volume loss
in the left
lower lobe.
No evidence of acute focal pneumonia.
CXR (___):
IMPRESSION:
No pneumothorax is identified. Persisting small left pleural
effusion with
subjacent atelectasis.
CT ABD PELVIS (___):
IMPRESSION:
1. The 2 more lateral catheters in the left upper abdomen appear
in good
position. Given the thick consistency of the left upper
abdominal collection,
up sizing and repositioning the left most lateral drain can be
considered.
Another potential way of drainage would be through endoscopic
placement of a
drain through the stomach, for which gastroenterology service
consultation
would be considered to determine feasibility.
2. The most medial drain can be removed as it does not terminate
in any
collection.
3. Minimal decrease in size of left upper abdominal gas
containing collection.
Up sizing the left most lateral catheter can be considered as
well as
repositioning it more cranially and posteriorly.
4. Decreased size left diaphragmatic crus collections with no
drains in place.
5. Decreased left side pleural fluid.
DISCHARGE LABS
==============
___ 05:25AM BLOOD ___
___ Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 6 CAP PO Q8H
2. Diltiazem 30 mg PO Q6H
3. Lantus (insulin glargine) 23 U subcutaneous DAILY
4. HumuLIN R ___ (insulin regular human) 5 U injection Q6H
5. Senna 8.6 mg PO BID:PRN constipation
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
7. ___ Neb 1 NEB NEB Q6H:PRN Shortness of
breath
8. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
9. Metoprolol Tartrate 50 mg PO Q6H
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
11. Pantoprazole 40 mg PO Q24H
12. Simvastatin 20 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
15. LOPERamide 2 mg PO TID:PRN Diarrhea
16. Bisacodyl 10 mg PO DAILY:PRN constipation
17. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. ___ MD to order daily dose PO Frequency is Unknown
Discharge Medications:
1. insulin syringes (disposable) 1 miscellaneous DAILY
RX *insulin syringes (disposable) 1 mL Daily Disp #*1 Package
Refills:*0
2. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 20 units Before bed
Disp #*1 Vial Refills:*0
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
4. OneTouch SureSoft Lancing Dev (lancets) 1 miscellaneous
DAILY
RX *lancets [OneTouch Delica Lancets] 30 gauge Daily Disp #*1
Package Refills:*0
5. OneTouch Ultra Test (blood sugar diagnostic) 1
miscellaneous DAILY
RX *blood sugar diagnostic [OneTouch Ultra Test] Daily Disp
#*100 Strip Refills:*0
6. OneTouch Ultra2 ___ meter) 1 miscellaneous DAILY
RX ___ meter [OneTouch Ultra2] Daily Disp #*1 Kit
Refills:*0
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg twice a day Disp #*60 Syringe
Refills:*0
11. ___ Neb 1 NEB NEB Q6H:PRN Shortness of
breath
12. LOPERamide 2 mg PO TID:PRN Diarrhea
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
15. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
16. Pantoprazole 40 mg PO Q24H
17. Senna 8.6 mg PO BID:PRN constipation
18. Simvastatin 20 mg PO QPM
19. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatic ___ Tumor
___ infection
Diabetes mellitus
Pericardial effusion
Pleural effusion
Atrial fibrillation
Pulmonary embolism
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with ptx// ? acute process
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Enteric tube is seen passing off the inferior field of view. Right PICC is no
longer visualized. Moderate to severe cardiac enlargement is noted. Central
pulmonary vascular engorgement with indistinct pulmonary vascular markings.
There is no pneumothorax. Retrocardiac is likely a combination of effusion
with atelectasis and possible consolidation. No large right pleural effusion.
Degenerative changes seen at the right shoulder.
IMPRESSION:
Dense left basilar opacity likely combination of effusion with atelectasis
noting superimposed infection would be possible.
Enlarged cardiac silhouette potentially due to combination of cardiomegaly
and/or pericardial effusion. Pulmonary vascular congestion.
Enteric tube off the inferior field of view.
Radiology Report
INDICATION: ___ year old man with hypoxia s/p intubation// s/p intubation
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea. An
enteric tube projects over the stomach. There is the tubing catheter which
projects over the left hemithorax. There is an unchanged moderate to large
left pleural effusion with subjacent atelectasis. The right lung is grossly
clear. The size of the cardiac silhouette is enlarged.
Radiology Report
INDICATION: ___ year old man intubated for hypoxemic respiratory failure.//
s/p CVL placement Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
An enteric tube courses below the level the diaphragms but beyond the field of
view of this radiograph. There is the catheter projecting over the left
hemithorax unchanged. The tip of the endotracheal tube projects 1.4 cm above
the carina and should be retracted. The tip of the right internal jugular
central venous catheter projects over the mid SVC.
The size the cardiac silhouette is enlarged but unchanged. Dense retrocardiac
opacification likely represents pleural fluid and atelectasis. The right lung
is grossly clear. No pneumothorax.
IMPRESSION:
The tip of the endotracheal tube projects 1.4 cm from the carina and should be
retracted by approximately 1 cm. The tip of a new right internal jugular
central venous catheter projects at the level of the mid SVC. Unchanged
cardiopulmonary findings.
Findings were communicated to and acknowledged by the patient's nurse at 22h37
by ___, MD.
Radiology Report
EXAMINATION: CT-GUIDED DRAINAGE CATHETER PLACEMENT.
INDICATION: ___ year old man with H/O abdominal abscess w 2 JP drains. Here
for hypoxic respiratory failure and purulent discharge from JP drains. Per
surgery, recommend a third JP drain to L upper abdomen- "2 existing
percutaneous drains are well located, and there is no undrained fluid adjacent
to the pancreatic transection margin. However,there is air and undrained
material adjacent to omentum in the left upper quadrant which is not
adequately drained by his existing catheters."
COMPARISON: CT abdomen/pelvis ___
PROCEDURE: CT-guided drainage catheter biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 25 cc of greenish thick purulent fluid was aspirated with a
sample sent for microbiology evaluation. The catheter was secured by a
StatLock. The catheter was attached to suction bulb. Sterile dressing was
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.6 s, 35.6 cm; CTDIvol = 20.9 mGy (Body) DLP =
717.1 mGy-cm.
2) Spiral Acquisition 7.6 s, 23.4 cm; CTDIvol = 19.4 mGy (Body) DLP = 427.5
mGy-cm.
3) Stationary Acquisition 0.4 s, 1.4 cm; CTDIvol = 3.8 mGy (Body) DLP = 5.4
mGy-cm.
4) Stationary Acquisition 5.4 s, 1.4 cm; CTDIvol = 113.3 mGy (Body) DLP =
163.2 mGy-cm.
Total DLP (Body) = 1,324 mGy-cm.
SEDATION: Moderate sedation and monitoring were provided by the ICU nurse as
well as the Radiology nurse. The total intra-service time of 30 minutes
during which patient's hemodynamic parameters were continuously monitored by
an independent trained radiology nurse.
FINDINGS:
1. Left upper quadrant large collection containing gas bubbles. Drainage
catheter along the most inferior portion of it.
2. Bilateral small pleural effusions. Trace of pericardial effusion.
3. Esophageal tube in place. Left upper quadrant drainage catheters x2 within
additional drainage catheter placed today.
4. Nonobstructing renal calculi.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old man with pancreatic tumor s/p distal
pancreatectomy/splenectomy, here with hypoxemia/AMS now intubated, found to
have R wrist pain and swelling.// effusion? r//o fracture
COMPARISON: None
IMPRESSION:
No acute fractures or dislocations are seen. There are severe degenerative
changes the first CMC and triscaphe joints. There is normal osseous
mineralization.Chondrocalcinosis is seen.
Radiology Report
INDICATION: ___ year old man with worsening hypoxia 40% to 100% facetent.//
Concern for worsening pulmonary edema vs. aspiration vs. atelectasis
COMPARISON: Radiographs from ___
IMPRESSION:
Endotracheal tube has been removed. There is a feeding tube and right IJ
central line which are in unchanged position. There is cardiomegaly. There is
a left retrocardiac opacity. There is mild pulmonary edema, stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic respoiratory failure// interval
changes
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged, as is the appearance of the heart and lungs.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man s/p panc/splenectomy// R shoulder dislocation
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___
FINDINGS:
Monitoring and supporting devices are unchanged. The heart is enlarged.
There is increased left retrocardiac density, possibly atelectasis. There is
subsegmental atelectasis at the right lung base. There is stable mild
pulmonary edema. Degenerative changes are seen in the right shoulder.
IMPRESSION:
Cardiomegaly. Increased left retrocardiac density. Mild pulmonary edema
appear
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p robotic distal panc/splenectomy for PNET, c/b panc
fistula s/p ___ drains, bleeding from third order middle colic s/p embol, Afib,
PE, now w/ hypercarbic resp failure.// L pleural effusion L pleural
effusion
IMPRESSION:
Right internal jugular line tip is at the level of superior SVC. Heart size
and mediastinum are unchanged. There is interval improvement, at least
partial of the left retrocardiac atelectasis and more central position of the
mediastinum. There is mild vascular congestion but no overt pulmonary edema.
No pneumothorax.
Radiology Report
INDICATION: ___ M status post robotic distal panc/splenectomy for PNET, c/b
pancreatic fistula status post ___ drains, bleeding from third order middle
colic status post emboli, Afib, PE, now with hypercarbic respiratory failure.
Ensure Dobhoff in right position. Thank you
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CTA chest abdomen pelvis from ___, abdominal radiograph
from ___ and ___
FINDINGS:
The Dobhoff tube is seen with its tip projecting over the left mid abdomen.
This is an expected position if within the duodenum, however cannot exclude
that Dobhoff is within the stomach. Dobhoff does appear in similar position
compared to CT from ___ in which was seen within the duodenum. There
are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. There are 3 pigtail drains overlying the
left upper quadrant.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Dobhoff tube projecting over the left mid abdomen in expected position.
Cannot exclude the Dobhoff is within the gastric lumen, however it appears in
similar position to prior CT from ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p robotic distal panc/splenectomy for PNET, c/b panc
fistula s/p ___ drains, bleeding from third order middle colic s/p embol, Afib,
PE, now w/ hypercarbic resp failure.// Ensure central line still in place.
Radiology technician aware because already on floor. Thank you
IMPRESSION:
In comparison with the study of ___, the tip of the right IJ catheter
again extends to the level of the carina in the upper to mid SVC.
Cardiomediastinal silhouette is stable and there again is mild vascular
congestion. Increased opacification at the left base with obscuration of the
hemidiaphragm is consistent with pleural fluid and volume loss in the left
lower lobe.
No evidence of acute focal pneumonia.
Radiology Report
INDICATION: ___ year old man with effusion s/p ___// PTX
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right internal jugular central venous catheter projects over the
upper SVC. Multiple drainage catheters project over the left upper quadrant.
There is a small left pleural effusion with subjacent
atelectasis/consolidation. No pneumothorax is identified. The right lung is
clear. The size and appearance of the cardiac silhouette is unchanged.
Marked degenerative changes around the right glenohumeral joint.
IMPRESSION:
No pneumothorax is identified. Persisting small left pleural effusion with
subjacent atelectasis.
Radiology Report
EXAMINATION: CT ABDOMEN/PELVIS WITH CONTRAST.
INDICATION: ___ year old man with PNET tumor resection and persistent left
upper abdominal infection with 3 JP drains; there is leakage around one of JP
sites, looking for drain location with thoughts of possible capsizing.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 3.4 s, 54.2 cm; CTDIvol =
20.4 mGy (Body) DLP = 1,105.0 mGy-cm. 2) Stationary Acquisition 5.1 s, 0.5 cm;
CTDIvol = 27.9 mGy (Body) DLP = 14.0 mGy-cm. Total DLP (Body) = 1,119 mGy-cm.
COMPARISON: Multiple prior CTs with the most recent dating ___.
FINDINGS:
LOWER CHEST: Interval decreased size left-sided pleural effusion. Left basal
atelectasis. Trace pericardial effusion.
HEPATOBILIARY: Unchanged focal area of enhancement in segment ___,
probably hemangioma. Remainder of the liver appears unchanged with scattered
cysts. No intrahepatic or extrahepatic bile ductal dilatation. Post
cholecystectomy.
PANCREAS: Visualized pancreatic head appears unremarkable. Post resection
remainder the pancreas.
SPLEEN: Post splenectomy.
ADRENALS: Adrenals are unremarkable.
URINARY:No hydronephrosis. No nephrolithiasis. Under distended urinary
bladder with presence of foci of air related to the Foley catheter placed.
GASTROINTESTINAL: Esophageal tube terminates within the third part of the
duodenum. No dilated loops of small bowel. Scattered colonic diverticulosis
without diverticulitis.
PERITONEUM: Re-demonstration of moderate-size left upper abdominal collection
containing thick material mixed with gas with interval decrease in size
measuring 14.4 x 6.8 x 9.3 cm compared to 17.6 x 7 x 11.4 cm. There has been
interval placement of a third pigtail catheter. 3 pigtail catheters present
in the left upper abdomen: Most central terminates between the liver on the
lesser curvature of the stomach (is not located within any collection) can be
removed. Lateral to it is a catheter that terminates within the left upper
abdominal collection (appears in good position) and the third most lateral
catheter, drained the most central collection (posterior to the stomach) and
coils into the left upper abdominal collection. The latter 2 catheters are in
good position. The third catheter had notable leakage around the tube. This
tube can be upsized.
Given the thick nature of the material of this collection another
consideration would be placing a drainage catheter through the stomach into
the collection endoscopically.
Posteriorly along the left diaphragmatic crus there is re-demonstration of rim
enhancing loculated collections with interval decrease in size measuring 5.2 x
3 cm compared to 7 x 3.9 cm.
Very small left lower anterior abdominal wall collection measures 4.6 x 2.3
cm, decreased in size compared to previously.
LYMPH NODES: No retroperitoneal adenopathy. Scattered prominent mesenteric
lymph nodes.
VASCULAR: Markedly atherosclerotic abdominal aorta with normal caliber.
Patent intra-abdominal branches.
PELVIS: Enlarged prostate. Rectum is unremarkable.
BONES:Degenerative changes of the lumbar spine.
SOFT TISSUES: Mild subcutaneous edema. Injection granulomas lower abdomen.
IMPRESSION:
1. The 2 more lateral catheters in the left upper abdomen appear in good
position. Given the thick consistency of the left upper abdominal collection,
up sizing and repositioning the left most lateral drain can be considered.
Another potential way of drainage would be through endoscopic placement of a
drain through the stomach, for which gastroenterology service consultation
would be considered to determine feasibility.
2. The most medial drain can be removed as it does not terminate in any
collection.
3. Minimal decrease in size of left upper abdominal gas containing collection.
Up sizing the left most lateral catheter can be considered as well as
repositioning it more cranially and posteriorly.
4. Decreased size left diaphragmatic crus collections with no drains in place.
5. Decreased left side pleural fluid.
Radiology Report
INDICATION: ___ year old man with 3 JP drains for peripancreatic fluid
collections, needs drain upsizing with ___// ___ year old man with 3 JP drains
for peripancreatic fluid collections, needs drain upsizing with ___.
COMPARISON: CT abdomen dated ___
PROCEDURE: CT-guided drainage of left upper quadrant abscess
OPERATORS: Dr. ___, MD, radiology trainee and Dr. ___
___, MD, attending radiologist. Dr. ___, MD 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 a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. 2- 12 ___
drainage catheters, 1 in the midline and another in the left upper quadrant
located adjacent to each other on the skin were identified. The catheter
extending from the left of the midline into the fluid collection was cut and a
0.038 ___ wire was placed through this catheter and coiled into the deeper
portion of the collection. Another 12 ___ drainage catheter over a plastic
stiffener was placed into the deeper portion of this collection over the
___ wire and approximately 30 mL of pus was aspirated. No samples were
sent.
The plastic stiffener and the wire were removed. The pigtail was deployed.
The position of the pigtail was confirmed within the collection via CT
fluoroscopy.
Approximately 30 cc of purulent fluid was aspirated. The catheter was secured
by a StatLock. The catheter was attached to bag. Sterile dressing was applied.
The midline 12 ___ drainage catheter was not removed as a small amount of
purulent discharge was noted in the JP drain connected to this catheter.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.1 s, 21.9 cm; CTDIvol = 16.5 mGy (Body) DLP = 340.3
mGy-cm.
2) Stationary Acquisition 2.2 s, 1.4 cm; CTDIvol = 22.6 mGy (Body) DLP =
32.5 mGy-cm.
Total DLP (Body) = 383 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 10
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
The left upper quadrant 12 ___ drainage catheter was exchanged and a
similar ___ catheter was repositioned into a deeper portion of the
collection and approximately 30 mL of purulent fluid was aspirated. The
abscess cavity was irrigated till clear fluid return was noted.
The midline drainage catheter was not removed because of persistent purulent
fluid within the JP drain connected to this catheter.
IMPRESSION:
1. Successful CT-guided repositioning of a 12 ___ pigtail catheter into the
left upper quadrant collection. 30 mL of purulent fluid was aspirated. The
cavity was irrigated till clear fluid return noted. Postprocedure images
demonstrated a small residual collection in the most dependent portion of this
collection which as the patient moves around should be drained via the
existing position of the pigtail.
2. The midline 12 ___ drainage catheter was not removed as a small amount
of purulent fluid was noted within the JP drain connected to this catheter.
3. The patient with stood the procedure well and was transferred back to the
floor in a hemodynamically stable condition.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Altered mental status, Hypoxia
Diagnosed with Sepsis, unspecified organism
temperature: nan
heartrate: 100.0
resprate: 28.0
o2sat: 97.0
sbp: 113.0
dbp: 76.0
level of pain: UTA
level of acuity: 1.0 | HOSPITAL COURSE
===============
Mr. ___ is a ___ M with HTN, HLD, OSA, afib, PNET s/p
distal pancreatectomy/splenectomy (___) w/ recent
hospitalization (___) for pancreatic fistula and a PE, who
presented from rehab with hypoxia and AMS, course complicated by
pericardial and pleural effusions.
ACTIVE ISSUES
=============
# Pancreatic fistula
# PNET s/p distal pancreatectomy/splenectomy: Patient presented
to the hospital with two JP drains in place. He was persistently
febrile on Zosyn (___), thus a third abdominal drain was
placed by ___ on ___. Afterwards the patient was largely
afebrile. ID was consulted and gave abx recs. Continued Zosyn
for 2 week total course from drain placement on ___, last day
___. Repeat CT ___ showed persistent LUQ fluid collection.
Repositioned LUQ JP drain with ___ on ___. Stable at discharge,
still with 3 JP drains, will f/u with surgery in ___ weeks and
continue tube feeds and clear liquids until that time.
# Left Pleural effusion: During ___ admission patient had
bilateral pleural effusions attributed to ___. However, now
this admission was unilateral and persistent despite diuresis.
S/p thoracentesis by IP on ___ with fluid studies suggestive of
an exudative effusion, Gram stain negative for microorganisms.
Cytology negative for malignant cells. Rheumatology feels
unlikely systemic rheum disorder, more likely related to
abdominal infection/inflammation. Negative ___, RF. Will f/u in
___ clinic.
# Pericardial effusion: Patient presented with large pericardial
effusion seen on admission with tamponade physiology. Underwent
pericardiocentesis on ___ with drainage of 470ml sanguineous
fluid. Cytology without malignant cells. Total nucleated cells #
___. No recurrence of symptoms.
# Prior PE
# Atrial fibrillation: Diagnosed with both atrial fibrillation
and PE during ___ admission, started on warfarin. During ICU
course was on heparin gtt. Heparin gtt transitioned to Lovenox
on ___. Will continue Lovenox ___ BID. Received Metoprolol
Tartrate 25 mg PO/NG Q6H inpatient, transitioned to Metoprolol
Succinate 100 mg PO/NG DAILY on discharge.
CHRONIC ISSUES
==============
# Chronic pain
- Continued Acetaminophen 500 mg PO/NG Q6H:PRN Pain
- Continued OxycoDONE Liquid 5 mg PO/NG Q4H:PRN
- Continued OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
# Diabetes: Patient received Lantus 20U Nightly with Humalog
sliding scale, BG still not completely controlled on discharged,
BG ___, should be titrated up by PCP.
# BPH: Admitted with Foley due to urinary obstruction with
failed voiding trial last admission. Foley pulled ___, able to
void. Continued tamsulosin 0.4 mg PO QHS.
# HLD: Continued Simvastatin 20 mg PO/NG QPM.
# GERD: Continued Pantoprazole 40 mg PO Q24H.
RESOLVED
========
# Delirium: Multifactorial given medical problems above.
# OSA
# Hypercarbia: Presented with hypercapneic respiratory failure
in the setting of an acute illness, encephalopathy, opioid use,
shock, enlarging pericardial effusion, and persistent left
pleural effusion. Intubated < 24 hours with intermittent BIPAP.
Resolved, patient on room air by discharge.
TRANSITIONAL ISSUES
===================
[] PCP to follow up patient blood sugar, titrate up Lantus
and/or short acting insulin if consistently hyperglycemic
[] Patient to continue current tube feed regimen with only clear
liquids by mouth
[] JP drains #2 and #3 to be flushed 4 times a day with normal
saline
[] Appointments
- PCP
- ___
- ___ Pulmonology
- Surgery ___ with Dr. ___ arranged. Patient to call
___ to set up an appointment time in the next ___
weeks.
[] New medications
- Metoprolol Succinate 200 mg PO DAILY
- Enoxaparin Sodium 100 mg SC Q12H
- Insulin (Glargine) 20 Units at Bedtime
[] Stopped medications
- Metoprolol Tartrate 50 mg PO Q6H
- Creon 12 6 CAP PO Q8H
- Diltiazem 30 mg PO Q6H
- Warfarin
I have seen and examined Mr. ___, reviewed the findings,
data, and plan of care documented by Dr. ___, MD dated
___ and agree with the discharge summary and plan.
___, MD, PharmD
Section of Hospital Medicine
___ ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aristocort Forte / Lidocaine / Polyethylene Glycol And
Derivatives / Novocain
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Emptying of lap band by bariatric surgery: 1cc removed,
emptying the band completely
___: Right heart catheterization
History of Present Illness:
PCP: ___
HPI: ___ with h/o of lap band in ___, and partial nephrectomy
for incidentally discovered renal mass (path: clear cell RCC) in
___ (___) with several recent hospitalizations for PNA
who now presents with increased SOB and new acute renal failure.
To summarize recent hospitalizations, she reports fevers/chills
1mo prior when she was admitted to OSH and discharged on
Levaquin. Her symptoms recurred 3 weeks later when she was
admitted to ___ with PNA, felt to be likely
aspiration, and treated with IV Abx and discharged on ___
___, with PICC line to recieve course of Vanc/Zosyn to finish
on ___ per OSH records. Boyfriend has been administering
infusions at home. Since that time she endorses SOB at baseline
(on home 2L O2 since d/c from ___ on ___, no
fevers, +fatigue. Endorses moderate fluid intake, denies any
changes in bowel habits, urinary frequency, hematuria, or
dysuria. Does endorse feeling bloated.
She presented to the ___ ED afebrile, labs notable for Cr 2.9
___ 0.8-1.2). She was seen by bariatric surgery who removed 1cc
from lap band, follwed by barium swallow revealing good band
position and no leakage, plan for stage 3 bariatric diet and
will follow up in 3wk as outpt. CXR at that time revealed
lingular and left lower lobe consolidation concerning for PNA
(unknown comparison to OSH), and new small left pleural
effusion. Subtle righ basal opacity similar to prior. Pt given
1g Vanc and admitted to medicine. She is comfortable,
complaining of bloating, but with baseline SOB satting well on
2L O2.
Past Medical History:
1. Asthma: on home inhalers.
2. Hypertension
3. Chronic Constipation - controlled with laxatives
4. lap band in ___, lost 55 pounds. Does endorse GERD Sx
5. three shoulder surgeries - last was ___
6. Robotic partial nephrectomy ___ - clear cell RCC, negative
margins. Due for f/u ___
7. Cardiac stent ___ after angina.
Social History:
___
Family History:
Mother with unknown kidney problem, DM, HTN
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98 BP: 148/60 P: 60 R: 16 O2: 93% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS at LLL
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. Bandaged
site in LUQ c/d/i
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Same as above except:
Lungs: improved air movement, still mildly decreased breath
sounds over L lung base
Pertinent Results:
___ 08:50PM GLUCOSE-78 UREA N-15 CREAT-2.9*# SODIUM-138
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
___ 08:50PM WBC-8.5 RBC-3.85* HGB-11.2* HCT-34.9* MCV-91
MCH-29.0 MCHC-32.0 RDW-14.7
___ 08:50PM NEUTS-70.4* ___ MONOS-6.1 EOS-2.3
BASOS-0.7
___ 08:50PM PLT COUNT-306
___ 08:30PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ Vancomycin trough: 74.8
___ CXR
IMPRESSION: Lingular and left lower lobe consolidation worrisome
for pneumonia, new since the prior study. New small left pleural
effusion. Subtle right basal opacity similar compared to prior.
Recommend followup to resolution.
Upper GI
IMPRESSION: Normal position of the gastric band with patent
stoma.
MICRO:
___ UCx negative
___ BCx negative
STUDIES/TESTING:
___ ECHO:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. No late contrast is seen in the left
heart (suggesting absence of intrapulmonary shunting). The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. The right ventricular free wall is hypertrophied. The
right ventricular cavity is mildly dilated with normal free wall
contractility. 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. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension (50mmHg). There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
___:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.78 m2
HEMOGLOBIN: 9.9 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} ___
RIGHT VENTRICLE {s/ed} ___
PULMONARY ARTERY {s/d/m} ___
PULMONARY WEDGE {a/v/m} ___
**CARDIAC OUTPUT
HEART RATE {beats/min} 60
RHYTHM SINUS
CARD. OP/IND FICK {l/mn/m2} 3.35
FICK
**% SATURATION DATA (FL)
RA HIGH 65
PA MAIN 62
AO
COMMENTS:
1. Resting hemodynamics revealed elevated left and right-sided
pressures. The RA pressure was elevated at 11 mmHg and the PA
mean
pressure was elevated at 31 mmHg. The wedge pressure was also
elevated
at 17 mmHg.
2. Oxygen saturations measured in the pulmonary artery and right
atrium
did not reveal a shunt.
FINAL DIAGNOSIS:
1. Elevated right and left sided filling pressures.
2. Moderate to severe pulmonary hypertension.
Medications on Admission:
1. Senna 1 TAB PO BID:PRN constipation
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Simvastatin 10 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Citalopram 40 mg PO DAILY
6. traZODONE 200 mg PO HS:PRN insomina
7. Omeprazole 40 mg PO DAILY
8. PrimiDONE 50 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation daily
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
3. PrimiDONE 50 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. Tiotropium Bromide 1 CAP IH DAILY
6. traZODONE 200 mg PO HS:PRN insomina
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY
9. Simvastatin 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
12. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aspiration PNA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of pneumonia with
increased shortness of breath.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. A
right-sided PICC is seen, distal aspect not well appreciated, but likely
terminating in the region of the mid-SVC. In the interval since the prior
study, there has been development of consolidation in the left lower lobe and
extending into the lingula. The blunting of the left costophrenic angle is
concerning for a small pleural effusion. Subtle right basal opacity is
similar to possibly minimally improved as compared to the prior study. In the
interval since the prior study, the hila appears slightly more prominent.
Barium is seen in the partially visualized colon in the upper abdomen from
recent prior barium study.
IMPRESSION: Lingular and left lower lobe consolidation worrisome for
pneumonia, new since the prior study. New small left pleural effusion.
Subtle right basal opacity similar compared to prior. Recommend followup to
resolution.
Radiology Report
INDICATION: ___ female with laparoscopic gastric band, now with
aspiration pneumonia, status post loosening of the band.
COMPARISON: ___.
TECHNIQUE: Fluoroscopic images of the gastric band were obtained before and
after oral administration of thin barium. The ingredients of the thin barium
suspension were reviewed and the suspension administered does not contain
polyethylene glycol.
FINDINGS: Scout image demonstrates residual contrast within the colon.
Contrast passes freely through the gastric band without evidence for hold-up,
leak, or malpositioning.
IMPRESSION: Normal position of the gastric band with patent stoma.
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX.
INDICATION: Recurrent pneumonia.
COMPARISON: Outside hospital CT from ___.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
FINDINGS: The examination is compared to ___.
No incidental thyroid findings. A right PICC line is in place. No
supraclavicular, infraclavicular, or axillary lymphadenopathy. All
mediastinal lymph nodes, most of which have a fatty hilus, are normal in size.
The largest mediastinal lymph node is in precarinal location and has a maximum
diameter of 9 mm. No enlarged lymph nodes along the aorta and the esophagus.
The heart is borderline in size. There are relatively severe coronary
calcifications and mild aortic valve calcifications. A small pericardial
effusion is present.
The large mediastinal vessels have normal diameters, the descending aorta
shows moderate calcifications. A small hiatal hernia is present, status post
gastric banding. Contrast material in the colon. No other noticeable
pathologies in the upper abdomen.
Moderate degenerative vertebral disease but no evidence of compression
fractures or true lytic lesions. Normal appearance of the sternum. No rib
fractures.
Evaluation of the lung parenchyma is limited by moderate respiratory motion
artifacts.
A small left pleural effusion is present, the extent of the effusion is
comparable to the previous CT examination. On the right, no pleural effusion
is present but bilaterally, minimal pleural irregularities are noted (for
example on series 4, image 162 and series 4, image 133).
Overall, the lung attenuation continues to be inhomogeneous but overall
increased, with minimally increased diameters of the interstitial structures,
notably in the lung apices, where minimally thickened interlobular septa
increase the visibility of secondary pulmonary lobules (4, 47).
The areas of parenchymal abnormalities in the lingula and the left lower lobe
are almost unchanged in extent and severity. The areas of abnormality consist
of a very mixed pattern, including predominantly peribronchial consolidations,
ground-glass opacities, areas of linear atelectasis, and nodular components.
The medial aspects of the abnormalities have atelectatic parts, adjacent to
the left heart border, leading to mild volume reduction of the left
hemithorax. The airways are patent. There is no focal airway narrowing or
endobronchial lesion visible. The airways, however, generally show mild
irregularities of their walls and mild generalized thickening.
Predominating in the right upper lobe, emphysema of moderate extent is seen.
Several non-characteristic nodular lesions in the right lung show a tendency
to decrease in size as compared to the previous examination (for example on
series 4, image 66 and series 4, image 71). The biggest lesion is a 5-mm
right upper lobe ground-glass nodule (series 4, 70). Areas of atelectasis at
the right lung base are overall unchanged.
No other changes are identified.
IMPRESSION: Extensive predominantly lingular and left lower lobe parenchymal
opacity that suggests chronic infection and is accompanied by a small pleural
effusion. No morphological reason for these changes can be identified,
notably there is no evidence of focal airway narrowing or airway obstruction.
Mild chronic airways disease and moderate right upper lobe predominant
pulmonary emphysema, with several mostly ground-glass nodules (the biggest of
which measures 5 mm in diameter and is located in the right upper lobe) that
should be followed in approximately three months.
Unchanged areas of atelectasis at the right lung base.
Mild pericardial effusion, moderate-to-severe coronary calcifications. Mild
aortic valve calcifications. Right PICC line. No mediastinal adenopathy.
Status post gastric banding, mild hiatal hernia.
Radiology Report
INDICATION: Status post gastric banding with persistent hypoxia and pulmonary
infiltrates. Evaluate for upper esophageal aspiration.
FINDINGS: A single view of the chest shows a persistent consolidation of the
left base, unchanged from the prior radiographs. A linear opacity at the
right base is likely atelectasis. With thin barium, multiple swallows were
performed. There is a small amount of penetration, best evaluted on the
lateral views, but no evidence of aspiration. Esophageal motility is normal.
There is no holdup of contrast at the GE junction or the gastric band.
Contrast flowed freely into the stomach.
IMPRESSION: No evidence of aspiration. Small amount of penetration.
Radiology Report
INDICATION: ___ female with persistent hypoxia, unable to get V/Q or
CT scan for PE. Evaluate for evidence of DVT.
COMPARISON: None available.
TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous
systems of both lower extremities was performed.
FINDINGS: There is normal compression and augmentation of the common femoral
veins, superficial femoral, popliteal, peroneals, and posterior tibial veins
bilaterally. There is a normal phasicity of the common femoral veins
bilaterally as well.
IMPRESSION: No evidence of deep vein thrombosis in either the right or the
left lower extremity.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with SHORTNESS OF BREATH
temperature: nan
heartrate: 51.0
resprate: 16.0
o2sat: 100.0
sbp: 146.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with hx of lap band ___, partial nephrectomy for
___, and several recent hospitalizations for PNA now presenting
with shortness of breath and ___.
# Shortness of breath- Patient complained of worsened shortness
of breath, though improved since presentation to OSH. CXR
demonstrated new opacity, OSH CT revealed multifocal nodular
infiltrate in lower left lobe and lingula. She was started on a
course of IV Vancomycin and Zosyn while hospitalized at ___
___, per OSH records to finish on ___. However,
vancomycin trough on ___ was 74, so vanco was discontinued. She
did recieve Zosyn until ___ given continued inability to wean
O2 (described below). She had a speech and swallow evaluation
___, where it was felt that her symptoms of reflux were
consistent with post-prandial regurgitation in the setting of
lap band, which improved per patient report after lap band fluid
removal. 1cc was removed from the band on initial admission (in
the ED) by bariatric surgery, and UGI study following this
procedure revealed no obstruction. The patient's symptoms
resolved to baseline, which she states is chronically mildly
short of breath. However, she did continue to have an O2
requirement which proved difficult to wean, with continued
desaturations to low ___ while ambulated on RA, so pulmonology
was consulted. Initiated hypoxemia workup which included ABG
which revealed pO2 57 PCO2 39 pH 7.49. Bglucan neg, antiGBM
neg. ECHO was performed, revealing moderate pulmonary artery
systolic hypertension; subsequent right heart cath demonstrated
elevated right and left sided filling pressures and moderate to
severe pulmonary hypertension. Additionally, rheumatologic
workup revealed ___ neg, RF neg, ANCA neg, ___, antiCCP
neg. Bronchoscopy or further imaging were deferred at this time.
The patient was discharged satting >92% on 2L, and has follow up
in place with cardiology, pulmonology, and will need follow up
imaging in ___.
# Hx lap band, anorexia- Pt underwent removal of 1cc from lap
band; she tolerated the procedure well. As above, upper GI
revealed no e/o leak or slippage on imaging. As above, her
symptoms of reflux improved after the procedure, and she was
maintained on a stage 3 bariatric diet while in house.
# ___: While hospitalized, the patient's Cr was noted to be 2.9
(up from normal baseline 0.8-1.0). Bland urine sediment, UA
negative. Elevated Cr was felt to be consistent with vancomycin
associated toxicity in the setting of significantly elevated
Vancomycin levels (trough 74). Vancomycin levels trended down to
7.9 at time of discharge. Cr initially trended upward to peak at
3.2, but came down to 2.3 at time of discharge.
# Asthma- Patient was maintained on her home medications.
#?history of IgG deficiency - In speaking with the patient's
PCP, and mentioned in OSH records, the patient has a documented
question of IgG deficiency. Workup was initiated while
hospitalized with IGG 680* IGM 321 IGA 95. Levels of antiTB,
antidiptheria, and antipertussis were obtained.
# HTN- the patient's home betablocker and ASA were continued
while in house.
# CAD- per report pt with stent in ___, on ASA/B-blocker. Home
simvastatin was discontinued upon admission given acute kidney
injury, but was restarted upon discharge.
# Code: full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lactose / morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with PMH notable for EtOH dependence, opiate
dependence, EtOH cirrhosis (no biopsy) c/b ascites, with recent
admission (___) for abdominal pain, transaminitis and
pancreatitis, with workup notable for unremarkable RUQ U/S
(other than cirrhotic changes), EGD notable for chemical
gastropathy w/o PUD/varices, who presents today with increased
abdominal pain in the setting of recent 2 week EtOH binge.
Patient presented to ED for further evaluation.
In ED patient's initial VS 98.0 104 135/79 16 95%RA. Patient
had moderate abdominal tenderness on exam. Labs were notable
for WBC 5, Hct 40.2, platelet 107, Cr 0.5, ALT 85, AST 246, AP
534, Lipase 154, Tbili 2.1, EtOH 296. Pt reported tactile
disturbances and hearing voices consistent with prior
withdrawal, denied SI/HI. He was given 4mg IV Morphine x2 and
2mg IV Ativan. Patient was admitted to medicine for further
management. VS prior to transfer were 98.1, 88, 135/94, 18,
96%RA.
On the floor, patient was sleeping but arousable. Vital signs
were 98.1 127/80 79 18 98%RA. Patient reported several days
nausea and abdominal pain, occassional vomitting, denied BRBPR,
tarry stools.
Past Medical History:
- EtOH abuse
- EtOH Cirrhosis (not biopsy proven)
- Gastritis
- Asthma (prior intubations)
- Opiate dependence on suboxone
Social History:
___
Family History:
Uncle died of EtOH cirrhosis. No other known family ailments on
maternal side, does not know about father's side of family
Physical Exam:
Admission Exam:
Vitals: 98.1 127/80 79 18 98%RA
General: Awake, alert, NAD
HEENT: MMM, oropharynx clear
Lungs: CTAB
CV: RRR no m/r/g
Abdomen: +BS, soft, diffuse tendering to palpation,
non-distended, no rebound tenderness or guarding, no
organomegaly
Ext: WWP, no edema
Psych: patient currently denies hearing voices, does report
feeling like animals are crawling on him
Discharge Exam:
General: Awake, alert, NAD
Lungs: CTAB
CV: RRR no m/r/g
Abdomen: +BS, soft, nontender, non-distended, no rebound
tenderness or guarding
Ext: WWP, no edema
Pertinent Results:
Admission Labs:
___ 04:00AM BLOOD WBC-5.0 RBC-4.80 Hgb-12.6* Hct-40.2
MCV-84 MCH-26.3* MCHC-31.5 RDW-18.8* Plt ___
___ 04:00AM BLOOD Neuts-53.8 ___ Monos-4.7 Eos-5.3*
Baso-0.7
___ 07:35AM BLOOD ___ PTT-42.8* ___
___ 04:00AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-144 K-3.4
Cl-107 HCO3-23 AnGap-17
___ 04:00AM BLOOD Lipase-154*
___ 04:00AM BLOOD ALT-85* AST-246* AlkPhos-534*
TotBili-2.1*
___ 04:00AM BLOOD Albumin-4.5 Calcium-8.7 Phos-3.5 Mg-1.8
___ 04:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 07:10AM BLOOD WBC-3.3*# RBC-4.26* Hgb-11.4* Hct-36.2*
MCV-85 MCH-26.8* MCHC-31.5 RDW-18.8* Plt ___
___ 05:13AM BLOOD ___ PTT-43.5* ___
___ 06:00AM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-27 AnGap-15
___ 06:00AM BLOOD ALT-54* AST-86* AlkPhos-491* TotBili-2.4*
___ 06:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7
___ 05:13AM BLOOD HIV Ab-NEGATIVE
Urine:
___ 06:40AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 06:40AM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
___ 06:40AM URINE CastHy-1*
___ 06:40AM URINE Mucous-OCC
Micro:
___ Blood culture x 2: PENDING
___ Abdominal U/S: IMPRESSION: 1. Cirrhosis with secondary
findings of portal hypertension including reversal of portal
venous flow and recannulization of the umbilical vein, as well
as splenomegaly. Trace ascites. 2. Unremarkable gallbladder.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Cetirizine *NF* 10 mg Oral daily
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob or wheeze
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob or wheeze
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Lactulose 30 mL PO DAILY
RX *lactulose 20 gram/30 mL 30 ml by mouth daily Disp #*1 Bottle
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
8. Cetirizine *NF* 10 mg Oral daily
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Abdominal ultrasound with liver Doppler.
CLINICAL INFORMATION: ___ female with abdominal pain in the setting
of recent ETOH binge, found to have transaminitis and elevated lipase,
question gallbladder pathology, question size of spleen, question evidence of
cirrhosis, question ascites.
___.
FINDINGS: Sonographic evaluation of the liver was obtained including color
and spectral Doppler analysis. The liver is diffusely echogenic and coarsened
in echotexture consistent with cirrhosis, as also seen previously. No intra-
or extra-hepatic biliary dilatation is seen. The common bile duct measures
0.5 cm in diameter. The gallbladder is relatively collapsed without evidence
of intraluminal stone or sludge. No gallbladder wall thickening is seen.
Trace perihepatic fluid is seen. The spleen is enlarged, measuring 17.5 cm in
length. No free fluid was seen in the right or left lower quadrants.
The pancreas is not well evaluated, partially obscured by overlying bowel gas.
No pancreatic ductal dilatation is seen.
LIVER DOPPLER: There is reversal of flow in the main portal vein and the
right and left portal vein branches. Recanalized umbilical vein is again
seen. The right, middle and left hepatic veins are patent. The main hepatic
artery is also patent.
IMPRESSION:
1. Cirrhosis with secondary findings of portal hypertension including
reversal of portal venous flow and recannulization of the umbilical vein, as
well as splenomegaly. Trace ascites.
2. Unremarkable gallbladder.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: SUBSTANCE MISUSE/INTOXICATION
Diagnosed with ALTERED MENTAL STATUS , ALCOHOL ABUSE-UNSPEC, ABDOMINAL PAIN LUQ, ACUTE PANCREATITIS
temperature: 98.0
heartrate: 104.0
resprate: 16.0
o2sat: 95.0
sbp: 135.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | ___ yo male with PMH notable for EtOH dependence, opiate
dependence, EtOH cirrhosis p/w abdominal pain in the setting of
recent 2 week EtOH binge, found to have transaminitis and
elevated lipase consistent with alcoholic hepatitis and
pancreatitis and in need of safe EtOH detox. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Humira / lisinopril
Attending: ___.
Chief Complaint:
Left Leg Pain
Major Surgical or Invasive Procedure:
___ Internal fixation L distal femur.
History of Present Illness:
___ female who presents for left leg pain after a fall.
She states that she tripped over her sandals today and fell onto
her left side. She denies headstrike, LOC, CP, SOB. She feels
well overall
She has a hx of a remote R TKR ___ yearsr ago at ___) who was
admitted this past ___ for repair of a femoral complete stress
fracture, thought to be ___ bisphosphonate use. Her procedure
was an intramedullary nail fixation Left intertrochanteric hip
fracture on ___.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
Severe aortic stenosis
Morbid obesity
GERD
Lower back pain
Interstitial lung disease
Rheumatoid arthritis
Osteoporosis
Monoclonal gammopathy
Asthma
Bronchiectasis
Left arm fracture
Past Surgical History
left TKR
left foot surgery
Social History:
___
Family History:
Mother deceased after age ___.
Physical Exam:
PHYSICAL EXAMINATION in ADM:
General: NAD
Vitals: T98.2 HR 78 BP 108/92 RR 16 Pox 99 RA
LLE:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft compartments. TTP of distal thigh.
- Full, painless AROM/PROM of hip and ankle. Limited ROM of knee
___ pain.
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Cor: RRR
Pulm: Non-labored respirations
Abd: Soft, nondistended
PE in DC:
AVSS
NAD, A&Ox3
LLE: Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
n/p
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 30 mg PO DAILY
6. Methotrexate 20 mg IM WEEKLY
7. PredniSONE 5 mg PO DAILY
8. Sertraline 25 mg PO DAILY
9. Orencia (abatacept) 125 mg/mL subcutaneous Weekly
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 0.4 ml QPM Disp #*30 Syringe
Refills:*0
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO TID:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth every four (4)
hours Disp #*45 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Furosemide 30 mg PO DAILY
14. Methotrexate 20 mg IM WEEKLY
15. Orencia (abatacept) 125 mg/mL subcutaneous Weekly
16. PredniSONE 5 mg PO DAILY
17. Ramelteon 8 mg PO DAILY:PRN agitation
18. Sertraline 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
periprosthetic fracture of L distal femur
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: DX TIB/FIB AND ANKLE/FOOT
INDICATION: ___ woman status post fall with left distal femur
fracture, tenderness to left ankle and midfoot. Evaluate for fracture
TECHNIQUE: Left Tibia-fibula, two views
Left ankle, three views
Left foot, three views
COMPARISON: Knee and tibia fibula radiographs ___
FINDINGS:
Left tibia-fibula: There is a partially visualized total knee arthroplasty.
No fractures or dislocations.
Left ankle: No fractures or dislocations. Ankle mortise is congruent.
Left foot: There are degenerative changes throughout midfoot and the first
MTP and IP joints. There is prominent calcification along the plantar fascia.
The bones are diffusely demineralized. There are vascular calcifications.
IMPRESSION:
No fracture or dislocation.
Radiology Report
INDICATION: ___ year old woman with fall, L thigh pain // please evaluate
periprostetic fracture of distal femur
TECHNIQUE: Axial CT images of the left thigh was obtained without IV
contrast.
DOSE: No IV contrast administered.
COMPARISON: Left femur radiograph dated ___.
FINDINGS:
There is a comminuted longitudinally oriented fracture of the distal femoral
shaft with mild anterior displacement and dorsal angulation of the distal
fragment. The fracture extends distally to lie immediately proximal to the
lateral proximal edge of the femoral prosthesis component (3:144). The
intramedullary rod is intact without displacement or loosening. It courses
from posterior to anterior such that the distal tip lies along the anterior
portion of the distal femoral medullary cavity.
There is a fissure like fenestration in the anterior cortex of the proximal
femur (series 3, 47), which could represent a nondisplaced fracture, possibly
an insufficiency fracture insufficiency fracture.
The previously seen femoral mid diaphyseal insufficiency fracture is healing
with bridging callus formation and a less conspicuous fracture line.
The left knee total arthroplasty appears intact without hardware loosening or
failure.
Partially visualized left pelvis shows a small lucency in the anterior
acetabulum (04:25) which is unlikely to be a fracture since there is no
associated joint effusion or fat fluid level. Degenerative changes of the
right hip are noted. There is vacuum phenomenon in the SI joint.
The leg muscles are intact with mild diffuse atrophy, not uncommon in someone
of this age. There is small joint effusion in the knee. There is mild
vascular calcification. The partially visualized pelvis demonstrates
diverticulosis without obvious diverticulitis. There is a Foley catheter in
the bladder, with a small amount of air in the bladder. The bladder is
decompressed. No free pelvic fluid or enlarged left iliac nodes are
identified. Scattered vascular calcifications noted. Left buttock and
cracked and granuloma noted in the subcutaneous fat.
IMPRESSION:
1. Comminuted longitudinally oriented oblique fracture of the distal femoral
shaft with mild anterior displacement and dorsal angulation of the distal
fragment.
2. Small fissure-like fenestration in the anterior cortex of the proximal
femur could represent a nondisplaced incomplete fracture, likely an early
insufficiency fracture.
3. Interval healing of the known insufficiency fracture of the mid femoral
diaphysis. Faint residual linear lucency is noted.
4. Intact intramedullary rod and total knee arthroplasty. No hardware
loosening identified.
5. Linear lucency at the posterior edge of the anterior acetabular column is
noted, without other findings to suggest acetabular fracture.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT IN O.R.
INDICATION: LEFT FEMUR FX.ORIF
TECHNIQUE: Intraoperative fluoroscopy images.
COMPARISON: Left femur radiograph dated ___.
FINDINGS:
3 intraoperative fluoroscopy images were available for review. Total
fluoroscopy time of 94 seconds. The images demonstrate the distal femoral
shaft fracture and placement of distal interlocking screws. For additional
details, please see operative report.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with placement of Right internal jugular
central line // placement of Right internal jugular central line Contact
name: ___: ___ placement of Right internal jugular central
line
IMPRESSION:
Compared to chest radiographs ___ through ___.
New right internal jugular catheter ends in the upper right atrium
approximately 2.5 cm below the estimated location of the superior cavoatrial
junction.
Borderline cardiomegaly. Lungs grossly clear. Pleural effusions small if
any. No pneumothorax. Patient has had T AVR.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Femur fracture
Diagnosed with Displaced oblique fracture of shaft of left femur, init, Displaced comminuted fracture of shaft of left femur, init, Fall on same level, unspecified, initial encounter
temperature: 98.2
heartrate: 78.0
resprate: 16.0
o2sat: 99.0
sbp: 108.0
dbp: 92.0
level of pain: 8
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 periprosthetic fracture of L distal femur and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for Internal fixation L
distal femur , which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to Rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TWBB in the LLE, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark stools, fatigue
Major Surgical or Invasive Procedure:
EGD (___)
Colonoscopy (___)
History of Present Illness:
___ with prior history of LIGB with radiation proctitis s/p APC
therapy, AVM's, CAD s/p CABG and recent BMS (1 wk ago), prostate
cancer s/p RT, bleeding internal hemorrhoids, cirrhosis d/t
NAFLD, celiac's disease, pancytopenia, and iron-deficiency
anemia (req. iv iron therapy) who presents with fatigue over 5
days. He has had black tarry stools for the past 3 days with
some BRBPR today. While unclear, but he was found to have Hct of
29.3 on ___. Baseline Hct around ___.
In the ED, labs were significant for WBC3.3, Hct 22 (Hb 7.5),
PLT 118. LFTs were only significant for AST 42. He was given 2
large-bore IVs. He was transfused 1U. He was given aspirin and
Plavix ___ as well, which was required per Dr. ___. Patient
was started on PPI. GI saw the patient in the ED and felt that
he was safe to be on the floor. Currently, the patient reports
feeling better after the unit of blood. Most of his GI records
are at ___.
The patient notes use of aspirin and Plavix since his cardiac
cath and stent placement 8d ago. Last colonoscopy ___ years ago
though unclear on findings. He has a history of Celiac's disease
with frqeuent BMs (~4/day though more lately). Patient notes
increasing fatigue that has been debilitating. No anxiety,
lightheadedness, hematemesis, hematochezia, weight loss,
anorexia, change in stool caliber, N/V, or NSAID use.
At baseline, the patient has known radiation proctitis and
internal hemorrhoids and has intermittent bright red blood per
rectum. He has had issues with GI bleeding throughout the years.
No fever/chills, nausea/vomiting.
ROS: Negative except per HPI.
Past Medical History:
CAD Hx: CABG in ___ stress nuclear test in ___ showed 1mm ST
depression with moderate exertion; echo in ___ shows LVEF>75%
PMHx: celiac disease, nonalcoholic cirrhosis; Hx of radiation to
prostate ___ years ago
Pancytopenia felt secondary to cirrhosis.
Cirrhosis caused possibly by nonalcoholic fatty liver associated
with sprue.
Nontropical sprue, under good control.
Radiation proctitis -- received ___ treatment in ___.
Status post upper endoscopy in ___ showing small varices.
Status post colonoscopy in ___ showing radiation proctitis that
was treated with APC and adenomas from the ascending colon that
were removed.
Status post carcinoma of the prostate treated with radiotherapy.
Social History:
___
Family History:
Heart disease
Physical Exam:
Admission Physical Exam:
98.8 120/58 91 20 96/RA
GEN: NAD, laying in bed comfortably
HEENT: dry oral mucosa, supple neck, no LAD
COR: +S1S2, RRR, II/VI holosystolic murmur
PULM: CTAB, no c/w/r
___: obese, soft, nontender, nondistended, no ascites or
organomegaly appreciated, no caput medusae or spider angiomatas
EXT: WWP, 2+ pulses distally
Discharge Physical Exam:
98.6 111/51(96-129 / 38-65) 52(52-79) 18 98RA
GEN: NAD, laying in bed comfortably
HEENT: MMM, supple neck, no LAD
COR: +S1S2, RRR, II/VI holosystolic murmur
PULM: CTAB, no c/w/r
___: obese, soft, nontender, nondistended, no ascites or
organomegaly appreciated, no caput medusae or spider angiomatas
EXT: WWP, 2+ pulses distally, tenderness to palpation of left
first toe without warmth or erythema, no palmar erythema
NEURO: AOx3, alert and appropriate, no asterixis
Pertinent Results:
Admission Labs:
___ 12:05PM ___ PTT-36.1 ___
___ 11:00AM GLUCOSE-239* UREA N-49* CREAT-1.2 SODIUM-142
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-20* ANION GAP-19
___ 11:00AM estGFR-Using this
___ 11:00AM ALT(SGPT)-28 AST(SGOT)-42* ALK PHOS-70 TOT
BILI-0.9
___ 11:00AM LIPASE-33
___ 11:00AM cTropnT-<0.01
___ 11:00AM ALBUMIN-4.1
___ 11:00AM WBC-3.3* RBC-2.34*# HGB-7.5*# HCT-22.6*
MCV-97 MCH-32.1* MCHC-33.1 RDW-15.9*
___ 11:00AM NEUTS-82.1* LYMPHS-12.6* MONOS-4.0 EOS-0.7
BASOS-0.6
___ 11:00AM PLT COUNT-118*
Pertinent Labs:
___ 11:00AM BLOOD WBC-3.3* RBC-2.34*# Hgb-7.5*# Hct-22.6*
MCV-97 MCH-32.1* MCHC-33.1 RDW-15.9* Plt ___
___ 12:47AM BLOOD Hgb-8.0* Hct-22.4*
___ 07:00AM BLOOD WBC-4.5 RBC-3.01*# Hgb-9.6* Hct-28.2*#
MCV-94 MCH-32.1* MCHC-34.2 RDW-17.1* Plt ___
___ 01:25PM BLOOD Hgb-11.3* Hct-32.5*
___ 09:00PM BLOOD Hgb-9.9* Hct-29.1*
___ 06:05AM BLOOD WBC-2.7* RBC-2.87* Hgb-9.1* Hct-26.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-17.6* Plt ___
___ 02:50PM BLOOD WBC-3.4* RBC-3.46* Hgb-10.9* Hct-31.6*
MCV-91 MCH-31.5 MCHC-34.5 RDW-17.6* Plt ___
___ 07:30AM BLOOD WBC-2.8* RBC-3.25* Hgb-10.2* Hct-29.3*
MCV-90 MCH-31.2 MCHC-34.6 RDW-17.6* Plt ___
___ 07:30AM BLOOD WBC-3.2* RBC-3.14* Hgb-10.3* Hct-28.6*
MCV-91 MCH-32.8* MCHC-35.9* RDW-17.7* Plt Ct-94*
___ 05:25PM BLOOD Hgb-10.9* Hct-30.4*
___ 07:30AM BLOOD ___ PTT-36.3 ___
___ 07:30AM BLOOD ___ PTT-35.4 ___
___ 07:00AM BLOOD Glucose-132* UreaN-51* Creat-1.3* Na-146*
K-3.9 Cl-110* HCO3-21* AnGap-19
___ 06:05AM BLOOD Glucose-124* UreaN-42* Creat-1.3* Na-144
K-3.8 Cl-109* HCO3-21* AnGap-18
___ 07:30AM BLOOD Glucose-147* UreaN-35* Creat-1.4* Na-143
K-3.8 Cl-107 HCO3-20* AnGap-20
___ 07:30AM BLOOD Glucose-153* UreaN-25* Creat-1.3* Na-139
K-4.0 Cl-107 HCO3-22 AnGap-14
Discharge Labs:
___ 07:55AM BLOOD WBC-4.4 RBC-3.68* Hgb-11.9* Hct-34.5*
MCV-94 MCH-32.3* MCHC-34.4 RDW-17.8* Plt Ct-93*
___ 07:55AM BLOOD Plt Ct-93*
___ 07:55AM BLOOD Glucose-142* UreaN-19 Creat-1.2 Na-140
K-4.3 Cl-107 HCO3-21* AnGap-16
___ 07:55AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1
Pertinent Micro/Path:
None
Pertinent Imaging:
None (except ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gemfibrozil 600 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 60 mg PO BID
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Omeprazole 20 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -200 unit
Oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Gemfibrozil 600 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
This dose has been decreased.
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
9. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram/10 mL 10 mL by mouth twice a day Disp #*60
Unit Refills:*0
10. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -200 unit
Oral BID
11. Nadolol 10 mg PO DAILY
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Gastrointestinal bleeding
Secondary diagnoses: Cirrhosis, Esophageal Varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Cirrhosis with massive GI bleed of unknown etiology. Evaluation
of the liver vasculature.
TECHNIQUE: Grayscale, color, and pulse wave Doppler of the liver.
COMPARISON: None.
FINDINGS: The liver is coarse and nodular in echotexture, consistent with
known cirrhosis. However, no focal liver lesion is identified. The main,
left, and right portal veins are patent with hepatopetal flow. The main
hepatic artery is patent with sharp systolic upstroke and antegrade diastolic
flow. The hepatic veins are patent with antegrade flow and normal waveforms.
Several stones are noted in the gallbladder. However, there is no wall
thickening or pericholecystic fluid. There is no intra- or extra-hepatic
biliary ductal dilatation and the common bile duct measures 4 mm. The spleen
is enlarged, measuring 18.9 cm. The visualized pancreas is normal. The tail
is not seen, likely due to overlying bowel gas. There is no ascites.
IMPRESSION:
1. Cirrhosis. No focal liver lesion.
2. Patent hepatic vasculature.
3. Splenomegaly.
4. No ascites.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FATIGUE, WEAKNESS
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS
temperature: 97.9
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 56.0
level of pain: 7
level of acuity: 2.0 | ___ w several prior lower GI bleeds, NAFLD cirrhosis,
pancytopenia, CAD s/p CABG & recent stents who p/w fatigue,
melena ___ GIB now s/p ___ which did not show an active
source. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ yo man with a history of CAD, inferior MI in
___ s/p DES to LCx, HTN, HLD, who was recently discharged on
___ with RUL CAP, on a course of levofloxacin, now
returning with worsening shortness of breath for 3 days.
Since last discharge, he has noted dry cough, but otherwise
feeling well until ___ when he had worsening shortness of
breath. This occurred usually in the evening, was intermittent,
and not associated with activity. On the evening of
presentation, he woke up at 4 am short of breath, and had
constant dyspnea throughout the day. He reports no ___ swelling
and no orthopnea/PND. No chest pain, palpitations,
lightheadedness, nausea, sick contacts, recent travel or
surgery, fevers/chills, runny nose. On ___, 2 days prior to
onset of symptoms, he reports some URI symptoms, including cough
and runny nose.
Of note, he had recent admission where they found RUL community
acquired pneumonia on CTA. During this hospitalization, he had
BNP 3884 and loud heart murmur, but TTE showed EF > 60% and no
valvular disease. He was discharged on levofloxacin, albuterol
prn. Losartan was decreased for ___ to 1.3.
In the ED, he experienced new bradycardia and arrhythmia. He
experienced HR from ___ to 110s (baseline HR last admission
80-90). Blood pressure was in 150s/60s-100s, and good oxygen
saturation on room air. He had taken his home metoprolol at
home. Cardiologist was contacted for variable HR, and he was
admitted to medicine for further management.
REVIEW OF SYSTEMS:
All other 10-system review negative except as indicated per HPI.
Past Medical History:
- HTN
- inferior STEMI with LCX occlusion s/p PCI with drug-eluding
stent.
- history of ischemic colitis
- gout
- mild cognitive impairment
- OSA on CP AP
- Hypercholeserolemia
- polymyalgia rheumatic (off pred since ___
- benign prostatic hypertrophy
- h/o pneumonia
- new on this admission: SVT with aberrancy, atrial bigeminy
Social History:
___
Family History:
No family history of sudden cardiac death or arrhythmia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 141 / 58 58 18 94 RA
GENERAL: NAD
HEENT: AT/NC, MMM
NECK: No JVD
HEART: RRR, S1/S2, IV/VI systolic murmur loudest at base
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: NTND, NABS
EXTREMITIES: No edema, warm and well perfused
PULSES: 2+ DP pulses bilaterally
NEURO: No gross motor/coordination abnormalities
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 97.9 141 / 58 58 18 94 RA
GENERAL: NAD
HEENT: AT/NC, MMM
NECK: No JVD
HEART: RRR, S1/S2, IV/VI systolic murmur loudest at base
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: NTND, NABS
EXTREMITIES: No edema, warm and well perfused
PULSES: 2+ DP pulses bilaterally
NEURO: No gross motor/coordination abnormalities
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
=================================
ADMISSION/IMPORTANT LABS
=================================
___ 09:11AM BLOOD WBC-7.1 RBC-4.67 Hgb-13.4* Hct-41.8
MCV-90 MCH-28.7 MCHC-32.1 RDW-14.2 RDWSD-46.3 Plt ___
___ 09:11AM BLOOD Neuts-74.7* Lymphs-14.2* Monos-7.3
Eos-2.8 Baso-0.6 Im ___ AbsNeut-5.30 AbsLymp-1.01*
AbsMono-0.52 AbsEos-0.20 AbsBaso-0.04
___ 09:11AM BLOOD Plt ___
___ 10:12AM BLOOD ___ PTT-30.7 ___
___ 09:11AM BLOOD Glucose-111* UreaN-21* Creat-1.2 Na-139
K-4.0 Cl-104 HCO3-23 AnGap-16
___ 09:11AM BLOOD ALT-16 AST-17 AlkPhos-94 TotBili-1.4
___ 09:11AM BLOOD proBNP-406*
___ 09:11AM BLOOD cTropnT-<0.01
___ 01:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:11AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.6* Mg-2.2
___ 09:32AM BLOOD Lactate-1.8
=================================
IMAGING
=================================
CXR ___: IMPRESSION: Subtle opacity in the left lower lung is
concerning for atelectasis versus an early pneumonia.
CXR ___: IMPRESSION: Left lower lobe opacity appears minimally
improved from the prior examination however subtle streaky
opacities at the base of the left lung still persistent could
reflect atelectasis or infection in the appropriate setting.
EKG: New bIgeminy from premature atrial contractions @ 88, no ST
elevations or depressions. No T wave inversions.
TTE ___ (ON PRIOR ADMISSION):
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>65%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is
moderately dilated. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Moderate pulmonary artery
systolic hypertension. Dilated thoracic aorta. Mild mitral
regurgitation. Mild aortic regurgitation.
CLINICAL IMPLICATIONS:
The patient has a moderately dilated ascending aorta. Based on
___ ACCF/AHA Thoracic Aortic Guidelines, if not previously
known or a change, a follow-up echocardiogram is suggested in 6
months; if previously known and stable, a follow-up
echocardiogram is suggested in ___ year.
==============================
DISCHARGE LABS
==============================
___ 08:25AM BLOOD WBC-7.7 RBC-4.79 Hgb-13.6* Hct-42.7
MCV-89 MCH-28.4 MCHC-31.9* RDW-14.3 RDWSD-45.6 Plt ___
___ 08:25AM BLOOD Glucose-140* UreaN-21* Creat-1.3* Na-139
K-4.3 Cl-102 HCO3-25 AnGap-16
___ 01:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:11AM BLOOD cTropnT-<0.01
___ 09:11AM BLOOD proBNP-406*
___ 08:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Finasteride 5 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Tamsulosin 0.4 mg PO QHS
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN Shortness of breath or
wheeze
Discharge Medications:
1. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Shortness of breath or
wheeze
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Finasteride 5 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
---------
- Dyspnea of unknown etiology
- SVT with aberrancy
Secondary
----------
- Coronary artery disease s/p stent
- Recent pneumonia
- Hypertension
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 increased sob, r/o pna
COMPARISON: Prior dated ___
FINDINGS:
AP portable upright view of the chest. Elevated right hemidiaphragm is
unchanged. Subtle opacity in the left lower lobe could represent atelectasis
versus early pneumonia. No large effusion is seen. Cardiomediastinal
silhouette is grossly unchanged allowing for patient rotation to the right.
No large pneumothorax. No overt signs of edema. Bony structures are intact.
IMPRESSION:
Subtle opacity in the left lower lung is concerning for atelectasis versus an
early pneumonia.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with LLL finding suggesting PNA on portable today
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiographs from ___ through ___
FINDINGS:
The lung volumes are low which accentuates bronchovascular markings. The
mediastinal and hilar contours are stable. Subtle opacity within the left
lower lobe persists. The right lung appears clear.
IMPRESSION:
Subtle opacity persists in the left lower lobe concerning for pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Cough
Diagnosed with Weakness
temperature: 97.1
heartrate: 40.0
resprate: 18.0
o2sat: 100.0
sbp: 158.0
dbp: 100.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ yo man with a history of CAD, inferior MI in
___ s/p DES to LCx, HTN, HLD, who was recently discharged on
___ with RUL CAP, on a course of levofloxacin, now
returning with worsening shortness of breath for 3 days.
# Dyspnea
His dyspnea had resolved at the time of transfer to the floor.
Possibly was related to recent URI symptoms (rhinorrhea, cough,
congestion) a few days prior to dyspnea. Pulmonary edema was
unlikely given euvolemic on exam, recent TTE with normal EF, BNP
< 450. Pneumonia was also unlikely given no fever, leukocytosis,
or sputum production. CXR with streaky opacities on L lung that
could represent atelectasis or pneumonia, but this was in the
setting of recent pneumonia 3 weeks prior. Antibiotics were
held. Angina/ischemia was also unlikely given EKG without
ischemic changes, non-exertional nature of dyspnea, and negative
troponin.
# Rhythm Abnormalities: new atrial bigeminy, SVT with aberrancy
The patient has no documented history of arrhythmia. In the ED,
the patient had episode of bradycardia, thought to be in the
setting of metoprolol administration. EKG revealed new atrial
bigeminy. He was asymptomatic. He was kept on telemetry
monitoring after transfer to the floor. On the morning after
admission, he developed a 23-beat run of SVT with aberrancy in
the 150s. He was asymptomatic. EKG was unchanged from admission
EKG with atrial bigeminy. Cardiology was consulted and
recommended increasing metoprolol to 100 from 50, and decreasing
losartan to 25 from 50.
# Diaphoresis
The morning after admission, the patient had two episodes of
diaphoresis. The first was gradual onset and non-exertional. The
second was when opening his window. He had no chest pain,
palpitations, dyspnea, lightheadedness, or nausea. Troponin was
negative and EKG was stable. He was therefore kept an additional
night for monitoring on telemetry, as it was felt that this may
have been related to SVT discussed above.
# New murmur
IV/VII holosystolic murmur with obliteration of S2 loudest over
base. TTE on last admission without any valvular disease. Plan
for outpatient follow up with ___ and repeat TTE with bubble
study to assess for VSD as outpatient.
# Hypertension - Losartan and metoprolol as above
# CAD s/p PCI - Continued home ASA 81, atorvastatin 80, and
metoprolol (dosing as above)
CAD with IMI ___ with 95% proximal circumflex lesion treated
with DES. LAD with ostial ___ eccentric calcified lesion, mid
and distal mild diffuse disease. D1 moderate size vessel with
moderate diffuse disease.
# OSA - Continued CPAP in house
# BPH - Continued home tamsulosin and finasteride
===================================
TRANSITIONAL ISSUES
===================================
[ ] Medication change: metoprolol increased to 100 from 50,
losartan decreased to 25 from 50.
[ ] Continue to titrate metoprolol and losartan as outpatient.
[ ] Repeat TTE with bubble study to assess for VSD as
outpatient.
[ ] ___ of ___ cardiac monitoring will be followed up Dr.
___
#CODE: Full
#HCP: ___ ___ |
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, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving
on interval CT) now p/w worsening n/v, weakness. On ___, pt fell
with head strike and CT imaging revealed an 8 mm R subdural
hemorrhage w/ 5 mm of leftward shift. Interval CT since that
time has shown improvement.
Last night the patient woke up with severe headache around 2am,
she took APAP but headache did not resolve. By 4am she made the
decision to come to the ED. Per report she also vomiting 3x
times prior to admission. ROS otherwise negative for changes in
vision, tinnitus, neck pain, focal numbness or weakness. Pt had
a mild headache in the AM that was frontal, but neither sudden
nor maximal in onset. Since the AM, her HA has resolved. Patient
is on aspirin (holding since initial fall at the recommendation
of her outpatient doctors), but no other anticoagulation. Pt
took 4 mg Zofran at home before coming to the ED.
In the ED, initial vitals: 98.9 156/65 71 18 99% RA
- Labs: CBC 6.4/9.4/29.1/295, Cr 0.6, K 4.1, Lactate 1.7, INR
1.0, UA negative.
- CXR showed no acute cardiopulmonary process, CT revealed no
new hemorrhage, and there was "increased thickness of the right
hemispheric subdural hematoma with increased effacement and mass
effect of the right lateral ventricle and worsening midline
shift to the left measuring up to 8 mm, previously 4 mm."
However, neurosurg saw pt and felt that she was neurologically
intact and stable for admission to medicine for optimization of
her BP management.
- Received:
___ 12:09 IV Ondansetron 4 mg ___
___ 12:36 IVF NS ___ Started
___ 13:06 IVF NS 500 mL ___ Stopped (___)
___ 16:15 PO Acetaminophen 1000 mg ___
___ 16:15 IV Labetalol 5 mg ___ Partial
Administration
___ 16:23 IV Labetalol 5 mg ___ Partial
Administration
- In the ED, she received Zofran, tylenol, and labetalol.
- Vitals prior to transfer: 72, 123/49, 16, 100%RA
Upon arrival to the floor, pt complaining of right sided head
pain recurring. She denies vision changes, chest pain, sob,
abdominal pain, nausea or vomiting. Her daughter is at the
bedside and helps with the history. She adds that her mother is
also overall much weaker than prior without clear explantation.
Her headaches seem to be coorelated with increases in her blood
pressure. She was given a prescription for labetolol 200mg BID
after her last hiospitalization. Before she takes this
medication her SBP is 170s and after her SBP drops to as low as
80. One episodes resulted in presyncope, requiring then to place
her in ___ before she awoke. Daughter is a ___ and
is concerned about her blood pressure regimen. Prior to
admission for her initial fall she was super active and is the
primary caregiver for her husband who has ___. she wants
her to be able to return to this baseline. With regards to her
other medications, she completed a course of ppx keppra today
and has been holding her asa ever since the ___.
Past Medical History:
Subdural hemorrhage (___)
HLD
R clavicular fracture (___)
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.4 PO 169 / 70 L Sitting 82 20 98 Ra
General: Alert, oriented, no acute distress but rubs right
temple
HEENT: mild healing abrasions on right temple, MMM, OP clear,
EOMI, PERRL, neck supple
CV: RRR, normal S1 + S2, soft systolic flow murmur
Lungs: CTAB, no wheezes/crackles
Abdomen: SNTND, +BS, no rebound or guarding
GU: No foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.0, 134/50, 70, 18, 99% RA
General: Alert, awake, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Lungs: No increased work of breathing; clear to auscultation
anteriorly, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated.
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity.
Pertinent Results:
ADMISSION LABS
==============
___ 11:54AM BLOOD WBC-6.4 RBC-2.91* Hgb-9.4* Hct-29.1*
MCV-100* MCH-32.3* MCHC-32.3 RDW-13.2 RDWSD-48.2* Plt ___
___ 11:54AM BLOOD Neuts-73.2* Lymphs-16.4* Monos-7.8
Eos-1.3 Baso-0.8 Im ___ AbsNeut-4.68# AbsLymp-1.05*
AbsMono-0.50 AbsEos-0.08 AbsBaso-0.05
___ 11:54AM BLOOD ___ PTT-27.9 ___
___ 11:54AM BLOOD Plt ___
___ 11:54AM BLOOD Glucose-126* UreaN-21* Creat-0.6 Na-137
K-4.1 Cl-99 HCO3-26 AnGap-16
___ 11:54AM BLOOD ALT-16 AST-18 AlkPhos-104 TotBili-0.3
___ 12:37PM BLOOD Lactate-1.7
IMAGES:
=======
CXR (___):
No acute cardiopulmonary process
CT Head (___):
There is increased thickness of the right hemispheric subdural
hematoma with increased effacement and mass effect of the right
lateral ventricle and worsening midline shift to the left
measuring up to 8 mm, previously 4 mm. No new hemorrhage.
Continued evolution of the right subdural hematoma with overall
decreased density.
CTA head and neck (___):
1. Stable bilateral subdural hematomas as described above with
stable 7 mm
leftward midline shift.
2. No evidence of new hemorrhage or acute territorial
infarction.
3. Mild luminal narrowing of the P1 segment of the left
posterior cerebral
artery.
4. Atherosclerotic vascular calcifications of the bilateral
vertebral arteries with mild narrowing of the distal left V4
segment.
5. Atherosclerotic disease at the bilateral carotid bifurcations
with
approximately ___ right and 50-60% left internal carotid
artery stenosis by NASCET criteria.
6. Mild narrowing at the origin of the left vertebral artery.
7. Nonspecific patchy parenchymal opacities within the right
upper lung with small adjacent calcific foci measuring 0.8 x 0.8
cm and 1.1 x 0.7 cm. Recommend further evaluation with CT chest.
MICRO:
======
Urine culture (___): negative
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-5.6 RBC-2.80* Hgb-9.1* Hct-27.8*
MCV-99* MCH-32.5* MCHC-32.7 RDW-13.1 RDWSD-46.8* Plt ___
___ 06:15AM BLOOD Glucose-93 UreaN-17 Creat-0.6 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-16
___ 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Labetalol 200 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Acetaminophen 325-650 mg PO Q8H
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 g by mouth daily
Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Labetalol 100 mg PO BID
Hold dose if your systolic blood pressure is less than 120.
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Subdural hematoma
Hypertension
Orthostatic Hypotension
SECONDARY DIAGNOSIS:
====================
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with SDH// CXR: eval for pnaCT head: eval for change in ICH
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lungs are well inflated. There is biapical scarring. The lungs are clear
without focal consolidation. Cardiomediastinal silhouette is stable. Recent
right lateral clavicular fracture is again noted. Hypertrophic changes seen
in the spine. No interval osseous abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with SDH// CXR: eval for pnaCT head: eval for change
in ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Re-demonstration of subdural hematoma along the right hemispheric convexity,
falx, and tentorium with a prepontine component. Interval evolution of
subdural blood with overall decreased density, especially along the right
frontal convexity. However, there is increased thickness of the subdural
bleed measuring up to 8 mm, previously measuring 5 mm over the right frontal
lobe. Components of subdural hematoma along the left tentorial leaflet and
overlying the cerebellum on the left are unchanged. No new hemorrhage.
There is increased midline shift measuring up to 8 mm, previously measuring up
to 4 mm. Overall increased mass effect and effacement of the right lateral
ventricle. Basal cisterns are patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavitiesare essentially clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
There is increased thickness of the right hemispheric subdural hematoma with
increased effacement and mass effect of the right lateral ventricle and
worsening midline shift to the left measuring up to 8 mm, previously 4 mm. No
new hemorrhage. Continued evolution of the right subdural hematoma with
overall decreased density.
NOTIFICATION: The update findings were discussed with Dr. ___. by
___, M.D. on the telephone on ___ at 3:48 pm, 4 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ patient with subdural hematoma. Evaluate for
hemorrhage and vascular patency.
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 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 6.5 s, 1.0 cm; CTDIvol = 48.6 mGy (Head) DLP =
48.6 mGy-cm.
4) Spiral Acquisition 10.2 s, 39.2 cm; CTDIvol = 33.6 mGy (Head) DLP =
1,263.2 mGy-cm.
Total DLP (Head) = 2,172 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Re-identified is acute on chronic right hemispheric subdural hematoma
measuring approximately 9 mm in greatest thickness exerting mass effect on the
adjacent brain, resulting in approximately 7 mm leftward midline shift,
unchanged from prior examination. The predominantly hypodense component
overlies the right frontal lobe. The hyperdense component overlies the right
temporal lobe. Hyperdense subdural hematoma extends along the right tentorium
(03:16) and posterior interhemispheric falx. Again seen is hyperdensity in
the region of the left cerebellar hemisphere (03:13, 12), which may represent
additional subdural hematoma, although the possibility of intraparenchymal
hemorrhage is difficult to entirely exclude.
Otherwise, there is no evidence of new hemorrhage. There is no acute
territorial infarction. Extensive atherosclerotic vascular calcifications of
the bilateral vertebral arteries are seen. The paranasal sinuses and
bilateral mastoid air cells appear clear. There is small amount of cerumen
within left external auditory canal.
CTA HEAD:
There is mild luminal narrowing of P1 segment of the left posterior cerebral
artery (7:332, 652:1). There are vascular calcifications of the V4 segments
of the bilateral vertebral arteries with mild narrowing of distal V4 segment
of the left vertebral artery. Otherwise, the intracranial vasculature appears
patent without stenosis, occlusion, or aneurysm. There is hypoplastic A1
segment of the right anterior cerebral artery, likely a congenital variation.
There is fetal origin of the right posterior cerebral artery. The dural
venous sinuses appear patent.
CTA NECK:
There is atherosclerotic disease at the bilateral carotid bifurcations and
proximal internal carotid arteries resulting in approximately ___ right and
50-60% left internal carotid artery stenosis by NASCET criteria. There is
mild narrowing at the origin of the right common carotid artery. The left
common carotid artery appears patent. There is mild narrowing at the origin
of the left vertebral artery due to vascular calcification. The right
vertebral artery appears patent.
OTHER:
The thyroid gland appears unremarkable. There is subcentimeter mediastinal
lymph nodes without evidence of lymphadenopathy per size criteria. There is
ectasia of the ascending aorta measuring 3.6 cm. There are multiple calcified
right upper lobe pulmonary nodules. There is biapical opacities. Additional
parenchymal opacities are seen within the right upper lung (07:53 and 6) with
adjacent small calcific foci streak artifact related to dental hardware
obscures visualization of adjacent structures.
Right lateral clavicular fracture is re-identified.
IMPRESSION:
1. Stable bilateral subdural hematomas as described above with stable 7 mm
leftward midline shift.
2. No evidence of new hemorrhage or acute territorial infarction.
3. Mild luminal narrowing of the P1 segment of the left posterior cerebral
artery.
4. Atherosclerotic vascular calcifications of the bilateral vertebral arteries
with mild narrowing of the distal left V4 segment.
5. Atherosclerotic disease at the bilateral carotid bifurcations with
approximately ___ right and 50-60% left internal carotid artery stenosis by
NASCET criteria.
6. Mild narrowing at the origin of the left vertebral artery.
7. Nonspecific patchy parenchymal opacities within the right upper lung with
small adjacent calcific foci measuring 0.8 x 0.8 cm and 1.1 x 0.7 cm.
Recommend further evaluation with CT chest.
RECOMMENDATION(S): Recommend CT chest to further evaluate nonspecific
parenchymal opacities in the right upper lung.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Nausea, Vomiting, Weakness
Diagnosed with Nausea with vomiting, unspecified, Nontraumatic acute subdural hemorrhage
temperature: 98.9
heartrate: 71.0
resprate: 18.0
o2sat: 99.0
sbp: 156.0
dbp: 65.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving
on interval CT) now p/w worsening n/v, weakness, found to be
neurologically stable, and now being admitted to medicine for
optimization of her BP management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ibuprofen / Erythromycin Base
/ Novocain
Attending: ___.
Chief Complaint:
Nausea, vomiting, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female who was traveling in ___,
___ on ___ at which time she suffered a mechanical fall
and fell back and struck her head. A CT was completed in
___, which showed a small parafalcine hematoma,
nondisplaced R occipital fracture. An overlying R occipital
laceration was sutured with 2 sutures. She was admitted
overnight
there and discharged the next day after her CT was stable. She
remained in ___ for 5 days and c/o of headache, nausea and
vomiting but reports slow improvement of her symptoms. She flew
from ___ to ___ then drove from ___ to ___. The patient
had another episode of emesis this yesterday and went to see her
PCP today who recommended that she come to ___ for repeat
imaging today. On examination she complains of minor headache
and reports feeling nauseous earlier today with some dizziness
with changing positions but this has overall improved.
In the ED intial vitals were: 98 68 170/70 16 100% ra. Labs were
significant for Na to 123. Urine studies were not sent. CT Head
showed 3 mm parafalcine subdural hematoma near the vertex.
Review of Systems:
Otherwise negative in detail
Past Medical History:
Hypertension, elevated cholesterol,
seasonal allergies, osteoarthritis knees, GERD, carpal tunnel
syndrome, left rotator cuff tendinitis, constipation.
Social History:
___
Family History:
Positive for two sisters with postmenopausal
breast cancer. Glaucoma father and sister. Brother: status post
aortic dissection. Mother and older sister: hypertension,
cerebral hemorrhage.
Physical Exam:
Admission:
97.8 67 158/85 18 100% RA
General- NAD
HEENT- EOMI, PERRL, dry MM, sutured R occipital lac present
Neck- supple
Lungs- CTAB
CV- RRR, no m/r/g
Abdomen- s/nt/nd normoactive BS
GU- no foley
Ext- no edema
Neuro- CN II-XII in tact, ___ strength, no drift, sensation in
tact to light touch
Discharge:
Vitals- 97.8 98.2 174/85 75 20 100% RA
General- NAD
HEENT- EOMI, PERRL, MMM, R occipital lac present, healing.
Neck- supple
Lungs- Decreased BS at bilateral lung bases
CV- RRR, no m/r/g
Abdomen- Soft, NT/ND, NABS
Ext- no edema, no skin tenting, nml cap refill
Neuro- CN II-XII in tact, strength/sensation grossly nml. A+Ox3.
Ambulatory without assistance
Pertinent Results:
Admission labs:
___ 09:15PM ___ PTT-28.3 ___
___ 09:15PM PLT COUNT-330
___ 09:15PM NEUTS-65.1 ___ MONOS-5.7 EOS-3.7
BASOS-0.7
___ 09:15PM WBC-9.2# RBC-4.45 HGB-13.2 HCT-39.4 MCV-88
MCH-29.6 MCHC-33.4 RDW-12.0
___ 09:15PM OSMOLAL-255*
___ 09:15PM estGFR-Using this
___ 09:15PM GLUCOSE-106* UREA N-12 CREAT-0.6 SODIUM-123*
POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-22 ANION GAP-20
___ 05:20AM PLT COUNT-330
___ 05:20AM WBC-7.4 RBC-4.32 HGB-12.7 HCT-38.3 MCV-89
MCH-29.5 MCHC-33.2 RDW-12.1
___ 05:20AM CORTISOL-25.6*
___ 05:20AM TSH-3.7
___ 05:20AM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 05:20AM GLUCOSE-107* UREA N-11 CREAT-0.6 SODIUM-122*
POTASSIUM-4.4 CHLORIDE-87* TOTAL CO2-23 ANION GAP-16
___ 05:38AM URINE MUCOUS-RARE FR FAT-RARE
___ 05:38AM URINE RBC-2 WBC-23* BACTERIA-FEW YEAST-NONE
EPI-2 TRANS EPI-<1
___ 05:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 05:38AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:38AM URINE OSMOLAL-674
___ 05:38AM URINE HOURS-RANDOM UREA N-882 CREAT-151
SODIUM-91 POTASSIUM-99 CHLORIDE-61
___ 03:31PM SODIUM-126* POTASSIUM-4.0 CHLORIDE-93*
___ 09:10PM SODIUM-126* POTASSIUM-4.2 CHLORIDE-94*
Discharge labs:
___ 07:00AM BLOOD WBC-6.8 RBC-4.04* Hgb-12.4 Hct-36.4
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.4 Plt ___
___ 07:00AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-128*
K-4.9 Cl-93* HCO3-27 AnGap-13
___ 07:00AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.2
___ 08:10PM URINE Hours-RANDOM Na-77 K-34 Cl-93
___ 08:10PM URINE Osmolal-408
Micro:
___ 5:38 am URINE Site: NOT SPECIFIED
CHEM # ___ 12.31.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Radiology:
CT head ___:
IMPRESSION:
Interval decrease in size of the subdural hematoma along the
falx when
compared to prior.
Unchanged nondisplaced posterior right occipital skull fracture.
CXR ___:
IMPRESSION: PA and lateral chest compared to ___:
Heart size top normal, unchanged. Lungs fully expanded and
clear. Normal
mediastinal and hilar silhouettes and pleural surfaces.
CT neck ___:
IMPRESSION:
1. Mild-to-moderate degenerative changes involving the cervical
spine with no
evidence of malalignment or displaced fracture. However, as
only two views of
the cervical spine were acquired, if the mechanism of injury is
concerning for
cervical spine fracture, further imaging with a dedicated CT may
be helpful.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. azelastine 137 mcg nasal BID
3. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
4. Atorvastatin 20 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Calcium Carbonate 500 mg PO DAILY
7. Vitamin D 200 UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. Loratadine 10 mg PO DAILY:PRN as needed
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Omeprazole 40 mg PO BID
5. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
RX *alprazolam 0.25 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. azelastine 137 mcg nasal BID
7. Calcium Carbonate 500 mg PO DAILY
Do not take with levothyroxine pill
8. Vitamin D 200 UNIT PO DAILY
9. Loratadine 10 mg PO DAILY:PRN as needed
10. Furosemide 20 mg PO DAILY
11. Outpatient Lab Work
Please draw chem7 panel.
Hyponatremia, 276.1
Dr. ___, Phone: ___
Fax: ___
12. Lisinopril 40 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg 1 spray NU Daily Disp #*1 Bottle
Refills:*0
14. Outpatient Physical Therapy
Cervical ligament sprain, 847.0
Dr. ___, Phone: ___
Fax: ___
15. Walker
Please allow patient to obtain walker for aid with balance.
Cervical ligament sprain, 847.0
Dr. ___, Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hyponatremia, SIADH
Subdural hematoma
Post-concussive symptoms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PA AND LATERAL CHEST ___
HISTORY: A ___ man with SIADH. Assess for infection.
IMPRESSION: PA and lateral chest compared to ___:
Heart size top normal, unchanged. Lungs fully expanded and clear. Normal
mediastinal and hilar silhouettes and pleural surfaces.
Radiology Report
CERVICAL SPINE SERIES, ___ AT 13:16
CLINICAL INDICATION: ___ with recent fall, question fracture.
AP and lateral views of the cervical spine are submitted without comparisons.
The prevertebral soft tissues are unremarkable. The C1 through C7 vertebral
bodies are visualized and there is no evidence of malalignment. There are
mild-moderate degenerative changes in the cervical spine, most marked at the
C4/C5 and C6/C7 levels where there is intervertebral disc space narrowing and
osteophytes. There are prominent facet degenerative changes of the mid
cervical spine as well. Some irregularity of the C2 spinous process is seen
but this is felt to be either related to old trauma or represent ligamentous
calcification. There is also calcification in the left lateral soft tissues
on the frontal projection, which may be carotid in etiology. The visualized
lung apices are unremarkable. If the patient has a mechanism where cervical
spine fracture is of clinical concern, further imaging with a dedicated
cervical spine CT may be helpful.
IMPRESSION:
1. Mild-to-moderate degenerative changes involving the cervical spine with no
evidence of malalignment or displaced fracture. However, as only two views of
the cervical spine were acquired, if the mechanism of injury is concerning for
cervical spine fracture, further imaging with a dedicated CT may be helpful.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Headache, Head injury
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, CL SKL BASE FX/MENIN HEM, UNSPECIFIED FALL
temperature: 98.0
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 170.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ with hx of GERD, HTN with recent parafalcine hematoma in
setting of mechanical fall, presenting with hyponatremia likely
___ SIADH.
# Hyponatremia - Likely subacute. Not symptomatic. Improved
slowly after nadir of 121. Her HA/LH have been present since her
fall and are improving at time of discharge, and likely
post-concussive. Likely was a mixed SIADH/volume picture on
presentation, now only SIADH ___ SDH, CXR neg) after volume
repletion. Renal was consulted, who recommended fluid
restriction (1000 cc at discharge), salt tabs (stopped at
discharge), and furosemide daily. Urine osms trend down. HCTZ
was not restarted. She will have close PCP follow up and Na
monitoring (___), as well as renal follow up.
# Sinus sx: Treated with Flonase and saline spray.
# Parafalcine Subdural Hematoma - stable per neurosurgery.
Post-concussive symptoms continuously improved. Gait was stable.
C-spine imaging was negative for gross injury. Restarted asa 81
per neurosurgery recommendations. Per neurosurgery, no
indication for repeat imaging at this time.
# Hypothyroidism: Continued levothyroxine.
# HTN: Remained stable despite salt tabs. HCTZ was not
restarted. Continued home lisinopril, increased dose to 40 mg to
compensate for stopped HCTZ and new high salt diet.
# GERD: Continued omeprazole.
# HLD: Continued simvastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin / Bactrim / Biaxin / Iodine / Nsaids / Penicillins /
IV Dye, Iodine Containing / Symbicort
Attending: ___.
Chief Complaint:
fever, rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of ESRD, Restrictive Lung Disease and COPD with 3L
O2 requirement at baseline, presents from dialysis for fevers
and cough. He developed a new cough yesterday night. This
morning, he woke with abdominal pain but otherwise felt well.
Developed rigors at dialysis. Afterwards, was very weak,
somnolent per wife. ___ were called, but wife drove him
to ___ as all of his care is here. Currently endorses
headache, severe cough, mild dyspnea, periumbilical abdominal
pain. No nausea, vomiting, chest pain, diarrhea.
On arrival to the floor the patients vitals were 99.1 ___ 93 on 3L NC. The patient was not ___ acute distress and
sitting up ___ bed. The patient reports that he feels much better
than during his dialysis session.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative ___ detail.
Past Medical History:
ESRD (on HD since ___, AVF ___ forearm, ___
CAD status-post MI ___ ___ status-post PTCAx2 at ___, STEMI
s/p ___ ___ He is followed by Dr. ___.
Type II Diabetes (poorly controlled, complicated by nephropathy
and retinopathy and neuropathy, FSBG 180-240 usually)
Diastolic Congestive Heart Failure EF>55% ___ ___
Restrictive Lung Disease (after heart attack, sees Dr. ___
___ on 3L Home O2 at rest/sitting or 4L if exerting himself
Obstructive Sleep Apnea on BiPAP ___ @ 6L)
Morbid Obesity
Neurogenic Bladder with recurrent UTIs and Suprapubic Catheter
since ___ (since ___ gave ibuprofen, Kidneys went
down and had fluid overload and never regained muscle tone)
Hypertension
Osteomyelitis status-post right ___ metatarsal amputation
Recurrent Clostridium difficile infections
Glaucoma
Cataract Surgery (bilateral, no glasses, left eye is good)
Anxiety
GERD
Social History:
___
Family History:
Unknown biological family history and as patient is adopted and
has no siblings. Knows that mother was ___ ___, father
was ___, and he was a product of rape
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 99.1 ___ 93 on 3L NC
GENERAL: chronically ill appearing obese gentleman, tired
appearing, oriented x 3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, II/VI systolic murmur at LLSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: 2cm R calcaneus ulcer, clean appearing but malodorous, R
leg circumference > L, bilateral 2+ pitting edema and venous
stasis changes worse on R
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
GU: suprapubic catheter site clean, non-erythematous, small
amount of clear yellow urine ___ bag
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.1 tm:98.6 HR:68 BP:127/64 RR:20 O2: 97 on3L
GENERAL: chronically ill appearing obese gentleman, alert ___ NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, good
dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, II/VI systolic murmur at LLSB
LUNG: CTAB no wheezes, rhonchi, breathing comfortably without
use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: RLE ulcer with dressing ___ place c/d/i, R leg
circumference > L, bilateral 2+ pitting edema and venous stasis
changes worse on R
NEURO: No focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
GU: suprapubic catheter ___ place
Pertinent Results:
ADMISSION LABS:
=================
___ 06:02PM BLOOD WBC-12.1*# RBC-4.04* Hgb-13.6* Hct-40.6
MCV-101* MCH-33.7* MCHC-33.5 RDW-13.6 RDWSD-49.8* Plt ___
___ 06:02PM BLOOD Neuts-85.5* Lymphs-7.2* Monos-6.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.31*# AbsLymp-0.87*
AbsMono-0.80 AbsEos-0.00* AbsBaso-0.04
___ 06:02PM BLOOD Glucose-166* UreaN-34* Creat-5.1*# Na-135
K-4.6 Cl-92* HCO3-27 AnGap-21*
___ 06:02PM BLOOD Lipase-18
___ 06:02PM BLOOD ALT-25 AST-34 AlkPhos-210* TotBili-0.7
___ 06:02PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.0 Mg-2.2
___ 06:37AM BLOOD CRP-71.4*
___ 11:25AM BLOOD SED RATE-22
DISCHARGE LABS:
=================
___ 06:15AM BLOOD WBC-5.4 RBC-3.69* Hgb-12.4* Hct-37.7*
MCV-102* MCH-33.6* MCHC-32.9 RDW-13.6 RDWSD-50.9* Plt ___
___ 06:15AM BLOOD Glucose-114* UreaN-44* Creat-5.8*# Na-140
K-4.2 Cl-97 HCO3-32 AnGap-15
___ 06:15AM BLOOD Calcium-10.0 Phos-4.9*# Mg-2.3
MICROBIOLOGY:
=================
Blood cultures: NGTD
Sputum cx: Contaminated with upper respiratory flora
RLE Ulcer wound culture:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
MEROPENEM sensitivity testing performed by ___.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CIPROFLOXACIN--------- 2 I =>4 R
GENTAMICIN------------ 2 S 4 S
MEROPENEM------------- I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING:
=================
CXR ___
Lung volumes remain low. Cardiac silhouette size is top normal
___ size,
unchanged. Mediastinal contour is unremarkable. Crowding of
bronchovascular
structures is present without overt pulmonary edema. Streaky
and patchy
bibasilar airspace opacities most likely reflect atelectasis.
No focal
consolidation, pleural effusion or pneumothorax is present.
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
R Foot xray ___
IMPRESSION:
Soft tissue ulcer subjacent to the calcaneus without definite
cortical
destruction to suggest osteomyelitis.
CT A/P W/O contrast ___
IMPRESSION:
1. No acute abdominopelvic pathology.
2. The appendix remains dilated up to 10 mm, unchanged since
___, with no
significant surrounding inflammatory changes to suggest acute
appendicitis.
3. Severe atherosclerotic disease.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with history of ESRD, COPD, with 1 day of cough,
fevers
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes remain low. Cardiac silhouette size is top normal in size,
unchanged. Mediastinal contour is unremarkable. Crowding of bronchovascular
structures is present without overt pulmonary edema. Streaky and patchy
bibasilar airspace opacities most likely reflect atelectasis. No focal
consolidation, pleural effusion or pneumothorax is present.
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
Radiology Report
INDICATION: History: ___ with history of ESRD, DM II, chronic right calcaneal
wound. // Please eval for osteomyelitis
TECHNIQUE: Right foot, three views
COMPARISON: ___
FINDINGS:
The osseous structures are diffusely demineralized. Soft tissue ulcer is
noted dorsal to the calcaneus. No cortical destruction is seen to suggest
osteomyelitis. Deformity of the calcaneus appears unchanged, likely due to
prior fracture. Extensive vascular calcifications are re- demonstrated. No
definite acute fracture or dislocation is seen. No subcutaneous gas is noted,
however there is diffuse soft tissue swelling about the foot.
IMPRESSION:
Soft tissue ulcer subjacent to the calcaneus without definite cortical
destruction to suggest osteomyelitis.
RECOMMENDATION(S): If there is continued clinical concern for osteomyelitis,
consider MRI.
Radiology Report
EXAMINATION:
CT abdomen and pelvis without IV contrast.
INDICATION: History: ___ with umbilical pain and tenderness, ESRD, IV
contrast allergy
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.4 s, 58.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 988.0
mGy-cm.
Total DLP (Body) = 988 mGy-cm.
COMPARISON: CT abdomen and pelvis: ___.
FINDINGS:
LOWER CHEST: Extensive coronary arterial and mitral valvular calcifications
are noted. There is no pleural or pericardial effusion. Mild atelectasis is
noted in the lung bases (2:6).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder distended, but otherwise unremarkable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix remains dilated up to 10 mm (601 B: 37),
unchanged since ___, with no evidence of surrounding inflammatory fat
stranding to suggest acute inflammation.
PELVIS: A suprapubic catheter is in place within the urinary bladder which is
otherwise decompressed. There is no free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: A fat containing umbilical hernia is noted. Extensive fatty
atrophy of the psoas and paraspinal musculature is noted. Anasarca is seen
within the lower abdomen and pelvis.
IMPRESSION:
1. No acute abdominopelvic pathology.
2. The appendix remains dilated up to 10 mm, unchanged since ___, with no
significant surrounding inflammatory changes to suggest acute appendicitis.
3. Severe atherosclerotic disease.
NOTIFICATION: The findings were discussed in person by Dr. ___ with Dr.
___ on ___ at 8:10 ___, 5 minutes after discovery of the findings.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: ILI
Diagnosed with Fever, unspecified, Syncope and collapse
temperature: 100.6
heartrate: 93.0
resprate: 20.0
o2sat: 100.0
sbp: 146.0
dbp: 107.0
level of pain: 2
level of acuity: 2.0 | ___ with ESRD, COPD with 3L O2 requirement at baseline presents
with chronic cough and new fevers,rigors and lethargy following
dialysis.
#Fever: On presentation to the ED, pt was afebrile,
hemodynamically stable and sating 93% on 3L NC ___ no acute
distress. Labs were notable for leukocytosis of 12.1, CRP 71,
ESR 22. CXR showed bibasilar opacities consistent with
atelectasis. On the floor, his max temp was 100.5 when he first
arrived, but he defervesced without intervention and he remained
afebrile throughout the rest of the admission. He was initially
started on vanc/cefepime empirically for HCAP/bacteremia given
comorbidities and significant health care exposure/HD. Blood
cultures and sputum cultures had no growth. Noted to have R
calcaneal ulcer that appeared to be at baseline with no purulent
discharge or surrounding cellulitis. R foot x-ray showed no
signs of osteomyelitis. Podiatry was consulted to evaluate, who
had low suspicion for infection and recommended daily dressing
changes and podiatry outpatient f/u. Wound culture grew flora
and sparse growth of pseudomonas thought to be colonization. CT
abd/pelv w/o IV contrast showed no acute abnormality. He was
noted to have an intermittent systolic murmur thought to be a
flow murmur, and given lack of blood culture growth no TTE was
performed. Leukocytosis resolved. Antibiotics were discontinued
given lack of culture growth without subsequent fever or
symptoms, so fevers were attributed to likely viral illness. He
was evaluated by ___ who recommended home ___.
# ESRD Continued with hemodialysis on ___,
___ schedule.
#DM: Managed on home regimen of glargine 60u BID as well as
lispro sliding scale coverage. Noted to have an episode of
fasting hypoglycemia with blood sugar ___ the ___ resulting ___
need to hold home glargine dose. Continued on home dose of
glargine on discharge to be further modified as outpatient as
needed.
# CAD: continued ___, ___ (pt continues to take at home
despite NSAID listed as allergy, resumed yesterday) metoprolol
and atorvastatin .
# Restrictive Lung Disease/COPD: Continued home oxygen of 3L
and home inhalers.
TRANSITIONAL ISSUES:
-Noted to have episodes of morning hypoglycemia on current
insulin regimen of glargine 60units BID, which per pt he and his
wife modify based on his blood sugar levels. Please f/u
appropriate insulin dosing as an outpatient.
-To continue outpatient hemodialysis with ___ and
___ schedule (last HD on ___.
-Discharged with home physical therapy.
-Needs f/u ___ ___ clinic ___ days after discharge
-Noted to have mild thrombocytopenia to 118 likely ___ setting of
viral syndrome, please follow with repeat CBC as outpatient
-Code: Full Code
-Contact: ___ (Wife, HCP): ___ |
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, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female s/p pipeline embolization of left PCA
aneurysm on ___ who was transferred from OSH with severe
headache and N/V. The patient reports headache began yesterday
morning and worsened throughout the day. ___ demonstrated
thrombosis of aneurysm. Neurosurgery was consulted for further
recommendations and evaluation. On exam the patient denies SOB,
CP, visual disturbances. She endorsed photophobia, phonophobia
and chills.
Past Medical History:
Sinus surgery x 3, Knee arthroscopy, Lumpectomy, pipeline
embolization of left PCA aneurysm on ___ with Dr. ___
___ History:
___
Family History:
___
Physical Exam:
On Discharge:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs Full
Neck: Supple.
Lungs: No resp distress
Abd: Soft, NT
Extrem: Warm and well-perfused.
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 tested
II: Pupils equally round and reactive to light, 3mm to
2 mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Pertinent Results:
IMAGING
=======
CT HEAD Study Date of ___
Thrombosis of aneurysm
MR HEAD W & W/O CONTRAST Study Date of ___ 11:56 ___
IMPRESSION:
1. Pipeline stent embolization of a 1.4 x 1.3 cm left posterior
cerebral
artery aneurysm demonstrating internal clot and probable
peripheral vascular wall enhancement, without definite evidence
of residual flow to the aneurysm.
Though in stent thrombosis cannot be excluded on the basis of
this
examination, there is no secondary evidence for in stent
thrombosis. No edema is seen around the aneurysm.
2. No hemorrhage, infarct, or enhancing mass.
LABS
====
___ 06:25AM BLOOD WBC-7.0 RBC-3.40* Hgb-9.7* Hct-30.8*
MCV-91 MCH-28.5 MCHC-31.5* RDW-12.4 RDWSD-40.9 Plt ___
___ 05:40AM BLOOD WBC-8.7 RBC-3.45* Hgb-10.1* Hct-30.7*
MCV-89 MCH-29.3 MCHC-32.9 RDW-12.5 RDWSD-40.6 Plt ___
___ 10:10AM BLOOD WBC-8.2 RBC-3.45* Hgb-10.2* Hct-31.1*
MCV-90 MCH-29.6 MCHC-32.8 RDW-12.5 RDWSD-41.0 Plt ___
___ 10:10AM BLOOD Neuts-80.7* Lymphs-14.1* Monos-4.6*
Eos-0.1* Baso-0.0 Im ___ AbsNeut-6.64* AbsLymp-1.16*
AbsMono-0.38 AbsEos-0.01* AbsBaso-0.00*
___ 06:25AM BLOOD ___ PTT-26.9 ___
___ 05:40AM BLOOD ___ PTT-28.6 ___
___ 10:10AM BLOOD ___ PTT-29.3 ___
___ 06:25AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-100 HCO3-25 AnGap-17
___ 05:40AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-134
K-3.8 Cl-99 HCO3-25 AnGap-14
___ 10:10AM BLOOD Glucose-116* UreaN-12 Creat-0.7 Na-137
K-4.0 Cl-103 HCO3-26 AnGap-12
___ 06:25AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1
___ 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0
___ 10:10AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
Medications on Admission:
Brilinta 90 mg BID, ASA 81 mg qd
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 3 mg PO EVERY 8 HOURS X 2 DOSES Duration: 2
Doses
Take at 6pm and 2am on ___, then discontinue
RX *dexamethasone 1 mg 3 tablet(s) by mouth Every 8 hours x 2
doses Disp #*6 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H PRN Disp #*30
Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth Every 4 hours PRN
Disp #*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Aspirin 325 mg PO DAILY
8. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
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: Pipeline embolization of left posterior cerebral artery aneurysm.
Assess for stent thrombosis, infarct or edema around aneurysm.
TECHNIQUE: Sagittal 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 as well as sagittal T1.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Outside hospital MR head ___. CTA head ___.
CT head ___.
FINDINGS:
There is susceptibility artifact from a pipeline stent within left posterior
cerebral artery for embolization of a previously noted left PCA aneurysm.
There is a 1.4 x 1.3 cm left posterior cerebral artery aneurysm with areas of
intrinsic T1 hyperintensity and susceptibility artifact denoting clot
formation. Peripheral enhancement around the aneurysm, likely represents
vessel wall enhancement. In stent thrombosis cannot be assessed on the
included sequences, however enhancement is noted in the P2 segment of the
posterior cerebral artery, just distal to the stent.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. Few, scattered areas of bifrontal subcortical white matter
T2/FLAIR hyperintensity are nonspecific, likely representative of chronic
small vessel ischemic disease. There is no abnormal enhancement after
contrast administration. The dural venous sinuses are patent on MP rage
images. The principal intracranial vascular flow voids are preserved.
The paranasal sinuses are grossly clear. The orbits are grossly unremarkable.
IMPRESSION:
1. Pipeline stent embolization of a 1.4 x 1.3 cm left posterior cerebral
artery aneurysm demonstrating internal clot and probable peripheral vascular
wall enhancement, without definite evidence of residual flow to the aneurysm.
Though in stent thrombosis cannot be excluded on the basis of this
examination, there is no secondary evidence for in stent thrombosis. No edema
is seen around the aneurysm.
2. No hemorrhage, infarct, or enhancing mass.
RECOMMENDATION(S): If dedicated assessment for in stent thrombosis is
desired, MRA of the head with and without gadolinium can be obtained, or
alternatively CTA of the head.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Abnormal CT
Diagnosed with Headache, Dizziness and giddiness
temperature: 98.4
heartrate: 66.0
resprate: 16.0
o2sat: 97.0
sbp: 108.0
dbp: 60.0
level of pain: 10
level of acuity: 3.0 | Mrs. ___ is a ___ year old female S/P pipeline embolization of
left PCA aneurysm with Dr. ___ on ___ who presents with
severe headache and nausea and vomiting. A NCHCT was performed
and demonstrated a thrombosed aneurysm. An MRI was performed to
assess patency of the stent and did not show any occlusion,
hemorrhage, or infarct. On HD 1 the patient continued with
headache and was started on Dexamethasone for headache control.
She continued on Brilinta and Aspirin. The patient remained
neurologically and hemodynamically stable. Her nausea and
headache improved. She was discharged home in stable condition
on HD2. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
near-syncopal event
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with CLL on ibrutinib, CAD/HLD with NSTEMI in
___, nonischemic cardiomyopathy, CKD stage III, depression,
presenting with presyncope and fall
with humeral fracture, with elevated troponin in the emergency
room.
He describes a recent history over about ___ year of postural
lightheadedness (says dizziness but clarifies the room is not
but
that he feels off-balance), and several falls. He reports his
last major fall prior to tonight was ___ when he stood
up
suddenly and was rushing to get the door - fell backwards as
soon
as he opened it. Have had other falls onto his knees. Reports a
negative w/u and had an unremarkable cardiac event monitor
around
that time. He also had his cath (described below) then.
Prior to present admission, he got home and noticed it was quite
hot in the house. He disrobed and turned on the AC and was
planning to lay down until it had turned on, but was worried he
would fall asleep so he stood up suddenly; he felt lightheaded
when he got to the cabinet and took the medicine, but as he
reached for water he blacked out (but did not lose
consciousness)
and fell backwards; he was aware of what was happening and did
not strike his head but fell on his left arm and immediately
noticed it was damaged.
He had no chest pain, pressure, palpitations, dyspnea, or other
symptoms with the event.
When I spoke with patient, he said he did not have LOC. His
Flomax was recently increased to BID which he says has helped a
lot. He notices his lightheadness only after standing up
abruptly. After the fall, he developed left shoulder pain which
he says is sharp intermittent and worsened with movement without
radiation.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Dx'd CLL with WBC of 48,000 ___ when he was seen in
___ clinic. He had not had a CBC since ___, at which
point his WBC was normal. Differential showed an increase in
lymphocytes. Flow cytometry was sent to ___ and returned
consistent with CLL.
Zap-70 19%
Unmutated IgVH
Beta-2 10.5
___ : CT Scans: Cervical, supraclavicular and axillary
adenopathy and splenomegaly similar to recent exam. Multiple
pulmonary nodules bilaterally several of which are stable;
however, a few have marginally increased in size and there is
new
more focal consolidative changes within the inferior posterior
lateral left lower lobe which could be inflammatory but
underlying malignancy cannot be excluded and followup is
recommended. Trace right pleural fluid.
___: Chest CT - stable pulm nodules. Slight increase in
mild
adenopathy. Mild splenomegaly (17 CM).
___: FIsh analysis showed 13q-
___: Started Bendamustine alone for rise in wbc to 226K,
plt
81K with bulky axillary nodes. LDH normal. Tolerated well.
Transient rise in uric acid and creatinine, rx'd allopurinol.
___: Drop in wbc but plts also very low (47K). Tried on
decadron 40 mgx4dx2 for possible immune mediated drop.
___: Cycle 2 Bendamustine with split dose Rituxan. WBC 63K,
plt 85K., followed by Neulasta.
___: Cycle 3 ___.
___: Cycle 4 ___ - Stopped due to chest pain.
PAST MEDICAL HISTORY:
-HTN
-HLD
-Squamous cell skin cancer left ear s/p MOHS ___
-CLL
-Depression/Anxiety
-CAD
-BPH
Social History:
___
Family History:
- CAD, PVD, CHF, Breast Cancer, Lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. 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: left arm in sling
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
VITALS: T98.4, BP 134/66, RR 16, 91%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, no S3, no S4.
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: left arm in sling. non-tender to gentle palpation. slightly
weaker grip on L compared to R.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout, grip strength LUE 4+/5, ___ on R,
strength ___ in lower extremities bilaterally
PSYCH: anxious, circumstantial and occasionally tangential
thought process
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:20PM WBC-42.7* RBC-3.89* HGB-11.8* HCT-37.4*
MCV-96 MCH-30.3 MCHC-31.6* RDW-16.9* RDWSD-58.4*
___ 04:20PM NEUTS-18* BANDS-4 LYMPHS-78* MONOS-0* EOS-0*
BASOS-0 AbsNeut-9.39* AbsLymp-33.31* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.00*
___ 04:20PM GLUCOSE-92 UREA N-39* CREAT-1.4* SODIUM-145
POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14
___ 04:20PM CK-MB-20* MB INDX-4.5 cTropnT-0.27*
___ 04:20PM CK(CPK)-444*
___ 08:45PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:45PM URINE RBC-11* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:20PM ___ PTT-31.2 ___
___ 10:15PM TSH-3.3
___ 10:15PM cTropnT-0.23*
___ 10:15PM ALT(SGPT)-24 AST(SGOT)-30 ALK PHOS-56 TOT
BILI-0.6
MICRO:
======
UCx:NEGATIVE
IMAGING:
========
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is moderately enlarged. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional
left ventricular function. Overall left ventricular systolic
function is normal. The visually estimated left ventricular
ejection fraction is 60%. 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 valve is not well seen. There is no aortic valve
stenosis. There is mild to moderate [___] aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is
physiologic mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is trivial tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Poor image quality. No obvious structural cardiac
cause of syncope identified.
___-SPINE W/O CONTRAST:
1. No acute fracture or traumatic malalignment.
2. Redemonstration of 1.1 cm left thyroid lobe nodule. Please
refer to
recommendations section below for further instructions.
RECOMMENDATION(S): 1.1 cmThyroid nodule. No follow up
recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
___ Imaging CT HEAD W/O CONTRAST: No acute intracranial
process within limitations of this noncontrast study. No
evidence of acute intracranial hemorrhage or acute fracture
___ Imaging GLENO-HUMERAL SHOULDER: Acute impacted
fracture through the surgical neck of the left humerus.
LABS ON DISCHARGE:
===================
___ 06:00AM BLOOD WBC-40.7* RBC-3.25* Hgb-9.8* Hct-33.4*
MCV-103* MCH-30.2 MCHC-29.3* RDW-17.2* RDWSD-64.2* Plt Ct-68*
___ 06:00AM BLOOD Glucose-87 UreaN-30* Creat-1.0 Na-143
K-4.4 Cl-112* HCO3-18* AnGap-13
___ 06:00AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ibrutinib 280 mg oral DAILY
2. Tamsulosin 0.4 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Zolpidem Tartrate 10 mg PO QHS
5. Fluvoxamine Maleate 100 mg PO QAM
6. Gabapentin 300 mg PO BID
7. Gabapentin 600 mg PO QAM
8. Citalopram 40 mg PO DAILY
9. Pravastatin 20 mg PO QPM
10. Allopurinol ___ mg PO BID
11. Ensure (food supplemt, lactose-reduced) 5 bottle oral DAILY
12. LOPERamide 1 mg PO BID:PRN loose stools
13. Fluvoxamine Maleate 200 mg PO HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO DAILY
4. Allopurinol ___ mg PO BID
5. Citalopram 40 mg PO DAILY
6. Ensure (food supplemt, lactose-reduced) 5 bottle oral DAILY
7. Finasteride 5 mg PO DAILY
8. Fluvoxamine Maleate 100 mg PO QAM
9. Fluvoxamine Maleate 200 mg PO HS
10. Gabapentin 300 mg PO BID
11. Gabapentin 600 mg PO QAM
12. ibrutinib 280 mg oral DAILY
13. LOPERamide 1 mg PO BID:PRN loose stools
14. Pravastatin 20 mg PO QPM
15. Zolpidem Tartrate 10 mg PO QHS
16.Outpatient Physical Therapy
ICD: ___, I95.1, R26.2
Please provide ___ for gait stability, balance training and
humeral fracture
17.Outpatient Occupational Therapy
ICD: ___.201A, I95.1, R26.2
Please provide ___ for gait stability, balance training and
humeral fracture rehabilitation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Fall
Orthostatic hypotension
L humerus fracture
Urinary retention
Hypertension
Elevated troponin
___
SECONDARY
Chronic lymphocytic leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with L shoulder deformity s/p fall// ?fx
TECHNIQUE: Three views of the left shoulder including a scapular Y-view.
COMPARISON: None.
FINDINGS:
There is an acute impacted fracture through the proximal left humerus at the
surgical neck. Distal fracture fragment is displaced slightly anteriorly.
Glenohumeral joint remains anatomically aligned. The acromioclavicular joint
is within normal limits. Included portion of left hemithorax is grossly
unremarkable.
IMPRESSION:
Acute impacted fracture through the surgical neck of the left humerus.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with thrombocytopenia, fall// eval for bleed, fx
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 20.8 cm; CTDIvol = 43.5 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast head CT ___. Sinus CT ___.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of age-related
cerebral volume loss. Periventricular and subcortical white matter
hypodensities are nonspecific, though likely sequelae of chronic small vessel
ischemic disease.
No acute osseous abnormalities seen. Small mucous retention cyst in the left
maxillary sinus. The remaining imaged paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits demonstrate no acute
abnormalities.
IMPRESSION:
No acute intracranial process within limitations of this noncontrast study. No
evidence of acute intracranial hemorrhage or acute fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with thrombocytopenia, fall// eval for bleed, fx
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 24.8 cm; CTDIvol = 23.1 mGy (Body) DLP = 572.3
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP =
26.5 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP =
26.5 mGy-cm.
Total DLP (Body) = 625 mGy-cm.
COMPARISON: CT C-spine ___.
FINDINGS:
There is minimal retrolisthesis of C4 on C5, unchanged. Otherwise, remaining
alignment is normal. No acute fractures are identified.There are multilevel
degenerative changes which are mild with intervertebral disc space narrowing,
endplate sclerosis and cysts, and osteophyte formation. There is mild central
canal narrowing at C4-5 and C5-6 as well as mild bilateral neural foraminal
stenosis at C4-5. However, no significant or severe spinal canal or neural
foraminal narrowing.There is no prevertebral edema.
Again demonstrated, is a 11 mm left isodense inferior thyroid lobe nodule.
Otherwise, the remaining thyroid and included lung apices are unremarkable.
There are moderate bilateral carotid bulb calcifications, right greater than
left.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Redemonstration of 1.1 cm left thyroid lobe nodule. Please refer to
recommendations section below for further instructions.
RECOMMENDATION(S): 1.1 cmThyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Shoulder injury, s/p Fall
Diagnosed with Unsp disp fx of surgical neck of left humerus, init, Other fall on same level, initial encounter
temperature: 98.3
heartrate: 98.0
resprate: 18.0
o2sat: 98.0
sbp: 115.0
dbp: 67.0
level of pain: 6
level of acuity: 2.0 | for Outpatient Providers: Mr ___ is a ___ male with
CLL on ibrutinib, CAD/HLD with NSTEMI in ___, non-ischemic
cardiomyopathy, CKD stage III, depression, presenting with
presyncope and fall with humeral fracture, with elevated
troponin, CK and ___. Patient's humeral fracture was treated
non-operatively. He was fluid resuscitated to good effect, with
normalization of Cr and CK. His troponin downtrended on repeat;
CK-MB was normal, ECG was unremarkable and patient was
asymptomatic throughout. Patient was followed by ___ and felt
safe to go home with services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bacitracin / Ciprofloxacin / azithromycin
Attending: ___
Chief Complaint:
Profound fatigue, shortness of breath and dizziness
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
___ with a history of b/l breast cancers s/p mastectomies ___,
___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p
CK therapy, left atrial clot on ASA, p/w worsening sx of
profound fatigue, shortness of breath and dizziness. She is
unable to ambulate safely at home due to lightheadedness.
The patient contacted her PCP ___ (HCA) on ___ to report
hoarseness x 3 weeks without any associated symptoms of URI. At
the time she also reported increasing dizziness and a recent
fall on ___ at which time she hit her leg and fell on her
coccyx. She started using her walker consistently due to
dyspnea on exertion.
For the last two days she has had worsening dyspnea and
increased orthopnea. She has had increased home O2 requirement
from 2 to 4 L NC. Her chronic cough is unchanged,
non-productive. She denies fever, chills, sweats. She does
endorse weight loss of 20 pounds in the last 3 months, possibly
partially due to poor appetite. She denies any worsening ___
edema, but does note some unilateral leg tenderness in her left
calf. She has had vague chest discomfort with deep inspiration.
No hemoptysis. She called her PCP office again today given
concern for dyspnea and being unable to ambulate safely at home
___ lightheadedness; she was referred to the ED.
Of note, the patient was admitted to this facility in ___
for multi-focal pneumonia. She was initially started on vanco
and tigecycline due to an extensive history of reactions to abx
including quinolones and penicillins. She was switched to
aztreonam and doxy for 10 day course. She was discharged on RA.
At that time, a left atrial clot was noted and she was started
on Lovenox anti-coagulation. Repeat CTA chest in ___ was
negative for PE, thus her Lovenox was stopped. This CT also
showed progressive mass-like consolidation around the site of
her prior cyberknife procedure as well as new R lung nodules,
concerning for infection vs. malignancy. In response to this
finding, she was seen in the ___ clinic in late ___ for
the first visit since ___. Etiology of the imaging findings
was unclear, thus the recommendation at that time was to do
follow-up imaging with CT and PET in several months to check for
interval change. No immediate treatment recommended.
In the ED, initial vitals ___ 98 68 80/44 20 100% 4L NC. Found
to have lactate 2.7, CXR showed multifocal PNA. She was started
on azithromycin PO and levofloxacin IV, received 2L NS in ED.
___ u/s negative for DVT.
On arrival to the floor, pt down to baseline 2L NC and breathing
comfortably. Denies worsened SOB or cough from baseline. No
current vertigo, although pt says that this was her main concern
this morning when she came to the ED. VS were 97.8, 101/40, 68,
20, 98%2L.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Regarding her breast cancers, she underwent a right mastectomy
in ___ and a left mastectomy in ___, and she had no
postmastectomy radiation therapy.
After her initial diagnosis of lung cancer in ___, she
underwent a left upper lobectomy for stage IA non-small cell
carcinoma of the lung; she had no postoperative adjuvant
radiation therapy or chemotherapy.
- ___: developed cough
- ___: CT chest showed a 1.9 x 1.2 cm right upper lobe lung
mass, which was suspicious for carcinoma. PET-CT on ___
showed a 1.3 x 1.1 cm right upper lobe lung lesion with an SUV
of 11.7; there were no FDG avid mediastinal or hilar lymph
nodes, and there were no liver, adrenal, or bone metastases.
Ms. ___ was evaluated by Dr. ___ consideration
of treatment of what appeared to be a right upper lobe lung
cancer. Since she was not a good candidate for surgical
treatment (DLCO was 41% of predicted), she underwent CT guided
biopsy that showed mucinous lung adenocarcinoma, acinar pattern,
moderately differentiated, and subsequently underwent CK
radiation to the lesion.
- CyberKnife SBRT to the right upper lobe lung adenocarcinoma to
a dose of 55 Gy given in five fractions of 11 Gy each completed
on ___.
- ___ repeat chest CT showed progression of the mass-like
consolidation around the fiducial marker and new multiple right
lung nodules is either cryptogenic organizing pneumonia
(perphaps triggered by radiation therapy) or unusually
aggressive recurrent lung cancer. Repeat imaging and PET
scanning planned as outpatient with follow-up appt in ___.
PAST MEDICAL HISTORY:
ANKLE FRACTURE
BREAST CANCER
CHEST NODULE
CORONARY ARTERY DISEASE
DEPRESSION
HYPERTENSION
LUNG CANCER
MEMORY DISORDER
OSTEOPOROSIS
SEIZURE DISORDER
SLEEP APNEA
SEBORRHEIC DERMATITIS
ENCHONDROMA
HOME SERVICES
LEFT ATRIAL CLOT on Lovenox ___, now on ASA
- ___: admission for significant weakness, chest
pain, and dyspnea to the point that she could barely walk. CT
angiography of the chest on ___ showed multifocal
pneumonia in the right lung; there was no pulmonary embolism;
there were right hilar lymph nodes up to 2.8 x 2.9 cm, which
were felt likely reactive; there was a small left atrial
thrombus. Ms. ___ was treated with aztreonam, doxycycline,
and Lovenox.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8, 101/40, 68, 20, 98%2L
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: Few crackles diffusely, course breath sounds throughout,
no wheezes, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal, gait deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.1, HR 77, BP 134/70, RR 20, O2 sat 100% on 2L
GENERAL: NAD
HEENT: AT/NC, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: Normal respiratory rate and effort, CTAB, no wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: alert and oriented x3
SKIN: warm and well perfused, dry skin on/around lips, no rashes
Pertinent Results:
ADMISSION LABS:
============
___ 12:30PM BLOOD WBC-7.9 RBC-4.77 Hgb-13.0 Hct-38.2
MCV-80* MCH-27.2 MCHC-34.0 RDW-13.6 Plt ___
___ 12:30PM BLOOD Neuts-72.1* ___ Monos-6.3 Eos-2.8
Baso-0.7
___ 12:30PM BLOOD Glucose-126* UreaN-21* Creat-0.8 Na-136
K-5.1 Cl-95* HCO3-26 AnGap-20
___ 12:30PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.1
___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1
___ 12:40PM BLOOD Lactate-2.7*
DISCHARGE LABS:
============
___ 06:15AM BLOOD WBC-4.9 RBC-3.90* Hgb-10.4* Hct-32.0*
MCV-82 MCH-26.7* MCHC-32.6 RDW-15.2 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
___ 06:15AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
OTHER PERTINENT LABS:
============
___ 07:33AM BLOOD ___ PTT-69.1* ___
___ 05:30AM BLOOD PTT-76.1*
___ 10:00PM BLOOD PTT-73.5*
___ 02:30PM BLOOD PTT-71.0*
___ 06:20AM BLOOD ___ PTT-25.3 ___
___ 06:23AM BLOOD CK(CPK)-24*
___ 12:00AM BLOOD CK(CPK)-14*
___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1
___ 06:23AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:20PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:15AM BLOOD TSH-3.0
___ 06:15AM BLOOD Free T4-1.1
___ 06:40AM BLOOD Phenyto-LESS THAN
___ 07:17AM BLOOD Lactate-1.1
IMAGING:
============
CXR ___:
FINDINGS: The lungs are hyperinflated, consistent with known
emphysema. Opacity is again seen within the right upper lobe
compatible with known malignancy with a fiducial marker
identified. There is increased opacity adjacent to tumor, most
likely representing post-obstructive infection or atelectasis.
There is a new patchy opacity in the right lung base, which
likely represents infection. Bibasilar atelectasis or scarring
is seen. The cardiomediastinal silhouette is unremarkable.
Sclerotic lesion in the left humeral head is unchanged from
___, likely representing medullary infarct or enchonroma. A
stable bone island is seen in the left glenoid.
IMPRESSION: Multifocal pneumonia in the right lung.
b/l ___ ultrasound ___:
IMPRESSION: No evidence of deep vein thrombosis in the right or
left lower extremity.
Chest CT ___:
IMPRESSION:
1. Significant interval increase in the bulk of the tissue
consolidation around the fiducial marker in the right upper
lobe, the area of thE patient's radiation-treated malignancy.
Innumerable scattered right lung nodules are overall increased
in size compared to the prior exam. Many of these nodules have
become more confluent into larger nodules.
2. Interval increase in the size of the innumerable left lung
nodules
concerning for worsening metastatic foci.
3. Interval increase in the diffuse lymphadenopathy.
ECHO ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified. ompared with the prior
study (images reviewed) of ___, the findings are similar.
CT Head ___:
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or infarction. No evidence of metastatic disease.
Prominent ventricles and sulci most consistent with age related
involutional changes. Diffuse ___ ventricular and subcortical
white matter hypodensities consistent with small vessel ischemic
disease. The basal cisterns appear patent. Visualized major
vessels and their branches are patent. Osseous structures are
unremarkable. Mild mucosal thickening within the left
sphenoid sinus. The remainder of the visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No evidence of metastatic disease.
CXR ___:
FINDINGS: Following the procedure, there is no evidence of
pneumothorax. There is some increased opacification in the
right mid and upper zone, suggesting some post-procedure
hemorrhage.
CXR ___:
No pneumothorax is detected. Again seen are background COPD, a
large
mass-like opacity in the right upper zone, and interstitial and
more confluent opacities at the bases. No new CHF, effusion or
pneumothorax is detected. Note is made of an irregular
sclerotic lesion in the left proximal humerus and small rounded
sclerotic focus in the left glenoid, not fully evaluated on
these views.
IMPRESSION:
1. No pneumothorax or acute superimposed pulmonary process
detected compared with ___ at 11:59 a.m.
2. Sclerotic densities in the left proximal humerus and left
glenoid, not fully evaluated.
CTA CHEST ___:
FINDINGS: Partially visualized thyroid is normal. There is no
axillary
lymphadenopathy. Slightly prominent bilateral axillary lymph
nodes are
unchanged. Subcarinal soft tissue consolidation is seen and
there is an
increase in compressive attenuation on the adjacent right main
bronchus.
There are new bilateral small pleural effusions, right greater
than left. The consolidation in the right mid lung is increased
in size. There are multiple small nodules throughout the right
lung, some of which are slightly increased in size compared to
prior study, the right middle lobe nodule measures 1.0 cm,
increased from prior study when it measured 0.8 cm. Multiple
small left pulmonary nodules are grossly unchanged. There is no
filling defect in the pulmonary arteries to the subsegmental
level. Right hilar lymphadenopathy is unchanged. The aorta is
normal in caliber. Limited evaluation of the upper abdominal
organs is unremarkable. There is an incidental note of a gastric
fundal diverticulum. Bilateral breast implants are seen. Heart
size is normal. There is no pericardial effusion.
IMPRESSION:
1. Mild increase in size of soft tissue consolidation in the
right mid lung.
2. New bilateral small pleural effusions, right greater than
left.
3. Multiple pulmonary nodules bilaterally, some of which have
slightly
increased in size.
4. Subcarinal soft tissue consolidation is seen and there is an
increase in attenuation on the adjacent right main bronchus.
BRONCHOSCOPY REPORT ___
Impression: Flexible bronchscope passed via LMA and vocal cords
with ease. Airways visualized to the subsegmental level. There
was diffsue calcification in the airways mainly in the central
airways. LUL stump of the previous ___ lobectomy was noticed.
Then EBUS scope
Otherwise normal to tracheobronchial tree
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Omeprazole 20 mg PO BID
5. Ondansetron 4 mg PO Q6H:PRN nausea
6. Phenytoin Sodium Extended 100 mg PO BID
7. QUEtiapine Fumarate 25 mg PO QHS
8. Simvastatin 40 mg PO DAILY
9. Venlafaxine XR 225 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Acetaminophen 325 mg PO Q6H:PRN TMJ pain
14. Lorazepam 0.5 mg PO Q4H:PRN prior to CT
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN TMJ pain
2. Benzonatate 100 mg PO TID:PRN cough
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO BID
6. Ondansetron 4 mg PO Q6H:PRN nausea
7. Phenytoin Sodium Extended 100 mg PO BID
8. QUEtiapine Fumarate 25 mg PO QHS
9. Simvastatin 40 mg PO DAILY
10. Venlafaxine XR 225 mg PO DAILY
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
12. Meclizine 12.5 mg PO Q8H:PRN dizziness
13. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
14. Docusate Sodium 100 mg PO BID
15. Lorazepam 0.5 mg PO Q4H:PRN prior to CT
16. Aspirin 81 mg PO DAILY
17. Heparin IV Sliding Scale
No Initial Bolus
Initial Infusion Rate: 700 units/hr
Target PTT: 60 - 100 seconds
18. Ipratropium Bromide Neb 1 NEB IH Q6H
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Warfarin 3 mg PO DAILY16
21. Acetaminophen 1000 mg PO Q8H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: lung cancer
Secondary: paroxsysmal atrial fibrillation with rapid
ventricular rate, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
COMPARISON: Comparison is made with chest radiographs from ___,
___, an ___.
FINDINGS: The lungs are hyperinflated, consistent with known emphysema.
Opacity is again seen within the right upper lobe compatible with known
malignancy with a fiducial marker identified. There is increased opacity
adjacent to tumor, most likely representing post-obstructive infection or
atelectasis. There is a new patchy opacity in the right lung base, which
likely represents infection. Bibasilar atelectasis or scarring is seen. The
cardiomediastinal silhouette is unremarkable. Sclerotic lesion in the left
humeral head is unchanged from ___, likely representing medullary infarct or
enchonroma. A stable bone island is seen in the left glenoid.
IMPRESSION: Multifocal pneumonia in the right lung.
Radiology Report
HISTORY: Acute dyspnea.
TECHNIQUE: Grayscale and color and spectral Doppler evaluation was performed
of the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS: There is normal compressibility, flow, and augmentation of the
bilateral common femoral, proximal femoral, mid femoral, distal femoral, and
popliteal veins. Normal compressibility is demonstrated in the posterior
tibial and peroneal veins bilaterally. There is normal respiratory variation
of the common femoral veins bilaterally.
IMPRESSION: No evidence of deep vein thrombosis in the right or left lower
extremity.
Radiology Report
INDICATION: History of non-small cell lung cancer, who presents with
worsening shortness of breath and fatigue. CT chest in ___ showed
progression of mass and new right lung nodules. Please evaluate.
COMPARISONS: Chest CTA from ___.
TECHNIQUE: ___ MDCT images were obtained through the chest without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes were generated and reviewed.
FINDINGS:
Thyroid is normal. There is no axillary lymphadenopathy; however, there is a
left-sided node which measures 0.6 cm x 1.1 cm, series 2, image 18, overall
stable compared to the prior exam. There is a right axillary node measuring 1
cm in short axis, series 2, image 13, which appears overall slightly increased
compared to the prior exam. Soft tissue infiltration around the subcarinal
region extends superiorly towards the trachea and appears to have slightly
increased in size compared to the prior study with the subcarinal portion
grossly measuring 2.5 cm x 3.8 cm, series 2, image 30, compared to the prior
exam, at which time this measured 1.5 cm x 3.2 cm. There appears to have also
been a slight interval increase in the right hilar lymphadenopathy measuring
2.7 cm x 2 cm, series 2, image 28, slightly increased in size compared to the
prior exam, at which time this measured 2.3 cm x 1.5 cm.
Heart size is normal. There is a small pericardial effusion. Mild coronary
and valvular calcifications are identified. The esophagus is normal without
evidence of wall thickening or a hiatal hernia.
The mass-like consolidation around the fiducial marker in the posterior
segment of the right upper lobe abuts the fissure and has overall increased in
size compared to the prior exam. Innumerable nodular soft tissue deposits in
the right lung have overall increased in size and become more confluent to
become larger soft tissue lesions, compared to the prior exam. For example,
in the right lower lobe, there is a 2.3 cm x 1.6 cm lesion, series 102, image
172, which has increased in size compared to the prior exam, at which time
this measured 1.5 cm x 1.1 cm. In the right lower lobe, there is a second
lesion, series 102, image 163, which now measures 2.2 cm x 1.1 cm, increased
in size compared to the prior exam, at which time this measured 1.6 cm x 0.8
cm. There is a conglomerate of nodular opacities in the right middle lobe
which have fused to become a larger soft tissue mass along the right major
fissure measuring up to 3 cm, series 102, image 148.
Additional new nodules are seen, for example, in the right upper lobe, there
is a pleural-based lesion which measures 0.7 cm x 0.4 cm, series 102, image
95. There is no pleural effusion or pneumothorax. At the left lower lobe,
there has also been an interval increase in size of a 5-mm nodule, series 102,
image 167, compared to the prior exam, at which time this measured 4 mm.
There are nodular opacities in the left lower lobe, series 102, image 126,
measuring up to 0.9 cm. There is a soft tissue lesion measuring 0.9 cm x 0.6
cm, series 102, image 162, in the left lower lobe, overall increased in size
compared to the prior exam, at which time this measured 0.6 cm x 0.6 cm,
series 102, image 163. Severe centrilobular emphysema has an upper lobe
predominance bilaterally.
The patient is status post bilateral breast implants. This study is not
tailored for the evaluation of the subdiaphragmatic structures; however, the
imaged portion of the upper abdomen demonstrates no acute abnormalities. A
gastric diverticulum is noted, unchanged compared to the prior exam.
OSSEOUS STRUCTURES: No suspicious bony lesions are demonstrated. A
benign-appearing sclerotic focus in T4 has been stable since at least ___.
IMPRESSION:
1. Significant interval increase in the bulk of the tissue consolidation
around the fiducial marker in the right upper lobe, the area of the patient's
radiation-treated malignancy. Innumerable scattered right lung nodules are
overall increased in size compared to the prior exam. Many of these nodules
have become more confluent into larger nodules.
2. Interval increase in the size of the innumerable left lung nodules
concerning for worsening metastatic foci.
3. Interval increase in the diffuse lymphadenopathy.
Findings were placed in the critical results dashboard by Dr. ___ on the
day of the exam.
Radiology Report
HISTORY: ___ female with non-small cell lung cancer presenting with
vertigo and lightheadedness. Evaluate for brain metastasis.
TECHNIQUE: Contiguous axial multi detector images of the brain were obtained
after administration of intravenous contrast. DLP 1040 mGy-cm. CTDI 62 mGy.
COMPARISON: None available.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction. No
evidence of metastatic disease. Prominent ventricles and sulci most
consistent with age related involutional changes. Diffuse ___ ventricular
and subcortical white matter hypodensities consistent with small vessel
ischemic disease. The basal cisterns appear patent. Visualized major vessels
and their branches are patent.
Osseous structures are unremarkable. Mild mucosal thickening within the left
sphenoid sinus. The remainder of the visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear.
IMPRESSION:
No evidence of metastatic disease.
Radiology Report
HISTORY: Flexible bronchoscopy.
FINDINGS: Images from the procedure are presented. Further information can
be gathered from the procedure report.
Radiology Report
HISTORY: Bronchoscopy, to assess for pneumothorax.
FINDINGS: Following the procedure, there is no evidence of pneumothorax.
There is some increased opacification in the right mid and upper zone,
suggesting some post-procedure hemorrhage.
Radiology Report
HISTORY: Chest pain, EKG changes, status post bronchoscopy, question
pneumothorax, mediastinal changes.
CHEST, SINGLE AP PORTABLE VIEW.
No pneumothorax is detected. Again seen are background COPD, a large
mass-like opacity in the right upper zone, and interstitial and more confluent
opacities at the bases. No new CHF, effusion or pneumothorax is detected.
Note is made of an irregular sclerotic lesion in the left proximal humerus and
small rounded sclerotic focus in the left glenoid, not fully evaluated on
these views.
IMPRESSION:
1. No pneumothorax or acute superimposed pulmonary process detected compared
with ___ at 11:59 a.m.
2. Sclerotic densities in the left proximal humerus and left glenoid, not
fully evaluated.
Radiology Report
INDICATION: Breast cancer and primary lung cancer, now with shortness of
breath and chest pain and paroxysmal AFib, with RVR, evaluate for pulmonary
embolism.
COMPARISON: Chest CT on ___.
TECHNIQUE: MDCT images were obtained through the chest with IV contrast.
Coronal and sagittal reformations were performed. Right and left MIP
reconstructions were performed.
FINDINGS: Partially visualized thyroid is normal. There is no axillary
lymphadenopathy. Slightly prominent bilateral axillary lymph nodes are
unchanged. Subcarinal soft tissue consolidation is seen and there is an
increase in compressive attenuation on the adjacent right main bronchus.
There are new bilateral small pleural effusions, right greater than left. The
consolidation in the right mid lung is increased in size. There are multiple
small nodules throughout the right lung, some of which are slightly increased
in size compared to prior study, the right middle lobe nodule measures 1.0 cm,
increased from prior study when it measured 0.8 cm. Multiple small left
pulmonary nodules are grossly unchanged. There is no filling defect in the
pulmonary arteries to the subsegmental level. Right hilar lymphadenopathy is
unchanged. The aorta is normal in caliber. Limited evaluation of the upper
abdominal organs is unremarkable. There is an incidental note of a gastric
fundal diverticulum. Bilateral breast implants are seen. Heart size is
normal. There is no pericardial effusion.
IMPRESSION:
1. Mild increase in size of soft tissue consolidation in the right mid lung.
2. New bilateral small pleural effusions, right greater than left.
3. Multiple pulmonary nodules bilaterally, some of which have slightly
increased in size.
4. Subcarinal soft tissue consolidation is seen and there is an increase in
attenuation on the adjacent right main bronchus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, FTT
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, HX-BRONCHOGENIC MALIGNAN, HX OF BREAST MALIGNANCY
temperature: 98.0
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 80.0
dbp: 44.0
level of pain: 0
level of acuity: 1.0 | ___ with a history of b/l breast cancers s/p mastectomies ___,
___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p
CK therapy, left atrial clot on ASA, h/o BPPV, p/w worsening sx
of profound fatigue, shortness of breath and dizziness, found to
have multifocal pneumonia and progression of lung cancer as well
as newly diagnosed afib with RVR. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Mercaptopurine Analogues (Thiopurines) / Remicade / Humira /
Cymarin / Dilaudid / Morphine / Erythromycin Base / Halothane /
Mercaptopurine / ciprofloxacin / Zofran (as hydrochloride)
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Drainage of Peritoneal Cyst
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ year old woman,
with past history of ulcerative colitis s/p colectomy with ileal
pouch anal anastomosis, c/b pouchitis (on Vedolizumab,
budesonide), primary sclerosing cholangitis, GERD, Bipolar
Disorder, and PTSD, who is presenting today for evaluation of
abdominal pain.
Patient reports that she has been having increased right lower
quadrant pain since the end of ___. Patient reports that this
has been worsened specifically over the past week, with
bloating, flank pain, and breast pain on the right side, as well
as nausea/vomiting. She has also been experiencing some
increased urinary retention, without dysuria, and has been
trying to manage the pain at home. Patient initially thought
this was similar to pouchitis that she has had previously, and
was hospitalized for this but did not have any relief. Given
that the pain was not improving, and patient was having
worsening symptoms with inability to tolerate significant PO
intake, patient was seen in the ED. Notably, patient has been
evaluated about 2 weeks ago by her GYN for peritoneal inclusion
cysts, and underwent ultrasound on ___, which was remarkable
for continued chronic 11 cm periotoneal inclusion cyst, without
significant change, extended into the left hemipelvis and
insinuates around the urinary bladder. Patient reports that she
has had this drained by ___ in the past to help relieve symptoms.
She describes that she feels "full of fluid", no other symptoms.
She states that over the past week, she has been not able to
tolerate PO intake, feels nauseated most of the day. She has not
been able to tolerate PO intake, with pain in the lower
quadrant, and she has been vomiting all night.
Notably, patient was recently hospitalized from ___.
At that time, patient was having BRPBR, nausea, worsening
abdominal pain, and concerning for pouchitis. Patient had flex
sigmoidoscopy and MRE at that time, and prescribed 10%
hydrocortisone into pouch. Patient was continued on home
budesonide, added hydrocortisone foam, and vedolizumab and
probiotic and home reglan. Since, then patient had her last
Vedolizumab infusion on ___. She also was seeing her OB/GYN
for fertility in the setting of ovarian cysts and recurrent
peritoneal inclusions cysts. At that visit, reviewed complex
adnexal cyst potentially representing a hemmhoragic ovarian
cyst, and was planning to have repeat ultrasound of the pelvis.
She underwent this on ___, and showed a right ovary noted to
be surrounded by adhesions and fluid reflecting a peritoneal
inclusion cyst, measuring up to 11 cm largest in diameter, and
not significantly changed from prior MRI. The right peritoneal
inclusion cysts extends into the left hemipelvis and insinuates
around the urinary bladder.
Patient has also had previous drainages by ___, with prior
placement of an US Pigtail catheter in ___, and with
peritoneal inclusion cysts she usually has discomfort, urinary
retention, loose stools and dyspaurenia.
In the ED, initial vitals: 7 99.1 97 124/72 18 100% RA
Exam was notable for: Mild distress, trace ___ swelling, +
diffuse abdominal pain, + CVAT.
- Labs were significant for :
Urinalysis: Spec ___ 1038, Epi 10, Many bacteria, WBC 8, Trace
leuk, Ketone negative.
Sodium 139, K 4.1, Chloride 106, Bicarb 20, BUN 13, Creatinine
0.6.
WBC 8.1, Hgb 11.7, Hct 35.8, Platelet 477. PMN 44, L39
INR 1.1. PTT 29.5.
- Imaging showed: None obtained.
- In the ED, she received:
___ 06:59 IVF NS
___ 06:59 IV Lorazepam 1 mg
___ 06:59 IV Ketorolac 15 mg
___ 09:30 IV Ketorolac 15 mg
___ 09:30 IV Lorazepam 1 mg
___ 09:31 IVF NS 1 mL
- Vitals prior to transfer: 98.2 79 108/ 18 98% RA
Upon arrival to the floor, patient is now s/p procedure.
Past Medical History:
- UC s/p total colectomy and ileal pouch-anal anastomosis (___)
c/b recurrent pouchitis and intraabdmoinal abscess
- PSC
- SBO
- Vit D deficiency
- GERD
- Hx of hip bursitis
- Depression
- Anxiety
- Bipolar disorder (per patient)
- PTSD
- Eating disorder
- ___ Total colectomy with ileoanal pouch and diverting
ileostomy (c/b sepsis and abscess)
- ___ Ileostomy takedown and reversal
- Broken ankle surgery
- Sinus surgery
- Wisdom teeth extraction
Social History:
___
Family History:
- Father: Living ___. ___ disease, depression, IBS
- Mother: ___, arthritis
- MGF: HTN
- Uncle: ___ Cancer
Physical Exam:
>> Admission Physical Exam:
Vitals: 98.0 PO 100 / 66 L Lying 62 18 99 Ra
General: Alert, oriented, no acute distress. Pale, and fatigued.
HEENT: Sclera anicteric. MM dry. EOMI. PERRL. Neck supple.
CV: RRR, S1, S2. No extra sounds.
Lungs: Clear to auscultation bilaterally, no adventitial sounds
heard.
Abdomen: Soft, mild diffuse tendernesss. No rebound, guarding.
negative murphys.
Extremities: No ___ edema bilaterally. Sensation intact.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
.
>> Discharge Physical Exam:
Vitals: 108 / 67 L Sitting 82 97 RA
General: Appears fatigued, uncomfortable. She is conversing
well, however appears frustrated with care.
HEENT: Mucous membranes mildly dry. Appears mildly pale. Wearing
glasses.
CV: RRR, S1, S2. No extra sounds heard.
Lungs: Diminished at bases, no adventitial sounds heard.
Abdomen: Soft, surgical scar on inspection. There is tenderness
generalized, without rebound or guarding. Mild distension. +BS
Extremities: No ___ Edema bilaterally.
Neuro: CN II-XII grossly intact. able to move extremities.
Pertinent Results:
>> Admission Labs:
___ 02:45AM BLOOD WBC-8.1 RBC-4.21 Hgb-11.7 Hct-35.8 MCV-85
MCH-27.8 MCHC-32.7 RDW-15.3 RDWSD-46.9* Plt ___
___ 02:45AM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-139
K-4.1 Cl-106 HCO3-20* AnGap-17
___ 02:45AM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.6 Mg-2.1
.
>> Discharge Labs:
___ 06:10AM BLOOD WBC-7.9 RBC-3.90 Hgb-10.8* Hct-34.4
MCV-88 MCH-27.7 MCHC-31.4* RDW-15.9* RDWSD-50.5* Plt ___
___ 08:27AM BLOOD Glucose-79 UreaN-16 Creat-0.6 Na-132*
K-4.7 Cl-100 HCO3-23 AnGap-14
___ 08:27AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
.
>> Pertinent Reports:
IMAGING:
___ Imaging PELVIS, NON-OBSTETRIC: 4 cm right adnexal
hypoechoic cystic structure, unclear, possibly representing
previously drained right lower quadrant cyst. If further
delineation is desired, MRI would provide further assessment.
Small amount of free fluid may be minimally complex, difficult
to discern whether truly free-fluid or if represents previously
described residual peritoneal inclusion cyst.
___ Imaging PERC IMAGE GUID FLUID C;
The patient was placed in a supine position on the US scan
table. Limited preprocedure ultrasound was performed to localize
the collection. Based on the ultrasound findings an appropriate
skin entry site for the aspiration was chosen. The site was
marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using continuous sonographic guidance, a 5 ___ ___ needle
was inserted into the cyst. Approximately 150 cc of clear
straw-colored fluid was aspirated.
The procedure was tolerated well, and there were no immediate
post-procedural complications.
SEDATION: Moderate sedation was provided by administering
divided doses of 3.5 mg Versed and 100 mcg fentanyl throughout
the total intra-service time of 43 minutes during which
patient's hemodynamic parameters were continuously monitored by
an independent trained radiology nurse.
FINDINGS: Limited postprocedural ultrasound demonstrates near
complete resolution of the right lower quadrant cyst.
IMPRESSION: Successful US-guided aspiration of a right lower
quadrant cyst with 150 cc of clear straw colored fluid removed.
___ Imaging PELVIS, NON-OBSTETRIC:
The uterus is anteverted and measures 6.7 x 4.0 x 4.8 cm. The
endometrium is
homogenous and measures 15 mm. Stable 2.2 cm posterior
subserosal fibroid.
The left ovary is again surrounded by a small amount of
loculated fluid reflecting a peritoneal inclusion cyst,
previously drained. The right ovary is also noted to be
surrounded by adhesions and fluid reflecting a peritoneal
inclusion cyst, measuring up to 11 cm in largest diameter, not
significantly changed from prior MRI (up to 11 cm). This right
peritoneal inclusion cyst again extends into the left hemipelvis
and insinuates around the urinary bladder. The ovaries are
otherwise unremarkable.
IMPRESSION: No significant change in right peritoneal inclusion
cyst extending into the left hemipelvis and measuring up to 11
cm.
Fibroid uterus.
___ Imaging MR ENTEROGRAPHY ___: Status post total
colectomy with ileal pouch anal anastomosis with mild pouchitis.
There is no abscess, fistula, or stricture. There are bilateral
fluid-filled tubular structures which likely represent
hydrosalpinx. There is also a moderate amount of free-fluid in
the pelvis which conforms to the peritoneal reflections, likely
due to a peritoneal inclusion cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Cholestyramine 4 gm PO DAILY
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
4. Diazepam 10 mg PO QHS anxiety / insomnia
5. Famotidine 20 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nose
7. HydrOXYzine 100 mg PO QHS
8. LORazepam 0.5 mg PO Q6H:PRN nausea
9. Ursodiol 600 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Hydrocortisone Acetate 10% Foam 1 Appl PR QHS
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
13. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN
headache
14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
15. Metadate CD (methylphenidate) 20 mg oral QAM
16. Methylphenidate SR 72 mg PO QAM
17. Metoclopramide 5 mg PO Q8H:PRN nausea
18. Multivitamins 1 TAB PO DAILY
19. olopatadine 0.1 % ophthalmic BID
20. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
21. butalbital-acetaminophen-caff 50-300-40 mg oral Q6H:PRN
22. Hyoscyamine 0.125 mg PO TID:PRN spasma
Discharge Medications:
1. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours Disp #*12
Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*8 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
5. Budesonide 9 mg PO DAILY
6. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN
headache
7. butalbital-acetaminophen-caff 50-300-40 mg oral Q6H:PRN
headache
8. Cholestyramine 4 gm PO DAILY
9. ClonazePAM 0.5 mg PO QHS:PRN anxiety
10. Diazepam 10 mg PO QHS anxiety / insomnia
11. Famotidine 20 mg PO BID
12. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nose
13. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
14. Hydrocortisone Acetate 10% Foam 1 Appl PR QHS
15. HydrOXYzine 100 mg PO QHS
16. Hyoscyamine 0.125 mg PO TID:PRN spasma
17. LORazepam 0.5 mg PO Q6H:PRN nausea
RX *lorazepam 0.5 mg 1 tab by mouth every ___ hours Disp #*10
Tablet Refills:*0
18. Metadate CD (methylphenidate) 20 mg oral QAM
19. Methylphenidate SR 72 mg PO QAM
20. Metoclopramide 5 mg PO Q8H:PRN nausea
21. Multivitamins 1 TAB PO DAILY
22. olopatadine 0.1 % ophthalmic BID
23. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
24. Ursodiol 600 mg PO BID
25. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Peritoneal Inclusion Cyst s/p drainage.
2. Cystitis, complicated.
SECONDARY DIAGNOSIS:
1. Ulcerative Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED ASPIRATION
INDICATION: ___ year old woman with known cyst// Drainage of cyst
COMPARISON: Prior ultrasound dated ___
PROCEDURE: Ultrasound-guided drainage of a right lower quadrant cyst.
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, a 5 ___ ___ needle was inserted
into the cyst. Approximately 150 cc of clear straw-colored fluid was
aspirated.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of
3.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
43 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited postprocedural ultrasound demonstrates near complete resolution of the
right lower quadrant cyst.
IMPRESSION:
Successful US-guided aspiration of a right lower quadrant cyst with 150 cc of
clear straw colored fluid removed.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with history of inclusion peritoneal cyst now
s/p drainage.// repeat eval of cyst
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: ___
FINDINGS:
The uterus measures 9.1 x 4.0 x 5.0 cm. The endometrium is homogenous and
measures 10 mm. In the right adnexa, it potentially internally associated
with the right ovary is a 4.0 x 2.2 x 1.5 cm hypoechoic cystic structure. The
ovaries are normal in size. Arterial and venous waveforms were demonstrated
over both ovaries with pulsed spectral Doppler. Some free fluid is seen,
which may be minimally complex; difficult to discern whether truly free-fluid
or previously described residual peritoneal inclusion cyst.
IMPRESSION:
4 cm right adnexal hypoechoic cystic structure, unclear, possibly representing
previously drained right lower quadrant cyst. If further delineation is
desired, MRI would provide further assessment.
Small amount of free fluid may be minimally complex, difficult to discern
whether truly free-fluid or if represents previously described residual
peritoneal inclusion cyst.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Right lower quadrant pain
temperature: 99.1
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ year old woman, with past history of UC s/p
colectomy with ileal pouch anal anastomosis, PSC, SBO,
depression, GERD, Bipolar disorder, PTSD, now presenting with
RLQ abdominal pain, urinary retention, concerning for
symptomatic peritoneal cyst.
.
>> ACTIVE ISSUES:
# Peritoneal Inclusion Cyst:
# Abdominal Pain: Patient has had an inclusion peritoneal cyst
for the past several months, as documented by MRE during past
hospitalization. Patient over the past several months has been
having increased waxing / waning abdominal pain, with urinary
retention / incontinence. Patient had seen her outpatient
providers, underwent transvaginal ultrasound demonstrating 11 cm
peritoneal inclusion cyst, and because of persistence of
symptoms came to the ED. Patient was evaluated by ___, with
laboratory values normal, and underwent ___ guided aspiration and
drainage of the cyst (150 cc of straw colored fluid) prior to
arrival to medical floor. Upon arrival, patient was maintained
on pain regimen of IV ketorolac and acetaminophen, and
intermittent oxycodone as needed because of significant pain.
Patient continued to have urinary retention, which she has had a
history of in the past, and thought to be related to the cyst
abutting the bladder. Patient underwent repeat ultrasound to
identify if any obstructive from the cyst itself, which
continued to show an adnexal cyst with ? septation, however no
significant obstruction. Outpatient providers contacted for
continuity, and alerted that patient may require MRI for further
evaluation if needed. Prior to hospital discharge, patient's
pain was controlled, and was given short supply of oxycodone
upon discharge. Patient was instructed on use given concomitant
benzodiazapenes, and able to teach back understanding of safety
and use. Further, case was again discussed with ___ to determine
the interval for repeat imaging, and was informed that likely
will be based on symptoms on whether to re-image in the future
and consider further drainages or more definitive type solutions
in outpatient setting.
.
# Urinary Retention: Thought to be multifactorial. Patient has
been evaluated several times in the outpatient setting, and has
had to straight catheterize in the past. As above, repeat
transvaginal ultrasound without any significant obstruction even
post-drainage, and thought to be combination of irritation from
the cysts, urinary tract infection likely from self
catheterization, as well as medications. Patient was started on
oxybutynin as previously been prescribed and well-tolerated, and
monitored on technique for self catheterization. Patient did
have supplies that last until end of ___, and therefore
will be renewed in the outpatient setting by her urogynecologist
as needed. Follow up appointment arranged, and patient started
to have improvement in symptoms upon discharge.
.
# Urinary Tract Infection, complicated: Patient was found to
have mixed culture upon arrival to the ED, however with straight
catheterization started to note worsening dysuria and repeat
urine culture with E. coli (despite normal U/A). Patient was
started on TMP-SMX for course of 5 days given complicated, and
will follow up sensitivities and make changes upon discharge.
Patient reported dysuria starting to improve.
.
# Ulcerative Colitis: Patient now s/p colectomy s/p ileal pouch
and anal anastomosis, with mild pouchitis documented previously
Patient was continued on hydrocortisone PR, budesonide,
hyocyamine, and vedolizumab to be continued in outpatient
setting.
.
# Anxiety / PTSD / Depression: Patient on complex regimen
including diazapem, clonazepam, and lorazepam as an outpatient.
Patient does also have other sedating and activating medications
including hydroxyzine (used for itching given PSC), as well as
fiorcet and Adderall. PMP verified during hospital stay,
prescribed by outpatient providers. Patient continued on
modified regimen, and continued on discharge. Discussed
extensively that with additional oxycodone, patient should
refrain from driving or other activities given additional
sedative effects. Would consider re-evaluating regimen to tailor
in outpatient setting.
.
# History of Right Ankle Sprain: Patient was noted to be using a
cane during hospital stay, has had previous workup including
Xray and MRI. Patient to have f/u in outpatient setting.
.
# Primary Sclerosing Cholangitis: Patient was continued on
cholesytramine, and ursodiol.
.
# Vitamin D Deficiency: Patient continued on home vitamin D.
.
# GERD: Patient continued on home famotidine.
.
# ADD: Adderall on hold given that patient only utilizes at
work. An out of school letter was presented to patient upon
discharge.
.
>> TRANSITIONAL ISSUES:
# Peritoneal Cyst: Please continue to follow up with outpatient
GYN and urogynecology. Patient may require serial imaging of
this in the future to be determined as an outpatient by her
outpatient GYN. ___ require MRI imaging based on ultrasound
report.
# Benzodiazpenes: Patient is on several different medications
that are similar class (clonazepam, diazepam, and lorazepam),
please continue to address as an outpatient.
# Patient with urinary retention while hospitalized, likely
secondary to cyst as above vs. pelvic floor dysfunction
(previously evaluated with urodynamic studies). Started
tamsulosin in house, discharged with instructions to straight
cath PRN. Should f/u with urology vs. gyn as outpatient.
# UTI: Found to have E. coli in urine s/p catheterization Urine
culture sent and started on TMP-SMX (end date ___. Please
follow up urine culture for sensitivities.
# Ulcerative Colitis: Patient to have f/u with outpatient GI to
continue vedolizumab as outpatient.
# PMP: PMP was checked prior to discharge to verify prescribers.
Discussed with patient to limit use of narcotics especially with
use of benzodiazapenes in outpatient setting.
# CODE STATUS: Full
# CONTACT: ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
prostate cancer
DVT (LLE)
___ s/p channel TURP
hematuria
compartment syndrome
Cardiac arrest (circulatory arrest)
Major Surgical or Invasive Procedure:
Date: ___
Surgeon: ___, MD
PROCEDURES: Exploratory laparotomy and superior abdominal
closure.
Date: ___ Surgeon: ___, MD
PROCEDURE: Removal of VAC sponge and secondary abdominal
closure.
Date: ___ Surgeon: ___, MD
PROCEDURE: Exploratory laparotomy with complex repair of
bladder laceration, temporary abdominal wound closure.
PRIOR ADMISSION:
Date: ___ Surgeon: ___, MD
PROCEDURE: Bipolar transurethral resection of prostate.
History of Present Illness:
Mr. ___ is an ___ M w/PMHx prostate CA s/p TURP on ___,
LLE DVT on Coumadin at home (bridging with Lovenox s/p TURP),
presented to the ED on POD#4 with decreased UOP, belly pain,
hematuria, and vomiting. The foley was exchanged by urology and
CBI was started. Patient went to the floor and became worse-
hypotensive to SBP 70's, tachypneic, hypothermic to T ___, and
lethargic, with belly looking more distended. He was moved to
the FICU with plans to do a stat CT, but pt continued to
decompensate- increasingly hypotensive and tachypenic. FAST exam
showed free fluid, pt was intubated for stat OR; when resident
went to place arterial line, felt the pulse get lost. CPR
initiated, multiple rounds of epi, chest compressions continued
while bedside ex lap was done. Large amount of blood tinged free
fluid from bladder perforation. Was started on Levophed,
fentanyl gtt, and sent to OR. ACS team called to assist. In
OR, closed bladder injury. Placed suprapubic catheter as well as
a foley, irrigating through the SPC and draining out foley.
Abdomen was left open. Pt was stabilized post-operatively in the
FICU and then transferred to the TICU.
Past Medical History:
PMH:
- Prostate cancer with bone mets
- Hypertension
- DVT, LLE
- urinary retention
- arthritis
- GERD
PSH:
___ Cystoscopy, Bipolar Transurethral Resection of
Prostate
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
Gen: No acute distress, alert & oriented
HEENT: Extraocular movements intact, face symmetric
CHEST: Warm and well-perfused
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, non-tender, mild distention, no guarding or rebound
SPT care; waste elimination
Wound care/monitoring; staples removed ___ prior to discharge
and steristrips applied.
EXT: Bilateral lower extremities are warm, dry, well perfused.
There is no reported calf pain to deep palpation. No edema or
pitting
PSY: Appropriately interactive
Pertinent Results:
___ 10:40AM BLOOD WBC-10.5* RBC-3.38* Hgb-9.4* Hct-29.0*
MCV-86 MCH-27.8 MCHC-32.4 RDW-14.4 RDWSD-44.5 Plt ___
___ 07:40AM BLOOD WBC-9.0 RBC-2.87* Hgb-7.9*# Hct-24.1*
MCV-84 MCH-27.5 MCHC-32.8 RDW-14.4 RDWSD-43.6 Plt ___
___ 07:40AM BLOOD WBC-8.9 RBC-2.30* Hgb-6.3* Hct-19.7*
MCV-86 MCH-27.4 MCHC-32.0 RDW-14.1 RDWSD-43.5 Plt ___
___ 05:32PM BLOOD WBC-11.0* RBC-2.57* Hgb-7.2* Hct-22.6*
MCV-88 MCH-28.0 MCHC-31.9* RDW-15.5 RDWSD-49.7* Plt Ct-93*
___ 01:35PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.5* Hct-20.6*
MCV-84 MCH-26.6 MCHC-31.6* RDW-15.1 RDWSD-46.7* Plt ___
___ 03:28AM BLOOD WBC-15.6*# RBC-2.49*# Hgb-6.7* Hct-20.9*#
MCV-84 MCH-26.9 MCHC-32.1 RDW-15.3 RDWSD-46.3 Plt ___
___ 03:28AM BLOOD Neuts-83.9* Lymphs-9.2* Monos-5.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.14*# AbsLymp-1.44
AbsMono-0.90* AbsEos-0.00* AbsBaso-0.01
___ 03:10PM BLOOD ___
___ 10:40AM BLOOD ___
___ 05:58AM BLOOD ___ PTT-34.2 ___
___ 02:43PM BLOOD ___ PTT-86.2* ___
___ 03:28AM BLOOD ___ PTT-32.8 ___
___ 07:40AM BLOOD Glucose-85 UreaN-16 Creat-1.7* Na-141
K-3.6 Cl-108 HCO3-21* AnGap-16
___ 07:40AM BLOOD Glucose-91 UreaN-17 Creat-1.8* Na-143
K-3.4 Cl-111* HCO3-21* AnGap-14
___ 01:35PM BLOOD Glucose-141* UreaN-52* Creat-6.2* Na-134
K-5.3* Cl-100 HCO3-12* AnGap-27*
___ 03:28AM BLOOD Glucose-162* UreaN-46* Creat-5.5*# Na-136
K-4.8 Cl-98 HCO3-16* AnGap-27*
___ 01:30AM BLOOD ALT-725* AST-462* AlkPhos-49 TotBili-0.3
___ 01:30AM BLOOD ALT-960* AST-967* AlkPhos-45 TotBili-0.4
___ 03:41PM BLOOD ALT-107* AST-130* AlkPhos-45 TotBili-0.7
___ 03:41PM BLOOD Lipase-17
___ 07:40AM BLOOD Calcium-7.5* Mg-1.6
___ 12:55AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.9
___ 06:59PM BLOOD Calcium-8.5 Phos-10.2* Mg-2.0
___ 03:41PM BLOOD Albumin-3.1*
___ 01:35PM BLOOD Mg-2.2
___ 07:12PM ASCITES Creat-3.5
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD
4. Enoxaparin Sodium 70 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
5. Famotidine 20 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Cyanocobalamin 1000 mcg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain or fever
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. amLODIPine 5 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Famotidine 20 mg PO BID
8. Finasteride 5 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. QUEtiapine Fumarate 50 mg PO QHS
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin B Complex 1 CAP PO DAILY
13. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD
14.rolling walker
Diagnosis: bladder perforation
Prognosis: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Bladder perforation
2) abdominal compartment syndrome
3) Cardiac Arrest: cardiovascular collapse with return of
circulation after CODE
4) Acute kidney injury on chronic kidney disease
5) generalized deconditioning
6) thrombosis, deep vein (pre-existing)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man who had a bladder perf c/b abd compartment
syndrome, was coded with chest compressions prior to going to OR, now back in
ICU// eval for chest wall fractures
TECHNIQUE: Chest single view
COMPARISON: ___ 00:56
FINDINGS:
Endotracheal tube tip is 2 cm above carina. Enteric tube tip is mid stomach.
Postoperative changes upper abdomen. Right IJ central line tip is in mid to
low SVC. Opacity right lung apex, with volume loss, scarring, likely
atelectasis. Underlying obstruction cannot be excluded. No adjacent rib
destruction. Stable right lower lateral rib expansion, adjacent pleural
thickening, indeterminate. No new fractures.
IMPRESSION:
Stable cardiopulmonary findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with open abdomen s/p perf bladder.
intubated/sedated// eval for changes, especially RUL
TECHNIQUE: Chest single view
COMPARISON: ___ 19:27
FINDINGS:
Endotracheal tube tip 2.5 cm above carina. Volume loss right lung apex with
atelectasis, superior right hilar retraction, stable, most likely from right
upper lobe atelectasis. Enteric tube tip well below diaphragm, out of view.
Right IJ central line tip in low SVC. Stable right lateral rib lesion. Left
lung is clear. No sizable effusion. No pneumothorax.
IMPRESSION:
Stable exam
Radiology Report
INDICATION: ___ year old man with open abdomen, intub/sedated// eval for RUL
improvement s/p bronch, other changes
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There is again seen area consolidation
and volume loss in the right upper lobe, stable. The rest of lung fields are
grossly clear aside for a small right-sided pleural effusion. There are no
pneumothoraces. Overall findings are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p bedside exlap, intub/sedated// eval for
changes eval for changes
IMPRESSION:
ET tube tip terminates right above the carinal. Right internal jugular line
tip terminates at the level of lower SVC. NG tube tip is in the stomach.
Heart size and mediastinum are stable. Right apical pleural thickening is
unchanged. There is no appreciable pleural effusion. There is no
pneumothorax.
Radiology Report
INDICATION: ___ year old man with RUL collapse on CXR, s/p bronch// interval
change s/p bronch, ETT placement
COMPARISON: Radiographs from ___ at 05:47.
IMPRESSION:
Endotracheal tube, feeding tube, and right IJ central line are unchanged
position. There remains volume loss and collapse of the right upper lobe
similar to prior. The rest of the lung fields are grossly clear. There are
no pneumothoraces. There is again seen a known right sixth lateral rib
lesion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with perf'd bladder, open abdomen// eval for
changes eval for changes
IMPRESSION:
Comparison to ___. Stable monitoring and support devices. Stable
right upper lobe atelectasis and right lateral pleural thickening. Increasing
retrocardiac atelectasis. No other changes are seen in the lung parenchyma.
Stable borderline size of the heart.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with bladder injury// Evaluate kidneys
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None available.
FINDINGS:
The right kidney measures 9.6 cm and is normal in appearance without
hydronephrosis, stones, or mass. Normal cortical echogenicity and
corticomedullary differentiation is noted.
The left kidney is not seen secondary to extensive overlying bowel gas.
The bladder is poorly visualized, and appears collapsed around Foley catheter.
IMPRESSION:
1. Normal right renal ultrasound. Nonvisualized left kidney secondary to
overlying bowel gas and bedside portable approach.
2. Suboptimal visualization of the urinary bladder, which appears collapsed
around Foley catheter.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man w/open abdomen, intub/sedated// eval for changes
eval for changes
IMPRESSION:
Compared to chest radiographs ___ through ___.
Right upper lobe has been collapsed since at least ___. Prior radiograph
should be obtained to document whether this is a chronic finding or one which
requires further investigation with chest CT.
Heart size normal. Moderate left lower lobe atelectasis has worsened. Small
right pleural effusion is likely. No left pleural effusion or pneumothorax.
Cardiopulmonary support devices in standard placements.
Radiology Report
INDICATION: ___ year old man, inaccurate surgical sponge count.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Chest radiograph ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
large amount of stool in the ascending and descending colon. Assessment for
free intraperitoneal air is limited on supine radiographs.
An enteric catheter side port projects over the proximal gastric body.
Multiple staples project over the periphery of the abdomen and pelvis. No
evidence of retained sponge. A drain or wound VAC projects over the upper
left pelvis.
IMPRESSION:
No evidence of retained sponge.
NOTIFICATION: The findings were discussed with Dr. ___ by ___,
M.D. on the telephone on ___ at 4:05 pm, less than 5 minutes after
discovery of the findings. and by Dr. ___ with Dr. ___- 10
minutes after observation of these findings
Radiology Report
EXAMINATION: CR chest
INDICATION: ___ year old man with new NGT// NGT placement
TECHNIQUE: Portable AP radiograph of the chest was performed
COMPARISON: Chest radiograph from earlier today performed at 05:20
FINDINGS:
Again seen is a left internal jugular central venous catheter with tip at the
cavoatrial junction, and a nasogastric tube coursing into the stomach. There
is right upper lobe collapse, stable. The left lung is grossly clear, aside
from linear subsegmental atelectasis in the midlung. Blunting of the right
costophrenic angle may be secondary to pleural thickening or a small amount of
pleural fluid, unchanged. The cardiomediastinal contour remains unchanged.
Midline skin staples project over the mid abdomen.
IMPRESSION:
1. Nasogastric tube coursing into the stomach.
2. Right upper lobe collapse stable, comparison to priors or investigation
with chest CT recommended to exclude central obstruction.
Radiology Report
INDICATION: ___ year old man with intubation// Interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There are low bilateral lung volumes. Unchanged right upper lobe collapse.
Opacities over the right lung base and right diaphragm may reflect underlying
atelectasis and/or consolidation. No new pleural effusion or pneumothorax is
identified. Thickening of the right lateral sixth rib is again seen,
suspicious for a rib lesion. The size the cardiac silhouette is mildly
enlarged but unchanged.
Interval removal of the nasogastric tube and right internal jugular central
venous line.
IMPRESSION:
Low bilateral lung volumes and persisting right upper lobe atelectasis.
Thickening of the right sixth lateral rib is again seen, suspicious for an
underlying rib lesion.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with bladder perforation, evaluate for ureteral
injury// evaluate for hydro
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound from ___
FINDINGS:
The right kidney measures 8.8 cm. There is no hydronephrosis or calculi of the
right kidney in its limited evaluation secondary to overlying bowel gas.
Normal cortical echogenicity and corticomedullary differentiation is seen of
the right kidney.
The left kidney measures 8.5 cm. There is moderate hydronephrosis, partially
seen on prior, not significantly changed. There are no calculi in the left
kidney. Normal cortical echogenicity and corticomedullary differentiation is
present. A few pararenal cysts are suggested.
The urinary bladder is decompressed via Foley catheter.
IMPRESSION:
Moderate left hydronephrosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with history of prostate cancer with new CVL// CVL
placement?
TECHNIQUE: Single frontal view of the chest and bone scan from ___
COMPARISON: None.
FINDINGS:
A right IJ central venous catheter terminates in the proximal right atrium.
There is an opacity in the right upper lobe with elevation of the fissure,
consistent with atelectasis. Heart size is mildly enlarged, slightly
accentuated by portable supine technique. There is a small right pleural
effusion. No pneumothorax. There is again seen thickening and irregularity
of the right lateral sixth rib which showed uptake on the prior bone scan.
IMPRESSION:
-A right IJ central venous catheter terminates in the proximal right atrium.
-Small right pleural effusion and right upper lobe atelectasis.
-Thickening of the right lateral sixth rib
Radiology Report
INDICATION: ___ year old man with SOB// lung process causing SOB
COMPARISON: Radiographs from ___ and bone scan from ___
IMPRESSION:
There is a right IJ central line with the distal lead tip at the cavoatrial
junction. There is again seen opacity within the right upper lobe and
elevation the minor fissure consistent with atelectasis. Thickening of the
right sixth lateral rib is again seen and demonstrated uptake on the prior
bone scan suspicious for a rib lesion.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Hematuria, Urinary retention
Diagnosed with Hematuria, unspecified
temperature: 98.7
heartrate: 121.0
resprate: 24.0
o2sat: 100.0
sbp: 117.0
dbp: 71.0
level of pain: 8
level of acuity: 2.0 | ___ male hx prostate cancer, DVT (LLE) POD4 from channel TURP,
presented to the on ___ with hematuria. Had perforated bladder
and developed abdominal compartment syndrome. Opened acutely at
bedside after circulatory arrest, then taken to OR for
exploration. Subsequently wound vac removed and abdominal wound
closed by ACS on ___ and returned to ___. Extubated ___
ready for floor ___.
Mr. ___ received ___ intravenous antibiotic
prophylaxis and deep vein
thrombosis prophylaxis with subcutaneous heparin, later
converted to lovenox and restarted on Coumadin. With the
eventual passage of flatus, diet was gradually advanced and the
patient was transitioned from IV pain medication to oral pain
medications. At the time of discharge the wound was healing
well
with no evidence of erythema, swelling, or purulent drainage.
His drain was removed and his SPT care reinforced.
Post-operative follow up appointments were
arranged/discussed and the patient was discharged home with
visiting nurse services to further assist the transition to home
with OT, ___, Coumadin titration and waste elimination/care of
the SPT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
___ hx ___ dz on Remicaide, h/o MV endocarditis, gastritis,
s/p cholecystectomy, s/p pancreatic stent & removal ___, presents with abdominal pain.
Patient reports that he's been having crampy abdominal pain,
diffuse but worst in the RLQ at the site of his ileocolonic
resection, with accompanying nausea and loose, nonbloody
diarrhea. This is reminiscent of his previous ___ flares. He
had a fever to ___s an episode of emesis.
There have been no sick contacts, no medication changes, no new
or unusual foods, no alcohol intake. He made it through his
Remicade treatment in the hope it would help, but his sx were
not alleviated and continued to progress after, for which he
went to the ED.
In the ED, initial vitals were: 99.0 83 142/88 18 98%RA.
Labs notable for: No leukocytosis, H/H ___ (at baseline), K
3.5 (Cr 1.0). Lipase 42. Lactate 1.3. CRP 2.2 (WNL).
Imaging notable for: Nonspecific bowel gas pattern.
Patient given: Morphine 5mg IV x2, Zofran 4mg IV x2, 1L NS.
Vitals prior to transfer: 98.0 79 135/86 18 96% RA.
On the floor, patient is awoken from sleep to recount the story
above, continues to feel unwell with continued abdominal pain,
but slightly better than when he came in.
Review of systems:
(+) Per HPI. Cardiac, respiratory, GU ROS negative.
Past Medical History:
PAST MEDICAL HISTORY:
# ___ disease (dx-ed ___ ileocolonic anastamosis
___ on Remicaide
# Mitral Valve Endocarditis ___ port infection, growing
S. viridans and ___ in blood s/p tx 6 weeks of
IV antibiotics
# Cholecystectomy (___)
# Appendectomy (___)
# Asthma
# Migraines --___, takes Tylenol and/or Imitrex for
abortive relief
# Hypertension
# Gastritis
Social History:
___
Family History:
One sister and cousin with chronic abdominal pain and migraines.
# Mother: ___, kidney cancer, kidney stones
# Father: ___ cell carcinoma of finger
# Brother: ___ disease, migraines
# Sisters: 2 healthy sisters, one with migraines and chronic
abdominal pain
# Paternal Grandfather: ___ disease
# Maternal Grandfather: ___ cancer, lymphoma
# Paternal Uncle: ___ disease
# Paternal Cousin: ___ disease
# Maternal Cousin: ___
# ___ Uncle: kidney stones
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 133/96 75 18 95%RA
General: Young male reclined in bed awoken from sleep, NAD
HEENT: NCAT, pupils symmetric, anicteric sclera, clear OP, dry
MM Neck: JVP not elevated
CV: RRR, no r/g/m
Lungs: CTAB
Abdomen: Well-healed midline scar, soft, TTP RUQ and RLQ, ND,
+BS
GU: Deferred
Ext: WWP, no edema
Neuro: Face symmetric, moving all four limbs on command
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.2 135/85 74 20 98 RA
General: NAD, appears stated age, lying in bed
HEENT: NCAT, PERRL, EOMI, MMM
CV: RRR, nl S1, S2
Lungs: CTAB
Abdomen: Midline scar, soft, non-distended, +BS, diffuse
abdominal pain most pronounced in RLQ, no g/r/r
GU: No foley
Ext: pulses 2+ dp b/l, no edema
Neuro: CN2-12 intact, moving all extremities
Skin: WWP
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-9.6 RBC-4.07* Hgb-12.1* Hct-35.1*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.0 Plt ___
___ 12:00PM BLOOD Neuts-54.0 ___ Monos-6.0 Eos-1.8
Baso-0.5
___ 09:55PM BLOOD Glucose-127* UreaN-16 Creat-1.0 Na-139
K-3.5 Cl-102 HCO3-25 AnGap-16
___ 12:00PM BLOOD ALT-36 AST-27
___ 09:55PM BLOOD Lipase-42
___ 09:55PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
___ 12:00PM BLOOD CRP-2.5
___ 10:04PM BLOOD Lactate-1.3
PERTINENT LABS:
___ 06:09AM BLOOD CRP-2.9
___ 07:30AM BLOOD CRP-32.8*
___ 08:00AM BLOOD CRP-53.5*
___ 07:50AM BLOOD CRP-28.0*
___ 07:30AM BLOOD Lipase-20
___ 07:30AM BLOOD ALT-48* AST-30 AlkPhos-77 TotBili-0.8
___ 08:00AM BLOOD ALT-53* AST-36 AlkPhos-73 TotBili-0.4
___ 07:50AM BLOOD ALT-52* AST-34 AlkPhos-68 TotBili-0.4
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-7.5 RBC-4.32* Hgb-13.0* Hct-39.2*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.0 Plt ___
___ 07:50AM BLOOD Glucose-90 UreaN-16 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
___ 07:50AM BLOOD ALT-50* AST-37 AlkPhos-61 TotBili-0.2
___ 07:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
___ 07:50AM BLOOD CRP-13.8*
IMAGING/REPORTS:
- ___ KUB: Nonspecific bowel gas pattern. No evidence of
obstruction.
- ___ EKG: Sinus rhythm. Normal tracing. No major change from
previous tracing. QTc 408
- ___ MRE: Mild proctocolitis extending from the splenic
flexure to the rectum. No active inflammation of the small
bowel or complication of transmural disease.
- ___ CXR: As compared to the previous radiograph, the left
PICC line was removed. The lung volumes are low. Normal size of
the cardiac silhouette. Normal hilar and mediastinal structures.
Mild elongation of the descending aorta. No pneumonia.
No pneumothorax, no pleural effusions, no pulmonary edema.
- ___ colonoscopy:
Impression: No gross endoscopic evidence of inflammation.
(biopsy, biopsy, biopsy, biopsy)
Fair prep
20 cm into terminal ileum appeared grossly normal
Otherwise normal colonoscopy to neo-terminal ileum
MICRO:
- blood cx ___: negative
- blood cx ___: pending
- urine cx ___: negative
___ 4:33 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Felodipine 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Ranitidine 300 mg PO QHS
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
10. Vitamin D 1000 UNIT PO DAILY
11. Infliximab 0 mg IV Q6WEEKS
12. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Felodipine 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Ranitidine 300 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*7 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*11 Tablet Refills:*0
10. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
11. Infliximab 0 mg IV Q6WEEKS
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Abdominal pain/diarrhea
Secondary diagnosis: ___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ year old man with Crohn's disease
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast ( cc). Oral contrast consisted of 900 mL of VoLumen.
COMPARISON: Multiple prior abdominal CTs and MRIs dating from ___, the most recent from ___.
FINDINGS:
MR ENTEROGRAPHY:
The patient is status post right hemicolectomy, with ileocolonic anastomosis
identified within the right upper quadrant.
The remaining small bowel demonstrates normal peristalsis and distensibility
throughout. There is no segmental wall thickening, hyperenhancement or edema.
No mesenteric fibrofatty proliferation or inflammatory changes noted within
the small bowel.
The study is not intended to evaluate the colon given lack of a colonic prep.
While the colon is incompletely distended, there is mild circumferential wall
thickening and mucosal hyperenhancement of the descending colon (05:33),
sigmoid and rectum. This does not result in significant surrounding edema or
hyperemia. The transverse colon is spared. No extraluminal fluid collection
or fistula is identified.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Visualized portions of the liver demonstrate normal morphology and enhancement
pattern. There is low parenchymal signal on Fiesta sequences suggestive of
hepatic steatosis, although confirming and quantifying sequences are not
acquired as part of the enterography protocol. There is no focal lesion. The
patient is status post cholecystectomy. Intra and extrahepatic biliary tree is
unchanged in appearance with mild extrahepatic prominence (common hepatic duct
measuring 12 mm).
Pancreatic parenchyma maintains normal bulk, intrinsic hyperintense T1 signal
and enhancement pattern. There is no ductal abnormality.
The spleen and adrenal glands are unremarkable. There are tiny bilateral
simple renal cysts, none with concerning features. The largest is noted at the
inferior pole of the right kidney with a diameter of 14 mm.
There is no lymphadenopathy or ascites.
Arterial vascular anatomy is conventional. Venous structures are widely
patent.
Visualized osseous structures are unremarkable.
Note is made of a small fat containing periumbilical hernia.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
No free pelvic fluid or lymphadenopathy is noted.
The urinary bladder, visualized portion of the prostate gland and seminal
vesicles are unremarkable.
IMPRESSION:
Mild proctocolitis extending from the splenic flexure to the rectum. No
active inflammation of the small bowel or complication of transmural disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fevers // eval for intrathoracic process
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the left PICC line was removed. The
lung volumes are low. Normal size of the cardiac silhouette. Normal hilar and
mediastinal structures. Mild elongation of the descending aorta. No pneumonia.
No pneumothorax, no pleural effusions, no pulmonary edema.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.0
heartrate: 83.0
resprate: 18.0
o2sat: 98.0
sbp: 142.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | ___ hx ___ on Remicaide, gastritis, h/o MV endocarditis ___
picc line infection, s/p cholecystectomy, s/p prior pancreatic
stent no longer present, s/p appendectomy, presents with acute
abdominal pain and diarrhea. Febrile to 102 with elevation in
CRP prompting initiation of cipro/flagyl with no further fevers.
C. diff negative. Pain managed with morphine. MRE initially
concerning for proctocolitis but colonoscopy negative for
inflammation or signs of CMV infection. By discharge, tolerating
PO with improved pain. Plan for outpatient GI follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Back pain, T12 osteomyelitis.
Major Surgical or Invasive Procedure:
___: Bilateral psoas muscle abscess drainage
___: Diagnostic Spinal Angiogram
___: Corpectomy T11/12 and PSF T9 to L2, chest tube
placement
History of Present Illness:
___ year old gentleman with h/o IVDU, recent SBO with ostomy,
chronic back pain with multiple disk herniations and recent hx
T12 osteomyelitis treated with ___ weeks vancomycin in ___, who is transferred to ___ from ___ with evidence of
progression of osteomyelitis with associated with paraspinal
abscesses.
In ___ s/p surgery for SBO, post-op course was complicated by
persistent MRSA bacteremia with a MRSA UTI. TEE and TTE did not
show endocarditis. He was treated with IV vancomycin and
gradually defervesced. An 8 week course of antibiotics was
planned as an inpatient (___ not trusted with patient's history
of recent IVDU-last reported IVDU in ___. Patient became
frustrated with hospital and left AMA after several weeks.
He felt well until ___ when he developed worsening back pain
and gradual immobility ___ to pain primarily. At ___ he was
found to have destructive T12 osteomyelitis. He was treated with
?8 weeks of IV antibiotics. After his treatment, he returned
home but has felt that his back pain and bilat ___ weakness has
been progressively worsening.
Three days PTA he had CT imaging showing severe T12
degeneration, MRI performed which showed " progression of
diskovertebral osteo, complete destruction of T12, retropulsion,
kyphotic deformity; LOH @ L1 and T11; epidural collection,
likely abscess, resulting in cord compression, ? incr signal at
T10-T11, probable bilat focal psoas abscesses and abnormal
prevertebral soft tissues; unable to tolerate additional imaging
and gad not given/con phase not performed". He was transferred
here after discussing with Dr. ___ spine surgeon. Has had
some urinary incontinence in recent days but attributed this to
being in so much pain he could not get up to go to bathroom. He
was given IV vanc at ___ ED, bcx drawn. He had
a fluctuating exam with ___ L dorsiflexion, R knee flexion and
extension, rectal tone intact. Pt thinks "possible" numbness,
has trouble specifying.
In the ED, labs were significant for CRP of 256. UA with many
bacteria. Spine/Neurosurgery was consulted who felt that he as
neurologically intact with full strength and that symptoms were
likely from pain. They recommended MRI for possible surgical
planning. Multiple trips to MRI were attempted but aborted by
pain. Imaging revealed total destruction of T12 with bulging
epidural abscess with diskitis. Probably sudural abscess with
retrocrural extension. Bilateral opacities in lung
(atelectasis). Increased interstial edema. He was given IV
dilaudid, klonopin, Ativan, ondansetron.
Past Medical History:
- T12 destructive osteomyelitis
- bilateral psoas abscesses
- MRSA bacteremia
- IVDU c/b Hepatitis C s/p treatment with Sovaldi
- Alcoholism in recovery
- Hypertension
- Diverticulosis
- Anxiety: Has seen psychiatry in the past
- Attention deficit, has seen psychiatry in the past
- Hyperlipidemia bulging lumbar discs: ___, L5-S1: ___
flaring chronic
- Hypothyroidism
- Anemia
Social History:
___
Family History:
Does not know of any medical problems in the family.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Vitals: T: 98.0 F BP: ___ P: ___ R: 18 O2: 98% 1 L
General: Lethargic, conversant, intermittently in pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: II/VI systolic murmur strongest at the RUSB
Abdomen: soft, TTP around stoma site, good stoma output
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:
Neuro: small pupils, EOMI, PERRL, intact cranial nerves, good
handgrip strength. ___ muscle strength bilaterally in ___, able
to lift legs off the bed, no focal motor or sensory deficits.
Good rectal tone.
PHYSICAL EXAMINATION ON DISCHARGE:
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL
EOMs: Intact
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 IP Q H AT ___ G
Sensation: Intact to light touch
Pertinent Results:
==ADMISSION LABS==
___ 02:30PM BLOOD WBC-10.9* RBC-4.43* Hgb-10.2*# Hct-31.9*#
MCV-72*# MCH-23.0*# MCHC-32.0 RDW-17.1* RDWSD-43.9 Plt ___
___ 02:30PM BLOOD Neuts-78.6* Lymphs-13.2* Monos-7.0
Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.60* AbsLymp-1.44
AbsMono-0.76 AbsEos-0.04 AbsBaso-0.03
___ 02:30PM BLOOD ___ PTT-32.1 ___
___ 02:30PM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-133
K-3.6 Cl-93* HCO3-28 AnGap-16
___ 02:30PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.9
___ 02:30PM BLOOD CRP-256.9*
==INTERIM LABS==
___ 06:05AM BLOOD CRP-173.6*
___ 05:40AM BLOOD HIV Ab-Negative
___ 06:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:05
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 63 H < OR = 20 mm/h
___
==DISCHARGE LABS==
==MICRO==
==IMAGING==
SPINE CT W/O CONTRAST ___:
1. Osseous destruction and complete collapse of the T12
vertebral body, with
bulging soft tissue density material surrounding this area of
osseous
destruction. The posterior soft tissue at the T12 level is
highly concerning
for an epidural collection.
2. Additional osseous destructive changes are seen in the
inferior endplate of
the T11 vertebral body, as well as the superior endplate of the
L1 vertebral
body.
3. Peripherally enhancing centrally hypodense lobulated
collections are seen
within the bilateral psoas muscles, centered about T12,
extending caudally
into the retrocrural space. These collections are consistent
with abscesses.
4. Bibasilar consolidations in the lungs may represent
atelectasis, however
pneumonia cannot be completely excluded.
5. Increased prominence of the interstitial markings in the lung
bases is
concerning for pulmonary edema.
MRI SPINE ___:
1. Discitis/osteomyelitis with abscess formation and resultant
near-complete
destruction of the T12 vertebral body and adjacent T11-12 and
T12-L1
intervertebral discs.
2. Extension of infection posteriorly represents anterior
epidural phlegmon.
There is resultant compression and cord signal abnormality the
extending from
T11 to the conus, concerning for new/worsening cord compression.
3. No definite abscess or drainable fluid collection within the
epidural
space.
4. Extension of infection to involve the prevertebral and
bilateral paraspinal
musculature from T9-L2/3. In particular, multiloculated psoas
abscesses are
larger since prior measuring up to 3.6 cm, as above.
5. Possible focus of osteomyelitis in the posterior aspect of
the T10
vertebral body, likely secondarily involved via extension from
the adjacent
paraspinal musculature. The T10-11 intervertebral disc is
normal in
appearance.
PRE-OP CHEST X RAY ___:
Cardiomediastinal contours are normal. Nonspecific patchy and
linear
opacities at the right lung base are probably due to atelectasis
although
coexisting aspiration or developing infectious pneumonia are
possible in the
appropriate clinical settings. Known T12 lesion is seen to
better detail on ___ dedicated spine MRI study.
==OTHER RESULTS==
EKG ___:
Sinus rhythm with normal intervals and no diagnostic
abnormalities. No
previous tracing available for comparison.
PSOAS ABSCESS DRAINAGE ___:
32 mm right and 20 mm left psoas fluid collections. The
remaining foci of
collections were not completely discernible due to lack of
contrast and better
delineated on previous CT and MRI. Destruction T12 vertebral
body with moderate erosions of inferior T12 endplate
and superior L1 endplate.
Complete drainage of bilateral psoas abscesses yielding purulent
fluid. No
drainage catheters were left.
CXR ___
Cardiomediastinal contours are normal. Nonspecific patchy and
linear
opacities at the right lung base are probably due to atelectasis
although
coexisting aspiration or developing infectious pneumonia are
possible in the appropriate clinical settings. Known T12 lesion
is seen to better detail on ___ dedicated spine MRI
study.
___ ___
Complete drainage of bilateral psoas abscesses yielding purulent
fluid. No drainage catheters were left.
Echo ___
No echocardiographic evidence of endocarditis or pathologic
flow. Normal biventricular cavity sizes with preserved global
and regional biventricular systolic function. Mildly dilated
ascending aorta.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Angio ___
Left T10-L1 segmental artery arteriogram did not show
significant supply to spinal cord. Artery of ___ was
not visualized in the above segmental vessels.
CXR ___: Small left apical pneumothorax
CT Cspine w/wo ___: Expected postoperative appearance
status post T11/___ corpectomy with extensive posterior spinal
fusion. The left pedicle screw at T11 level projects over the
left lateral recess. Clinical correlation recommended. There
is no evidence of hardware failure and the spinal alignment
appears anatomic. However, evaluation of the adjacent soft
tissues is severely limited secondary to extensive
hardware-related streak artifact.
CXR ___
Persistent, small left apical pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
2. ClonazePAM 1 mg PO QID
3. Tamsulosin 0.4 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. CloniDINE 0.2 mg PO QHS
6. Amphetamine-Dextroamphetamine 15 mg PO TID:PRN fatigue
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
8. Senna 8.6 mg PO BID:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Amphetamine-Dextroamphetamine 15 mg PO TID
3. ClonazePAM 1 mg PO QID:PRN anxiety
4. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain
5. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
6. Senna 17.2 mg PO QHS
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Diazepam 5 mg PO Q8H:PRN muscle spasm
9. Gabapentin 600 mg PO TID
10. Heparin 5000 UNIT SC TID
11. HydrALAzine 10 mg IV Q6H for SBP > 160
12. Omeprazole 40 mg PO BID
13. Simethicone 40-80 mg PO QID:PRN gas
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
15. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
16. Vancomycin 1250 mg IV Q 12H
17. Tamsulosin 0.4 mg PO QHS
18. CloniDINE 0.2 mg PO QHS
19. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T12 osteomyelitis
Anemia
Acute on chronic 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: CT L-SPINE W/ CONTRAST
INDICATION: ___ with known severe degenereation of ___ osteo, surrounding
abscesses // Eval for bony erosion, superior extension of abscesses
TECHNIQUE: Non-contrast helical multidetector CT was performed after the
intravenous administration of 100 mL of Omnipaque contrast agent. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 1,190 mGy-cm.
COMPARISON: Reference MRI of the lumbar spine dated ___.
FINDINGS:
There is near complete osseous destruction and complete collapse of the T12
vertebral body as seen on recent MRI from an outside hospital consistent with
osteomyelitis. Destructive changes also involve the inferior endplate of T11
and the superior endplate of L1. There is perivertebral soft tissue
thickening with discrete rim enhancing fluid collections in the paravertebral
space extending inferiorly along the upper portion of the psoas musculature.
The largest right-sided collection measures 7.1 x 3 x 2.5 cm. The largest
left-sided collection measures 3.4 x 3.5 x 1.5 cm. There is soft tissue
thickening along the central spinal canal spanning T11 through L1 which may
represent an epidural collection. Due to destructive changes in the T11
through L1 vertebral bodies there is a mild kyphotic angulation centered at
this level.
There is compressive lower lobe atelectasis in the lower lungs with mild
septal thickening which may indicate mild pulmonary edema. Scattered
prominent retroperitoneal lymph nodes are likely reactive. The kidneys
enhance homogeneously, without hydronephrosis, definite stones, or mass
lesions. The adrenal glands are normal in size and shape. Imaged bowel is
grossly unremarkable.
IMPRESSION:
1. Vertebral osteomyelitis and diskitis at the thoracolumbar junction with
complete destruction of the T12 vertebra, also involving the inferior endplate
of T11 and the superior endplate of L1.
2. Perivertebral soft tissue thickening with probable epidural abscess. MRI
may be performed to further evaluate.
3. Perivertebral abscesses extend into the upper psoas musculature, detailed
above. These may be amenable to percutaneous drainage.
4. Opacities in the lower lungs likely represent atelectasis less likely
pneumonia. Septal thickening suggests mild interstitial pulmonary edema.
NOTIFICATION: Impression was discussed with Dr. ___ by Dr. ___ by
phone at 12:30am on ___ approximately 45 minutes after discovery.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ man with history of MRSA bacteremia, known
destructive T12 vertebral body osteomyelitis and psoas muscle abscesses,
evaluate for epidural abscess.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 6 mL of
Gadavist contrast agent.
COMPARISON: MRI L-spine ___.
FINDINGS:
The T12 vertebral body demonstrates near complete destruction and collapse.
Intrinsically T1 isointense and heterogeneous, mixed T2 hypo- and hyperintense
material occupies much of the T11- L1 interval, replacing the normal T12
vertebral body and T11-T12 and T12-L1 intervertebral discs, and demonstrates
heterogeneous enhancement following contrast administration (series 16, image
7 and 8). There are areas of non-enhancement internally, compatible with
mixed phlegmon and multifocal abscesses, the largest of which measures 4.3 x
2.1 x 1.7 cm (TV by CC by AP). A T1 and T2 hypointense, nonenhancing focus
posteriorly likely represents residual necrotic T12 vertebral body (series 3,
image 8).
There is bulging of the enhancing material posteriorly into the anterior
epidural space; in particular, an irregular enhancing soft tissue collection
posteriorly, anterior to the spinal cord within the epidural space, measures
6.7 cm in craniocaudal extent, concerning for anterior epidural phlegmon. A
tiny focus of non enhancement internally is millimetric in size, possibly a
developing focus of abscess, but there is no drainable fluid collection. There
is resultant mass effect on the spinal cord (see series 16, image 8 and series
7, image 31), with worsening heterogeneous T2 cord signal abnormality
extending from T11 to the conus medullaris, concerning for new/worsening cord
compression.
Again seen is involvement/extension of infection into the bilateral paraspinal
and psoas musculature. In particular, T2 hyperintense collections within the
psoas muscles are larger, currently measuring 3.3 x 2.5 cm on the right
(series 7, image 35, previously 2.5 x 1.6 cm on ___ and 3.6 x 1.6 cm on
the left (series 7, image 37, previously 1.8 x 1.7 cm). These appear
continuous with the adjacent process centered on the T12 vertebral body, and
likely reflect extension of infection and resultant psoas muscle abscesses.
Overall, the extent of paraspinal musculature involvement extends from T9 to
L2/3.
A focus of intrinsically T1 hypointense, T2 hyperintense and enhancement of
the posterior T10 vertebral body, without signal abnormality of the
intervening T10-11 intervertebral disc, may represent secondary osteomyelitis
of the posterior T10 vertebral body via extension from paraspinal musculature.
The remaining thoracolumbar vertebral bodies demonstrate normal alignment.
There are minimal multilevel posterior disc bulges within the lumbar spine
without resultant spinal canal or neural foraminal narrowing. The remaining
thoracolumbar intervertebral discs demonstrate normal signal intensity.
IMPRESSION:
1. Discitis/osteomyelitis with abscess formation and resultant near-complete
destruction of the T12 vertebral body and adjacent T11-12 and T12-L1
intervertebral discs.
2. Extension of infection posteriorly represents anterior epidural phlegmon.
There is resultant compression and cord signal abnormality the extending from
T11 to the conus, concerning for new/worsening cord compression.
3. No definite abscess or drainable fluid collection within the epidural
space.
4. Extension of infection to involve the prevertebral and bilateral paraspinal
musculature from T9-L2/3. In particular, multiloculated psoas abscesses are
larger since prior measuring up to 3.6 cm, as above.
5. Possible focus of osteomyelitis in the posterior aspect of the T10
vertebral body, likely secondarily involved via extension from the adjacent
paraspinal musculature. The T10-11 intervertebral disc is normal in
appearance.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ year old man with h/o MRSA bacteremia, known destructive T12
osteo, psoas abscesses // pre-op Surg: ___ (epidural abscess removal)
COMPARISON: No prior chest radiographs
IMPRESSION:
Cardiomediastinal contours are normal. Nonspecific patchy and linear
opacities at the right lung base are probably due to atelectasis although
coexisting aspiration or developing infectious pneumonia are possible in the
appropriate clinical settings. Known T12 lesion is seen to better detail on ___ dedicated spine MRI study.
Radiology Report
EXAMINATION: CT-guided drainage.
INDICATION: ___ year old man with known osteomyelitis, destroyed T12, with b/l
psoas abscesses R>L // pls drain psoas abscesses
COMPARISON: CT spine ___
PROCEDURE: CT-guided drainage of bilateral psoas muscle collection.
OPERATORS: Dr. ___ radiology fellow, Dr. ___
resident ___ 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 CT scan was performed to localize the collection. Based on the CT
findings an appropriate skin entry site for drainage was chosen. The site was
marked. Local anesthesia was administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the right collection . A sample of fluid was aspirated,
confirming needle position within the collection. 0.038 ___ wire was
placed through the needle and needle was removed. This was followed by
placement of ___ pigtail catheter into the collection. The
stiffener and the wire were removed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy. 30 cc of purulent material
was aspirated. When there was no further return, the catheter was removed.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the left collection . A sample of fluid was aspirated,
confirming needle position within the collection. 0.038 ___ wire was
placed through the needle and needle was removed. This was followed by
placement of ___ pigtail catheter into the collection. The
stiffener and the wire were removed. The position of the pigtail was confirmed
within the collection via CT fluoroscopy. 3 cc of purulent material was
aspirated. When there was no further return, the catheter was removed.
Sterile dressing was applied. The procedure was tolerated well, and there were
no immediate post-procedural complications.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Spiral Acquisition 4.9 s, 15.0 cm; CTDIvol = 6.7 mGy (Body) DLP
= 92.0 mGy-cm. 4) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 49.5 mGy
(Body) DLP = 24.8 mGy-cm. Total DLP (Body) = 129 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
3.5 mg Versed and 175 mcg fentanyl throughout the total intra-service time of
35 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
32 mm right and 20 mm left psoas fluid collections. The remaining foci of
collections were not completely discernible due to lack of contrast and better
delineated on previous CT and MRI.
Destruction T12 vertebral body with moderate erosions of inferior T12 endplate
and superior L1 endplate.
IMPRESSION:
Complete drainage of bilateral psoas abscesses yielding purulent fluid. No
drainage catheters were left.
Radiology Report
CLINICAL HISTORY ___ year old man with T12 osteomyelitis, scheduled for
T11-T12 corpectomy and fusion ___. // Pre-operative embolization in
preparation for ___ sx with Dr. ___.
EXAMINATION: Left T10 segmental artery arteriogram.
Left T11 segmental artery arteriogram.
Left T12 segmental artery arteriogram.
Left L1 segmental artery arteriogram.
Right T11 segmental artery arteriogram. Right L1 segmental artery
arteriogram.
Right common femoral artery arteriogram and Angio-Seal closure of right common
femoral artery puncture site with 6 ___ Angio-Seal.
ANESTHESIA: ANESTHESIA: MAC. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
TECHNIQUE: OPERATORS: Dr. ___ MD,
PROCEDURE: The patient was brought to the angiography suite. IV sedation was
given. Both groins were prepped and draped in a sterile fashion. Access was
gained to the femoral artery using a Seldinger technique and a 5 vascular
sheath was placed in the right common femoral artery. The above-mentioned
spinal arteries were catheterized and AP filming was performed. This
demonstrated that the artery of ___ did not originate from these
vessels.
FINDINGS:
Left T10 segmental artery arteriogram does not show any evidence of
significant supply to the spinal cord.
Left T11 segmental artery arteriogram does not show any evidence of
significant supply to the spinal cord.
Left T12 segmental artery arteriogram does not show any evidence of
significant supply to the spinal cord
Left L1 segmental artery arteriogram does not show any evidence of significant
supply to the spinal cord .
Right T11 segmental artery arteriogram does not show any evidence of
significant supply to the spinal cord .
Right L1 segmental artery arteriogram does not show any evidence of
significant supply to the spinal cord.
Right common femoral artery arteriogram shows widely patent right common
femoral artery.
IMPRESSION:
Artery of ___ was not visualized in the above segmental vessels
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ year old man with osteomylytis. Preop.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 9.8 s, 38.5 cm; CTDIvol = 31.4 mGy (Body) DLP =
1,208.3 mGy-cm.
Total DLP (Body) = 1,208 mGy-cm.
COMPARISON: MR thoracic spine ___, CT interventional procedure ___
FINDINGS:
There are 12 rib-bearing vertebrae.
T12 vertebral body is nearly completely destroyed, as seen previously. Small
posterior remnant of T12 vertebral body is sclerotic, with sclerosis extending
into the bilateral pedicles. There is destruction of the T11 inferior
endplate and L1 superior endplate with irregular sclerotic margins. There is
a kyphotic angulation centered at T12. The prior MRI better demonstrates the
abscess spanning the T11-T12 disc, T12 vertebral body remnant, and T12-L1
disc. The prior MRI also better demonstrates the epidural phlegmon centered
at T12 with associated spinal canal narrowing.
T1 through T10 vertebrae demonstrate normal vertebral body heights without
evidence for osseous destruction. Of note, T10 vertebral body demonstrated in
a area of marrow edema on the recent MRI.
Images through the lower cervical spine demonstrate right greater than left
central disc osteophyte complex causing moderate spinal canal stenosis at
C6-7, with left greater than right neural foraminal narrowing due to
uncovertebral osteophytes at C6-7 right C7-T1 neural foramen is mildly
narrowed by facet arthropathy.
Small Schmorl's nodes are present at multiple mid and lower thoracic levels.
Significant decrease in size of the multiloculated right psoas fluid
collection now measuring 1.5 x 1.1 cm (previously 1.9 x 1.4 cm) along its
largest component. Left psoas fluid collection also appears decreased.
However, these are not fully evaluated in the absence of intravenous contrast.
Left para-aortic lymphadenopathy is adequately reassessed compared to ___ contrast enhanced lumbar spine CT.
Paratracheal lymph nodes measure up to 1.0 cm in short axis diameter on the
left. Subcarinal lymph nodes measure up to 1.0 cm in short axis diameter.
There are small bilateral pleural effusions, partially visualized, with
adjacent dependent atelectasis.
IMPRESSION:
1. Near complete destruction of T12 vertebral body is again demonstrated, with
a small sclerotic posterior vertebral body remnant and sclerosis extending
into bilateral pedicles. Destruction of the T11 inferior endplate and L1
superior endplate is also again seen, marginated by irregular sclerosis.
Unchanged kyphotic angulation centered at T12.
2. Abscess involving the T11-12 and T12-L1 disc spaces was better demonstrated
on the ___ MRI.
3. Epidural phlegmon centered at T12 with associated spinal canal narrowing
were also better demonstrated on the ___ MRI.
4. Previously noted bilateral psoas collections appear improved, but are not
fully visualized and and not adequately evaluated in the absence of
intravenous contrast. Left para-aortic lymphadenopathy is also not adequately
reassessed.
5. Borderline enlarged paratracheal and subcarinal lymph and small bilateral
pleural effusions may be reactive.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:22 AM, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with osteomyelitis // preop Surg: ___ (T12
corpectomy) OSTEOMYELITIS
IMPRESSION:
In comparison with the study of ___, there has been some decrease in the
opacification at the right base, most likely due to atelectasis. No evidence
of acute pneumonia or vascular congestion.
Severe changes in the lower lobe thoracic region are consistent with known
osteomyelitis.
Radiology Report
EXAMINATION: Intra op fluoroscopic images
INDICATION: T12 and T11 corpectomy and placement of inter vertebral bio
mechanical device
TECHNIQUE: Fluoroscopic study
COMPARISON: CT of the spine from ___
FINDINGS:
31 intraoperative images were acquired without a radiologist present.
Images show corpectomy of lower thoracic vertebra and placement of expandable
cage. Suboptimal evaluation of thoracic spine.
Fluoroscopic time is 41 seconds.
IMPRESSION:
Intraoperative images during corpectomy of thoracic spine and placement of a
biomechanical device. Please refer to the operative note for details of the
procedure.
Radiology Report
EXAMINATION: Intra op fluoroscopy
INDICATION: Posterior T9 through L2 fusion
TECHNIQUE: Fluoroscopic images in the OR
COMPARISON: CT from ___
FINDINGS:
7 intraoperative images were acquired showingan expandable cage, pedicle
screws and posterior vertical rods spanning at least 6 vertebrae which include
lower thoracic and upper lumbar spine.
Fluoroscopic time is 1 minutes and 17 seconds.
IMPRESSION:
Intraoperative images were obtained during posterior fusion of lower thoracic
and upper lumbar spine.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man chest tube placement for anterior spinal fusion.
// chest tube placement/?pneumothorax chest tube placement/?pneumothorax
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable. Lungs are essentially clear with
bibasal atelectasis. Left chest tube is in place. No pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube // r/o effusion, please perform
at 1000 on ___ r/o effusion, please perform at 1000 on ___
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable. Left chest tube is in place. Small
left apical pneumothorax is present, not seen on previous examination. . No
pleural effusion is noted. Right basal atelectasis is minimal.
Radiology Report
EXAMINATION: AP and lateral chest radiographs
INDICATION: ___ year old man s/p L chest tube after T11-T12 corpectomy and
multi-level fusion. // Chest tube pulled at 1400. Please perform x-ray to
assess for pneumothorax around 1600 today.
TECHNIQUE: Chest AP and lateral
COMPARISON: Portable chest radiograph dated ___ at 10:02
FINDINGS:
In comparison to the chest radiograph obtained 6 hours prior, there has been
interval removal of the left-sided chest tube with no change in the small left
apical pneumothorax. A small amount of subcutaneous emphysema is unchanged.
Heart size, mediastinal silhouette, and right basilar atelectasis are
unchanged.
IMPRESSION:
Interval removal of a left-sided chest tube with no change in the small left
apical pneumothorax.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ year old man with s/p Corpectomy T11/12 and PSF T9 to L2.
Please evaluate fusion // ___ year old man with s/p Corpectomy T11/12 and PSF
T9 to L2. Please evaluate fusion ___ year old man with s/p Corpectomy
T11/12 and PSF T9 to L2. Please evaluate fusion
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 25.7 s, 39.3 cm; CTDIvol = 21.1 mGy (Body) DLP =
801.5 mGy-cm.
Total DLP (Body) = 818 mGy-cm.
COMPARISON: CT T-spine dated ___.
FINDINGS:
There has been interval corpectomy of the T11 and T12 vertebral bodies, with
posterior spinal fusion extending from the level of T9-L2. There is no
evidence of hardware fracture or periprosthetic lucency to to suggest hardware
loosening. A vertebral body spacer now replaces the T11 and T12 vertebrae.
Overall, alignment appears grossly anatomic. A central depression involving
the superior endplate of the L1 vertebral body is unchanged.
Expected postoperative changes are noted, including subcutaneous edema
multiple foci of air within the pararenal/retroperitoneal space, and numerous
surgical clips. A surgical drain terminates at the level of L1-L2.
Evaluation of the surrounding soft tissues and spinal canal is limited
secondary to extensive streak artifact. Limited assessment of the lung bases
demonstrates bibasilar consolidations most compatible with atelectasis.
IMPRESSION:
Expected postoperative appearance status post ___ corpectomy with extensive
posterior spinal fusion. The left pedicle screw at T11 level projects over
the left lateral recess. Clinical correlation recommended. There is no
evidence of hardware failure and the spinal alignment appears anatomic.
However, evaluation of the adjacent soft tissues is severely limited secondary
to extensive hardware-related streak artifact.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with chest tube d/c'd ___ // Evaluate for PTX
TECHNIQUE: AP and lateral views of the chest were obtained.
COMPARISON: ___
FINDINGS:
The cardiomediastinal silhouette and pulmonary vasculature are unremarkable
and unchanged since most recent examination. The lungs are clear aside from
bibasilar atelectasis. Again noted is a small left apical pneumothorax.
Minimal subcutaneous emphysema is noted. The stomach is distended.
IMPRESSION:
Persistent, small left apical pneumothorax.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with 45cm right PICC. ___ ___ // 45cm right
PICC. ___ ___ Contact name: ___: ___ right PICC.
___ ___
IMPRESSION:
New right-sided PICC line. The course of the line is unremarkable, the tip of
the line. Projects over the cavoatrial junction. No complications, notably
no pneumothorax. The stomach remains overinflated. And could be decompressed
by insertion of a nasogastric tube.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Leg weakness
Diagnosed with Osteomyelitis of vertebra, thoracic region
temperature: 98.5
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 91.0
level of pain: 9
level of acuity: 2.0 | ___ year old male with h/o IVDU, recent SBO with ostomy in ___
___, chronic back pain with multiple disk herniations and
recent hx T12 osteomyelitis treated with ___ weeks vancomycin in
___ with evidence of progression of osteomyelitis with
associated with paraspinal asbcesses. He was transferred to the
ED on the day of admission, ___ ___ for
spine surgery evaluation.
On ___, the patient underwent a MRI for possible ___ drainage of
psoas abscess.
On ___, the patient underwent a bilateral psoas muscle abscess
drainage.
On ___, the patient was transferred from medicine to
neurosurgery.
On ___, the patient underwent an ECHO which was negative for
endocarditis. He underwent a spinal diagnostic angiogram later
that day.
On ___, the patient remained neurologically stable on
examination. His Vanc trough was 22 and his Vancomycin was
decreased to 1g every 12 hours. He noted new onset bilateral
anterior thigh radiculopathy. He was started on Gabapentin BID
dosing.
___: Neuro exam stable. To start Gabapentin TID dosing today.
HCT downtrending to 23.7/7.2; Vanco level 18.6
___: Transfused for H/H 6.___. Sent anemia labs.
Re-consulted Medicine. ___ discontinued as medicine thinks there
may be an internal bleed.
___: vanco 16.3, added bowel meds
___: 1 units packed cells, consent for surgery, t spine ct no
contrast
___: OR, chest tube placed intraop
___: Chest tube to waterseal by Thoracics, CXR at 1000 with
small PTX. AM CXR ordered per Thoracic.
___: Micro called- growing rare staph aureus in the vertebral
body sent from OR on ___. Dressing removed, drain kept in
place. Hct drop 3 pts today.
___: Patient is doing well and continues to work with ___. Pt
was evaluated by CPS today who recommended stopping the PCA and
starting him on Oxycodone 20mg PO Q 4 PRN pain and continuing
his Oxycontin. His Hgb and HCT was 7.1 and 22.4, however he
remains asymptomatic and we will continue to trend his levels.
His JP put out 40cc overnight and was removed.
___: The patient's hemoglobin was 7.6, though he remained
asymptomatic. His pain was well controlled. The vancomycin
dosing was increased to 1250 q12 for trough 11.8
___: His hemoglobin was 7.3, and again was asymptomatic. His
back brace was available at bedside.
___: The hemoblgobin was up to 8.1, and hematocrit up to 25.2.
An order was placed for a PICC line to be placed for longterm
vancomycin treatment. The screening process for rehab was
initiated.
On ___ PICC line was placed. He was screened for rehab
placement. His Hct/Hgb was stable.
On ___ Patient remained stable awaiting insurance
authorization for discharge to rehab. Home medications adderal,
gabapentin and klonopin were restarted.
On ___, the patient remained hemodynamically and
neurologically stable with no overnight events. The patient was
transitioned to PO pain medication. His insurance was accepted
for rehab, and he is stable and ready for discharge to rehab for
ongoing physical therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Minocycline / Tetracycline
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ left thoracentesis
History of Present Illness:
___ yo male s/p CABGx3 (LIMA-ALD, SVG-OM, SVG-Ramus) on ___.
Overall he tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He developed slow
afib post-operatively but lopressor was initially held due to
continued hypotension. On POD#2, he received 2 units of PRBC for
a hematocrit of 17. Stat bedside echo was unremarkable. Plavix
was resumed for his history of DES placed in ___. He
transferred to the telemetry floor for further recovery. He was
started on coumadin for persistent atrial fibrillation. He
continued to have paroxysmal atrial fibrillation and Amiodarone
was initiated. His Hct remained low but stable. He was
discharged to home on ___. He was doing well initially
except for some persistent SOB with minimal exertion and stairs.
Over the past
few nights, he experienced PND, awakening several times per
night. Otherwise he has felt well - no CP, palitations, pain
well controlled. He presented to PCP for ___ routine follow up and
was unable to lie flat for an exam. His PCP sent him to the ED
for further evaluation.
Past Medical History:
Past Medical History:
MI ___, angioplasty 6 months later
DMII
dyslipidemia
Hypertension
BPH
Past Surgical History:
herniorrhaphy
Past Cardiac Procedures:
angioplasty ___
DES to Cx ___
Social History:
___
Family History:
Family History: Premature coronary artery disease
Father MI < ___ [] Mother < ___ []
Father died in his ___, had MI in late ___
Physical Exam:
T 98.8
Pulse:72 Resp:18 O2 sat: 95-96% RA
B/P Right: 123/60 Left:
Height: 5'7" Weight: 176 (reported)
General: AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [] Decreased left base
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
___ 05:25AM BLOOD WBC-10.9 RBC-3.68* Hgb-10.4* Hct-33.5*
MCV-91 MCH-28.4 MCHC-31.2 RDW-15.0 Plt ___
___ 05:25AM BLOOD ___ PTT-30.9 ___
___ 05:25AM BLOOD Glucose-145* UreaN-26* Creat-1.3* Na-133
K-4.4 Cl-97 HCO3-26 AnGap-14
___ 12:16AM BLOOD ALT-19 AST-19 LD(LDH)-258* AlkPhos-69
Amylase-61 TotBili-0.5
___ ___ M ___ ___
Radiology Report CHEST (PORTABLE AP) Study Date of ___
12:15 ___
___ CSURG FA6A ___ 12:15 ___
CHEST (PORTABLE AP) Clip # ___
Reason: eval effusion post thoracentesis
Final Report
CHEST RADIOGRAPH
HISTORY: ___ man status post CABG. Evaluate for
effusion after
thoracentesis.
An AP portable upright chest radiograph shows significant
diminution in what was previously a large left pleural effusion.
There is now only some haziness in the left costophrenic and
cardiophrenic angles and residual overlying plate-like
subsegmental atelectasis. No pneumothorax. Intact sternal wires
are seen in this patient status post CABG.
CONCLUSION: Notable decrease in left pleural effusion with
residual overlying subsegmental atelectasis at the left base.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Glucovance *NF* (glyBURIDE-metformin) 1.25-250 ORAL BID
6. Amiodarone 400 mg PO BID
___ bid x 1 week, then 400mg daily x 1 week, then 200mg daily
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Metoprolol Tartrate 12.5 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Furosemide 20 mg PO DAILY Duration: 5 Days
11. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
12. Ranitidine 150 mg PO BID
13. Warfarin 5 mg PO DAILY16 dose to change daily for goal INR
___, Dx: AFib, Dr. ___ to manage - Pt has been alternating
5 mg and 2.5 mg
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Tamsulosin 0.4 mg PO HS
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Furosemide 40 mg PO BID Duration: 7 Days
11. Potassium Chloride 20 mEq PO BID Duration: 7 Days
12. Omeprazole 20 mg PO QOD
13. Clopidogrel 75 mg PO DAILY
14. GlyBURIDE 2.5 mg PO BID
15. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
s/p Left thoracentesis ___
s/p Urgent coronary artery bypass graft x3: ___
Left internal mammary artery to left anterior descending
artery and saphenous vein graft to distal circumflex and
ramus arteries
Past Medical History:
MI ___, angioplasty 6 months later
DMII
dyslipidemia
Hypertension
BPH
Past Surgical History:
herniorrhaphy
Past Cardiac Procedures:
angioplasty ___
DES to Cx ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath status post CABG.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The patient is status post median sternotomy and CABG. There has been
interval increase in size of the left pleural effusion which is now large, and
obscures assessment of the cardiac silhouette size. No pulmonary vascular
congestion is identified, and there is mild rightward shift of mediastinal
structures. The mediastinum is not widened. Left basilar compressive
atelectasis is demonstrated. Right lung is clear. Trace right pleural
effusion is slightly smaller compared to the prior study. No pneumothorax is
identified. No acute osseous abnormalities are seen.
IMPRESSION:
Increased size of left pleural effusion which is now large with associated
left basilar atelectasis. Trace right pleural effusion.
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: CABG. Check left effusion.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
persistent large left pleural effusion with associated atelectasis, stable in
appearance as compared to the prior study. There is very slight rightward
shift of the cardiac silhouette, stable. There is slight blunting of the
posterior right costophrenic angle which may be due to a trace right pleural
effusion. No focal consolidation is seen in the right lung. There is no
pneumothorax. The cardiac and mediastinal contours are stable, although not
well evaluated given the large left pleural effusion.
IMPRESSION: Stable large left pleural effusion with overlying atelectasis.
Possible trace right pleural effusion.
Radiology Report
CHEST RADIOGRAPH
HISTORY: ___ man status post CABG. Evaluate for effusion after
thoracentesis.
An AP portable upright chest radiograph shows significant diminution in what
was previously a large left pleural effusion. There is now only some haziness
in the left costophrenic and cardiophrenic angles and residual overlying
plate-like subsegmental atelectasis. No pneumothorax. Intact sternal wires
are seen in this patient status post CABG.
CONCLUSION: Notable decrease in left pleural effusion with residual overlying
subsegmental atelectasis at the left base.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with SHORTNESS OF BREATH, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 98.8
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 123.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | The patient had a large left effusion on chest xray. His INR on
admission was 2.4 and his coumadin was held. He was diuresed
but there was no change in the effusion. His INR came down to
1.7 and he had a left thoracentesis and 2 liters of
serosanguineous drainage was obtained. His breathing improved
greatly. He remained in sinus rhythm throughout this
hospitalization and his coumadin was discontinued. His blood
sugars had been high and his metformin and glucophage were
increased. He was discharged to home in stable condition with
follow up appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Liver disease
Biloma
Hyperkalemia
Hyponatremia
Major Surgical or Invasive Procedure:
___:
1. Cholangiogram through existing right percutaneous
transhepatic biliary drainage access.
2. Exchange of the existing right percutaneous transhepatic
biliary drainage catheter with a new 10 ___ anchor catheter.
3. Sinogram through existing left drain
4. Exchange of left drain to a 10 ___ APD L
.
___
1. Scout radiograph image of the indwelling drains
2. Antegrade cholangiogram through the indwelling anchor drain.
3. Drain check injection through the existing percutaneous drain
in the hepatic collection
4. Over the wire Pull-back cholangiogram via the right PTBD
5. Balloon angioplasty of the hepaticojejunostomy using a 6 mm
Conquest balloon
6. Post HJ plasty antegrade cholangiogram
7. New right 10 ___ biliary internal-external drainage
catheter.
History of Present Illness:
Mr. ___ is a ___ year old male well known to the
Transplant Surgery service who underwent a DDLT in ___ for
HCV cirrhosis and HCC and has a had a prolonged postoperative
course complicated by hepatic artery thrombosis with hepatic
lobe
necrosis, early mild to moderate cellular rejection, infected
biloma with recurrent bacteremia, multiple intraabdominal
collections, several ___ interventions, and a right iliacus
hematoma causing RLE compression paralysis, resolved with ___
drainage and multiple hospitalization. He was most recently
admitted ___ for failure to thrive and acute SDH
after several falls at home. He was also noted to have increased
fluid collections and underwent ___ drainage exchange of existing
left hepatic lobe drain with ___ APDL. He was continued on
pre-admission Daptomycin and Cefepime.
Today, he presented to for scheduled CT scan to evaluate his
known collections. At the appointment his Cr was elevated to
7.3. He was sent to the ED for hyperkalemia management. His
repeat K was decreased to 6.9 upon presentation. In the ED renal
transplant was consulted and they recommend he receive calcium
gluconate, insulin/dextrose, sodium bicarb, and 20 IV Lasix. His
repeat K was 6.4, however he had not the sodium bicarb and lasix
at this point. He is receiving sodium bicarb (150 in D5W) and 20
lasix then we will plan to repeat again once he has received
these medications. He reports eating a diet rich in tomatoes/red
sauce and potatoes over the last few days. He continues to have
some output from his known abscess cavity, requiring emptying
his
bag approximately every other day. He reports he had been
working
with ___ at rehab but it continues to weakness and pain in his
RLE
which he developed after he developed a right iliacus hematoma.
He denies any other symptoms including fevers, chills, cough, or
urinary symptoms.
Past Medical History:
PMH: HCV cirrhosis (c/b portal HTN with grade II/III varies),
HCC (s/p RFA ___, TIPS & revisions, emboldened of coronary v.),
insulin-dependent DM, esophageal vatical bleed, pancreatitis,
non-occlusive splenic vein thrombosis, thrombocytopenia,
hypersplenism, diverticulitis, colonic polyps
PSH: ddLT w RnYHJ (___) c/b HAT, multiple ___ drainage
procedures, TIPS procedure ___, extension ___, revision
___, embolization of coronary vein supplying esophageal &
gastric varices
Social History:
___
Family History:
Mother died of breast cancer. Father died at age ___. He has a
healthy daughter and healthy siblings.
Physical Exam:
Exam on Admission:
Vitals: 98.0, 80, 118/93, 18, 100% RA
Gen: cachectic, no acute distress
Head: NC/AT, well healed scar right temporal region, mild
temporal wasting
CV: regular rate and rhythm
Pulm: breathing comfortably on room air
Abd: Soft, nondistended, nontender, incisional scars well
healed,
R ___ drain with minimal bilious output, PTBD capped
Ext: warm and well perfused, no edema
Psych: appropriate affect
.
Exam at Discharge:
24 HR Data (last updated ___ @ 019)
Temp: 98.6 (Tm 99.4), BP: 114/68 (101-114/65-70), HR: 83
(79-88), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: Ra,
Wt: 152.7 lb/69.26 kg
Fluid Balance (last updated ___ @ 2142)
Last 8 hours Total cumulative -35ml
IN: Total 0ml
OUT: Total 35ml, Urine Amt 0ml, PTBD 35ml
Last 24 hours Total cumulative 711ml
IN: Total 1341ml, PO Amt 1140ml, IV Amt Infused 201ml
OUT: Total 630ml, Urine Amt 500ml, PTBD 130ml, abscess
drain 0ml
GENERAL: [x]NAD [x]A/O x 3
CARDIAC: [x]RRR
LUNGS: [x]no respiratory distress
ABDOMEN: [x]soft [x]Nontender [x]nondistended
Abdomen: R PTBD with bilious output, L drain with scant bilious
output
EXTREMITIES: [x]no CCE Able to move R leg against gravity,
strength reduced compared to Left
Pertinent Results:
Labs on Admission: ___
WBC-4.8 RBC-4.29* Hgb-11.3* Hct-37.4* MCV-87 MCH-26.3 MCHC-30.2*
RDW-15.5 RDWSD-49.5* Plt ___ PTT-32.6 ___
Glucose-171* UreaN-58* Creat-1.3* Na-132* K-7.3* Cl-105 HCO3-15*
AnGap-12
___ 09:35AM K-7.4*
ALT-172* AST-73* AlkPhos-1138* TotBili-0.5
Albumin-4.1 Calcium-10.6* Phos-4.0 Mg-1.7
tacroFK-9.2
.
Labs at Discharge: ___
CMV VL-NOT DETECT
WBC-3.4* RBC-3.54* Hgb-9.1* Hct-29.8* MCV-84 MCH-25.7*
MCHC-30.5* RDW-15.9* RDWSD-48.3* Plt Ct-97*
Glucose-142* UreaN-21* Creat-0.6 Na-130* K-4.8 Cl-94* HCO3-24
AnGap-12
ALT-75* AST-30 AlkPhos-1028* TotBili-0.7
Calcium-9.6 Phos-2.9 Mg-1.7
tacroFK-3.6*
.
___ BLOOD IMMUKNOW-PND
.
___ 8:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
___ 4:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID:PRN cough
2. CefePIME 2 g IV Q12H
3. Daptomycin 800 mg IV Q24H
4. Dronabinol 2.5 mg PO BID
5. Fluconazole 400 mg PO Q24H
6. Gabapentin 300 mg PO TID
7. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 0 units
subcutaneous TID W/MEALS
8. Lantus U-100 Insulin (insulin glargine) 30 units subcutaneous
QHS
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Pantoprazole 40 mg PO Q12H
13. PredniSONE 5 mg PO DAILY
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Ursodiol 300 mg PO BID
16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
17. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
18. Aspirin 81 mg PO DAILY
19. Psyllium Powder 1 PKT PO BID:PRN constipation
20. Tacrolimus 1 mg PO Q12H
Discharge Medications:
1. Dapsone 100 mg PO DAILY
2. Aspart 12 Units Breakfast
Aspart 12 Units Lunch
Aspart 12 Units Dinner
Levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Gabapentin 400 mg PO TID
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
Maximum 4 of the 500 mg tablets daily
6. Aspirin 81 mg PO DAILY
7. Benzonatate 100 mg PO BID:PRN cough
8. CefePIME 2 g IV Q12H
RX *cefepime 100 gram 2 g IV twice a day Disp #*60 Intravenous
Bag Refills:*1
9. Daptomycin 800 mg IV Q24H
RX *daptomycin 500 mg 800 mg IV once a day Disp #*30 Intravenous
Bag Refills:*1
10. Dronabinol 2.5 mg PO BID
11. Fluconazole 400 mg PO Q24H
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. PredniSONE 5 mg PO DAILY
16. Psyllium Powder 1 PKT PO BID:PRN constipation
17. Tacrolimus 1 mg PO Q12H
18. Ursodiol 300 mg PO BID
19.Right ___ Brace S74.10XA supply one, wear when out of bed
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyperkalemia
History of liver transplant
DM
h/o right iliacus hematoma with right femoral nerve compression
Right leg numbness/pain/weakness
Neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
and ___ brace)
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABDOMEN W/CONTRAST
INDICATION: Please eval for abscess for improvement to help with antibiotic
management,. // Please eval for improvement of hepatic abscess.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.8 s, 37.2 cm; CTDIvol = 11.1 mGy (Body) DLP = 411.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.1 mGy (Body) DLP =
15.0 mGy-cm.
Total DLP (Body) = 429 mGy-cm.
COMPARISON: Prior CT dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Patient is status post deceased liver transplant with Roux-en-Y
hepaticojejunostomy. There has been stenting of the proper hepatic artery.
Again seen are 2 percutaneous biliary drains in unchanged position. Fluid
surrounding drains has nearly completely resolved. There is unchanged
intrahepatic biliary dilatation.
Previously seen cluster of hypodensities in segment 8 now visualized as a
single hypoattenuating lesion measuring 9 x 11 mm, decreased in size compared
to prior.
There has also been interval decrease in size with resolution of internal gas
of a hypoattenuating lesion within segment 6 measuring 2.0 x 2.8 cm
(previously measured 2.7 x 2.3 cm).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is splenomegaly. There are multiple wedge-shaped hypodense
lesions which represent sequelae of prior infarcts. There has been interval
decrease in size of a previously drained fluid collection at the left inferior
aspect of the spleen measuring 5.7 x 1.6 x 2.0 cm (previously measured 8.6 x
3.1 x 8 cm). More centrally located fluid collection now spans up to 6.2 cm.
Spleen is enlarged measuring 16.9 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Large left
lower pole simple cyst measures 3.9 x 4.1 cm.
GASTROINTESTINAL: The stomach is unremarkable. Visualized small and large
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Degenerative changes are seen in the lumbar spine. There is an
unchanged wedge compression deformity of L1 vertebra
SOFT TISSUES: There is subcutaneous air in the anterior abdominal soft tissue
possibly due to recent injection.
IMPRESSION:
1. There has been near resolution of fluid surrounding 2 percutaneous drains
near the gallbladder fossa.
2. Interval decrease in size of hypoattenuating lesions in segment 8 and
segment 6 of the liver. The lesion in segment 6 has also had interval
resolution of internal gas.
3. Trace fluid remains near previously drained fluid collection adjacent to
the lateral inferior spleen.
4. There has been decrease in size of more centrally located fluid collection
in the spleen.
5. No new O focal fluid collections.
6. Unchanged splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with OSH placed PICC // please comment on
position
TECHNIQUE: AP chest x-ray
COMPARISON: AP chest x-ray dated ___
FINDINGS:
Lungs are well expanded and clear. Cardiomediastinal and silhouette are
normal. No pneumothorax or pleural effusion. The right PICC line terminates
within the upper SVC. Acute osseous abnormalities. Perihepatic drains and
prior embolization coils partially project over the abdomen.
IMPRESSION:
The right PICC line terminates within the upper SVC.
Radiology Report
INDICATION: ___ year old man with h/o DDLT w RNY HJ c/b HAT, infected biloma,
VRE bacteremia splenic bleed s/p perc embo of PSA. Recent cholangiogram with
6mm balloon dilatation. Patient presents for cholangiogram // routine follow
up cholangiogram
COMPARISON: Multiple prior examinations and CT
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 9 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:
CONTRAST: 10 ml of OPTIRAY contrast
FLUOROSCOPY TIME AND DOSE: 2 min, 6 mGy
PROCEDURE:
1. Cholangiogram through existing right percutaneous transhepatic biliary
drainage access.
2. Exchange of the existing right percutaneous transhepatic biliary drainage
catheter with a new 10 ___ anchor catheter.
3. Sinogram through existing left drain
4. Exchange of left drain to a 10 ___ APD L
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.
Both tubes were injected. The ___ BD catheter was cut and ___ wire
introduced into the bowel. Then, a sheath was placed in a cholangiogram
performed. This demonstrated brisk flow of contrast into the
hepaticojejunostomy. Again this was performed different angulations, but
again brisk pearl was noted. There was no hang-up of contrast. Therefore the
decision was made to leave an anchor drain. The sheath was removed and a 10
___ anchor drain was placed. The anchor was formed in the drain secured to
the skin with a suture and StatLock.
The sinogram through the existing left-sided drain demonstrated a small
residual cavity but communication with the biliary tree. This 12 ___ drain
was downsized to a 10 ___ drain. This drain was secured to the skin with 0
silk sutures and a StatLock. This drain was attached to a bag.
FINDINGS:
Brisk flow of contrast through the hepaticojejunostomy with no holdup. Anchor
drain placed. Down size of left hepatic drain given CT findings in sinogram
findings from today.
IMPRESSION:
Drain exchanges as above.
Radiology Report
INDICATION: ___ year old man s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE
bacteremia. with pericatheter leakage following recent drain downsize // ___
year old man s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia. with
pericatheter leakage following recent drain downsize
COMPARISON: Biliary drain check-and change dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___ fellow performed the procedure. The
attending(s) personally supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 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: 1 g IV ceftriaxone pre-procedure
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 12.4 minute, 198 mGy
PROCEDURE:
1. Scout radiograph image of the indwelling drains
2. Antegrade cholangiogram through the indwelling anchor drain.
3. Drain check injection through the existing percutaneous drain in the
hepatic collection
4. Over the wire Pull-back cholangiogram via the right PTBD
5. Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest
balloon
6. Post HJ plasty antegrade cholangiogram
7. New right 10 ___ biliary internal-external drainage catheter.
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. Both
drains were 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 an Amplatz
wire was advanced through the catheter into the jejunum. Antegrade and pull
back cholangiogram was then performed with findings as outlined below.
Cholangioplasty was performed at multiple stations across the
hepaticojejunostomy in the region of the narrowing using 6 x 4 Conquest
balloons. The balloon and sheath were then removed over the wire and a 10
___ percutaneous trans hepatic biliary drainage catheter was advanced into
the jejunum. Side holes were positioned above and below the level of the
stenosis 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. Scout radiograph demonstrated the existing drains to be in stable position.
2. Injection through the existing hepatic collection drain demonstrated
opacification of the biliary system, suggestive of a communication.
3. Over the wire antegrade and pull-back right cholangiograms demonstrated
narrowing at the region of the hepaticojejunostomy.
4. Antegrade cholangiogram through the right biliary access from showed
external leakage of contrast around the perihepatic drain.
5. Successful plasty using a 6 mm Conquest balloon at the region of the
hepaticojejunostomy.
6. Successful exchange of the existing right external biliary drain to a 10
___ internal-external biliary drain.
IMPRESSION:
Technically successful plasty in the region of the hepaticojejunostomy.
Successful exchange of existing percutaneous transhepatic biliary anchor drain
with new 10 ___ internal-external biliary drainage catheters.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by OTHER
Chief complaint: Hyperkalemia
Diagnosed with Hypokalemia, Type 2 diabetes mellitus without complications
temperature: 98.0
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 93.0
level of pain: 5
level of acuity: 2.0 | ___ year old male h/o deceased donor liver transplant ___ for
HCV cirrhosis and HCC with prolonged postoperative course
complicated by hepatic artery thrombosis with hepatic lobe
necrosis, early mild to moderate cellular rejection, infected
biloma with recurrent bacteremia, multiple intraabdominal
collections, several ___ interventions, and a right iliacus
hematoma causing RLE compression paralysis, resolved with ___
drainage and multiple hospitalization. He was most recently
admitted ___ for failure to thrive and scute SDH
after several falls at home. He was also noted to have increased
fluid collections and underwent ___ drainage exchange of existing
left hepatic lobe drain with ___ APDL. He was continued on
pre-admission Daptomycin and Cefepime.
.
He presented for CT scan on ___ to evaluate known collections.
At the appointment, potassium was elevated to 7.3. He was sent
to the ED for hyperkalemia management. In the ED he received
calcium gluconate, insulin/dextrose, sodium bicarb, and 20 IV
Lasix. Repeat K was 5.3. He reported eating a diet rich in
tomatoes/red sauce and potatoes over the last few days. Bactrim
was stopped and he was put on a low K diet. He was continually
monitored on telemetry and there were no abnormalities. K on
repeat checks was 5.3, 5.0 and 5.0.
.
On ___ he underwent Cholangiogram through existing right
percutaneous transhepatic biliary drainage access, Exchange of
the existing right percutaneous transhepatic biliary drainage
catheter with a new 10 ___ anchor catheter.
Sinogram through existing left drain and Exchange of left drain
to a 10 ___ APD
He remained afebrile after this procedure
.
On ___ he went back to ___ for Scout radiograph image of the
indwelling drains,
Antegrade cholangiogram through the indwelling anchor drain,
Drain check injection through the existing percutaneous drain in
the hepatic collection. Over the wire Pull-back cholangiogram
via the right PTBD, Balloon angioplasty of the
hepaticojejunostomy using a 6 mm Conquest balloon with Post HJ
plasty antegrade cholangiogram and new right 10 ___ biliary
internal-external drainage catheter.
.
The patient was also seen by ___ while inpatient. ___ recommended
home for discharge after a right ___ brace was obtained that
he was able to apply himself.
.
DM was also monitored and he was continued on Lantus and
standing meal time doses of Humalog with sliding scale. Glucoses
averaged 100s to 200.
.
LFTs were stable. Immunosuppression consisted on Prednisone 5mg
daily and Tacrolimus dosed per trough levels.
.
Immuknow was sent on ___, result pending at time of discharge
.
Patient became increasingly neutropenic during the admission. He
received 2 doses of 300 mcg each of filgrastim with good
recovery of white count and the ANC.
.
Transitional issues:
f/u weekly transplant labs
f/u with ___ ... ID.... transplant surgery |