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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history of epilepsy, followed
by
Dr. ___, who presented with symptoms of slurred speech,
vertigo, and problems walking. Initially a code stroke was
called
but this was de-escalated based on the time course and gradual
onset of the patient's symptoms.
Per the patient's sister, he developed slurred speech on ___
that has been persistent. The patient himself has not noticed
this. Per the patient, he first noticed symptoms the night prior
to presentation, involving a sensation of the room moving and
problems walking. He does not report any falls. However, his
family states that he was found passed out on the ground today,
and once EMS arrived, he had regained consciousness but had
slurred speech. There was no clear witnessed seizure activity.
The patient last saw Dr. ___ in ___, and since then he has
been started on lamotrigine with a slow uptitration to an
intended goal dose of 250 mg BID. However, the patient's
insurance stopped covering 100 mg tablets and his prescription
had to be changed to 200 mg tablets. He was previously taking
2.5
tabs BID, and states that he still is, and that he increased
lamotrigine to 500 mg BID starting yesterday. He has taken 3
doses of 500 mg so far. He states that his prior dose was 400 mg
BID for 1 week, and 300 mg BID for the week prior to that. He
seems unaware that his goal dose is supposed to be 250 mg BID.
He
also states that he missed half of his phenytoin dose last night
(he divides the 200 mg evening dose into two doses to avoid
peak-dose effects) and that he often misses the second part of
his evening dose. He is currently taking his carbamazepine,
sertraline, and aspirin as prescribed.
He has had diarrhea and a stomach ache since yesterday. He has
not had any sick contacts or eaten at a restaurant recently. He
has mild photophobia today since arriving in the ED.
He endorses chronic blurry vision that resolves with sleep and
chronic left foot numbness.
Past Medical History:
Seizure disorder - per patient, grand mal seizures diagnosed at
age ___ per notes, focal onset seizures. Last seizure, per
outpatient notes, was ___.
HTN
BPH
Depression
Social History:
___
Family History:
grandmother and cousin with seizures
Physical Exam:
On admission:
T= 97.8F, BP= 175/102, HR= 80, RR= 16, SaO2= 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no nuchal rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
but
with difficulty and family adds many details. Language is
fluent
with intact repetition and comprehension. Normal prosody.
There
were no paraphasic errors. Pt. was able to name both high and
low frequency objects. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Inattentive,
makes 2 mistakes on ___ backward. Pt. was able to register 3
objects and recall ___ at 5 minutes. There was no evidence of
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI, right beating nystagmus on right gaze.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-Coordination: Ataxia on bilateral FNF. Ataxia on bilateral HKS
initially, but on repeat testing only ataxic on R HKS.
-Gait: not tested.
On discharge:
CN: no nystagmus, EOMI, PERRL, face symmetric, tongue midline
Motor: ___ throughout
Sensory: intact to LT throughout
Coordination: intention tremor bilaterally on FNF but no
dysmetria, no dysmetria on HKS
Gait: Pt presents with mildly unsteady gait
patterning as manifested by slowed, discontinuous cadence,
slowed
gait speed (although improved from initial evaluation), arms
held
out in extension especially with negotiation of turns, decreased
heel strike at initial contact bilaterally, narrowed BOS
throughout stance with occasional (___) L>R
___ crossing midline, variable stance time BLE, decreased trail
limb posturing and push off in terminal stance bilaterally,
decreased foot clearance throughout swing phase with variable
step length observed. + LOB with turns secondary to LLE crossing
midline.
Pertinent Results:
___ 05:05AM BLOOD WBC-7.1 RBC-4.56* Hgb-14.3 Hct-41.7
MCV-91 MCH-31.4 MCHC-34.3 RDW-12.0 RDWSD-40.5 Plt ___
___ 05:05AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-134
K-4.5 Cl-99 HCO3-27 AnGap-13
___ 05:05AM BLOOD ALT-17 AST-20 LD(LDH)-147 AlkPhos-123
TotBili-0.3
___ 11:15AM BLOOD Lipase-30
___ 11:15AM BLOOD cTropnT-<0.01
___ 05:05AM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.4 Mg-2.1
___ 11:15AM BLOOD Phenyto-6.4*
___ 11:15AM BLOOD ASA-NEG Ethanol-NEG Carbamz-9.7
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:24AM BLOOD Glucose-123* Na-137 K-4.3 Cl-95*
calHCO3-29
CTA head/neck: normal
MRI head:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of acute infarct.
4. Paranasal sinus disease as described.
___ EEG: This is an abnormal continuous video-EEG monitoring
session
because of mild diffuse background slowing and slow posterior
dominant rhythm. These findings are indicative of mild diffuse
cerebral dysfunction, which is nonspecific as to etiology.
Compared to the prior day's recording, there is no significant
change.
___ EEG: This is an abnormal 24 hour video-EEG monitoring
session because of mild diffuse background slowing and slow
posterior dominant rhythm. These findings indicate mild diffuse
cerebral dysfunction, which is nonspecific as to etiology.
Compared to the prior day's recording, there is no significant
change.
___ EEG: This is an abnormal 8 hour video-EEG monitoring
session because
of mild diffuse background slowing and slow posterior dominant
rhythm. These findings are indicative of mild diffuse cerebral
dysfunction, which is nonspecific as to etiology. Compared to
the prior day's recording, there is no significant change.
___ EEG: This telemetry captured no pushbutton activations. It
showed a
mildly slow background in wakefulness. There were no areas of
prominent focal slowing. There were no epileptiform features or
electrographic seizures.
Medications on Admission:
Imitrex ___ mg daily prn headache, can repeat after 2 hours if HA
persists
ASA 81
Calcium citrate vitamin d3 315-200 tablet - 2 tabs BID
carbamazepine ER 600 qam, 800 qpm
lamotrigine 500 BID (supposed to be on 250 BID)
phenytoin ER 100 qam, 200 qpm
sertraline 200
tamsulosin ER 0.4
Valsartan 80 daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbamazepine (Extended-Release) 600 mg PO QAM
3. Carbamazepine (Extended-Release) 800 mg PO QPM
4. LaMOTrigine 250 mg PO BID
5. Phenytoin Sodium Extended 100 mg PO QAM
6. Phenytoin Sodium Extended 200 mg PO QPM
7. Sertraline 200 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lamotrigine toxicity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no nystagmus, CN exam benign, full strength, Pt presents
with mildly unsteady gait
patterning as manifested by slowed, discontinuous cadence,
slowed
gait speed (although improved from initial evaluation), arms
held
out in extension especially with negotiation of turns, decreased
heel strike at initial contact bilaterally, narrowed BOS
throughout stance with occasional (___) L>R
___ crossing midline, variable stance time BLE, decreased trail
limb posturing and push off in terminal stance bilaterally,
decreased foot clearance throughout swing phase with variable
step length observed. + LOB with turns secondary to LLE crossing
midline.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ man with dizziness. Evaluate for dissection,
aneurysm, or steno-occlusive disease.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 8.0 s, 20.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,121.4 mGy-cm.
4) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 21.8 mGy (Head) DLP =
10.9 mGy-cm.
5) Spiral Acquisition 5.4 s, 42.6 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,367.2 mGy-cm.
Total DLP (Head) = 2,499 mGy-cm.
COMPARISON: ___ contrast brain MRI.
FINDINGS:
Dental almalgam streak artifact limits study.
CT HEAD WITHOUT CONTRAST:
There is no evidence of hemorrhage, edema, or mass. The ventricles and sulci
are normal in size and configuration.
There is periapical lucency around the left lower ___ molars. There is
mild mucosal thickening of the inferior left maxillary sinus. The visualized
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle ___ and their principal intracranial branches
demonstrate variable atherosclerotic burden, but otherwise appear normal
without stenosis, occlusion, or aneurysm formation. The dural venous sinuses
are patent.
CTA NECK:
There is mild narrowing of the origin of the left vertebral artery associated
with a calcified atherosclerotic plaque. The carotid and right vertebral
arteries and their major branches appear normal with no evidence of stenosis,
occlusion, or aneurysm formation. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. Scattered subcentimeter nonspecific
lymph nodes are noted throughout the neck bilaterally. There is no
lymphadenopathy by CT size criteria. Soft tissue density is noted within the
left external auditory canal which may represent cerumen.
IMPRESSION:
1. Dental almalgam streak artifact limits study.
2. No evidence of acute infarction or hemorrhage.
3. Narrowing of left vertebral artery origin without occlusion. Otherwise, no
evidence ofsignificant cervical carotid or vertebral artery or circle of
___ luminal narrowing.
4. No evidence ofaneurysm greater than 3 mm, dissection or vascular
malformation.
5. Paranasal sinus disease as described.
6. Periodontal disease as described. Recommend correlation with dental
examination.
7. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
RECOMMENDATION(S): Periodontal disease as described. Recommend correlation
with dental examination.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 12:40 ___, approximately 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with vertigo, ataxia, nystagmus. Evaluate for
acute infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head and neck CTA.
FINDINGS:
Study is mildly degraded by motion. There is no evidence of hemorrhage,
edema, masses, mass effect, midline shift or infarction. The ventricles and
sulci are normal in caliber and configuration.
There are few scattered foci of T2/FLAIR hyperintensity in the subcortical and
periventricular white matter, nonspecific, likely secondary to small vessel
ischemic disease.
The orbits are unremarkable. There is mild mucosal thickening in bilateral
ethmoid air cells with a mucous retention cyst in the left maxillary sinus.
The remaining visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of acute infarct.
4. Paranasal sinus disease as described.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Unsteady gait
Diagnosed with Dizziness and giddiness, Ataxia, unspecified
temperature: 97.8
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 175.0
dbp: 102.0
level of pain: 0
level of acuity: 2.0 | ___ man with focal onset epilepsy who was admitted ___
with slurred speech and falls concerning for lamotrigine
toxicity. He had been on a slow lamotrigine uptitration to goal
dose 250mg po BID but continued to a total 500mg po BID after
his pills changed from 100mg to 200mg. Initial exam showed R
beating nystagmus, R ataxia to FNF, and ataxia on R HKS. This
morning's exam was much more symmetric and only showed intention
and postural tremors. NCHCT negative for acute processes. Labs
showed decreased PHT levels, which might be ___ increased
lamotrigine levels. He was evaluated by ___ who found him to have
great difficulty walking steadily. MRI was normal. EEG showed
mild diffuse background slowing and a slow posterior dominant
rhythm. No seizures were captured. He was weaned off his home
Dilantin, and lamictal was kept at 250mg po BID. Home
carbamazepine was maintained the whole hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o colon CA s/p sigmoid colectomy (OSH, ___ complicated
by SBO requiring ex-lap with SBR (OSH, ___, subsequently
admitted for SBO managed conservatively in ___, presented
with abdominal pain for one day. Reportedly, the pain was
located in LLQ in association with nausea and multiple
episodes of NBNB emesis. Last BM was on the day prior to
presentation; patient passed flatus earlier on the day of
presentation. Previous to onset of symptoms, she felt well. No
fever or chills. She reported her symptoms felt similar to
previous when she had a bowel obstruction. No sick contacts.
*Note: history obtained through OMR records, pt and pt's family
Past Medical History:
PMH: colon cancer (___), SBO x2 ___ -> OR, ___ -> managed
conservatively at ___, R ankle fx ___, HTN, celiac A
stenosis, GERD, trigeminal neuralgia, osteopenia, blind R eye,
h/o constipation
PSH: glaucoma surgery, sigmoid colectomy (OSH, ___, ex-lap
w/SBR (OSH, ___, endoscopy ___ patch of
abnormal-appearing mucosa,bx neg), colonoscopy ___
adenomatous polyps), colonoscopy ___, adenomatous polyp),
colonoscopy ___, several polyps)
Social History:
___
Family History:
Sister had trigeminal neuralgia
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: T 97.2 HR 78 BP 123/60 RR 14 95%RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: clear to auscultation, bilaterally
Abd: soft, well-healed lower midline incision, tender to
palpation LLQ although no voluntary guarding or rebound
tenderness, distended
Ext: warm, well-perfused
PHYSICAL EXAM ON DISCHARGE
Vitals: T 98.8 HR 56 BP 155/50 RR 16 98%RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: clear to auscultation, bilaterally
Abd: soft, well-healed lower midline incision, non-tender,
non-distended, no voluntary guarding or rebound tenderness
Ext: warm, well-perfused
Pertinent Results:
___ 04:35AM BLOOD WBC-5.2# RBC-3.75* Hgb-12.0 Hct-36.9
MCV-99* MCH-32.1* MCHC-32.6 RDW-13.7 Plt ___
___ 06:55AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-138
K-4.0 Cl-102 HCO3-26 AnGap-14
___ 06:55AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Oxcarbazepine 300 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Oxcarbazepine 300 mg PO BID
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Prior colon cancer status post resection and prior small bowel
obstruction now presenting with abdominal pain, nausea and vomiting. Evaluate
for obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
after the uneventful administration of 130 mL of Omnipaque and oral contrast.
Coronal and sagittal reformations were provided and reviewed.
DLP: 382.82 mGy/cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Abdomen: The included lung bases show bibasilar atelectasis. The included
heart is mildly enlarged. No pericardial effusion. Focal coronary artery
calcifications are present.
The liver is normal in contour and enhances homogeneously with no focal
lesion. Lower attenuation of hepatic parenchyma is consistent with diffuse
hepatic steatosis. Focal thickening of the gallbladder fundus is consistent
with adenomyomatosis. There is no intra or extrahepatic biliary ductal
dilation. The spleen, pancreas and adrenal glands are unremarkable. The
kidneys enhance as expected and excrete contrast without hydronephrosis. A
small hypodensity within the interpolar region of the right kidney is too
small to characterize but likely represents a simple cyst and is unchanged.
The opacified portions of the ureters are normal in course and caliber.
There is a small hiatal hernia. The stomach is unremarkable. There is
dilation of the small bowel up to 3.8 cm with a transition point noted in the
left lower quadrant (2:75). Distal loops of small bowel are collapsed with
moderate amount of stool remaining in the colon. There is free fluid seen
near the transition point. There is no evidence of pneumatosis or bowel
perforation. The small bowel and rectal anastomoses are intact. There is no
free air.
There is a moderate amount of atherosclerosis within a non aneurysmal aorta.
There is likely high-grade stenosis at the origin of the celiac axis. The
portal vein, splenic vein and superior mesenteric vein are patent.
Pelvis: The bladder is normal. Fibroid uterus is again noted. There is no
pelvic lymphadenopathy.
Bones and soft tissues: There are no concerning lytic or blastic osseous
lesions. A midline laparotomy scar is noted.
IMPRESSION:
1. High-grade small bowel obstruction, transition point in the left lower
quadrant, with adjacent free fluid. No free air or evidence of perforation.
2. High-grade celiac stenosis, unchanged.
3. Chronic findings unchanged, including gallbladder adenomyomatosis, fatty
liver, fibroid uterus and a hiatus hernia.
Radiology Report
INDICATION: Small-bowel obstruction. Evaluation of NG tube position.
COMPARISON: ___.
FINDINGS: Portable AP chest radiograph. NG tube tip and sidehole are well
within the stomach. Lung volumes are low with crowding of the bronchovascular
markings and bibasilar atelectasis. There is no large pleural effusion or
pneumothorax. No distended air filled loops of small bowel are seen in the
included portions of the abdomen.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with VOMITING, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.2
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 55.0
level of pain: 8
level of acuity: 3.0 | The patient presented as above. She underwent a CT Abd/Pelvis
with PO contrast in the ED that showed high-grade small bowel
obstruction, transition point in the left lower quadrant, with
adjacent free fluid. There was no free air or evidence of
perforation. Consequently she was admitted to the ___ service
under Dr ___ conservative management.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed IV tylenol which was
then transitioned to oral medications once the patient was
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO/IVF with a NGT in
place. She passed flatus on HD1 and had a bowel movement on HD2
so her diet was advanced sequentially to regular diet which was
well tolerated. Patient's intake and output were closely
monitored. NG tube output was minitored closely and the tube was
dc'ed when the output tapered off. The patient had a Foley
placed for monitoring which was dc'ed on HD2 and the patient
voided adequately afterwards.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions and verbalized understanding of and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
aspirin / Levaquin / Bufferin / Methylphenidate
Attending: ___.
Chief Complaint:
Difficult secretion management and poor verbalising in setting
of advanced MS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a PMH of HTN and advanced secondary progressive
multiple sclerosis, bed to wheelchair bound and dependent for
all
ADLs under Dr ___ with dysphagia and aspiration pneumonia s/p
PEG tube insertion ___ recent admission to neurology
___ for visual hallucinations at which point amantadine
was stopped and quetiapine started now presents with decreased
verbalising and difficulty managing her secretions over the past
3 days.
The patient presents with her daughter, husband and sister who
translate in ___ for her. Her current presentation is markedly
below her recent baseline.
Patient had a recent hospitalisation from ___ due to
visual hallucinations thought to be secondary to oxybutynin but
did not improve when oxybutynin and tolterodine were stopped.
She
described complex visual hallucinations at night with men,
monkeys and worms and also tactile hallucinations with the
perception of batteries and a flashlight in her hands. Her
hallucinations were felt likely due to delirium in the setting
of
MS and amantadine was stopped and was started on quetiapine. She
was also found to have a sacral decubitus ulcer.
Since her discharge, she had ___ seen by Dr ___ her
husband noted that he was beginning to feel overwhelmed by
caring
for her. The plan was for repeat swallow evaluation for some
oral
intake. Since ten, she has had poor energy levels and has been
minimally verbalising which her daughter attributes to being on
the quetiapine. In particular, this has been over the last ___
days. She has been very terse and has also been confused and it
is unclear whether at times she is understanding what is being
told to her. She has also been more mellow and also has had
decreased ability to expectorate her secretions with increasing
coughing over the past 3 days or so. This difficulty handling
her
secretions was felt likely due to her mental state and her
family
has been giving her Tessalon pearls for this. She has not been
in
respiratory distress. She has been having gurgling respiration
occasionally. Her daughter and family deny any symptoms of
infection and she has had no fevers. Her daughters note that her
visual hallucinations have also changed and is now no longer
describing complex visions but now green and gold spots. These
have not been associated with a change in alertness. Her
daughter
notes prior to the quetiapine, she would be talking non-stop
about her hallucinations and this stopped after this.
Patient unable to provide ROS due to very limited verbalising
and
confusion.
Past Medical History:
- HTN
- Advanced secondary progressive multiple sclerosis with
severe quadriparesis, dependent on support with all ADLs and
bed/wheelchair bound with dysphagia s/p GJ tube placement in
___
- Previous respiratory failure with hypoxia and no intubation
- Severe protein-calorie malnutrition
- Osteoporosis
- Allergic rhinitis
Social History:
___
Family History:
- Mother diabetes; father with heart disease; no history of MS
in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T:98.6 P:98 R:16 BP:114/66 SaO2:98% RA
NIF x3 with poor effort and technique.
General: Awake, very limited verbalising and very inconsistently
following commands.
HEENT: NC/AT, no scleral icterus noted, MM somewhat dry, no
lesions noted in oropharynx. Wide eyed stare with frontalis
overaction.
Neck: Spastic with no carotid bruits appreciated. Significant
decreased neck rotation and flexion/extension with spasm and
tenderness.
Pulmonary: Generally poor air entry with decreased breath sounds
at the right base.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: PEG tube with clean site and soft, NT/ND, normoactive
bowel sounds, no masses or organomegaly noted.
Extremities: Some myokymia noted in both calves for a few
seconds. No C/C/E bilaterally, 2+ radial, DP pulses bilaterally.
Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
Patient with very limited verbalising, able to say "ok" and
husband and ___ first name but not her name. Unable to
answer orientation questions. Difficulty following commands but
does so with prompting inconsistently.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm and brisk. Right RAPD. Blinks to threat
bilaterally. Funduscopic exam reveals no papilloedema but
bilaterally pale optic discs right>left and no exudates, or
hemorrhages.
III, IV, VI: Right eye esotropia and downbeat nystagmus with
bilateral right>left INO.
V: Facial sensation intact to light touch grossly. Good power in
muscles of mastication.
VII: No facial weakness, facial musculature symmetric. Frontalis
overaction with eyebrows constantly raised.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically but very poor effort.
XI: Difficulty following commands.
XII: Does not protrude tongue.
- Motor: Generally reduced bulk and spastic tone throughout
although distally very loose with contractures. No pronator
drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Minimal limb movements all 4 limbs.
- Sensory: Patient stats intact to light touch throughout and
grimaces to noxious throughout.
- DTRs:
BJ SJ TJ KJ AJ
L 0 0 0 0 0
R 0 0 0 0 4
There was no evidence of clonus.
___ negative.
Plantar response was majestically extensor bilaterally.
- Coordination: Unable to assess.
- Gait: Unable to assess.
DISCHARGE PHYSICAL EXAM: unchanged.
Pertinent Results:
ADMISSION LABS:
- WBC-6.0 RBC-3.92* Hgb-11.2* Hct-34.3* MCV-87 MCH-28.4
MCHC-32.5 RDW-14.2 Plt ___
- Neuts-73.9* Lymphs-17.4* Monos-7.0 Eos-1.3 Baso-0.4
- Glucose-91 UreaN-11 Creat-0.2* Na-135 K-4.2 Cl-96 HCO3-28
AnGap-15
- ALT-67* AST-53* AlkPhos-89 TotBili-0.2
- Albumin-4.1 Calcium-10.1 Phos-3.5 Mg-1.6
- UA: Color-Straw Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-SM
RBC-6* WBC-8* Bacteri-FEW Yeast-NONE Epi-6 TransE-<1 Mucous-FEW
PERTINENT LABS:
- UA (___): Color-Red Appear-Cloudy Sp ___ Blood-LG
Nitrite-POS Protein-600 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-7.5 Leuks-LG
RBC->182* WBC-171* Bacteri-FEW Yeast-NONE Epi-5
- UCx (___): ***PENDING***
- VBG (___): pO2-200* pCO2-38 pH-7.48* calTCO2-29 Base XS-5
Comment-GREEN TOP
DISCHARGE LABS:
- WBC-11.8*# RBC-3.92* Hgb-11.0* Hct-34.9* MCV-89 MCH-28.1
MCHC-31.5 RDW-14.4 Plt ___
- Neuts-80.3* Lymphs-11.4* Monos-6.6 Eos-1.3 Baso-0.4
- ___ PTT-26.7 ___
- Glucose-124* UreaN-14 Creat-0.2* Na-138 K-3.9 Cl-101 HCO3-28
AnGap-13
- Calcium-9.5 Phos-3.7 Mg-1.6
STUDIES:
- CXR (___): Frontal and lateral radiographs of the chest
demonstrate leftward rotation, which limits interpretation of
the exam. Streaky opacity of the left base likely represents
atelectasis. The cardiomediastinal and hilar contours are
unchanged. There is no pneumothorax, pleural effusion, or focal
consolidation.
IMPRESSION: No acute cardiopulmonary process seen on this
limited exam.
Radiology Report
HISTORY: History of multiple sclerosis now with increased secretions.
Evaluate for pneumonia.
COMPARISON: Multiple prior radiographs the chest dated ___ through
___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate leftward rotation,
which limits interpretation of the exam. Streaky opacity of the left base
likely represents atelectasis. The cardiomediastinal and hilar contours are
unchanged. There is no pneumothorax, pleural effusion, or focal
consolidation.
IMPRESSION:
No acute cardiopulmonary process seen on this limited exam.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Altered mental status
Diagnosed with ALTERED MENTAL STATUS , MULTIPLE SCLEROSIS
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | ___ with a PMH of HTN and advanced secondary progressive
multiple sclerosis, bed to wheelchair bound and dependent for
all ADLs under Dr ___ with dyphagia and aspiration pneumonia
s/p PEG tube insertion ___ recent admission to neurology
___ for visual hallucinations at which point amantadine
was stopped and quetiapine started now presents with decreased
verbalising and difficulty managing her secretions over the past
3 days.
# NEURO: She was admitted to the General Neurology service for
monitoring of her mental and respiratory status. The quetiapine
was stopped as was likely worsening her sedation. Toxic
metabolic and infectious workup were unrevealing, and no
hypercarbia on VBG. Over the next 5 days, there was not
significant improvement in her mental status. She remained
nearly nonverbal, able only to say a couple of words in ___.
Her family felt this was worse than her prior baseline, but
recent Neurology notes document a fairly similar exam. Also, she
may have become more lethargic in setting of Amantadine being
stopped in late ___. Thus, after discussing with her MS ___
(___), she was started on low-dose Provigil 2.5mg qAM
to help with arousal. She was also evaluated by ___ and OT in the
hospital, who recommended a new wheelchair with neck support as
well as home Yankauer suction equipment to help with oral
secretions. Both of these will be delivered directly to the
home.
# ID: On hospital day 4, patient developed gross hematuria, and
was found to have a UTI on repeat urinalysis (which had been
clean one day before). She did not spike any fevers. Was started
on IV ceftriaxone on that day (___), then narrowed to
Cefpodoxime 200mg BID on discharge. She will complete 5 day
course (last day ___, and PCP ___ follow up results of urine
culture. Importance of this was discussed with family.
=============================
STUDIES PENDING ON DISCHARGE:
- Urine culture from ___ (should be followed up by PCP, as
discussed w family) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
elevated Cr
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ woman with history of HFpEF, AF on
rivaroxaban, s/p PPM, prior traumatic SAH/SDH, nonverbal at
baseline presenting w/ lethargy, and pink/orange urine found to
have acute renal failure. Family notes that she has been
increasingly lethargic and had recently moved from rehab back
home with the family. Her urine has become a pink/orange color
over the past 24 hours. No fever/chills. No change in PEG
intake. +cough which is chronic. OR debridement of sacral and
scapula ulcers on ___ PEG placed ___ and PICC in place for IV
antibiotics (end date ___.
Of note, she was recently admitted to ___ from ___ to
___ w/ infected pressure ulcers on her sacrum and right
scapula from which cultures grew multiple organisms including
staph epi, proteus m., bacteroides, pseudomonas. She was
switched to vanc/flagyl/cefepime for a 4 week course (d1 = ___
- ___, to be followed by ID OPAT. She also had an NSTEMI w/ Tn
peak 0.13 and EKG unchanged, likely representing a type II
demand ischemia (in setting of significant sacral infection) or
small branch vessel disease. Further testing was deferred
(stress, cath) as she is a poor candidate for antiplatelet
therapy given her recent SDH/SAH
and overall is chronically ill. PEG placement was undertaken on
___ malnutrition. A Foley catheter was placed because of
the location of the decubiti and incontinence.
Notably, on ___ OPAT labs were Vanco: 18.4 BUN: 45 Creat: 0.7
WBC: 11.1 Neuts%: 69.3 Eos: 2.7. On ___ vanco level was 22.7
so on ___, dose was reduced to 750mg IVQ24 hours. On ___ one
of the ID fellows received a phone call from outside facility
regarding her vanco trough being 35; the level was drawn at 9.30
am and vanco was given at 10. They asked her nurse to
discontinue IV vancomycin and check BUN, Cr; vanco random will
be checked again on ___ around
___ am.
In the ED, initial vitals were: 97.1 146/89 78 18 100%RA
- Exam notable for:
Abd: benign
Rectal: solid dark brown stool, heme +
Foley with pink urine
Large sacral stage 4 decub, right shoulder stage 4 decub
- Labs notable for:
UA with >182 RBC, 92WBC, few bacteria, few yeast, no epis, 300
protein, normal specific gravity
13.5>7.5/___.8<279 with 85%N
___
-----------<140
4.5/___/3.2
phos 6.5
troponin 0.7 @2150, CK 40 MB 5
INR 1.8
lactate 1.8
- Imaging was notable for:
CXR (portable): Right PICC seen at the level of the upper SVC.
Tip obscured by transvenous pacing wires which end in the right
atrium and right ventricle. Mild cardiomegaly is unchanged. No
pneumothorax. There is increasing left basilar airspace opacity
with obscuration of the left costophrenic angle.
- Patient was given: ceftriaxone 1g and started on NS at
150cc/hr
- Vitals prior to transfer: 113/79 74 17 94%RA
Past Medical History:
Hypertension
Hyperlipidemia
PAF on rivoraxaban
hypothyroidism, post-radioactive iodine ablation for
hyperthyroidism in ___.
Deep venous thrombophelbitis
Peripheral Vascular Disease
Social History:
___
Family History:
per OMR, mother and father died of MI.
Physical Exam:
Admission PHYSICAL EXAM:
Vital Signs: 97.4 153 / 80 70 97RA
General: Laying in bed, eyes closed, NAD
HEENT: Sclerae anicteric, MMM
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: + foley
Skin: Large 5X5 wound, few mm deep, pink/red in sacral region,
non purulent, but very open with some granulation tissue, small
~3X2 wound near R shoulder, also non-purulent but very open
pink/red w/ some granulation tissue, R sided PICC
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to RLE,
1+ to LLE, 2+ pitting edema to R hand, none on L hand
Neuro: non-verbal on exam, does not open eyes, does not follow
commands, per reports, pt is somewhat more responsive when
family asks questions
DISCHARGE EXAM:
VITALS: No vitals. RR ___
GENERAL: Opens eyes, does not follow commands
CV: RRR
Pertinent Results:
Day of Admission Labs:
======================
___ 09:51PM BLOOD WBC-13.5*# RBC-2.39* Hgb-7.5* Hct-23.8*
MCV-100*# MCH-31.4 MCHC-31.5* RDW-20.0* RDWSD-71.1* Plt ___
___ 07:00AM BLOOD WBC-11.1* RBC-2.33* Hgb-7.2* Hct-23.6*
MCV-101* MCH-30.9 MCHC-30.5* RDW-19.9* RDWSD-73.1* Plt ___
___ 09:51PM BLOOD Neuts-84.6* Lymphs-6.4* Monos-7.0 Eos-1.1
Baso-0.2 Im ___ AbsNeut-11.41* AbsLymp-0.86* AbsMono-0.95*
AbsEos-0.15 AbsBaso-0.03
___ 09:51PM BLOOD ___ PTT-28.2 ___
___ 07:00AM BLOOD ___ PTT-74.8* ___
___ 09:51PM BLOOD Glucose-140* UreaN-143* Creat-3.2*#
Na-139 K-4.5 Cl-101 HCO3-16* AnGap-27*
___ 07:00AM BLOOD Glucose-104* UreaN-142* Creat-3.3* Na-139
K-4.3 Cl-103 HCO3-15* AnGap-25*
___ 11:37AM BLOOD Glucose-108* UreaN-137* Creat-3.3* Na-142
K-4.2 Cl-104 HCO3-15* AnGap-27*
___ 07:00AM BLOOD ALT-15 AST-29 LD(LDH)-441* CK(CPK)-36
AlkPhos-70 TotBili-0.2
___ 09:51PM BLOOD CK-MB-5 cTropnT-0.70*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.48*
___ 11:37AM BLOOD CK-MB-5 cTropnT-0.52*
___ 09:51PM BLOOD Albumin-2.7* Calcium-8.5 Phos-6.5*
Mg-3.3*
___ 11:37AM BLOOD Calcium-8.3* Phos-6.8* Mg-3.2*
___ 09:51PM BLOOD Vanco-31.2*
___ 01:15AM BLOOD Lactate-1.6
___ 01:13PM BLOOD Lactate-2.2*
Other significant labs:
___ 09:51PM BLOOD CK-MB-5 cTropnT-0.70*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.48*
___ 11:37AM BLOOD CK-MB-5 cTropnT-0.52*
___ 09:51PM BLOOD Vanco-31.2*
___ 02:05AM BLOOD Vanco-25.3*
___ 02:40AM BLOOD Vanco-24.6*
___ 05:42PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:42PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 05:42PM URINE RBC-10* WBC-55* Bacteri-FEW Yeast-NONE
Epi-0 TransE-1
___ 12:05AM URINE Hours-RANDOM UreaN-464 Creat-25 Na-<20
___ 12:05AM URINE Osmolal-358
Micro:
___ CULTURE-FINALINPATIENT
___ Urinary Antigen
-FINALINPATIENT
___ STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ Urinary Antigen
-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTURE-FINAL {YEAST}EMERGENCY
WARD
Discharge Labs:
- No labs performed
Imaging:
CXR ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous left lower lobe consolidation has substantially
cleared. Small left
pleural effusion is unchanged for at least a month. Moderate
cardiomegaly is
chronic. Right lung clear. No pneumothorax.
Right PIC line ends in the right brachiocephalic vein just above
the origin of
the SVC, no less than 7 cm from the estimated location of the
superior
cavoatrial junction. Indwelling atrial ventricular pacer leads
are continuous
from the left pectoral generator.
CT Head ___
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, or mass.
The
ventricles and sulci are prominent consistent with involutional
changes.
Periventricular white matter hypodensities stable in appearance,
nonspecific,
in a pattern suggestive of chronic small vessel ischemic
changes. Hypodensity
in the left corona radiata consistent with chronic infarct
appears unchanged.
No new hypodensities are identified.
No acute osseous abnormalities seen. The paranasal sinuses, left
mastoid air
cells, and middle ear cavities are clear. Partial opacification
of the right
mastoid air cells are nonspecific and possibly due to prolonged
supine
positioning, and unchanged in appearance from prior examination.
The orbits
are unremarkable.
IMPRESSION:
No acute intracranial process.
Renal U/S ___
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 10.9
cm. There is
no hydronephrosis. There is a 3.1 cm simple cyst in the right
kidney. Normal
corticomedullary differentiation is seen in the right kidney.
Views of the
left kidney are limited.
Foley seen within a decompressed bladder.
IMPRESSION:
Limited views of the left kidney, but no hydronephrosis
bilaterally.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO BID
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Rivaroxaban 15 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Aquaphor Ointment 1 Appl TP TID:PRN wound care
11. Ascorbic Acid ___ mg PO DAILY
12. CefePIME 2 g IV Q8H
13. MetroNIDAZOLE 500 mg PO Q8H
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Vitamin A ___ UNIT PO DAILY
16. Zinc Sulfate 220 mg PO DAILY
17. Bisacodyl 5 mg PO DAILY:PRN constipation
18. Vitamin D 800 UNIT PO DAILY
19. TraMADol 25 mg PO Q6H:PRN pain
20. amLODIPine 5 mg PO DAILY
21. Lisinopril 40 mg PO DAILY
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
23. Aspirin 81 mg PO DAILY
24. Metoprolol Tartrate 6.25 mg PO BID
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl [Bisac-Evac] 10 mg 1 suppository(s) rectally once
a day Disp #*12 Suppository Refills:*0
2. LORazepam 0.25 mg PO Q4H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) tablet(s) by mouth
every four (4) hours Disp #*10 Tablet Refills:*0
3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN Pain - Moderate
RX *morphine concentrate 20 mg/mL ___ mg by mouth every 2 hours
as needed Disp #*50 Syringe Refills:*0
4. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
Apply behind ear
RX *scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over
3 days) Apply behind ear Q72H Disp #*10 Patch Refills:*0
5. Acetaminophen 1000 mg PO Q8H
6. Aquaphor Ointment 1 Appl TP TID:PRN wound care
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Septic shock secondary to pneumonia
Acute renal failure
Severe malnutrition
Secondary Diagnosis
===================
Atrial fibrillation with rapid ventricular response
Sacral decubitus ulcer
Hypertension
Constipation
Hypothyroidism
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic and not arousable.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with CVA, nonverbal, PICC placement?
TECHNIQUE: Portable Chest
COMPARISON: Chest radiograph ___
FINDINGS:
Right PICC seen at the level of the upper SVC. Tip obscured by transvenous
pacing wires which end in the right atrium and right ventricle. Mild
cardiomegaly is unchanged. No pneumothorax. There is increasing left basilar
airspace opacity with obscuration of the left costophrenic angle.
IMPRESSION:
1. Right PICC ends in the upper SVC.
2. Increasing left basilar airspace opacity, could represent pneumonia in the
correct clinical setting.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with acute renal failure, foley in place, evaluate for
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT Abdomen and Pelvis ___
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 10.9 cm. There is
no hydronephrosis. There is a 3.1 cm simple cyst in the right kidney. Normal
corticomedullary differentiation is seen in the right kidney. Views of the
left kidney are limited.
Foley seen within a decompressed bladder.
IMPRESSION:
Limited views of the left kidney, but no hydronephrosis bilaterally.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with history of likely vascular dementia here
w/ septic shock ___ PNA, ?UTI with worsening somnolence x several weeks// eval
for acute process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Noncontrast head CT from ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, or mass. The
ventricles and sulci are prominent consistent with involutional changes.
Periventricular white matter hypodensities stable in appearance, nonspecific,
in a pattern suggestive of chronic small vessel ischemic changes. Hypodensity
in the left corona radiata consistent with chronic infarct appears unchanged.
No new hypodensities are identified.
No acute osseous abnormalities seen. The paranasal sinuses, left mastoid air
cells, and middle ear cavities are clear. Partial opacification of the right
mastoid air cells are nonspecific and possibly due to prolonged supine
positioning, and unchanged in appearance from prior examination. The orbits
are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of HFpEF, AF on rivaroxaban, s/p
PPM, prior traumatic SAH/SDH presenting w/ afib w/ RVR, altered mental status
found to have aspiration PNA w/ increased secretions// eval for interval
change eval for interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous left lower lobe consolidation has substantially cleared. Small left
pleural effusion is unchanged for at least a month. Moderate cardiomegaly is
chronic. Right lung clear. No pneumothorax.
Right PIC line ends in the right brachiocephalic vein just above the origin of
the SVC, no less than 7 cm from the estimated location of the superior
cavoatrial junction. Indwelling atrial ventricular pacer leads are continuous
from the left pectoral generator.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Urinary tract infection, site not specified, Acute kidney failure, unspecified
temperature: 97.1
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | ___ yo ___ woman with history of HFpEF, AF on
rivaroxaban, s/p PPM, prior traumatic SAH/SDH, and recent
admission for infected sacral and R scapular decubitus ulcers
s/p 4 week course of vanc/cef/flagyl for polymicrobial
infection, who was admitted on ___ for acute renal failure and
found to be in septic shock and in afib with RVR. Patient was
transitioned to ___-based care after extensive discussion
with patient's family and health care proxy given her
significant comorbidities and poor prognosis. Tube feeds were
stopped given goals of care discussion and patient was started
on oral care regimen. Patient's symptoms were controlled with
dilaudid liquid administered through PEG tube, Ativan for
anxiety (which she did not require), and glycopyrlate for
secretions. Her symptoms were well controlled and she stabilized
for transition to home-based care. She will be followed by a
palliative ___ after discharge with follow up with palliative
care doctor/hospice per family wishes. Hospice saw patient in
the hospital, but patient's family declined hospice in favor of
___.
#Goals of care: Patient with multiple serious comorbidities
including end stage dementia, multiple severe skin ulcers, acute
renal failure, and serious infection. After extensive discussion
with family regarding the patient's poor quality of life over
the last month and potential for pain with further
interventions, her family felt it appropriate to focus care on
comfort. Her tube feeds were stopped and her symptoms were
controlled with dilaudid, lorazepam, zofran, and glycopyrollate.
Per family wishes, she will be discharge with palliative ___
instead of hospice. Family was concerned regarding nutrition
status of patient, but reiterated that tube feeds were not
helping patient given multi-organ failure and poor prognosis
even with treatment and were not well tolerated.
#Septic Shock ___ pneumonia
#UTI:
CXR at admission showed LLL infiltrate. Patient with multiple
chronic decubitus ulcers, but these were not thought to
represent the souce of infection per infectious disease. She had
been previously treated with 4 week course of
vanc/cefepime/flagyl which ended ___. She was started on
meropenem at admission which was discontinued after ___
discussion on ___.
#Acute Renal Failure:
Presented with Cr increased to 3.3 from baseline of 0.5. Likely
in the setting of hypovolemia from infection with possibly
contribution from supratherapeutic vancomycin levels. Stopped
trending based on GOC.
#Anemia: Worsening anemia without clear course of bleed. Likely
bone marrow suppression in setting of critical illness and
nutritional deficiency. Stopped monitoring.
#Acute toxic-metabolic encephalopathy on chronic vascular
dementia
Baseline bedbound, A+Ox ___. Persistently somnolent and not
following commands. Intermittently opens eyes, but no further
interaction. CT head negative for acute bleed. This remained
throughout course and likely in setting of infection, kidney
failure, and metabolic derangements.
#NSTEMI (type 2): Trop peak at 0.7, with flat CK-MB. Likely
demand in setting of renal failure and hypovolemia in setting of
Afib with RVR.
#Afib with RVR.
RVR occurred in setting of sepsis/hypovolemia. Converted back to
sinus rhythm after volume resuscitation and broadening
antibiotics. Likely precipitated by hypovolemia and underlying
infection.
#HFpEF: LVEF >55% in ___. Moderate edema may be from low
albumin vs. HF. Did not diurese after GOC dission.
#Sacral decubitus ulcer
#R upper back pressure ulcer
No signs of new acute infection and has completed 4 week broad
abx course for polymicrobial infection.
#Severe malnutrition
PEG tube placed last admission on ___ secondary malnutrition
and inability to take PO. Patient continued with low albumin
despite initiation. After extensive discussion with family
regarding poor prognosis, multi-organ failure, and inability to
tolerate feeds, decided to stop tube feeds and focus on comfort
based care. She continued to receive medications through G-tube.
#HTN: Held lisinopril.
#Constipation: Held lactulose BID, docusate, and bisacodyl PRN.
Will give bicacodyl PR for use after discharge if pain.
#Hypothyroidism: Held home levothyroxine after CMO.
Transitional Issues
===================
[] Transitioned to comfort-based care during this
hospitalization. Will be discharged with palliative ___ per
patient's family preferences instead of hospice.
[] Palliative ___ will refer patient to palliative care MD
depending on how she does after discharge with reconsideration
of hospice referral.
[] Filled out MOLST forming prior to discharge indicating no
further hospitalizations and CMO
[] Started morphine PO to be given through PEG tube for
discomfort and respiratory distress
[] Started lorazepam PRN for anxiety. Patient did not require
this medication during hospitalization
[] Started scopolamine patch to be given for excess secretions
q72 hours
[] Tube feeds will not be continued after discussion with
patient's family. She will only use PEG tube for medications to
control symptoms and improve comfort.
[] All other medications were discontinued that did not directly
improve comfort.
# CMO
# CONTACT: Proxy name: ___
Relationship: son Phone: ___
Comments: alternate ___ ___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman with a PMH of HTN, HLD, prior
LBBB noted on EKG, history of syncopal retinal vein occlusion
BIBA from home for syncope. This AM she was making her coffee
and suddenly felt light headed, lost consciousness, and fell on
the back of her head. She did not note any CP, SOB or
palpiations prior to falling and did not remember the fall
itself. One of her daughters witnessed the fall and said that
LOC was for 1 minute. No signs of seizure noted.
EMS was called to the scene and found the patient in atrial
fibrillation. Patient was also hypotensive to 88/60 and gave
500cc NS in the field.
In the ED patient she was found to have afib with rvr and
converted on 30 mg IV Dilt. CT Head and Spine were both
negative. ECG showed an old LBBB and no acute ischemic changes.
Troponin (-)
Further history was obtained on the floor:
Patient states that she has had no prior new changes in her
health. All ADLS intact. No orthopnea, PND, or declines in
functioning. Of note, she endorses drinking 5 cups of coffee per
day, which she has done for many years.
Patient had been hospitalized for a prior admission of syncope
and discharged with a diagnosis of vasovagal on ___. She
was setup for Holter monitoring but no recordings were taken. A
stress echo on ___ showed no areas of inducible ischemia, no
symptoms, but non-interpretable ECG changes due to old LBBB.
Last TTE was ___ showed LEVF>50%, Moderate TR, and a
mildly dilated RV
Past Medical History:
- Hx of pulmonary embolism (after surgery)
- Allergic rhinitis
- Anxiety
- Hypertension
- Benign positional vertigo (the patient denies any recent sx of
this)
- cataracts, glaucoma
- hearing loss
- Hyperlipidemia
- Hypothyroidism
- Left bundle branch block - documented in PCP records though no
EKG on file here
- osteoarthritis of bilateral knees
- tricuspid regurgitation
- osteopenia
- lumbar spinal stenosis and right leg sciatica
- s/p partial hysterectomy
- superior branch retinal vein occlusion in the right eye ___
years ago. She is status post panretinal photocoagulation
treatment superiorly in thiseye, and on ASA and fish oil for
this.
Social History:
___
Family History:
Mother - kidney disease. Father - MI at an old age
Physical Exam:
Admission Exam:
Vitals- 97.9 157/94 82 18 100%. No orthostatic changes
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
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
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge exam:
Vitals- 97.7 122/80 78 16 98%/RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
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
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 10:30AM BLOOD WBC-6.5 RBC-4.08* Hgb-13.1 Hct-38.1
MCV-94 MCH-32.0 MCHC-34.2 RDW-12.3 Plt ___
___ 10:30AM BLOOD ___ PTT-27.3 ___
___ 10:30AM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-141
K-4.2 Cl-108 HCO3-23 AnGap-14
___ 10:30AM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.1
___ 06:45AM BLOOD TSH-2.9
___ 03:20PM BLOOD Hct-36.0
___ 06:20AM BLOOD ___ PTT-64.3* ___
CXR
___
Head CT: No acute intracranial processes
Neck CT: No evidence of fracture or acute alignment abnormality
in the cervical spine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Losartan Potassium 50 mg PO BID
5. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
6. Calcium Carbonate 1500 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Alendronate Sodium 70 mg PO QSUN
Discharge Medications:
1. Calcium Carbonate 1500 mg PO BID
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Warfarin 5 mg PO DAILY16
Please follow up with ___ clinic to monitor the
dosing
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
6. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule,extended release 24hr(s) by
mouth daily Disp #*30 Capsule Refills:*0
7. Losartan Potassium 25 mg PO BID
RX *losartan [Cozaar] 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Alendronate Sodium 70 mg PO QSUN
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Atrial fibrillation with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fall with head strike.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head without contrast. Coronal and sagittal reformats as well as axial bone
algorithm images reviewed.
COMPARISON: None available.
FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or infarction.
The ventricles and sulci are prominent, consistent with age-related
involutional changes. There is no fracture. The imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Neck pain after fall.
TECHNIQUE: MDCT-acquired axial images through the cervical spine were
obtained without contrast. Bone algorithm axial images as well as coronal and
sagittal reformats prepared and reviewed.
COMPARISON: None available.
FINDINGS:
There is anterior subluxation of C2 on C3, C4 on C5, C6 on C7, and T1 on T2.
These appear to be on a degenerative basis. There is no evidence of fracture
or acute-appearing alignment abnormality. There is no prevertebral soft
tissue swelling. The thyroid gland appears normal. There is bilateral
pleural-parenchymal scarring and interlobular septal thickening in the imaged
lung apices. Non-contrast examination of the soft tissues of the neck are
unremarkable. Degenerative changes of the spine are noted. There is a
midline protrusion of the C2-3 disk, apparently without contact with the
spinal cord. Intervertebral ostephytes and a disk bulge narrow the canal at
C3-4.
At C5-6 intervertebral osteophytes encroach on the spinal canal but do not
appear to contact the spinal cord. Uncovertebral and facet osteophytes narrow
the neural foramina bilaterally. There is no high-grade spinal stenosis.
IMPRESSION:
No evidence of fracture or acute alignment abnormality in the cervical spine.
Radiology Report
PA AND LATERAL CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Bilateral apical pleural and parenchymal scarring with associated
volume loss appears similar to the prior radiograph. Remainder of lungs is
grossly clear. Heart size, mediastinal and hilar contours are normal. There
are no pleural effusions. Bones are diffusely demineralized.
IMPRESSION: Stable radiographic appearance of the chest, with no acute
cardiopulmonary radiographic abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: syncopal
Diagnosed with ATRIAL FIBRILLATION, SYNCOPE AND COLLAPSE, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 97.2
heartrate: 110.0
resprate: 16.0
o2sat: 95.0
sbp: 107.0
dbp: 42.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ year old woman with a PMH of HTN, HLD, prior
LBBB noted on EKG, retinal vein occlusion, p/w syncope
# Syncope: Likely due to unstable afib as patient was found in
this rhythm in the field and hypotensive. She was converted in
the ED which restored her blood pressures and converted her back
to normal sinus rhythm. In house, she remained in normal sinus
rhythm on telemetry. Had no chest pain with (-) troponin x 1. No
focal neurological signs and most recent echo done ___ showed
no concerning structural abnormalities.
# Afib w/ RVR: With a CHADS2 score of 2, we began rate control
and started her on coumdadin. She will follow up with PCP and
___ clinic to check her INR
# HTN: The Patient's amolodipine was held when diltiazem for
rate control was initiated. The patient's losartan was
continued. After starting the diltiazem her SBP had one
measurement of high ___, for which she was clinically stable,
with all other in the 120s. As a result, her losartan dose was
halved at discharge. In summary, at discharge she will no longer
be on amlodipine and her losartan dose was downtitrated to 25 mg
BID.
# Retinal vein occlusion: Anticoagulated on warfarin, we
discontinued her ASA 325. She will follow up in eye clinic
# Hypothyroidism: TSH in house was normal. Her synthroid was
continued
# Transitional issues
- Follow up with PCP and ___ clinic for INR checks
- Follow up with PCP for blood pressure monitoring now that she
has been started on diltiazem for afib rate control and her
prior HTN regimen was changed in the hospital |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transient memory loss
Major Surgical or Invasive Procedure:
Lumpectomy for breast cancer ___ years ago
History of Present Illness:
HPI: The patient is a ___ right-handed female with
history of atrial fibrillation not on any anticoagulation takes
amlodipine 5 mg daily for rate control, osteoporosis, history of
breast cancer ___ years ago status post chemo and radiation and
lymphectomy. She she was brought here by EMS for evaluation of
an episode of transient retrograde amnesia and is currently back
to baseline.
Patient was in her usual state of health today after completing
a
flight from ___ this morning. She completed her errands
with no issue. Around 6:45 ___ she was entering ___ to
watch ___ game when started reporting "I do not remember
what
happened the last 5min, I don't remember today". She was
speaking in clear sentences responding to stimuli following
commands walking well and was aware of her surroundings. There
was no behavioral arrest, no convulsions, no loss of
consciousness, no facial droop, no hallucinations, no visual
symptoms, weakness or sensory changes. Her daughter patient was
not aware of the date or day but was oriented to place and self.
Her long-term memory seem to be intact and she recognized her
family members and where she lived, her phone number and what
happened the day prior. The entire episode lasted approximately
1 hour and she was back to her normal self around 7:40 ___ with
no
evidence of post ictal confusion sleepiness or drowsiness.
Patient is currently now at her baseline and recalls her day.
The only gap she has is between 645 and 7:45 ___. She states she
remembers her entire day up to the point of ___ but
does not remember walking in or saying any of the things fer
family reports. Her memory picks up once more while she is in
EMS ride. She has no complaints currently.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
Atrial fibrillation
Breast cancer diagnosed ___ years ago status post lumpectomy and
radiation and chemotherapy
osteoporosis
Social History:
___
Family History:
No family history of seizures. Her mother had stroke at ___
years.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 97.6F, HR 75, BP 141/86, RR 16, 98% RA
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
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. Recalls a
coherent
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 - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. No dysarthria. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. essential tremor right
hand.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - deffered
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Labs:
___ 01:25PM BLOOD WBC-6.1 RBC-4.35 Hgb-12.5 Hct-39.2 MCV-90
MCH-28.7 MCHC-31.9* RDW-14.1 RDWSD-46.6* Plt ___
___ 01:25PM BLOOD Neuts-65.8 ___ Monos-6.4 Eos-1.8
Baso-0.7 Im ___ AbsNeut-4.04 AbsLymp-1.54 AbsMono-0.39
AbsEos-0.11 AbsBaso-0.04
___ 01:25PM BLOOD Plt ___
___ 07:20PM BLOOD ALT-<5 AST-69* AlkPhos-38 TotBili-0.4
___ 07:20PM BLOOD cTropnT-<0.01
___ 07:20PM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.6 Mg-2.2
IMAGING:
CT Head/CTA head and neck ___:
Head CT: No intracranial hemorrhage or acute territorial
infarct.
CTA head: Patent circle ___ and ___ territories.
CTA neck: Unremarkable neck vessels.
MRI Brain without contrast ___:
No acute intracranial process. Specifically, no evidence of
infarction.
EEG ___ (Final report pending):
-Bursts of L temporal lobe slowing, no epileptiform discharges
or seizures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient global amnesia
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 T___ MR HEAD
INDICATION: ___ year old woman with transient global amnesia and a fib// r/o
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck dated ___.
FINDINGS:
Study is mildly degraded by motion.
No evidence of infarction, hemorrhage, mass, or edema. Periventricular and
subcortical T2 and FLAIR hyperintensities are noted which may represent small
vessel ischemic changes. There is prominence of the ventricles and sulci
suggestive of involutional changes. The major intracranial flow voids are
preserved.
Bilateral maxillary sinus mucosal thickening is present. Bilateral ethmoid
air cell mucosal thickening is present. Minimal bilateral mastoid air cell
nonspecific fluid is noted. The orbits are preserved. There is a left
occipital skull vault osteoma (series 9, image 6) as seen on recent CT.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality, with no definite evidence of acute
infarct.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Transient global amnesia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 2.0 | Brief Hospital Course:
Ms. ___ is a very pleasant ___ R handed woman with a
history of paroxysmal atrial fibrillation diagnosed over ___
years ago, not on anticoagulation, hypertension, osteoporosis,
and history of breast cancer ___ years ago s/p chemotherapy,
radiation, and lumpectomy now in remission. She presented to
___ on ___ with her family for sudden confusion and
anterograde amnesia. She was admitted to the stroke service for
evaluation of possible transient global amnesia, vs. seizure vs.
TIA/ Stroke.
#Anterograde amnesia/confusion:
-Patient underwent ct head in the ER with CTA head and neck
which was unremarkable. She had stroke risk factor labs drawn
including an LDL which was pending at discharge, A1C of 5.6, and
a TSH of 3.2.
-She was placed on an aspirin 81mg daily in the ER
-The next morning on ___ the patient underwent an extended
routine EEG and MRI brain. The MRI brain did not reveal any
acute strokes, no large areas of encephalomalacia to suggest
prior large infarcts, nor any hippocampal DWI changes that can
be seen in TGA.
-EEG was read by the epilepsy fellow/attending as bursts of L
temporal slowing without epileptiform discharges. The final
report is pending. For this, we will set the patient up with
outpatient neurology f/u and repeat EEG in about 3-months. She
did not have any epileptiform activity and therefore the
likelihood that this represented a seizure is very low
-Her neurologic examination remained stable during the entire
admission without any further episodes of confusion, memory
loss, nor any other focal deficits
#Paroxysmal Atrial Fibrillation:
-Patient's ___ score was calculated at 3 , scoring points
for her age, sex, and hypertension history, which results in a
3.2% risk of stroke. Given that we feel this episode was more
likely a TGA and not a true stroke or TIA, we did not want to
start the patient on systemic anticoagulation. In addition, her
MRI brain did not reveal any evidence of prior embolic strokes
in the past.
-We counseled the patient on taking a baby aspirin 81mg daily
for stroke prevention
# Hypertension:
-Patient was continued on amlodipine 5mg daily which is her home
medication without issue
#Breast cancer:
-In remission, no issues during hospitalization.
Transitional Issues:
1. Please follow-up in the Neurology Clinic with Dr. ___.
___ on ___ at 3pm
2. We have ordered an outpatient EEG to be done prior to her
outpatient neurology appointment. The point of this study is to
ensure that the EEG remains stable as compared to the one we did
during her hospitalization and has not changed.
3. Patient to continue taking aspirin 81mg daily
4. Patient to follow-up with her PCP in the next two weeks |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
morphine
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
___: Right patellar tendon repair
History of Present Illness:
___ PMH significant for DVT currently on Coumadin, presents
with right knee pain s/p mechanical twist and fall from stand
injury. Denies HS, LOC. He reports he was walking down ___
construction site, twisted his right knee, heard a pop, and was
unable to ambulate afterwards. He denies paresthesias to the
right lower extremity, fevers, chills, nausea, vomiting, chest
pain, abdominal pain.
Past Medical History:
DVT on Coumadin
Prior right knee surgeries (unable to recall)
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
Gen: appears stated age, ___ pain
Vitals: 98.6 74 135/80 18 97%RA
Right lower extremity:
- Skin intact
- Edema over right knee
- Unable to straight leg raise, unable to extend leg
- Full, painless PROM of hip and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 03:01PM WBC-12.2* RBC-4.61 HGB-14.2 HCT-41.7 MCV-91
MCH-30.8 MCHC-34.1 RDW-14.1 RDWSD-47.0*
___ 03:01PM GLUCOSE-120* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 03:01PM ___ PTT-35.1 ___
INR at discharge ___ 11:20AM: 1.3
Medications on Admission:
Warfarin 5mg/7.5mg daily on alternating days
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4)
hours Disp #*90 Tablet Refills:*0
2. Diazepam 5 mg PO Q6H:PRN muscle spasms
RX *diazepam 5 mg 5 mg by mouth every six (6) hours Disp #*20
Tablet Refills:*0
3. Enoxaparin Sodium 80 mg SC Q12H Duration: 5 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous every twelve (12)
hours Disp #*10 Syringe Refills:*0
4. Axillary Crutches x 2
Axillary crutches x 2
Diagnosis: Right patellar tendon injury
Prognosis: good
Duration: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Right patellar tendon disruption
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with r. knee injury popping sound who presents
with knee pain. On coumadin // Rule out bony abnormality
TECHNIQUE: Three views of the right knee
COMPARISON: None.
FINDINGS:
No acute fracture is seen. The patella appears high-riding in relation to the
distal femur. Additionally, there is infrapatellar soft tissue swelling.
Findings raise concern for patellar tendon injury. No definite suprapatellar
joint effusion is seen. There may be subtle chondrocalcinosis in the knee
joint.
IMPRESSION:
No acute fracture. Patella appears high riding and there is infrapatellar
soft tissue swelling, findings can be seen in the setting of patellar tendon
injury.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg injury
Diagnosed with SPRAIN OF KNEE & LEG NEC, UNSPECIFIED FALL, LONG TERM USE ANTIGOAGULANT
temperature: 98.6
heartrate: 74.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 80.0
level of pain: 6
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right patellar tendon disruption and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for a right patellar tendon repair,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity in a
locked ___ brace in full extension, and will be discharged
on therapeutic Lovenox 80mg SC q12h bridge to Coumadin 5mg PO
daily for anticoagulation. 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: SURGERY
Allergies:
Clonidine / Trazodone / Ultram / Ambien / Ditropan / Dilaudid /
Sulfa (Sulfonamide Antibiotics) / Risperdal
Attending: ___.
Chief Complaint:
chest pain, crackles in skin s/p fall
Major Surgical or Invasive Procedure:
1. right chest tube placement
History of Present Illness:
___ hx of heavy smoking and COPD presents with right-sided chest
pain after a fall. Patient reports falling three days ago on
___ morning, falling onto R lower back. He denies head strike
or LOC. Has had rib pain and pain w/ breathing since the fall.
This morning he felt crackles in his skin prompting an him
to report to the ED. Pt has had chronic cough he feels is
improving. Denies fevers, chills, SOB, hemoptysis, or easy
bruising. Surgery is consulted given imaging findings after
fall.
Past Medical History:
MEDICAL HISTORY:
-OSA
-BPH
-cirrhosis of the liver
-HTN
-total joint replacement of R big toe
-hypothyroidism
-GERD
-s/p colon resection in ___
Social History:
___
Family History:
unknown.
Physical Exam:
ADMISSION Physical Exam:
Vitals: 97.8 68 9100/42 17 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist, no LAD or neck
TTP
CV: RRR, No M/G/R
Chest: TTP over right lateral ribs, mild ecchymosis
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Back: no TTP or step offs, rectal tone intact
Ext: No ___ edema, ___ warm and well perfused, strength ___, no
TTP; Right wrist deformity, palpable radial and ulnar pulses,
sensation to 5 digits intact, adduction and abduction intact
-------
DISCHARGE Physical Exam:
Afebrile, VSS, no respiratory distress
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist, no LAD or neck
TTP
CV: RRR, No M/G/R
Chest: TTP over right lateral ribs, mild ecchymosis
PULM: Clear to auscultation b/l, No W/R/R. Site of previous R
chest tube with dressing c/d/i.
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, strength ___ b/l
Pertinent Results:
CXR ___: PA and lateral views of the chest provided. The
extensive subcutaneous
emphysema is noted. Also noted is pneumomediastinum. No large
pneumothorax.
Lungs appear relatively clear. Heart size is normal.
Mediastinal contour is
within normal limits. Fracture of the right tenth posterior rib
noted.
CT Chest ___. Small right pneumothorax with extensive pneumomediastinum and
subcutaneous
emphysema extending through the anterior and posterior
thoracoabdominal wall,
right greater than left, including the posterior right pararenal
space.
2. No definite evidence of injury to the tracheobronchial tree.
3. Right posterior tenth rib fracture with adjacent parenchymal
ground-glass
opacity, likely a small contusion.
4. Additional subtle micronodular and ___ opacities
within the right
upper and left lower lobe may represent aspiration.
5. No acute intra-abdominal injury.
6. Cirrhotic liver with trace nonhemorrhagic ascites,
splenomegaly, and
varices.
CXR ___: 1. Interval mild improvement of pneumomediastinum,
deep cervical emphysema,
and bilateral subcutaneous emphysema.
2. Persistent small right medial pneumothorax unchanged from ___
chest radiograph.
3. Right lower lobe contusion is unchanged from prior study.
CXR ___: Comparison to ___. Stable apical 7-8 mm
right-sided pneumothorax.
The right chest tube is in stable position. Normal size of the
heart.
Elongation of the descending aorta. Stable air collection in
the soft
tissues.
CXR ___:
Comparison to ___. The right chest tube is in
stable position.
A 5 mm right pneumothorax is visualized. No evidence of
tension. On the
left, there currently is no visualization of a pneumothorax.
The air
collection in the bilateral soft tissues is stable.
CXR ___: A small right apical and lateral pneumothorax is
unchanged from ___. A
right-sided chest tube remains. No left pneumothorax. Right
tenth rib
fracture appears unchanged. Mediastinal contours, hila, and
cardiac
silhouette are normal. No pleural effusion. Subcutaneous
emphysema is
unchanged from ___.
CT Chest ___: Extensive subcutaneous emphysema, as well as
mediastinal and retroperitoneal
air is unchanged from the prior CT of ___. The right
chest tube
terminates at the right lung apex, and there is no residual
pneumothorax. No
mediastinal or hilar lymphadenopathy. Heart size is normal. No
pericardial
effusion. The airways are patent to the subsegmental level
bilaterally. The lungs are
clear without focal consolidation or pleural effusion. Right
tenth and eleventh rib fractures are again demonstrated. No
suspicious
osseous lesion.
Chest CT w/o contrast ___: 1. Right chest tube in appropriate
position with no residual right
pneumothorax.
2. Unchanged moderate amount of subcutaneous, mediastinal, and
retroperitoneal
air.
3. Bilateral upper pole nonobstructive renal calculi.
4. Cirrhotic liver.
5. Known right tenth and eleventh rib fractures are unchanged in
configuration
since ___.
CXR ___: The previously seen tiny right apical pneumothorax has
resolved.
Cardiomediastinal silhouette is within normal limits. There are
no focal
consolidations, pleural effusion, or pulmonary edema. There is
subcutaneous
emphysema along the chest wall.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. butalbital-acetaminophen-caff 50-325-40 mg oral Q4H:PRN
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP 3X/WEEK
(___)
3. ketotifen fumarate 0.025 % (0.035 %) ophthalmic 1 gtt each
eye daily
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
5. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
6. Mupirocin Ointment 2% 1 Appl NU DAILY
7. Mirtazapine 45 mg PO QHS
8. Acyclovir Ointment 5% 1 application Other Q4H:PRN
9. ClonazePAM 1 mg PO Q8H:PRN anxiety, insomnia
10. Docusate Sodium 100 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. polyvinyl alcohol 1.4 % ophthalmic TID:PRN
13. Lidocaine 2% 2 mL SC QHS:PRN intercourse
14. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY:PRN burn
15. Furosemide 20 mg PO DAILY:PRN edema
16. Spironolactone 50 mg PO DAILY
17. famciclovir 500 mg PO BID:PRN
18. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
19. Fluticasone Propionate 110mcg 4 PUFF IH BID
20. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
21. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
22. Omeprazole 20 mg PO BID
23. albuterol sulfate 1.25 mg/3 mL inhalation Q4H:PRN
24. Doxycycline Hyclate 50 mg PO Q12H
25. Levothyroxine Sodium 100 mcg PO DAILY
26. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
To treat pain from your rib fractures and recent chest tube
placement.
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth Daily Disp #*20 Tablet Refills:*0
3. Acyclovir Ointment 5% 1 application Other Q4H:PRN
4. albuterol sulfate 1.25 mg/3 mL inhalation Q4H:PRN
5. ClonazePAM 1 mg PO Q8H:PRN anxiety, insomnia
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Doxycycline Hyclate 50 mg PO Q12H
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
10. famciclovir 500 mg PO BID:PRN
11. Fluticasone Propionate 110mcg 4 PUFF IH BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Furosemide 20 mg PO DAILY:PRN edema
14. ketotifen fumarate 0.025 % (0.035 %) ophthalmic 1 gtt each
eye daily
15. Levothyroxine Sodium 100 mcg PO DAILY
16. Lidocaine 2% 2 mL SC QHS:PRN intercourse
17. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
18. Mirtazapine 45 mg PO QHS
19. Mupirocin Ointment 2% 1 Appl NU DAILY
20. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
21. Omeprazole 20 mg PO BID
22. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
23. polyvinyl alcohol 1.4 % ophthalmic TID:PRN
24. Spironolactone 50 mg PO DAILY
25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP 3X/WEEK
(___)
26. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. right 10th rib fracture
2. right pneumothorax
3. subcutaneous emphysema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with dyspnea, concern for PTX // eval for PTX
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. The extensive subcutaneous
emphysema is noted. Also noted is pneumomediastinum. No large pneumothorax.
Lungs appear relatively clear. Heart size is normal. Mediastinal contour is
within normal limits. Fracture of the right tenth posterior rib noted.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT chest, abdomen, and pelvis with IV contrast.
INDICATION: ___ year old man with COPD s/p mechanical fall ___ with
extensive subQ air, R lower rib pain
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique. Oral contrast was not administered. Coronal and sagittal
reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 519 mGy-cm.
COMPARISON: Chest radiograph dated ___. CT abdomen pelvis dated ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. There is mild atherosclerotic calcification within
the aortic arch and coronary arteries. Otherwise, the heart, pericardium, and
great vessels are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is extensive pneumomediastinum extending
to the neck, as well as surrounding the heart and all the major intra thoracic
vessels, including the descending aorta at the level of the diaphragm. No
axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal
mass or hematoma. The esophagus is normal in appearance.
PLEURAL SPACES: There is a small right pneumothorax. No pneumothorax on the
left. No pleural effusion bilaterally.
LUNGS/AIRWAYS: There is upper lobe predominant paraseptal emphysematous
changes bilaterally. There is a small amount of ground-glass opacity adjacent
to the right posterior tenth rib fracture, likely a mild lung contusion.
Additional subtle areas of centrilobular micronodules and ___
opacities are seen within the right upper and left lower lobes, which may
represent aspiration. The airways are patent to the level of the segmental
bronchi bilaterally. There is no definite evidence of injury to the trachea
or the bronchi.
ABDOMEN:
There is a small amount of nonhemorrhagic perihepatic ascites.
HEPATOBILIARY: The liver is diffusely nodular in appearance, consistent with
the patient's history of known cirrhosis. There is a linear hypodensity
extending through segment VI, which is unchanged since ___, likely fibrosis.
An additional subcentimeter hypodensity (series 2, image 104) is too small to
characterize, but likely represents a cyst or biliary hamartoma. There is no
evidence of solid lesion or laceration. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
There are prominent splenic and gastroesophageal varices.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring up to 16.1 cm. No evidence of focal
lesions or lacerations.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are numerous simple cysts within the kidneys bilaterally
measuring up to 2.3 cm within the right upper pole. Otherwise, the kidneys
are of normal and symmetric size with normal nephrogram. There is no evidence
of solid renal lesions or hydronephrosis. The pneumomediastinum and
subcutaneous emphysema extends to the right posterior pararenal space.
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 air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is an acute fracture of the right posterior tenth rib. No other
fractures are demonstrated. The sclerotic lesion within the left iliac wing
likely represents a bone island (series 2, image 202).
SOFT TISSUES: There is extensive subcutaneous emphysema extending from the
neck bilaterally through the anterior and posterior thoracoabdominal wall,
right greater than left. The air extends into the right inguinal canal.
IMPRESSION:
1. Small right pneumothorax with extensive pneumomediastinum and subcutaneous
emphysema extending through the anterior and posterior thoracoabdominal wall,
right greater than left, including the posterior right pararenal space.
2. No definite evidence of injury to the tracheobronchial tree.
3. Right posterior tenth rib fracture with adjacent parenchymal ground-glass
opacity, likely a small contusion.
4. Additional subtle micronodular and ___ opacities within the right
upper and left lower lobe may represent aspiration.
5. No acute intra-abdominal injury.
6. Cirrhotic liver with trace nonhemorrhagic ascites, splenomegaly, and
varices.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chest tube placement for pneumothorax
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: CT torso ___ at 10:40 and chest radiograph ___
09:54
FINDINGS:
There has been interval placement of a right apical chest tube. Previously
noted small right apical pneumothorax is not clearly visualized on the current
radiograph. There is persistent pneumomediastinum and extensive amount of
subcutaneous emphysema within the chest wall bilaterally extending into the
neck. Curvilinear lucency in the right upper quadrant of the abdomen is
compatible with retroperitoneal subcutaneous emphysema, as seen on the
previous CT.
The cardiac and mediastinal contours are unchanged. Pulmonary vasculature is
not engorged. Lungs remain hyperinflated. Minimal patchy right basilar
opacity likely reflects a small contusion. Right posterior tenth rib fracture
is re- demonstrated.
IMPRESSION:
Interval placement of right apical chest tube with previously noted tiny right
apical pneumothorax not visualized on the current radiograph. Persistent,
extensive amounts of pneumomediastinum and subcutaneous emphysema.
Radiology Report
INDICATION: ___ COPD s/p fall and rib fx/PTX, CT placed ___ // ? interval
change. Please do study ___ 0900
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ portable chest radiograph
FINDINGS:
In comparison to ___ portable chest radiograph, there is interval
mild improvement of pneumomediastinum, deep cervical emphysema, and
subcutaneous emphysema. The right medial pneumothorax is again seen and
unchanged from most recent study. No pneumothorax seen in the left lung.
Hazy ill-defined linear right lower lobe opacity is consistent with right
lower lung contusion status post right posterior tenth rib fracture. The
cardiac and mediastinal contours are unchanged. There is no pleural effusion.
The right apical chest tube is in stable position.
IMPRESSION:
1. Interval mild improvement of pneumomediastinum, deep cervical emphysema,
and bilateral subcutaneous emphysema.
2. Persistent small right medial pneumothorax unchanged from ___
chest radiograph.
3. Right lower lobe contusion is unchanged from prior study.
Radiology Report
INDICATION: ___ year year old male, s/p fall, r. 10 rib fracture, PTX,
placement of chest tube // please check status of PTX ( standing-end
expiratory film)
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Right apicolateral pneumothorax measures 9 mm in diameter. Extensive
subcutaneous emphysema. Pneumomediastinum also noted. Right-sided chest
drain in situ. Right tenth rib fracture again visualized. Spondylotic
changes of the thoracic spine. Minimal free air seen in the right
retroperitoneum.
IMPRESSION:
As above
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with PTX, subq emphysema s/p CT placement //
please eval for resolving PTX please eval for resolving PTX
IMPRESSION:
Comparison to ___. Stable apical 7-8 mm right-sided pneumothorax.
The right chest tube is in stable position. Normal size of the heart.
Elongation of the descending aorta. Stable air collection in the soft
tissues.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with PTX, subQ emphysema with CT // Please eval
for resolution of PTX Please eval for resolution of PTX
IMPRESSION:
Comparison to ___. The right chest tube is in stable position.
A 5 mm right pneumothorax is visualized. No evidence of tension. On the
left, there currently is no visualization of a pneumothorax. The air
collection in the bilateral soft tissues is stable.
Radiology Report
INDICATION: ___ year old man with 10th rib fx, PTX and subq emphysema s/p
chest tube placement to waterseal // please eval for resolving PTX, subq
emphysema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs since ___ most recently ___.
FINDINGS:
A small right apical and lateral pneumothorax is unchanged from ___. A
right-sided chest tube remains. No left pneumothorax. Right tenth rib
fracture appears unchanged. Mediastinal contours, hila, and cardiac
silhouette are normal. No pleural effusion. Subcutaneous emphysema is
unchanged from ___.
IMPRESSION:
Small right apical pneumothorax unchanged from ___.
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: ___ year old man with R 10th rib fx and PTX, subQ emphysema s/p CT
placement 5 days ago // please eval for resolution of PTX, subq emphysema
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ PA and lateral chest radiographs
FINDINGS:
A chest tube projects over the mid to upper right lung. The previously
identified small right apical pneumothorax appears unchanged to minimally
decreased in size. Extensive subcutaneous emphysema involving the lateral
right and upper left chest wall is unchanged. The lungs are otherwise clear.
No pleural effusion. Heart size is normal. Cardiomediastinal and hilar
silhouettes are normal.
IMPRESSION:
Essentially unchanged to minimally decreased right apical pneumothorax.
Otherwise unchanged examination.
Radiology Report
INDICATION: ___ year old man with R 10th rib fx and PTX, subQ emphysema s/p CT
placement 5 days ago // please eval for resolution PTX
COMPARISON: Radiographs from ___
IMPRESSION:
The previously seen tiny right apical pneumothorax has resolved.
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There is subcutaneous
emphysema along the chest wall.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ hx of COPD s/p fall and R 10th rib fx and associated PTC and
subcutaneous air s/p CT placement // ? residual PTX, ? persistent trauma from
punctured rib.
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: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 40.0 cm; CTDIvol = 9.4 mGy (Body) DLP = 374.2
mGy-cm.
Total DLP (Body) = 374 mGy-cm.
COMPARISON: CT torso from ___.
FINDINGS:
Extensive subcutaneous emphysema, as well as mediastinal and retroperitoneal
air is unchanged from the prior CT of ___. The right chest tube
terminates at the right lung apex, and there is no residual pneumothorax. No
mediastinal or hilar lymphadenopathy. Heart size is normal. No pericardial
effusion.
The airways are patent to the subsegmental level bilaterally. The lungs are
clear without focal consolidation or pleural effusion.
Right tenth and eleventh rib fractures are again demonstrated. No suspicious
osseous lesion.
Limited images of the upper abdomen demonstrate cysts in the right kidney as
well as nonobstructive bilateral renal calculi. Additionally, the liver
demonstrates a cirrhotic morphology.
IMPRESSION:
1. Right chest tube in appropriate position with no residual right
pneumothorax.
2. Unchanged moderate amount of subcutaneous, mediastinal, and retroperitoneal
air.
3. Bilateral upper pole nonobstructive renal calculi.
4. Cirrhotic liver.
5. Known right tenth and eleventh rib fractures are unchanged in configuration
since ___.
Radiology Report
INDICATION: ___ year old man fall, 10th rib fracture and PTX. Chest tube
pulled at 11.40 pm ___. // Interval change, PTXPlease complete at ___ pm
COMPARISON: Radiographs from ___.
IMPRESSION:
The right-sided chest tube has been removed. There remains a very tiny right
apical pneumothorax. There is subcutaneous emphysema. Lungs are without focal
consolidation, pleural effusions, or pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Rib pain
Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 99.8
heartrate: 79.0
resprate: 20.0
o2sat: 97.0
sbp: 140.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | The patient was admitted to the trauma surgery service after
presenting with right 10th rib fracture and associated right
pneumothorax and extensive subcutaneous emphysema. A right chest
tube was inserted and initially placed to suction, then was
transitioned to water seal. The patient had persistent
subcutaneous emphysema as well as small R pneumothorax on repeat
chest X-ray on hospital day 5, so the thoracic surgery service
was consulted and recommended non-contrast chest CT, which
showed no residual pneumothorax. The chest tube was pulled the
next day, with post-pull CXR showing no residual PTX. The
patient's respiratory status remained stable. Additionally, the
patient's pain control regimen was optimized during his stay to
allow for adequate respiratory effort. His respiratory status
was stable throughout his stay, and he was discharged him in
stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transient right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with h/o advanced
Alzheimer's dementia, HLD, PVD, polymyalgia rheumatica (on
chronic prednisone), and polyarticular chrondrocalcinosis who
presents as a CODE STROKE after a transient episode of syncope
and right facial droop.
Patient was in her usual state of health this morning. She
received her usual AM medications at 8:30 am and then ate
breakfast. At 9:30am, she was seated at the breakfast table when
staff observed her suddenly collapse onto her right side, and
noticed a right facial droop. They attempted to arouse her but
she was unresponsive to voice or noxious stimulation. No arm/leg
weakness or posturing were noted; unclear whether there was any
eye deviation. She appeared quite pale. No tongue bite; she is
incontinent of urine and stool at baseline and wears a diaper.
Staff checked her vital signs and found BP 90/48, HR 52 (and
"thready" pulse), and normoglycemia. 911 was called. Over the
next ___ minutes, she gradually woke up and the facial droop
resolved -- by the time EMS arrived after 20 minutes she was
completely back to her baseline mental status with no facial
droop. She was brought to the ___ where vitals were 114/90, 86
(sinus), afebrile, FSBS 136. Staff noted that her pupils
appeared
pinpoint. A CODE STROKE was called. STAT NCHCT showed
significant
small vessel disease and cortical atrophy, unchanged from prior
NCHCT in ___. No hemorrhage or large territory infarct were
noted.
Due to her advanced Alzheimer's disease, patient is nearly
nonverbal (speaks in "word salad" at baseline), so history is
provided by a ___ aide who cares for her frequently and
was present during the event. He confirms that she took her
usual
medications this morning and was in her usual state of health
previously. He notes that he color looks much better now
compared
to her significant pallor during the event. She has not had any
recent infections or illnesses.
Of note, patient was admitted to ___ in ___ for unwitnessed
syncopal event. Syncope workup (TTE, EKG, telemetry) was
unrevealing; discharge summary does not document hypothesis for
etiology of the event. Per staff, she has not had further
syncopal episodes since then.
Past Medical History:
- Alzheimer's dementia
- Hyperlipidemia
- Peripheral vascular disease
- Hypothyroidism
- Hearing loss
- Polymyalgia
- Seronegative arthritis
- GERD
- Gastritis/duodenitis
- Diverticulitis
- Hemorrhoids
- Polyarticular chondrocalcinosis
- Hiatal hernia
- Insomnia
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL EXAM:
- Vitals: 114/90, 86
- General: elderly woman in NAD, smiling, lying supine in bed
- HEENT: NC/AT, MMM
- Neck: supple
- Cardiac: RRR
- Pulm: CTABL
- ___: SNTND
- Extrem: WWP, significant contractures/stiffness of both legs
(knees flexed and ankles stiffly flexed, unable to straighten
them out)
- Skin: no rashes/lesions noted
NEURO EXAM:
- Mental status: awake, alert, eyes open spontaneously. Oriented
to person but not place or date (thinks it is ___. Unable to
assess attention as she does not follow command to state ___ or
count. Perseverative speech; when asked to name items on ___
card she repeats "card" over and over when each item is pointed
at. There is a marked anomia. She can follow one-step commands
(open/close eyes, squeeze hands etc) but only with multiple
redirections. Does not cooperate with command to repeat. No
evidence of neglect. Unable to test apraxia. +Grasp, snout, and
glabellar reflexes. ***Per her SNF caregiver, these findings are
all BASELINE for the patient***
- Cranial nerves: pupils are pinpoint but reactive (1 to 0.5mm
bilaterally). EOMI appear intact, able to track examiner around
room; limited upgaze. Face symmetric with no NLF flattening or
lag. Tongue protrudes in the midline.
- Motor: Paratonia in the arms. Legs are symmetrically
contracted
and stiffly flexed at the knees and ankles; pt protests loudly
when I attempt to straighten them out (baseline per caregiver).
She does not cooperate with formal strength testing but able to
hold both upper extremities against gravity for >10 seconds. Per
above, legs are stiffly contracted but do appear to move
symmetrically.
- Reflexes: diminished but symmetric throughout. Toes downgoing.
- Coordination: no ataxia on FNF, unable to test HKS.
- Gait: unable to test
Exam At Discharge:
GENERAL EXAM:
- General: elderly woman in NAD, smiling, sitting in bed, eating
- HEENT: NC/AT, MMM
- Neck: supple
- Cardiac: RRR
- Pulm: CTABL
- ___: SNTND
- Extrem: WWP,
- Skin: no rashes/lesions noted
NEURO EXAM:
- Mental status: awake, alert, eyes open spontaneously. Oriented
to person but not place or date. Unable to assess attention.
She can intermittently follow one-step commands (open/close
eyes, squeeze hands etc) but only with multiple redirections.
Does not cooperate with command to repeat. No evidence of
neglect. Unable to test apraxia. +Grasp, snout, and glabellar
reflexes.
- Cranial nerves: pupils are pinpoint but reactive (1 to 0.5mm
bilaterally). EOMI appear intact, able to track examiner around
room; limited upgaze. Face symmetric with no NLF flattening or
lag. Tongue protrudes in the midline.
- Motor: Paratonia in the arms. Legs are symmetrically
contracted and stiffly flexed at the knees and ankles; pt
protests loudly when I attempt to straighten them out (baseline
per caregiver). She does not cooperate with formal strength
testing but able to hold both upper extremities against gravity
for >10 seconds. Per above, legs are stiffly contracted but do
appear to move symmetrically.
- Reflexes: diminished but symmetric throughout. Toes downgoing.
- Coordination: no ataxia on FNF, unable to test HKS.
- Gait: unable to test
Pertinent Results:
ADMISSION LABS:
___ 10:30AM BLOOD WBC-9.8 RBC-4.16* Hgb-11.5* Hct-35.4*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.3* Plt ___
___ 10:30AM BLOOD Neuts-69.5 Lymphs-17.4* Monos-7.8
Eos-4.8* Baso-0.4
___ 10:30AM BLOOD ___ PTT-27.9 ___
___ 10:30AM BLOOD Glucose-107* UreaN-14 Creat-1.0 Na-141
K-4.2 Cl-101 HCO3-26 AnGap-18
___ 05:00PM BLOOD CK(CPK)-79
___ 10:30AM BLOOD cTropnT-0.06*
___ 05:00PM BLOOD CK-MB-3 cTropnT-0.05*
___ 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:41AM BLOOD Glucose-106* Lactate-1.5 Na-139 K-4.1
Cl-100 calHCO3-29]
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-9.2 RBC-3.69* Hgb-10.1* Hct-30.8*
MCV-83 MCH-27.5 MCHC-32.9 RDW-16.3* Plt ___
___ 07:50AM BLOOD Neuts-57.9 ___ Monos-7.0 Eos-5.7*
Baso-0.6
___ 07:00AM BLOOD %HbA1c-5.4 eAG-108
___ 07:00AM BLOOD Triglyc-85 HDL-54 CHOL/HD-2.9 LDLcalc-83
REPORTS:
___ ___- IMPRESSION: No acute intracranial abnormality.
No significant change in age-related volume loss and chronic
small vessel ischemic disease.
CXR ___ - IMPRESSION: Limited evaluation of the chest with
low lung volumes and bibasilar atelectasis.
EEG ___ - IMPRESSION: This is a normal waking and briefly
drowsy EEG.
TTE ___ - IMPRESSION: suboptimal image quality. Probable
hypokinesis of the basal to mid inferior/inferolateral segments.
Calcified aortic valve without significant stenosis.
Carotid Duplex ___ - IMPRESSION: No evidence of
hemodynamically significantly internal carotid artery stenosis
on either side.
CTA Head and Neck ___ - IMPRESSION:
There is no hemorrhage or evidence of acute infarct.
No vessel occlusion or significant stenosis.
CXR ___ - FINDINGS: In comparison with the study of ___,
there is little change in the cardiomediastinal silhouette in a
patient with relatively low lung volumes. No evidence of
pulmonary vascular congestion or acute focal pneumonia. On the
lateral view, there is suggestion of some increased
opacification in the retrocardiac region, which could raise the
possibility of developing consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Milk of Magnesia 30 mL PO DAILY:PRN constipation
2. ibandronate *NF* 150 mg Oral Qmonthly
3. Vitamin D 1000 UNIT PO DAILY
4. TraZODone 100 mg PO HS
5. TraZODone 25 mg PO TID PRN anxiety
6. Donepezil 10 mg PO HS
7. Memantine 10 mg PO BID
8. Methylprednisolone 2 mg PO QOD
9. Citalopram 10 mg PO DAILY
10. Azo Cranberry Plus Vit C *NF* (cranberry extract-vit C)
250-60 mg Oral BID
11. Collagenase Ointment 1 Appl TP DAILY
12. Calcium Carbonate 600 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Senna 2 TAB PO HS
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Voltaren *NF* (diclofenac sodium) 1 % Topical TID PRN pain
17. Lidocaine 5% Patch 1 PTCH TD DAILY
18. Levothyroxine Sodium 125 mcg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Calcium Carbonate 600 mg PO BID
3. Citalopram 10 mg PO DAILY
4. Collagenase Ointment 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID
6. Donepezil 10 mg PO HS
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Memantine 10 mg PO BID
9. Methylprednisolone 2 mg PO QOD
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Senna 2 TAB PO HS
12. TraZODone 100 mg PO HS
13. TraZODone 25 mg PO TID PRN anxiety
14. Vitamin D 1000 UNIT PO DAILY
15. Azo Cranberry Plus Vit C *NF* (cranberry extract-vit C)
250-60 mg Oral BID
16. ibandronate *NF* 150 mg Oral Qmonthly
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Voltaren *NF* (diclofenac sodium) 1 % Topical TID PRN pain
20. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
transient ischemic attack
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
INDICATION: Possible TIA. Evaluate for stroke.
COMPARISONS: CT of the head from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin
section bone reformatted images were obtained and reviewed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
recent infarction. The ventricles and sulci are prominent, consistent with
age-related volume loss. The overall ventricular size is not significantly
changed from ___. The basal cisterns are patent. Periventricular confluent
white matter hypodensities are most consistent with chronic small vessel
ischemic disease. A small hypodensity in the left thalamus (2:16), is
unchanged from prior exam and may represent a tiny lacunar infarct.
No fracture is identified. There is mild mucosal thickening in the ethmoidal
air cells with a small mucus retention cyst in the sphenoid sinus. The
remainder of the visualized paranasal sinuses, mastoid air cells and middle
ear cavities are clear. The soft tissues are unremarkable. Incidentally
noted is hyperostosis frontalis.
IMPRESSION: No acute intracranial abnormality. No significant change in
age-related volume loss and chronic small vessel ischemic disease.
Radiology Report
INDICATION: ___ woman with symptoms of TIA, here to evaluate for
acute cardiopulmonary process.
COMPARISON: CT torso with contrast dated ___. Otherwise, no
prior studies are available for comparison.
TECHNIQUE: Portable semi-erect AP radiograph of the chest.
FINDINGS: Evaluation of the chest is limited due to low inspiratory lung
volumes and slight patient rotation with resultant prominence of the
cardiomediastinal silhouette and lung markings due to under-inflation. Within
this limitation, there is no focal consolidation concerning for pneumonia. No
large pleural effusion or pneumothorax is detected, although evaluation at the
lung apices is limited due to superimposition of cervicocranial soft tissues.
Streaky retrocardiac opacities most likely reflect atelectasis in the setting
of low lung volumes. The pulmonary vasculature is not engorged and there is
no overt pulmonary edema. The cardiomediastinal silhouette is prominent, with
unfolding of the thoracic aorta and mild calcification of the aortic knob.
The trachea is slightly deviated to the right by the aortic arch. There is no
free air beneath the right hemidiaphragm on this semi-erect view.
IMPRESSION: Limited evaluation of the chest with low lung volumes and
bibasilar atelectasis.
Radiology Report
INDICATION: ___ female with history of Alzheimer's and peripheral
vascular sheath, now with syncopal episode. Today, patient comes in for
carotid evaluation.
TECHNIQUE:
Evaluation of bilateral extracranial internal carotid arteries was performed
with grayscale, color and spectral Doppler ultrasound.
FINDINGS:
There is mild heterogeneous plaque at the origin of bilateral internal carotid
arteries.
On the right, peak systolic velocity/diastolic velocities were 45/15 cm/sec in
the proximal ICA, 68/19 cm/sec in the mid ICA, as well as 43/13 cm/sec in the
distal right ICA. The right common carotid artery presented peak systolic
velocity of 38 cm/sec. The right ICA/CCA ratio was 1.7.
On the left, peak systolic velocity/diastolic velocities were 41/12 cm/sec in
the proximal ICA, 58/15 cm/sec in the mid ICA, as well as 53/17 cm/sec in the
distal left ICA. The left common carotid artery had peak systolic velocity of
65 cm/sec. The left ICA/CCA ratio was 0.89.
Bilateral vertebral arteries presented with antegrade flow.
IMPRESSION:
No evidence of hemodynamically significantly internal carotid artery stenosis
on either side.
Radiology Report
HISTORY: ___ woman with right facial droop. Question vascular
abnormality.
CTA of the head and neck is obtained after the intravenous administration of
70cc Omnipaque 350 contrast.
COMPARISON: No prior studies available for comparison.
FINDINGS:
Noncontrast head CT: There is no hemorrhage. There is no mass, midline shift
or hydrocephalus. There are prominent ventricles and sulci due to age related
volume loss.
CT head: There is mild calcified atherosclerotic plaque at the cavernous and
petrous a ICAs bilaterally. The ACAS, and MCAs are unremarkable. Right
intracranial vertebral artery is hypoplastic. The posterior circulation is
otherwise unremarkable. There is no vascular malformation or aneurysm.
CTA neck: There is mild calcified atherosclerotic plaque at the carotid
bifurcations bilaterally without stenosis based on the NASCET criteria. There
is a dominant left vertebral artery.
There are degenerative changes of the cervical spine.
Impression:
IMPRESSION:
There is no hemorrhage or evidence of acute infarct.
No vessel occlusion or significant stenosis.
Radiology Report
HISTORY: Desaturation with previous atelectasis.
FINDINGS: In comparison with the study of ___, there is little change in the
cardiomediastinal silhouette in a patient with relatively low lung volumes.
No evidence of pulmonary vascular congestion or acute focal pneumonia. On the
lateral view, there is suggestion of some increased opacification in the
retrocardiac region, which could raise the possibility of developing
consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O STROKE
Diagnosed with TRANS CEREB ISCHEMIA NOS, SENILE DEMENTIA UNCOMP
temperature: 98.2
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 114.0
dbp: 78.0
level of pain: 0
level of acuity: 1.0 | ___ is a ___ with h/o advanced Alzheimer's dementia,
HLD, PVD, PMR (on chronic prednisone), who presented with a
transient episode of slumping to the right with a possible R
facial droop and unresponsiveness then with subsequent return to
baseline within 20 minutes likely representative of TIA.
.
# TIA: Her exams were limited by her mental status, but the only
abnormality that is not part of her known baseline was a mild
flattening of the nasolabial fold noted on ___, which
subsequently resolved. She had a NCHCT which showed no new
strokes. She had a CTA of her head and neck which showed no
blood vessel abnormalities. She had carotid dopplers which
showed no significant stenosis. She had an EEG that was normal
(in case her transient event could have been a seizure). She
had a HgA1C which was normal as was her lipid panel. Her echo,
however did show some apical hypokinesis. Therefore, given the
liklihood that her event was a TIA, we started her on a baby
aspirin (after discussing this with her PCP's nurse
practitioner). This will help modify her stroke risk factors as
well as her cardiovascular risk factors.
.
# Dementia/AMS: Her mental status on this admissiton initially
appeeared to be slightly worse than pt's fluctuating baseline
per her daughter. UA and CXR done on admission were negative for
infection, but a repeat CXR done on the day prior to D/C showed
a question of an opacity. She was observed for an extra day to
ensure that she did not spike a fever or her WBC elevated and
when neither of these happened it was felt that the opacity was
likely atelectastis. While here, for her dementia we continued
her home dose memantine, donezepil, citalopram and trazodone.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Tetracycline / Rifampin / Levaquin in D5W /
Penicillins
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Bronchoscopy with transbronchial biopsy
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMHx s/f DMII, HTN, ESRD
on dialysis and awaiting transplant. She has been having fevers
chills for approximately 1 month. Cultures from ___
demonstrated stretococcus mitis for which she was started on IV
vancomycin. As a result of the positive cultures and persistent
fevers, she was admitted to ___ from ___
to ___ unt. CT and TTE were performed with no evidence of
infectious source. She was discharged with 2 weeks of total
vancomycin therapy which ended on ___. Ms. ___ has noted
recurrent fevers (approximately 3 times weekly to ___,
malaise, and daily chills. She also notes ___ myalgias which are
baseline for her, and states that her vertigo is at baseline
with daily dizziness which is positional in nature and responds
to epley maneuver.
.
In the ED, initial VS were 99 100 138/54 20 94% 4l, CXR was
obtained which demonstrated mild/moderate pulmonary edema and
left pleural effusion. Vancomycin was given for temperature of
101. Labs were notable for anemia to 29.0. No leukocytosis.
Blood Cultures were drawn.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
DM (insulin dependent on insulin pump)
morbid obesity
ESRD on Dialysis
OSA on bipap ___
asthma
Diverticulosis s/p partial colectomy
COPD on home oxygen
Cholecystectomy
Paroxysmal afib in the setting of hyperkalemia
Social History:
___
Family History:
Mother and sister with DM and HTN. Father died at ___ years old
with stroke and lung cancer. Mother died at ___ with CHF.
Physical Exam:
VS - Temp 99.8 F, 130/55 BP , 84 HR , 18 R , 94 O2-sat % 3L
GENERAL - obese woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - b/l crackles, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use, NC in place
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, no JVD
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema, 2+ peripheral pulses (radials, DPs)
SKIN - LUE graft side without tenderness or erythema
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
Upon discharge, afebrile, otherwise physical exam is unchanged.
Pertinent Results:
Admission labs:
___ 02:20PM BLOOD WBC-5.8 RBC-2.96* Hgb-9.4* Hct-29.0*
MCV-98 MCH-31.6 MCHC-32.4 RDW-14.7 Plt ___
___ 02:20PM BLOOD Plt ___
___ 07:15AM BLOOD ESR-45*
___ 02:20PM BLOOD Glucose-86 UreaN-22* Creat-4.2*# Na-142
K-4.3 Cl-102 HCO3-31 AnGap-13
___ 07:18AM BLOOD ALT-25 AST-24 LD(LDH)-265* AlkPhos-107*
TotBili-0.4
___ 08:00AM BLOOD Calcium-8.6 Phos-3.0# Mg-1.8
___ 07:18AM BLOOD calTIBC-226* Ferritn-534* TRF-174*
___ 08:00AM BLOOD CRP-66.8*
Discharge Labs:
___ 06:20AM BLOOD WBC-9.9 RBC-2.85* Hgb-9.5* Hct-26.6*
MCV-94 MCH-33.2* MCHC-35.5* RDW-16.0* Plt ___
___ 06:20AM BLOOD Glucose-115* UreaN-101* Creat-8.2*#
Na-136 K-4.7 Cl-94* HCO3-24 AnGap-23*
___ 06:55AM BLOOD ALT-25 AST-21 LD(LDH)-267* AlkPhos-111*
TotBili-0.2
___ 06:20AM BLOOD Calcium-9.2 Phos-5.8* Mg-1.9
Pertinent studies:
___ 03:30PM BLOOD HCV Ab-NEGATIVE
___ 08:00AM BLOOD C3-112 C4-24
___ 08:00AM BLOOD CRP-66.8*
___ 07:50AM BLOOD dsDNA-NEGATIVE
___ 04:40PM BLOOD ___ * Titer-1:80
___ 09:43AM BLOOD ANCA-NEGATIVE B
___ 03:30PM BLOOD HBsAb-NEGATIVE HAV Ab-POSITIVE IgM
HAV-NEGATIVE
___ 07:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
___ 07:18AM BLOOD calTIBC-226* Ferritn-534* TRF-174*
___ 08:00AM BLOOD %HbA1c-6.3* eAG-134*
B Glucan--negative
Galactomannan--negative
Right Upper Extremity US: IMPRESSION: Patent graft with no
appreciable fluid collection
TEE: IMPRESSION: No valvular vegetation seen. Right ventriclar
enlargement with preserved systolic function. At least moderate
tricuspid regurgitation is present with severe pulmonary
arterial sysolic hypertension.
Lower Extremity Non-Invasive Doppler US: IMPRESSION: No evidence
of DVT (although the right calf veins were not
visualized); bilateral ___ cysts.
MRI Lumbar Spine:
IMPRESSION:
1. Status post L3/L4 diskectomy and posterior instrumented
fusion with no
evidence of hardware failure, allowing for the limitations of
this imaging
modality.
2. No evidence of paraspinal or epidural phlegmon/abscess or
spondylodiscitis
(on this non-enhanced study).
3. Multilevel degenerative changes of the lumbar spine as
detailed above, with
most notable but only mild spinal canal stenosis at the L4/L5
level.
CT Chest: IMPRESSION:
1. Findings concerning for multifocal infection, less likely
hemorrhage.
2. Lymphadenopathy in the mediastinum and left hilum most likely
reactive.
3. Surveillance with chest radiograph is recommended.
After pulmonary findings resolve, reevaluation with chest CT is
recommended z8-10 weeks after the current examination.
Tagged WBC Scan: IMPRESSION: Slightly asymmetric tracer uptake
in the proximal right upper extremity could be due to an
infectious or inflammatory process.
CXR (2 days s/p CT chest): Moderate cardiomegaly and enlarged
main pulmonary artery are again noted and unchanged. Asymmetric
multifocal opacities, larger on the left side, have minimally
improved on the left upper lobe. There is no pneumothorax or
large pleural effusion.
Lung, left upper lobe, transbronchial biopsy:
Alveolar tissue with hemosiderosis and reactive pneumocyte
hyperplasia.
The biopsy specimen consists of six tissue fragments, four of
which contain alveolar tissue. Several fragments show
mild-to-moderate hemosiderosis with background reactive changes.
This finding is non-specific and can be seen in multiple
clinical settings. Clinical, radiologic, and laboratory
correlation is necessary.
AFB and GMS stains are negative for micro-organisms.
BAL Cx:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Studies pending at discharge:
None
Medications on Admission:
Symbicort 120 inhalations, 160-4.5 mcg 2 puffs BID
Levetiracetam 500 BID
Renelva 800mg tablet 2 tabs TID, ___
Meclizine 25mg 1 tab by mouth three times daily
Furosemide 160mg BID ___, Furosemide 160mg
daily other days
Vitamin B-1 100mg daily
Calcium acetate 667mg three tabs four times daily
Amlodipine 10mg daily
Benicar 60mg daily
Calcium w/ Vitamin D ___ tab by mouth dialy
Ferrous Sulfate 325mg tablet 1 tab daily
Minoxidil 2.5 mg daily
Omeprazole 20mg daily
Vitamin D3 5000 units daily
Doxazosin 4mg qhs
Simvastatin 20mg daily
Acetaminophen 650mg QID PRN
dulcolax PRN
Enema PRn
Vicodin 5mg/500mg q4h PRN
Milk of Magnesia PRN
Ventolin HFA PRN SOB
Insulin Pump
albuterol nebs q4h PRN
ipratropium nebs q4h PRN
1 nephrocap daily
Discharge Medications:
1. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation 2 puffs BID ().
2. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO qam on
___.
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): at noon and bedtime (in addition to AM dose on
non-dialysis days).
4. Renvela 800 mg Tablet Sig: Two (2) Tablet PO TID on
___.
5. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
6. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID ON
SAT/SUN/TUES/THURS ().
7. furosemide 80 mg Tablet Sig: Two (2) Tablet PO ONCE DAILY
___ ().
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. calcium acetate 667 mg Tablet Sig: Three (3) Tablet PO four
times a day.
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
12. Benicar 20 mg Tablet Sig: Three (3) Tablet PO daily ().
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
19. hydrocodone-acetaminophen ___ mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: 400 mg PO
every four (4) hours as needed for nausea.
21. insulin pump cartridge Cartridge Sig: use as directed by
Diabetes Clinic Subcutaneous continuous.
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*90 Capsule(s)* Refills:*0*
23. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*90 Tablet(s)* Refills:*0*
24. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*0*
25. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
26. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation every four (4)
hours as needed for dyspnea, wheezing.
Disp:*90 nebulizations* Refills:*0*
27. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
Disp:*90 nebulizations* Refills:*0*
28. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO BID (2 times a day).
Disp:*90 packets* Refills:*2*
29. Glucagon Emergency 1 mg Kit Sig: One (1) Injection three
times a day as needed for hypoglycemia.
Disp:*30 kits* Refills:*0*
30. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 doses.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes Mellitus II
End Stage Renal Disease
Obstructive Sleep Apnea
Obesity
Asthma
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
AP CHEST, 7:07 A.M., ___.
HISTORY: COPD, fever and increasing cough and wheezing.
IMPRESSION: AP chest compared to ___:
Pulmonary vascular congestion and borderline edema developed on ___
compared to ___. Today, there is still pulmonary vascular engorgement,
borderline edema, mediastinal venous engorgement. There is more consolidation
in the left lower lobe, but since there is more leftward mediastinal shift,
this could be due to atelectasis alone. Pleural effusions are small if any.
Radiology Report
EXAMINATION: Right shoulder.
HISTORY: Shoulder pain and fever.
IMPRESSION: Three views of the right shoulder reviewed in the absence of
prior imaging:
There is minimal degenerative change at the acromioclavicular joint. The
articular surfaces are otherwise all intact and there is no evidence of
shoulder joint effusion. Adjacent ribs are normal. No evidence of infection.
Radiology Report
HISTORY: ___ female with fevers.
STUDY: Bilateral lower extremity venous ultrasound.
COMPARISON: None.
FINDINGS: Grayscale and color Doppler sonographic imaging was performed of
the bilateral common femoral, superficial femoral, popliteal and left peroneal
and left posterior tibial veins. The right posterior tibial and right
peroneal veins were not visualized. Normal compressibility, flow, and
augmentation was demonstrated in the visualized veins.
In right popliteal fossa is a 2.2 x 0.7 x 1.3 cm hypoechoic region compatible
with a ___ cyst. A similar hypoechoic region is seen in the left
popliteal fossa measuring 1.2 x 1.8 x 1.1 cm. These are both compatible with
___ cysts.
IMPRESSION: No evidence of DVT (although the right calf veins were not
visualized); bilateral ___ cysts.
Radiology Report
AP CHEST, 4:49 P.M., ___
HISTORY: COPD, end-stage renal disease and shortness of breath. Question
volume overload.
IMPRESSION: AP chest compared to ___:
Leftward mediastinal shift suggests volume loss in the left lung, and
therefore heterogeneous opacification in the infrahilar left lower lobe could
be atelectasis. Small left pleural effusion may be present. Lateral view
would be very helpful in distinguishing among the possibilities. Moderate
cardiomegaly is stable. Right lung is fully expanded and probably clear, but
there is a suggestion of a 10-mm nodule projecting over the second anterior
rib partially obscured by tubing. When conventional radiographs are obtained
this area can be reexamined.
Radiology Report
INDICATION: ___ woman with status post lumbar stabilization, now
presenting with four weeks' history of fever.
COMPARISON: None available for comparison.
TECHNIQUE: Due to renal failure, the study was obtained as a non-contrast
study with sagittal STIR, T1 and T2 as well as axial T2 images of the lumbar
spine.
FINDINGS: The patient is status post L4 laminectomy as well as L3/L4
discectomy and posterior instrumented fusion with transpediculate screws.
There is expected susceptibility artifact related to the hardware, somewhat
compromising image quality at the respective segment.
There is mild (less than grade 1) anterolisthesis of L3 on L4, while the
dorsal alignment is otherwise well preserved. Besides ___ type 2 change at
L3/L4 and a T1- and T2- hyper- and STIR-hypointense lesion in L2, likely a
hemangioma, the vertebral bone marrow signal is normal throughout the lumbar
spine. Likwise, there is no STIR signal abnormality involving the
intervertebral discs.
Band-like STIR-/T2-hyperintensity is seen along the surgical tract. However,
there is no discrete fluid collection to raise suspicion for abscess.
At the L2/L3 level, there is a left foraminal protrusion, superimposed on a
minimal broad-based disc bulge. In conjunction with facet joint arthropathy,
the left neural foramen is moderately narrowed. Mild narrowing of the right
neural foramen is caused by facet joint osteophytes.
At the L3/L4 level, there is mild anterolisthesis, but no narrowing of the
spinal canal. The left neural foramen is patent, while evaluation of the
right is substantially limited by hardware-related susceptibility artifact.
At the L4/L5 level, the combination of broad-based disc bulge, facet joint
arthropathy, and thickening of the ligamenta flava causes mild spinal canal
narrowing. While the neural foramina are again partially obscured by
artifacts, there appears to be mild-to-moderate narrowing due to facet
arthropathy.
At the L5/S1 level, there is a minimal broad-based disc bulge without
significant narrowing of the spinal canal. The neural foramina are patent,
bilaterally.
The conus medullaris terminates at L1 level, and both the conus and the cauda
equina nerve roots demonstrate normal morphology and T2-signal.
IMPRESSION:
1. Status post L3/L4 diskectomy and posterior instrumented fusion with no
evidence of hardware failure, allowing for the limitations of this imaging
modality.
2. No evidence of paraspinal or epidural phlegmon/abscess or spondylodiscitis
(on this non-enhanced study).
3. Multilevel degenerative changes of the lumbar spine as detailed above, with
most notable but only mild spinal canal stenosis at the L4/L5 level.
Comment: In the absence of IV contrast, more subtle processes such as
leptomeningeal or radicular disease cannot be excluded.
Radiology Report
REASON FOR EXAMINATION: End-stage renal disease and fever of unknown
etiology.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen with subsequent 1.25- and 5-mm collimation. Axial images reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS: Multiple mediastinal lymph nodes are noted in all mediastinal lymph
node stations, ranging up to 7.5 mm in the right upper paratracheal area,
cluster of sub-5-mm nodules in the prevascular area, largest lymph node of 12
mm in the right lower paratracheal area is seen. Left hilar lymphadenopathy
is noted, although difficult to measure given the lack of IV contrast. The
aorta is normal. The main pulmonary artery is 3.5 cm, consistent with
enlargement. Coronary calcifications are noted, extensive. There is also
overall cardiac size enlargement, although no pericardial effusion is seen.
Extensive calcifications of the mitral valve are noted.
The imaged portion of the upper abdomen reveals prior cholecystectomy, rest
within the limitations of this study technique.
Airways are patent to the level of subsegmental bronchi bilaterally.
Multifocal opacities are predominantly involving the posterior aspect of left
upper lobe, lingula and left lower lobe but also seen in right lower lobe and
right upper lobe. The opacities represent a combination of consolidations and
groundglass areas consistent with infectious process with pulmonary hemorrhage
been less likely. There is no evidence of pulmonary edema. There is no
evidence of interstitial process on the current CT scan.
There are no bone lesions worrisome for infection or neoplasm.
IMPRESSION:
1. Findings concerning for multifocal infection, less likely hemorrhage.
2. Lymphadenopathy in the mediastinum and left hilum most likely reactive.
3. Surveillance with chest radiograph is recommended.
After pulmonary findings resolve, reevaluation with chest CT is recommended
___ weeks after the current examination.
Radiology Report
REASON FOR EXAMINATION: Fluoroscopic-guided left upper lobe biopsy.
23 spot images obtained during fluoroscopy was brought to our review
demonstrating the process of left upper lobe biopsy. Within the limitations
of this imaging technique no evidence of pneumothorax is seen but it should be
further documented with dedicated radiographs. Note is made that the
radiologist was not attending the procedure.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pulmonary infiltrates
after bronchoscopy and biopsy.
COMPARISON: Chest CT from ___ and chest radiograph from
___.
After the biopsy there is new opacity in the left upper lobe most likely
representing post-biopsy hemorrhage. Cardiomediastinal silhouette is
unchanged as well as there is no substantial change in multifocal opacities
although the impression is that there is slight decrease in their extent.
Mediastinal and hilar lymphadenopathy is still present.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Increasing shortness of breath.
Comparison is made with prior study, ___.
Moderate cardiomegaly and enlarged main pulmonary artery are again noted and
unchanged. Asymmetric multifocal opacities, larger on the left side, have
minimally improved on the left upper lobe. There is no pneumothorax or large
pleural effusion.
Radiology Report
CLINICAL INFORMATION: ___ female with fever and weakness, question
infectious process.
___.
FINDINGS: Frontal and lateral chest radiographs demonstrate interval removal
of a tunneled right IJ hemodialysis catheter. There is mild-to-moderate
pulmonary edema. There is a tiny left pleural effusion seen on the lateral
view. The heart size is moderately enlarged, the mediastinal contours are
otherwise unremarkable.
IMPRESSION: Mild-to-moderate pulmonary edema with a tiny left pleural
effusion.
Radiology Report
CLINICAL INFORMATION: ___ female with right upper extremity graft,
please assess for fluid around the graft.
COMPARISON: None.
FINDINGS: Sonographic images of the right upper extremity in the region of
the AV graft demonstrate a patent graft. There is no fluid collection around
the graft.
IMPRESSION: Patent graft with no appreciable fluid collection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAK/FEVERS
Diagnosed with FEVER, UNSPECIFIED, BACTEREMIA NOS, CHRONIC AIRWAY OBSTRUCTION
temperature: 99.0
heartrate: 100.0
resprate: 20.0
o2sat: 94.0
sbp: 138.0
dbp: 54.0
level of pain: 1
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a past medical history
significant for end stage renal disease on hemodialysis, type 2
diabetes mellitus and chronic obstructive pulmonary disease
admitted for fevers x1 month, which were ultimately felt to be
drug fever from either Vancomycin or minoxidil. Hospital course
was notable for a mild COPD exacerbation and steroid induced
hyperglycemia
#Fever of unknown origin/Drug Fever: Given history of bacteremia
with strep mitis and preceding 1 month of persistent fevers with
normal TTE and CT abdomen, initially our efforts focused on
finding a source persistent infection. Initial culprits were
thought to be the dialysis graft or endocarditis. Negative TTE
at OSH, and negative TEE in house made endocarditis unlikely.
Unremarkable US of right upper extremity graft made this
unlikely. Furthermore, there was only a mild increase in tracer
uptake in the right upper extremity compared to the left upper
extremity on tagged white blood cell scan. Bilateral lower
extremity vascular ultrasounds were negative for DVT. Blood
smear was negative for parasites. Hepatitis serologies were also
negative and LFTs were normal. An MRI was also obtained given
spinal hardware and was negative for signs of
infection/inflammation. Due to worsening shortness of breath
discovered in house, a CT of the chest was performed which was
significant for ground glass opacities involving the posterior
aspect of left upper lobe, lingula and left lower lobe. BAL and
bronchial biopsy were significant only for ___ cfu of gram
negative rods and respiratory flora. A transbronchial biopsy was
non-specific without evidence of malignancy or granulomas. Six
sets of blood cultures were obtained while Ms. ___ was off of
antibiotics. Beta Glucan and Galactomannal were within normal
limits.Rheumatologic labwork was relatively unimpressive with a
normal ANCA/RF and intermediate ___ (1:80). Given absence of
positive infectious workup, Vancomycin was discontinued, as was
minoxidil as patient gave history fevers starting around the
time of minoxidil initiation. After stopping these medications,
the patient defervesced and was afebrile for >5 days suggesting
drug fever.
#Mild exacerbation of chronic obstructive pulmonary disease:
Overall Ms. ___ respiratory symptoms and radiographic
findings were seen as most consistent with a COPD exacerbation.
Patient was treated with azithromycin and prednisone 40mg po
with improvement in symptoms and patient was discharged to
complete a one week total course. Of note, it took ~4 days for
patient to start responding to the steroids, which was similar
to when patient has required steroids for COPD exacerbation in
the past. Although patient grew ___ cfu E. coli in the BAL it
was not felt that these were pathogenic as patient responded to
treatment with azithro and prednisone.
#End stage renal disease on dialysis: MWF dialysis was continued
in house. Due to hypophosphatemia, revela and phoslo were
temporarily discontinued.
#Type II diabetes mellitus: Ms. ___ was maintained on her
insulin pump which was closely monitored by the ___.
Her blood sugars increased while on steroids (up to 400s), and
basal parameters of her pump were increased while she was on
steroids with input from ___. She was discharged with close
followup in ___ clinic two days post discharge and was
made aware that her insulin requirements will fall once her
steroids are completed. She is aware of signs of hypoglycemia
and was discharged with glucagon injectable as needed.
# BPPV: Meclizine was continued.
#Disposition:
Patient was discharged home with one more day of prednisone to
take. She ___ with her Endocrinologist who will give her
instructions on how to change her insulin as she comes off
prednisone. She will also follow up with her PCP, outpatient
renal and pulmonary doctors. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Detrol
Attending: ___.
Chief Complaint:
Bladder neck mass
Major Surgical or Invasive Procedure:
Cystoscopy/TURBT
Port placement
History of Present Illness:
PCP: Dr. ___, ___)
Uro: Dr. ___
___ with mild dementia, transferred from ___ to
___ for evaluation of abdominal pain. She reported has a
history of recently discovered bladder neck mass with external
growth inferiorly found recently (saw a Dr. ___ [urology]
and, per son, reportedly underwent cystoscopy without biopsy and
for which she was undergoing further workup (no records to
define this). She reportedly awoke this morning with severe
bilateral lower quadrant pain radiating to the back, without
associated fever, chills, nausea, vomiting, or diarrhea. She was
evaluated at ___ and her pain resolved after a "pain
pill". She underwent ultrasound and had reported right UVJ
hydro 9report states mild right hydronephrosis (R = 10.9cm
L=9.7). Estimated GFR was 58. A nephrologist there, Dr. ___,
___ stenting and biopsy. Son, who works at ___,
requested transfer to ___ ER for admission and an expedited
work up.
In the ER at ___, vital signs were stable. The abdomen was
soft without tenderness. Urinalysis showed leukocytosis without
nitrites. Her WBC, renal function, lactate, and electrolytes
were normal. She was mildly anemic and thrombocytopenic with
unknown baseline. She reportedly ate a half a ___ sandwich,
had some recurrent lower abdominal pain without nausea/vomiting
and without need for analgesic medication, so was admitted for
observation. Outside films were reportedly uploaded to the
radiology system.
ROS: no HA, fever, chills, N/V, diarrhea. Has intermittent
hematuria, as recently as 3 weeks ago (has a new recent dx of
anemia. No rash. Other 12 pt ROS negative in full including
urinary retention.
Past Medical History:
- Alzheimer's type dementia x 3+ years
- Bladder neck mass (new dx); h/o hematuria back in ___
for which was diagnosed with UTI at that time.
- Prior "irregular heart beat" for which was on warfarin for ___
weeks until discontinued a week or so ago
- s/p L TKR
- h/o shingles
Social History:
___
Family History:
Mo - died of infection
Fa - died of stroke, dementia
Sister - died of heart problems
Sister - alive with arthritis
Physical Exam:
ADMISSION EXAM:
AVSS
Well in NAD
Anicteric, OP clear w/o thrush, neck supple no ___
CHEST - RRR no MRG
LUNGS - CTA bilat
ABD - soft, NT/ND, no HSM, no palpable lower abd masses, no R/G
GU - no foley
**BLADDER SCAN** = 100cc 3 hr after last void
SKIN - no lesions
MSK - no deformities
NEURO - CN2-12 intact, memory is mildly impaired, speech fluent,
no sensorimotor deficits, sits unassisted
PSYCH - calm
DISCHARGE EXAM:
VS: 97.9 138/60 65 18 98RA
GEN: Appears well in no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Lymph: no lymphadenopathy in armpits, neck, or groin
Neck: Supple, no JVD
CV: nl S1S2, tachy, irreg irregular, no murmurs, rubs or
gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
GU: No foley, voiding adequately
DERM: Dermatitis consistent with candidiasis in the groin area.
Neuro: non-focal.
PSYCH: full range of affect
ACCESS: Port
Pertinent Results:
ADMISSION LABS:
___ 02:40PM WBC-5.9 RBC-2.85*# HGB-9.0*# HCT-28.3*#
MCV-99*# MCH-31.6 MCHC-31.8* RDW-16.9* RDWSD-59.2*
___ 02:40PM PLT COUNT-138*
___ 02:40PM NEUTS-64.8 LYMPHS-18.9* MONOS-14.8* EOS-0.5*
BASOS-0.5 IM ___ AbsNeut-3.84 AbsLymp-1.12* AbsMono-0.88*
AbsEos-0.03* AbsBaso-0.03
___ 02:40PM ___ PTT-27.2 ___
___ 02:40PM GLUCOSE-94 UREA N-14 CREAT-1.1 SODIUM-143
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-28 ANION GAP-11
___ 02:40PM ALT(SGPT)-14 AST(SGOT)-18 ALK PHOS-49 TOT
BILI-0.5
___ 02:40PM LIPASE-15
___ 02:40PM ALBUMIN-3.3* CALCIUM-9.4 PHOSPHATE-3.3
MAGNESIUM-2.1
___ 02:55PM LACTATE-0.9
___ 04:13PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 04:13PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 04:13PM URINE RBC-24* WBC-163* BACTERIA-FEW YEAST-NONE
EPI-17 TRANS EPI-1 RENAL EPI-<1
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-41.0* RBC-2.26* Hgb-7.4* Hct-23.2*
MCV-103* MCH-32.7* MCHC-31.9* RDW-17.0* RDWSD-63.9* Plt ___
___ 12:00AM BLOOD Neuts-98* Bands-2 ___ Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-41.00* AbsLymp-0.00*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD Glucose-133* UreaN-21* Creat-0.7 Na-141
K-3.6 Cl-103 HCO3-27 AnGap-15
___ 12:00AM BLOOD ALT-21 AST-17 AlkPhos-76 TotBili-0.2
___ 12:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8
=
=
=
=
================================================================
OSH Renal US report ___
"Mild right hydronephrosis"
=
=
=
=
================================================================
CXR ___: FINDINGS:
The lungs are hyperinflated and diaphragms are flattened,
consistent with
COPD.
There is mild to moderate cardiomegaly. Aorta is densely
calcified and
unfolded. Mitral annulus calcification is noted.
There is upper zone redistribution, but no overt CHF.
There is blunting of the costophrenic angles posteriorly with
evidence for
small right effusion and tiny left effusion.
Minimal bibasilar atelectasis, but no frank consolidation.
Ill-defined focal density at the right lung base laterally may
represent
artifact due to overlying rib shadows -- attention to this area
on followup
films is requested.
Osteopenia and degenerative changes of the thoracic spine are
noted.
IMPRESSION:
Hyperinflation suggestive of COPD.
Mild to moderate cardiomegaly. Small right-greater-than-left
pleural
effusions. Minimal bibasilar atelectasis.
No CHF or pneumonic infiltrate detected.
Small ill-defined focal density at the right base laterally of
uncertain
etiology or significance -- attention on followup films is
requested.
Bilateral oblique AP views of the chest may help for further
characterization.
RECOMMENDATION(S): When the patient is stable, bilateral
oblique AP views of
the chest to further evaluated focal opacity at the right lung
base laterally.
=
=
=
=
================================================================
CXR ___: oblique views to evaluate shadow seen on earlier CXR
FINDINGS:
The small nodular density questioned at the right base laterally
on the
radiograph obtained earlier the same day is not confirmed on the
current
images and likely represented artifact due to overlying osseous
and vascular
structures. The small right pleural effusion is again noted.
Incidental note is made of narrowing of the acromial humeral
distance in both
shoulders, consistent with bilateral chronic rotator cuff
thinning and/or
tearing, and bilateral glenohumeral joint osteoarthritis.
IMPRESSION:
As above.
=
=
=
=
================================================================
Echo ___: Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. Hyperdynamic LVEF >75%. No
resting LVOT gradient. Mid-cavitary gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root. Focal
calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. No MS. ___ to severe (3+) MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm
appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). A mild, poorly localized
intracavitary gradient is seen (peak 19mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is moderate mitral annular calcification.
Likley moderate to severe (3+) mitral regurgitation is seen
accounting for acoustic shadowing from mitral annular
calcification. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Hyperdynamic left ventricular systolic function.
___ moderate to severe mitral regurgitation in the context of
moderate mitral annular calcification. Mild pulmonary
hypertension. A TEE can better define the etiology of the mitral
regurgitation and severity if clinically indicated.
=
=
=
=
================================================================
Renal ultrasound ___:
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 11.1
cm. There is
hydronephrosis bilaterally, new since ___. There is no
stones, or
masses bilaterally. Normal cortical echogenicity and
corticomedullary
differentiation are seen bilaterally.
The bladder is complete collapse without Foley in place and can
not be fully
assessed on the current study. Known bladder mass is not
evaluated on this
study.
IMPRESSION:
1. Bilateral hydronephrosis without evidence of proximal
obstruction.
2. Bladder not evaluated due to decompression from a Foley.
3. Known bladder mass not evaluated on this exam.
=
=
=
=
================================================================
Renal Ultrasound ___
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 9.5
cm. There is no stones or masses bilaterally. Normal cortical
echogenicity and
corticomedullary differentiation are seen bilaterally. There is
interval
improvement of bilateral hydronephrosis, mild-to-moderate in
degree
bilaterally.
The bladder is not visualized, secondary to decompression from
the Foley
catheter.
IMPRESSION:
1. Mild interval improvement of bilateral hydronephrosis, now
mild to moderate
in degree.
2. Decompressed bladder with Foley in place.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. biotin (biotin-calcium carbonate) 1,000 mcg oral DAILY
2. cranberry (cranberry conc-ascorbic acid;<br>cranberry
extract) 450 mg oral Other
3. Donepezil 10 mg PO QHS
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
400-250 mcg oral DAILY
5. Rosuvastatin Calcium 5 mg PO QPM
Discharge Medications:
1. Donepezil 10 mg PO QHS
2. Rosuvastatin Calcium 5 mg PO QPM
3. biotin (biotin-calcium carbonate) 1,000 mcg oral DAILY
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
400-250 mcg oral DAILY
5. cranberry (cranberry conc-ascorbic acid;<br>cranberry
extract) 450 mg oral Other
6. Allopurinol ___ mg PO DAILY
Please take for 10 additional days after discharge. Last day
will be on ___.
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
7. Metoprolol Tartrate 37.5 mg PO TID
RX *metoprolol tartrate 37.5 mg 37.5 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
8. Filgrastim 300 mcg SC Q24H
Please start this on ___ and your last day will be ___.
RX *filgrastim [Neupogen] 300 mcg/0.5 mL 1 daily Disp #*7
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: High grade diffuse B-cell lymphoma
Secondary: Acute kidney injury, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with bladder neck mass, ? metastasis // Please
evaluate mass, please protocol for soft tissue depth of invasion
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist.
COMPARISON: Outside studies: Renal ultrasound ___, CT abdomen
pelvis ___.
FINDINGS:
UTERUS AND ADNEXA:
The uterus is anteverted and measures 5.9 x 2.6 cm on sagittal imaging.
The endometrium is not clearly visualized due to motion artifact.
The junctional zone is not clearly visualized due to motion artifact.
The right ovary is visualized and appears within normal limits.
The left ovary is visualized and appears within normal limits.
Trace pelvic free fluid noted.
LYMPH NODES: No pelvic lymphadenopathy identified.
BLADDER AND DISTAL URETERS:
The urinary bladder is decompressed by presence of a Foley catheter in place.
There is a pelvic mass measuring 4.1 x 3.6 x 4.8 cm (CC, AP, TA. 06:18,
13:38) whose epicenter is situated between the posterior bladder wall and
anterior vaginal wall. The mass appears to involve the posterior superior
urethra (06:14). There is mass effect on the posterior bladder wall, however
the detrusor muscle appears to demonstrate expected T2 hypo intensity
throughout. There is homogeneous enhancement as well as significant
restricted diffusion throughout the mass.
The cervix and anterior vagina are normal in appearance, although there is
loss of fat plane between these structures and the mass.
RECTUM AND INTRAPELVIC BOWEL: Normal appearance of rectum and intrapelvic
bowel.
VASCULATURE: Normal pelvic vascular structures without stenosis or occlusion.
OSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal
signal characteristics. No concerning osseous lesions.
IMPRESSION:
Scan is limited by motion artifact.
1. Pelvic mass measuring up to 4.8 cm at the posterior bladder base with mass
affect on the bladder base, arising either from the bladder wall or extrinsic
to it. The cervix and anterior vagina are normal in appearance, although there
is loss of fat plane between these structures and the mass and the mass does
not appear to arise from either the cervix or the vagina.
2. No abnormal lymph nodes or other evidence of metastatic disease.
RECOMMENDATION(S): Biopsy is recommended as this mass appears atypical for
urothelial origin and may originate from the wall or be extrinsic to the
bladder.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with AFib // r/o pna,
COMPARISON: None.
FINDINGS:
The lungs are hyperinflated and diaphragms are flattened, consistent with
COPD.
There is mild to moderate cardiomegaly. Aorta is densely calcified and
unfolded. Mitral annulus calcification is noted.
There is upper zone redistribution, but no overt CHF.
There is blunting of the costophrenic angles posteriorly with evidence for
small right effusion and tiny left effusion.
Minimal bibasilar atelectasis, but no frank consolidation.
Ill-defined focal density at the right lung base laterally may represent
artifact due to overlying rib shadows -- attention to this area on followup
films is requested.
Osteopenia and degenerative changes of the thoracic spine are noted.
IMPRESSION:
Hyperinflation suggestive of COPD.
Mild to moderate cardiomegaly. Small right-greater-than-left pleural
effusions. Minimal bibasilar atelectasis.
No CHF or pneumonic infiltrate detected.
Small ill-defined focal density at the right base laterally of uncertain
etiology or significance -- attention on followup films is requested.
Bilateral oblique AP views of the chest may help for further characterization.
RECOMMENDATION(S): When the patient is stable, bilateral oblique AP views of
the chest to further evaluated focal opacity at the right lung base laterally.
Radiology Report
EXAMINATION: CHEST (BOTH OBLIQUES ONLY)
INDICATION: ___ year old woman with abnormal cXR // please perform bilateral
oblique views as requested on CXR read from earlier today on ___ to evaluate
abnormal lung finding
COMPARISON: Chest x-ray from ___ at 09:02
FINDINGS:
The small nodular density questioned at the right base laterally on the
radiograph obtained earlier the same day is not confirmed on the current
images and likely represented artifact due to overlying osseous and vascular
structures. The small right pleural effusion is again noted.
Incidental note is made of narrowing of the acromial humeral distance in both
shoulders, consistent with bilateral chronic rotator cuff thinning and/or
tearing, and bilateral glenohumeral joint osteoarthritis.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with bladder mass with foley in place. Cr is
rising, ? obstruction // please rule out hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT from ___.
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 11.1 cm. There is
hydronephrosis bilaterally, new since ___. There is no stones, or
masses bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is complete collapse without Foley in place and can not be fully
assessed on the current study. Known bladder mass is not evaluated on this
study.
IMPRESSION:
1. Bilateral hydronephrosis without evidence of proximal obstruction.
2. Bladder not evaluated due to decompression from a Foley.
3. Known bladder mass not evaluated on this exam.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with new diagnosis of high grade diffuse large
b cell lymphoma (bladder mass) // assess for other sites of disease,
requested by heme, if any ?s please page
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 37.4 cm; CTDIvol = 6.3 mGy (Body) DLP = 231.3
mGy-cm.
2) Spiral Acquisition 4.8 s, 31.4 cm; CTDIvol = 5.5 mGy (Body) DLP = 168.6
mGy-cm.
Total DLP (Body) = 400 mGy-cm.
COMPARISON: Renal ultrasound ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Imaged portion of the base of the
neck is unremarkable. No supraclavicular or axillary lymphadenopathy.
UPPER ABDOMEN: Bilateral hydronephrosis is again seen.
MEDIASTINUM: There is a 1.3 cm precarinal lymph node (05:103). Subcarinal
lymph node measures up to 1.1 cm.
HILA: Evaluation is limited without IV contrast.
HEART and PERICARDIUM: Cardiomegaly is mild. There is coronary artery, aortic
valve, and severe mitral annular calcification. No pericardial effusion.
PLEURA: There are moderate right and small left nonhemorrhagic pleural
effusions with moderate associated atelectasis. No pneumothorax.
LUNG:
1. PARENCHYMA: There is scattered subsegmental atelectasis. No focal
consolidation.
2. AIRWAYS: The airways are patent to subsegmental levels.
3. VESSELS: The great vessels are normal caliber.
CHEST CAGE: No suspicious lytic or sclerotic lesion. Sclerotic lesion in the
T1 vertebral body is likely a bone island. No acute fracture.
IMPRESSION:
1. Borderline mediastinal lymph nodes are likely reactive to the pleural
effusions. No evidence of malignancy in the chest.
2. Moderate right and small left nonhemorrhagic pleural effusions with
moderate associated atelectasis.
3. Bilateral hydronephrosis is again seen.
Radiology Report
INDICATION: ___ year old woman with high-grade diffuse large cell lymphoma,
awaiting chemo // please place single lumen chest port and leave accessed for
patient that needs chemo - blanch aware
COMPARISON: None
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: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 0 mg of midazolam throughout the total intra-service
time of 15 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: Versed.
CONTRAST: 0
FLUOROSCOPY TIME AND DOSE: 0.1 min, 0 mGy
PROCEDURE
1. Right internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. ___ subcuticular Vicryl sutures and
Steri-strips were used to close the venotomy incision site. Steri-Strips were
applied over the sutures. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single 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.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with new dx of diffuse large b-cell lymphoma,
was in renal failure ___ obstruction from tumor with foley placed for drainage
// obstructive hydronephrosis, need for Foley.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Ultrasound from ___.
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 9.5 cm. There is
no stones or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. There is interval
improvement of bilateral hydronephrosis, mild-to-moderate in degree
bilaterally.
The bladder is not visualized, secondary to decompression from the Foley
catheter.
IMPRESSION:
1. Mild interval improvement of bilateral hydronephrosis, now mild to moderate
in degree.
2. Decompressed bladder with Foley in place.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.9
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 102.0
dbp: 57.0
level of pain: 0
level of acuity: 3.0 | ___ year old woman with dementia, prior hx of afib admitted for
intra-abdominal mass found to be high grade diffuse large B cell
lymphoma, completed C1 of R-mini-
CHOP without any complications. Hospital stay was complicated by
development of rapid afib now well controlled in NSR on
metoprolol, and renal failure likely ___ obstruction by tumor
with a foley in place for drainage. She was hemodynamically
stable with a Cr of 0.7 on discharge.
#High grade large b-cell lymphoma: Found on MRI on ___ that
showed "Pelvic mass at the posterior bladder base which appears
to demonstrate mass affect on the bladder, possibly arising from
the bladder wall or posterior bladder neck." Cystoscopy/TURBT
procedure done with biopsies showing high-grade diffuse large
b-cell
lymphoma. The patient had a port placed by ___ and completed one
cycle of R-mini-CHOP without complications. She was discharged
with allopurinol ___ mg daily and Neupogen 300 mcg daily with
___ services organized for teaching her how to administer it.
Patient is to follow-up with Dr. ___ on ___. Patient was
also given Ciprofloxacin 500 mg BID in case of fevers or chills,
but it was noted after discharge that the patient had an allergy
to the medication (reaction not noted). The pharmacy as well as
the patient and her son were notified and the prescription was
discontinued. She also has home visiting services with physical
therapy.
#Atrial fibrillation: Hx of afib for which she was on warfarin
for ___ weeks until discontinued a week ago due to hematuria and
anemia. Developed afib with RVR on ___, infectious workup
negative, TSH wnl, Echo showed normal EF with mod to severe MR
which can be a possible etiology. Patient was started on
metoprolol 75 mg TID and was in NSR since. Patient was
discharged on metoprolol 37.5 mg TID due to episodes of
bradycardia and hypotension.
#Acute renal failure: Cr increased up to 2.0 and returned to
baseline at 0.7 on discharge. This was likely ___ to obstruction
from the mass, which decreased in size with the chemotherapy.
Renal U/S showing evidence of b/l hydronephrosis which was
discussed with urology and a foley was placed for drainage.
Repeat renal U/S on ___ showed improved hydronephrosis
bilaterally. The patient had a void trial and was producing good
urine. She was discharged home without a foley. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
rectal pain
Major Surgical or Invasive Procedure:
Incision and drainage of ___ abscess with packing
History of Present Illness:
___ with 2 day history of worsening rectal pain. States
initially it was dull, now sharp and stabbing. Worsened with any
type of movement or touch. No fevers, chills, nausea, vomiting,
or change in bowel movements. He noted blood on toilet paper
today.
Past Medical History:
Past Medical History: headaches, depression
Past Surgical History: None
Social History:
___
Family History:
noncontributory
Physical Exam:
Vitals: Temp 97.6, HR 97, BP 132/63, R16, 99% Room air
GEN: A&OX3
HEENT: atraumatic
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: Large right side perirectal abscess approximately 8 x4 cm,
very tender, erythematous. patient unable to tolerate intubation
of rectum
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:42AM BLOOD WBC-11.2* RBC-4.26* Hgb-13.8* Hct-39.5*
MCV-93 MCH-32.5* MCHC-35.0 RDW-12.6 Plt ___
CT PELVIS W/CONTRAST
IMPRESSION:
1. A 2 x 3 cm right perianal abscess versus low fissure or
fistula.
2. Relative featureless appearance of the rectum and sigmoid
colon may be related to distention, this could be correlated
with clinical history if there is concern for inflammatory bowel
disease.
3. Diffuse enlargement of a fluid filled appendix without
surrounding
inflammatory changes. This is inconsistent with acute
inflammation.
Differential considerations include secondary appendiceal
involvement by
inflammatory bowel disease, although a mucocele cannot be
excluded. Correlate with clinical history and consider further
evaluation by MRI if indicated. Alternatively a CT enterography
could be performed in 3 months for follow-up.
Medications on Admission:
Lexapro 10', ibuprofen prn
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*15 Tablet Refills:*0
2. Escitalopram Oxalate 10 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
daily Disp #*10 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with perirectal pain and fluctuance about the
rectal area. Question perirectal abscess.
COMPARISON: CT dated ___.
TECHNIQUE: MDCT images were acquired through the pelvis prior to and
following administration of intravenous contrast and following administration
of rectal contrast administration. Only 30 ml of intravenous contrast was
injected, resulting in suboptimal contrast enhancement.
FINDINGS: There is a 2 x 3 cm low density region just to the right of the
anal canal, associated with soft tissue thickening and mild stranding, which
could represent a perianal abscess or low fissure. There is no evidence of
supralevator extension.
Incidental note is made of relative featureless appearance of the rectum and
sigmoid colon, which could be related to distention but should be correlated
with clinical history for any concern of inflammatory bowel disease. There is
also diffuse enlargement of the appendix up to 11 mm, similar as compared to
prior exams, but previously seen appendicolith is no longer evident. The
appendix appears to contain fluid but with no significant inflammation around
it.
The bladder, distal ureters, rectum, and seminal vesicles appear within normal
limits. Small inguinal and pelvic sidewall lymph nodes are noted, which do
not meet size criteria for adenopathy. Also noted is a prominent-appearing
appendix measuring up to 11 mm without specific evidence to suggest
inflammation.
BONE WINDOW: No focal concerning lesion.
IMPRESSION:
1. A 2 x 3 cm right perianal abscess versus low fissure or fistula.
2. Relative featureless appearance of the rectum and sigmoid colon may be
related to distention, this could be correlated with clinical history if there
is concern for inflammatory bowel disease.
3. Diffuse enlargement of a fluid filled appendix without surrounding
inflammatory changes. This is inconsistent with acute inflammation.
Differential considerations include secondary appendiceal involvement by
inflammatory bowel disease, although a mucocele cannot be excluded. Correlate
with clinical history and consider further evaluation by MRI if indicated.
Alternatively a CT enterography could be performed in 3 months for follow-up.
Findings reported to Dr. ___ at 10 a.m. on ___ via phone.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SCIATIC PAIN
Diagnosed with ABCESS OF ANAL & RECTAL REGIONS, ANAL OR RECTAL PAIN, LUMBAGO
temperature: 97.6
heartrate: 97.0
resprate: 16.0
o2sat: 99.0
sbp: 132.0
dbp: 63.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was admitted and underwent examination under
anesethia of the ___ abscess, which was excised,
drained, and packed with iodoform and kerlex dressing. He
tolerated the procedure well, was extubated and brought to the
PACU and then the floor for observation. He remained afebrile
and his white blood cell count decreased, so he was not placed
on antibiotics. The plan was for him to be discharged home on
post-operative day 2 after removal of the packing, however as he
was walking to the bathroom he felt very lightheaded and nearly
fainted, and had some mild orthostatic hypotension, which was
thought to be due to a vasovagal response from the tight
packing. The packing was removed and replaced, and later fell
out on its own on post-operative day 3. A light gauze dressing
was placed over the wound, and he was discharged on
post-operative day 4 with instructions to follow up in ___
clinic in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old ___ speaking female with diabetes, HTN
and HLD who presented for dizziness, and palpitations for a few
days. She also had nausea and emesis consisting of recently
ingested food. She denies fevers, cough and diarrhea. She also
denies dysuria, hematuria, urinary frequency, back pain and a
history of UTIs in the past.
In the ED, initial vitals were: T102.9, HR126, BP168/76, RR18,
Spo2 100% RA.
Labs were notable for normal CBC, chem panel with hyponatremia
to 132, bicarb 20, Cr 1.2 and anion gap 18, lactate 3.3 to 2.2
with IVF. Normal LFTs. UA with moderate ___, 19 WBCs, negative
RBCs, nitrite positive, few bacteria, 1000 glucose and trace
protein. Flu swab was negative.
CXR was negative with mild left base atelectasis without
definite focal consolidation.
ECG: sinus tachycardia 125, normal axis, normal intervals (QTc
414). No significant ST-t segment changes.
She was given 3L IVF, 1g Tylenol, vanc, zosyn and 10U regular
insulin.
On the floor, the states that her tachycardia and palpitations
had subsided.
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:
Diabetes mellitus
Hypertension
Hypercholesterolemia
Social History:
___
Family History:
Reviewed in detail. None pertinent to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: T97.6, BP 128/64, HR 92, RR 18, SpO2 99%RA. Wt 80.8
kg.
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, dentures in place in upper and
lower teeth, oropharynx clear, EOMI, pupils are 2mm and
reactive, neck supple
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; there is no CVA
tenderness
GU: No foley
Ext: bilateral lower extremities are tender to the touch causing
electric pain, otherwise warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
=======================
Vital Signs: 99.1 PO 138 / 50 60 18 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, dentures in place in upper and
lower teeth, oropharynx clear, EOMI, pupils are 2mm and
reactive, neck supple
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; there is no CVA
tenderness
GU: No foley
Ext: bilateral lower extremities are tender to the touch causing
electric pain, otherwise warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
ADMISSION LABS:
==============
___ 10:54PM LACTATE-2.2*
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 10:30PM URINE RBC-<1 WBC-19* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:15PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 07:41PM LACTATE-3.3*
___ 07:20PM GLUCOSE-214* UREA N-16 CREAT-1.2* SODIUM-132*
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-20* ANION GAP-23*
___ 07:20PM estGFR-Using this
___ 07:20PM ALT(SGPT)-15 AST(SGOT)-29 ALK PHOS-113* TOT
BILI-0.7
___ 07:20PM LIPASE-15
___ 07:20PM ALBUMIN-4.1
___ 07:20PM WBC-9.0 RBC-4.73 HGB-12.1 HCT-37.0 MCV-78*
MCH-25.6* MCHC-32.7 RDW-14.6 RDWSD-41.0
___ 07:20PM NEUTS-88.8* LYMPHS-7.5* MONOS-2.8* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-7.99* AbsLymp-0.67* AbsMono-0.25
AbsEos-0.00* AbsBaso-0.02
___ 07:20PM PLT COUNT-243
DISCHARGE LABS:
==============
___ 08:09AM BLOOD WBC-3.8* RBC-4.19 Hgb-10.7* Hct-33.1*
MCV-79* MCH-25.5* MCHC-32.3 RDW-14.5 RDWSD-41.7 Plt ___
___ 08:09AM BLOOD Glucose-206* UreaN-11 Creat-1.0 Na-137
K-3.8 Cl-102 HCO3-23 AnGap-16
___ 07:20PM BLOOD ALT-15 AST-29 AlkPhos-113* TotBili-0.7
___ 08:09AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8
MICRO:
======
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------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
IMAGING:
========
CXR ___: atelectasis, no definite consolidation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Glargine 24 Units Breakfast
Novolog 14 Units Breakfast
Novolog 14 Units Lunch
Novolog 14 Units Dinner
3. Simvastatin 10 mg PO QPM
4. Lisinopril 10 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Lumigan (bimatoprost) 0.01 % ophthalmic Q8H
7. Brimonidine Tartrate 0.15% Ophth. Dose is Unknown BOTH EYES
Q8H
8. Ranitidine 300 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Gabapentin 300 mg PO QHS
4. Glargine 24 Units Breakfast
Novolog 14 Units Breakfast
Novolog 14 Units Lunch
Novolog 14 Units Dinner
5. Lumigan (bimatoprost) 0.01 % ophthalmic Q8H
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Ranitidine 300 mg PO DAILY
8. Simvastatin 10 mg PO QPM
9. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until you talk with Dr ___ PCP
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
E.coli bacteremia
Pyelonephritis
Acute Kidney Injury
SECONDARY DIAGNOSIS:
IDDM
Neuropathy
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 dyspnea, cough // ? pna
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
No focal consolidation is seen. There is no large pleural effusion or
pneumothorax. The cardiac silhouette is top-normal to mildly enlarged.
Mediastinal contours are unremarkable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to suggest
pneumonia.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dizziness // ? Pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Minimal left base atelectasis is seen. There is no focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are stable.
IMPRESSION:
Mild left base atelectasis without definite focal consolidation.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: DIZZINESS,DYSPNEA
Diagnosed with Sepsis, unspecified organism, Urinary tract infection, site not specified
temperature: 102.9
heartrate: 126.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo F with IDDM c/b neuropathy who presents
with several days of dizziness and fever who was found to have
UA suspicious for infection and GNRs in BCx.
# E. Coli acute bloodstream infection due to UTI
She was initially tachycardic, tachypneic, and febrile to 103
with rigoring on admission. She was started on vanc/zosyn and
then narrowed to zosyn, followed by Cipro, when BCx were
positive for GNRs sensitive to ciprofloxacin. Ultimately
speciated to E. coli. UCx were negative, but she may have
received first dose of antibiotics prior to UCx. Her
tachycardia, tachypnea and fevers resolved shortly after
admission and she was afebrile w/neg BCx >48 hours prior to
switching her to PO ciprofloxacin (end ___ for total 14 day
course).
# Anion gap metabolic acidosis- Presented with gap 18, lactate
3.3 and bicarb 20. Thought to be related to sepsis. Normalized
with fluids and antibiotics.
# Hyponatremia: Thought likely hypovolemic, hyponatremia.
Normalized with fluids.
# Acute kidney injury: Cr 1.2 on arrival suspicious for acute
kidney injury iso of sepsis/poor PO intake. Resolved with
fluids. Trended to .___ throughout hospital course.
# IDDM c/b neuropathy: pt hyperglycemic on arrival to the ED.
Received 10U regular insulin with persistently elevated sugars.
No sign of DKA. BG well controlled during the rest of the
admission w/ lantus 28U, Humalog 14U and ISS while inpatient.
Metformin held. Gabapentin continued for neuropathy.
# HTN: Held Lisinopril 10 mg iso sepsis. Did not resumed on
admission. Recommend resuming as outpatient.
# HLD: continued simvastatin 10 mg.
CORE MEASURES
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS: ciprofloxacin 500mg bid (end ___ for full
___bx)
# HELD MEDICATIONS: lisinopril 10 mg (iso sepsis and held on
discharge)
[] Additional BCx pending at time of discharge
[] If continues to have recurrent UTIs would consider further
w/u, including abdominal imaging (cannot be sure of urinary
source as UCx was negative, can consider potential abdominal
abscess)
[] Please restart lisinopril as tolerated
# CODE: Full
# CONTACT: Son ___ (lives close by: ___ or daughter
___ (lives in ___: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral lower limb weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old right handed gentleman with a
history of asthma who presents with bilateral leg numbness.
The patient reports that on ___ at the end of a long run (he
was training for the ___) he felt like his legs
were
unusually tired. Then on ___ he was at the end of a run on
the
treadmill when he suddenly felt both legs up to the hips go
numb.
This lasted for 30 minutes and then gradually resolved. There
was no
weakness associated with this. Then on the ___ he had return of
the numbness gradually now rising from his feet up to his waist.
He went to the ___ on ___ and had an MRI L spine which
showed a small disc bulge and was discharged with NSAIDS and
follow up with neurosurgery. He was seen by Dr. ___ on ___
who did not feel the exam correlated with scan so ordered MRI T
and C. That showed a lesion around T6 so a scan with contrast
was
done on ___ which redomonstrated the lesion without contrast
enhancement and was read as likely inactive TM or MS lesion.
Since around ___ the patient has developed plainful spasms of
the feet and calves, the feeling of intense itchiness in the
legs
and over the last 2 days he feels like the numbness has risen to
his belly button. He cannot feel between his legs and doesn't
feel he can empty his bowel completely. There has been no
incontinence. He feels it's effortful to walk, especially with
going upstairs. He was set up with neurology as an outpatient
but
comes today because he feels his symptoms are progressing.
There has been no recent illnesses or exposures though he feels
aching and buzzing in his left ear. No recent travel. + blurred
vision with distances recently.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. 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:
Asthma
Social History:
___
Family History:
No stroke, seizures in the family
Uncle diagnosed with ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.1 80 123/50 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. No RAPD, no red desaturation, VFF
to confrontation, acuity ___ ___.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal strength
-Motor: Normal bulk, tone, and power throughout. No pronator
drift
bilaterally.
-Sensory: No pin prick deficit, does feel less cold below T10
but
then returns on the legs. Decreased joint position sense on the
left toe, intact on the right. Vibration sense intact in
bilateral feet. Romberg
absent.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 3 1
R ___ 3 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF. Mild ataxia on HKS bilaterally.
-Gait: Wide based, cautious, difficulty with tandem
DISCHARGE PHYSICAL EXAM
Unchanged from above except for the following:
-Sensory: No pin prick deficit throughout. Decreased joint
position sense on the left ___ toe, intact on the right.
Vibration sense intact in bilateral feet.
-Gait: Good initiation, narrow based. Stable with independent
ambulation. Romberg negative.
Pertinent Results:
=====
LABS
=====
___ 11:00AM GLUCOSE-93 UREA N-18 CREAT-0.9 SODIUM-143
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15
___ 11:00AM estGFR-Using this
___ 11:00AM WBC-5.1 RBC-4.57* HGB-15.4 HCT-41.5 MCV-91
MCH-33.7* MCHC-37.1* RDW-12.6
___ 11:00AM NEUTS-57.3 ___ MONOS-5.5 EOS-10.5*
BASOS-0.7
___ 11:00AM PLT COUNT-146*
===========
IMAGING
===========
MRI HEAD WITH AND WITHOUT CONTRAST (___): No evidence of
demyelinating disease within the brain.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Montelukast 10 mg PO DAILY
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. Montelukast 10 mg PO DAILY
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute post-infectious demyelination at T6
Secondary diagnosis:
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PA and lateral chest x-ray.
INDICATION: A ___ man presenting with bilateral lower extremity
weakness, concern for possible paraneoplastic syndrome, evaluate for infection
or masses.
TECHNIQUE: PA and lateral projections, upright positioning.
COMPARISON: Chest x-ray ___.
FINDINGS:
Lungs are clear without focal consolidation, effusion or pneumothorax. Mild
prominence of the hilar vasculature appears unchanged. Lungs appear
hyperinflated with mild bronchial cuffing could reflect airways inflammation
in this patient with history of asthma. Cardiomediastinal silhouette is
stable. No pleural effusion or pneumothorax. Bony structures are intact.
IMPRESSION:
Hyperinflation with possible central airways inflammation.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with demyleinating lesion at T6 // ?
demyelinating lesions
TECHNIQUE: Sagittal 3D FLAIR imaging was performed along with axial fast STIR
and axial diffusion imaging. The FLAIR images were re-formatted in axial and
coronal orientations. Sagittal MPRAGE and axial T1 weighted imaging were
performed after administration of 8 mL of Gadavist intravenous contrast.
COMPARISON: Thoracic spine MRI ___.
FINDINGS:
There is no evidence of hemorrhage or mass effect. The ventricles and basal
cisterns appear normal.
There is no evidence of acute infarct based on diffusion-weighted imaging.
There are normal vascular flow voids. The brain parenchymal volume is within
normal limits.
There is no abnormal brain parenchymal or leptomeningeal enhancement.
There is bilateral maxillary sinus, sphenoid sinus, ethmoid sinus, and frontal
sinus mucosal. The mastoid air cells and orbits are unremarkable.
IMPRESSION:
1. No evidence of demyelinating disease within the brain.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Leg numbness
Diagnosed with OTHER CAUSES OF MYELITIS
temperature: 98.1
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 50.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ is a ___ ___ gentleman who presented to ___
___ with worsening bilateral lower limb numbness spreading up
to the waist area. MRI done as an outpatient on ___ showed a T2
hyperintense and non-enhancing spinal cord lesion at T6 that may
have been the sequela of transverse myelitis. He was admitted to
the general neurology service for further management.
He underwent an MRI of the head with and without contrast that
was unremarkable. On hospital day #2, his exam improved without
any intervention (temperature sensation was intact throughout).
Given he had minimal symptoms, he underwent no other work-up and
was not given steroids. He was diagnosed with an acute
post-infectious demylination syndrome and close neurology
follow-up was arranged at discharge. He was also started on
gabapentin 300 mg TID for paresthesias in his toes bilaterally
at discharge.
======================
TRANSITIONS OF CARE
======================
-B12 level was pending at discharge.
-Final read of MRI brain was pending at discharge.
-Pt was started on gabapentin for paresthesias in his left leg;
this medication can be uptitrated as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Theophylline / Ultram / Ace Inhibitors / Cozaar / gabapentin
Attending: ___.
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an ___ y/o F with PMHx of remote breast CA, HTN, asthma, as
well as diverticulosis with prior GIB, here with 1 day of BRBPR.
Pt was in her USOH until the afternoon of ___, when she had 3
episodes of BRBPR. Denies nausea, abodmianl pain, or
lightheadedness/dizziness associated with this. No CP or heart
palpitations.
ED Course:
Initial VS: 99.7 81 132/114 16 100% RA
Labs significant for H/H decreased from recent outpt values but
overall stable in the ED. Cr 1.2.
Imaging: None
Meds given:
___ 03:21 PO/NG Simvastatin 10 mg
___ 15:17 PO Acetaminophen 1000 mg
VS prior to transfer: 98.1 69 126/53 21 100% RA
GI consulted in the ED: "If ongoing bleed would check CTA. Last
___ ___, likely diverticular. Repeat ___ likely not helpful
unless ongoing bleed and nothing seen on CTA."
Pt reports that, while in the ED, she had another BM which was
formed with only a small amount of residual blood. She was
monitored in the ED ~24 hours ___ bed shortage with largely
stable H/H and no further significant episodes of bleeding. She
was admitted to medicine.
On arrival to the floor, the patient's only complaint is mild L
sided hip / LB pain, which she attributes to lying on a
stretcher in the ED for 24 hours. No new concerns.
ROS: As above. Denies lightheadedness, dizziness, chest pain,
heart palpitations, shortness of breath, cough, nausea,
vomiting, diarrhea, constipation, urinary symptoms, muscle or
joint pains, skin rash. The remainder of the ROS was negative.
Past Medical History:
prior admission for GIB in ___, felt to be diverticular at that
time
Breast Cancer
- ___ needle bx: infiltrating lobular ca
- Dr ___ following.
- ___ surgery to get clean margins.
- Tumor 2.7cm, grade 2, ER pos, HER-2 neg, neg LNs on sentinel
node bx.
- declines chemo but agrees to tamoxifen x ___ yrs following XRT
Peripheral Neuropathy
Fatigue
Osteoarthritis
Hypertension
Asthma
h/o c.diff- most recently ___
Hip replacement- ___
Knee ___, no residual effects
s/p appy
s/p tah ? STATUS OF OVARIES at age of ___ - reason
for surgery related to ?frequent miscarriages ?fibroids
s/p lumbear disc surg x 2 for slipped disc - now asymptomatic
Social History:
___
Family History:
Mother-died of MI; ___ Kidney disease in
several siblings. Denies any FHX of GIB.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.8PO 136/71 78 18 96 RA
GEN - Alert, NAD
HEENT - NC/AT, face symmetric, MMM
NECK - Supple, EJ in place
CV - RRR, ___ systolic murmur at ___
RESP - CTA B
ABD - S/NT/ND, BS present
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - Nonfocal
PSYCH - Calm, appropriate
Pertinent Results:
___ 11:10PM BLOOD WBC-6.3 RBC-3.58* Hgb-9.5* Hct-31.1*
MCV-87 MCH-26.5 MCHC-30.5* RDW-18.0* RDWSD-57.6* Plt ___
___ 11:10PM BLOOD Neuts-57.5 ___ Monos-7.8 Eos-3.2
Baso-0.5 Im ___ AbsNeut-3.61 AbsLymp-1.93 AbsMono-0.49
AbsEos-0.20 AbsBaso-0.03
___ 11:10PM BLOOD Glucose-96 UreaN-27* Creat-1.2* Na-141
K-4.0 Cl-101 HCO3-31 AnGap-13
___ 07:10AM BLOOD Calcium-9.1 Phos-3.5 ___
Micro:
___ 4:00 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH
SKIN
AND/OR GENITAL CONTAMINATION.
CTA
IMPRESSION:
1. Evaluation of the pelvis is limited due to artifacts from
bilateral hip prosthesis. However, there is no contrast
extravasation to suggest active bleeding.
2. Extensive diverticulosis involving the sigmoid and in distal
left colon.
Hip Films - IMPRESSION:
No evidence of hardware related complications involving the left
hip prosthesis.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ year old woman with new L hip pain // assess for acute
process
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the left hip
COMPARISON: Pelvic radiograph dated ___
FINDINGS:
The patient is status post bilateral total hip arthroplasties. Since the
prior radiograph there is no interval change in alignment or appearance of the
left hip prosthesis. No periprostatic fractures or loosening.
Degenerative changes of the sacroiliac joints and pubic symphysis. A
substantial amount of stool is present in the visualized bowel. There is no
suspicious lytic or sclerotic lesion. There is no soft tissue calcification
or radio-opaque foreign body.
IMPRESSION:
No evidence of hardware related complications involving the left hip
prosthesis.
A substantial amount of stool is present in the visualized bowel.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with L calf tenderness // please assess for
DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: No recent priors available
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 tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of adeep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with GI bleeding, suspect diverticular, now
with recurrent bleedign // please assess for bleeding source
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 50.6 cm; CTDIvol = 2.9 mGy (Body) DLP = 145.7
mGy-cm.
2) Spiral Acquisition 7.5 s, 49.0 cm; CTDIvol = 9.1 mGy (Body) DLP = 438.5
mGy-cm.
Total DLP (Body) = 584 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries. Hepatic artery anatomy is
conventional. There is a right accessory renal artery.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 4
mm hypodensity is seen in segment 3 of the liver (04: 60), too small to
characterize but likely represents a cyst or biliary hematoma. A small portal
systemic fistula is seen in segment 8 (04:20). There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is is
resected.
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. A small
accessory spleen is noted.
ADRENALS: The right adrenal gland is normal in size and shape. The left
adrenal appears mildly nodular.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are bilateral duplex renal collecting systems. There is no evidence of
stones, focal renal lesions, or hydronephrosis. There are no urothelial
lesions in the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Extensive diverticulosis is noted involving the
sigmoid and distal left colon, without evidence of diverticulitis. There is
no contrast extravasation to suggest an acute bleed. Appendix is not
visualized. There is no evidence of mesenteric lymphadenopathy. There is
mild omental fat stranding within the left abdomen (04:49) of uncertain
clinical significance.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: Evaluation of the pelvis is limited by artifacts from bilateral hip
prosthesis. There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post hysterectomy.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is degenerative disc disease within the lower thoracic spine and
lumbosacral spine, most severe at L5-S1, with bilateral facet arthropathy.
SOFT TISSUES: A fat containing hernia is seen along the left flank, unchanged
compared to ___.
IMPRESSION:
1. Evaluation of the pelvis is limited due to artifacts from bilateral hip
prosthesis. However, there is no contrast extravasation to suggest active
bleeding.
2. Extensive diverticulosis involving the sigmoid and in distal left colon.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 99.7
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 114.0
level of pain: 0
level of acuity: 3.0 | ___ y/o F with diverticulosis, here with GIB. Course complicated
by lower back / hip pain.
# L Back / Flank Pain: Ddx included SI joint arthritis
(exacerbated by lying in bed during hospital course) vs. GI
pathology related to her current presentation. Hip films
negative. CTA without acute process on prelim read. She was
placed on standing Tylenol and Lidoderm for pain control. ___
evaluated her and recommended home versus rehab. Since she lives
near so many family her family preferred that she go home with
home services. She was discharged home with home ___.
# GI Bleeding / Diverticulosis / Acute Blood Loss Anemia: Given
known diverticulosis, GI bleeding is likely diverticular in
nature. Other considerations would be AVM vs. hemorrhoidal (less
likely given volume) vs. malignancy (less likely given sudden
onset). Bleeding initially resolved spontaneously but then
recurred during hospitalization. H/H had initial drop from
baseline but then remained stable thereafter. Pt never required
transfusion. GI evaluated patient and recommended against
emergent scope. CTA performed during recurrent bleeding episode
revealed no active extravasation.
# HTN: HCTZ held ___ bleeding. The patient's blood pressure was
well controlled and HCTZ was held until PCP follow up.
# HLD: Continue statin.
# Asthma: Albuterol PRN. Pt not taking Advair at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Right flank and low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p unwitnessed snowmobile accident jammed under the
snowmobile, +LOC, c/o pain in the right flank and low back. He
does not recall the event. Endorses drinking EtOH prior to
accident.
Past Medical History:
PMHx: hypertension, hyperlipidemia, diabetes
PSH: shoulder surgery
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Admission Physical Exam
VS in ED: Temp 99 (oral) HR 110 BP 132/palp RR 36 O2 99% RA
GEN: well appearing male, covered in gas
NEURO: R pupil 3mm, L pupil 2mm reactive bilaterally
HEENT: no hematympanum, no scalp trauma, no blood in nares or
mouth
Chest: tenderness over the right chest wall, decreased breath
sounds on the right
Abdomen: no abdominal tenderness, no pelvic instability,
tenderness in the right flank
Vasc: 2+ radial pulses bilaterally
Extremities: no evidence of trauma, tenderness over the right
scapula
eFAST negative
Discharge Physical Exam:
VS:
Gen: Alert and interactive sitting at edge of bed.
HEENT: No deformity. Mucus membranes moist. trachea midline,
neck supple.
CV: RRR
Lungs: Clear to auscultation bilaterally. Tenderness to
palpation over right ribs, shoulder. Ecchymosis to right
shoulder.
Abd: Soft, non-tender, non-distended
Ext: warm and dry. no edema. 2+ ___ pulses.
Neuro: A&Ox3, PERRL, follows commands and moves all extremities
equal and strong. speech is clear and fluent.
Pertinent Results:
___ 03:04AM BLOOD WBC-8.4 RBC-3.87* Hgb-12.1* Hct-35.2*
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.2 RDWSD-43.2 Plt ___
___ 05:50PM BLOOD WBC-10.3* RBC-4.31* Hgb-13.7 Hct-39.1*
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.8 RDWSD-42.1 Plt ___
___ 03:04AM BLOOD ___ PTT-23.2* ___
___ 05:50PM BLOOD ___ PTT-23.8* ___
___ 03:04AM BLOOD Glucose-132* UreaN-25* Creat-0.9 Na-137
K-4.4 Cl-103 HCO3-19* AnGap-19
___ 03:04AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.0
___ 05:50PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:55PM BLOOD Glucose-107* Lactate-2.5* Na-141 K-4.3
Cl-103 calHCO3-24
___ 03:15AM BLOOD Lactate-1.3
___ CXR:
Limited due to portions of the chest excluded, as above. Right
sided rib fractures better assessed on CT. No large focal
consolidation or pleural effusion.
___ CT Head
1. Subarachnoid hemorrhage involves the sulci of the right
parietal lobe as well as smaller focus within the right frontal
lobe. No significant mass effect.
2. Acute intracranial hemorrhagic parenchymal contusion in the
superior aspect of the right frontal lobe measures approximately
8 mm in size without significant mass effect or surrounding
edema.
3. No acute fracture.
___ CT C-Spine
No acute fracture. Mild retrolisthesis of C3 over C4 is of
indeterminate age, but may be degenerative. MRI is more
sensitive in detecting ligamentous injury.
___ CT Ch/Ab/Pelvis
1. Fractures of the right lateral fourth, fifth, sixth, and
seventh ribs with associated pleural thickening. There is no
pneumothorax. There is no large pleural effusion.
2. Remaining osseous structures are without evidence of
fracture. Bilateral scapular bones appear intact.
3. No evidence of intra-abdominal or pelvic visceral injury.
4. Extensive diverticular disease without evidence of acute
diverticulitis.
___ CXR
Right rib fractures ___ lateral) again noted. There is no
pneumothorax. Bibasilar atelectasis is present, slightly
increased. Lungs otherwise clear. Cardiomediastinal silhouette
is normal.
MRSA SCREEN (Final ___: No MRSA isolated.
Medications on Admission:
pravastatin, lisinopril, metformin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*30 Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation
Do not take if having diarrhea
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*40 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive or use machinery when taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
Use as directed
RX *lidocaine 5 % Apply as directed to site of chest pain daily
Disp #*30 Patch Refills:*0
7. LeVETiracetam 1000 mg PO BID
Use as directed to prevent seizures. Take as directed on label
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
8. Pravastatin 40 mg PO QPM
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
Do Not Crush; take with largest meal of the day
Discharge Disposition:
Home
Discharge Diagnosis:
-Subarachnoid hemorrhage
-Right rib fractures ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma
TECHNIQUE: Single supine AP portable view of the chest
COMPARISON: None.
FINDINGS:
The lower left lateral chest and and the lung apices, left greater than right,
are not fully included on the image. Given this, no large focal
consolidation. There is no gross evidence of pneumothorax or pleural effusion.
The cardiac and mediastinal silhouettes are grossly unremarkable. Right-sided
rib fractures better assessed on CT.
IMPRESSION:
Limited due to portions of the chest excluded, as above. Right sided rib
fractures better assessed on CT. No large focal consolidation or pleural
effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ s/p snowmobile accident jammed under the snowmobile,
HD stable, GCS 14 (confused), *** WARNING *** Multiple patients with same last
name! // assess for trauma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.8 cm; CTDIvol = 45.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Acute intracranial hemorrhagic contusion within the superior aspect of the
right frontal lobe measures approximately 9 mm in size (02:26). There is no
associated mass effect. Acute subarachnoid involves sulci of the right
parietal region (02:17) as does probable small focus of subarachnoid
hemorrhage involving the right frontal lobe (02:16). No acute blood is
identified within the basal cisterns, sylvian fissures, or within the
ventricles. Ventricles and sulci are normal in size and configuration.
Gray-white matter differentiation is preserved. There is no evidence of
subdural hemorrhage.
Bony calvarium appears intact. Orbits are unremarkable. Moderate mucosal
thickening involves the left maxillary sinus as well as ethmoidal air cells,
right greater than left. Mastoid air cells are clear. Middle ear cavities
are clear.
IMPRESSION:
1. Subarachnoid hemorrhage involves the sulci of the right parietal lobe as
well as smaller focus within the right frontal lobe. No significant mass
effect.
2. Acute intracranial hemorrhagic parenchymal contusion in the superior
aspect of the right frontal lobe measures approximately 8 mm in size without
significant mass effect or surrounding edema.
3. No acute fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ s/p snowmobile accident jammed under the snowmobile,
HD stable, GCS 14 (confused), *** WARNING *** Multiple patients with same last
name! // assess for trauma assess 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) Spiral Acquisition 6.2 s, 24.1 cm; CTDIvol = 37.4 mGy (Body) DLP = 900.3
mGy-cm.
Total DLP (Body) = 900 mGy-cm.
COMPARISON: None.
FINDINGS:
No fracture is identified within the cervical spine. Intervertebral disc
space narrowing is most prominent at the C3-C4 and C5-C6 level where there is
also marginal sclerosis and small anterior and posterior osteophytes. There
is mild retrolisthesis of C3 over C4. Alignment is otherwise anatomic. There
is no abnormal prevertebral soft tissue swelling. Lung apices are clear.
Imaged thyroid gland is unremarkable.
IMPRESSION:
No acute fracture. Mild retrolisthesis of C3 over C4 is of indeterminate age,
but may be degenerative. MRI is more sensitive in detecting ligamentous
injury.
Degenerative changes are most pronounced at the C3-C4 and C5-C6 levels.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: History: ___ s/p snowmobile accident jammed under the snowmobile,
HD stable, GCS 14 (confused), *** WARNING *** Multiple patients with same last
name! // assess for trauma
TECHNIQUE: Multi detector CT images through the torso were obtained in the
absence of intravenous contrast. No oral contrast was administered. Coronal
and sagittal reformations were generated and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.5 s, 66.6 cm; CTDIvol = 18.1 mGy (Body) DLP =
1,202.8 mGy-cm.
Total DLP (Body) = 1,203 mGy-cm.
COMPARISON: None prior
FINDINGS:
Chest: The imaged thyroid gland is homogeneous in attenuation without a focal
lesion. There is no axillary, supraclavicular, or central adenopathy.
Largest central nodes are located within the low left lower paratracheal
station and measures approximately 9 mm in short axis (02:36) not
pathologically enlarged. There is no hilar adenopathy.
Heart size is normal. There is no pericardial effusion. Moderate
atherosclerotic calcifications involve predominantly the left anterior
descending coronary artery. The ascending aorta is non aneurysmal. The main
pulmonary artery is within normal limits in caliber. The right pulmonary
artery is mildly enlarged measuring up to 26 mm (02:49), suggestive of though
not diagnostic for pulmonary hypertension. No esophageal abnormality is
identified.
The airways are patent to the subsegmental level. Bibasilar atelectasis is
mild and symmetric. Minimally displaced fractures involve the right lateral
fourth, fifth, sixth, and seventh ribs. The fifth and sixth right ribs are
medially displaced approximately 3 and 5 mm respectively. Findings are
associated with overlying pleural thickening. There is no pneumothorax. The
left ribs appear intact. Bilateral scapular bones are without evidence of
fracture. Multiple anchor screws are identified within the right humeral
head, may be from prior rotator cuff repair. Imaged clavicles appear intact
as does the sternum.
Abdomen: The liver appears homogeneous in attenuation without a focal lesion.
There is no intrahepatic ductal dilation. The portal veins are patent. The
gallbladder is without radiopaque cholelithiasis, gallbladder wall edema, or
gallbladder wall thickening. The pancreas, spleen, and bilateral adrenal
glands are normal. The kidneys present symmetric nephrograms excretion of
contrast. There is no focal renal lesion, hydronephrosis, or perinephric
fluid collection.
The stomach, duodenum, and loops of small bowel are grossly normal. There is
no evidence of obstruction. The appendix is visualized, air filled and
without inflammatory changes (3:147). Extensive diverticular disease involves
the sigmoid colon without evidence of acute diverticulitis. There is no
abdominal free fluid or air. Note is made of diastasis of the anterior
abdominal wall along the midline without evidence of a hernia.
The abdominal aorta demonstrates moderate atherosclerotic calcifications
without aneurysmal dilatation. Scattered retroperitoneal nodes do not meet CT
size criteria for pathology. Scattered mesenteric nodes are not
pathologically enlarged. There is no mesenteric stranding to suggest injury.
Pelvis: The bladder is moderately well distended, grossly unremarkable.
Prostate gland demonstrates central coarse calcifications, otherwise
unremarkable. There is no pelvic free fluid. There is no inguinal or pelvic
sidewall adenopathy.
Bilateral femurs are intact, heads well seated in the acetabulum.
Degenerative changes involve the lower lumbar spine with vacuum degeneration
and disc space narrowing most prominent at the L5-S1 level. No fractures
identified. Vertebral body heights appear preserved. Overall alignment of
the spine is anatomic.
IMPRESSION:
1. Fractures of the right lateral fourth, fifth, sixth, and seventh ribs with
associated pleural thickening. There is no pneumothorax. There is no large
pleural effusion.
2. Remaining osseous structures are without evidence of fracture. Bilateral
scapular bones appear intact.
3. No evidence of intra-abdominal or pelvic visceral injury.
4. Extensive diverticular disease without evidence of acute diverticulitis.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with rib fractures // please eval for interval
change
TECHNIQUE: AP upright portable
COMPARISON: CT torso ___
Chest radiograph ___
FINDINGS:
Right rib fractures ___ lateral) again noted. There is no pneumothorax.
Bibasilar atelectasis is present, slightly increased. Lungs otherwise clear.
Cardiomediastinal silhouette is normal.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with s/p snowmobiling accident, with SAH and rib
fracture, L foot weakness. Assess for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
No interval change in a 0.9 x 0.6 cm (02:26) (previously 0.9 x 0.6 cm) right
superior frontal lobe hematoma. There is associated mass effect. The small
amounts of subarachnoid hemorrhage within the sulci of the right parietal lobe
and right frontal lobe are stable. (02:16, 17). There is no evidence of
infarction, new hemorrhage, edema, or mass. The ventricles and sulci are
normal in size and configuration.
There is no evidence of fracture. Minimal mucosal thickening of the ethmoidal
air cells are noted. The additional visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No interval change.
2. Stable superior right frontal lobe hematoma.
3. Stable subarachnoid hemorrhage within right parietal lobe and right frontal
lobe.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Multiple fractures of ribs, right side, init for clos fx, Exposure to welding light (arc), initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ y M admitted to the trauma surgical service
on ___ at ___ after a snowmobile accident. He was found
down by a neighbor and is amnesic to the event. Imaging revealed
right subarachnoid hemorrhage and right rib fractures ___.
Neurosurgery was consulted and recommended a repeat head CT
scan, Keppra, maintaining systolic blood pressure less than 140,
and hourly neurological checks. He was admitted to the trauma
surgical ICU.
On HD2 his neurological exam remained intact and he was
transferred to the floor for further neurological monitoring and
pain control.
On HD3 he was ambulating, tolerating a regular diet, and pain
was controlled on oral medications. He was evaluated by physical
therapy and occupational therapy who recommended discharge to
home and follow up with the concussion clinic.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Per Neurosurgery
recommendations he will complete 7 days of seizure prophylaxis
with Keppra. Follow up appointments were arranged. He will
follow up with an MRI of his right shoulder as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00AM BLOOD WBC-21.7* RBC-3.30* Hgb-10.1* Hct-34.4
MCV-104* MCH-30.6 MCHC-29.4* RDW-14.9 RDWSD-56.9* Plt ___
___ 10:00AM BLOOD Neuts-87.1* Lymphs-3.9* Monos-7.7
Eos-0.3* Baso-0.2 Im ___ AbsNeut-18.84* AbsLymp-0.85*
AbsMono-1.67* AbsEos-0.07 AbsBaso-0.05
___ 10:00AM BLOOD ___ PTT-28.3 ___
___ 10:00AM BLOOD Glucose-90 UreaN-44* Creat-3.1* Na-140
K-5.8* Cl-104 HCO3-22 AnGap-14
___ 10:00AM BLOOD ALT-6 AST-17 AlkPhos-91 TotBili-0.3
___ 10:00AM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.7 Mg-2.1
___ 10:06AM BLOOD ___ pO2-28* pCO2-57* pH-7.27*
calTCO2-27 Base XS--2
___ 12:20PM BLOOD ___ pO2-29* pCO2-53* pH-7.29*
calTCO2-27 Base XS--2
___ 03:06PM BLOOD ___ pO2-57* pCO2-53* pH-7.26*
calTCO2-25 Base XS--3
___ 12:42AM BLOOD Type-ART Temp-36.5 pO2-64* pCO2-54*
pH-7.30* calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 12:42AM BLOOD Lactate-0.6
PERTINENT LABS:
===============
___ 10:15AM BLOOD HIT Ab-NEG HIT ___
___ 03:32PM BLOOD calTIBC-205* Ferritn-704* TRF-158*
___ 02:13AM BLOOD %HbA1c-4.5 eAG-82
___ 05:29AM BLOOD PEP-NO SPECIFI FreeKap-232.9*
FreeLam-148.7* Fr K/L-1.6 IgG-1794* IgA-359 IgM-49 IFE-NO
MONOCLO
DISCHARGE LABS
===============
___ 05:40AM BLOOD WBC-11.5* RBC-3.08* Hgb-9.5* Hct-31.0*
MCV-101* MCH-30.8 MCHC-30.6* RDW-14.6 RDWSD-52.8* Plt ___
___ 05:40AM BLOOD Glucose-78 UreaN-32* Creat-2.1* Na-135
K-5.0 Cl-101 HCO3-24 AnGap-10
___ 05:40AM BLOOD Calcium-9.0 Phos-4.8* Mg-1.9
IMAGING:
========
CXR Study Date of ___
Suboptimal due to respiratory motion and underpenetration
related to patient body habitus. Given this, there are
relatively low lung volumes. Possible pulmonary vascular
congestion. No definite focal consolidation, although this would
be difficult to exclude. Enlargement of the cardiac silhouette.
PELVIS, NON-OBSTETRIC Study Date of ___
IMPRESSION:
Very large incompletely evaluated cystic mass. Further
evaluation with either contrast-enhanced CT scan or MRI is
recommended as the lesion can not be fully characterized by
ultrasound.
CT ABD & PELVIS W/O CONTRAST Study Date of ___
SECOND OPINION READ
IMPRESSION:
1. There are locules of air in the bladder and vaginal vault,
raising the
possibility of colovesicular or colovaginal fistula. Recommend
CT with IV, P.O., and rectal contrast to assess for fistula.
2. There is asymmetric wall thickening of the sigmoid colon and
multiple
diverticula, along with surrounding mesenteric fat stranding and
multiple
prominent lymph nodes. These findings raise concern for acute
diverticulitis, however malignancy can not be excluded in the
patient should have colonoscopy when clinically stable.
3. There is a locule of air between the inflamed sigmoid colon
and a left
adnexal lesion, raising further concern for perforation of acute
diverticulitis.
4. Left-sided hydronephrosis and hydroureter
5. Large left adnexal lesion. Further characterization is
limited in the
absence of contrast.
7. Right lower pole nonobstructing renal stone.
RECOMMENDATION(S): Recommend CT with IV, P.O., and rectal
contrast to assess for fistula. Also recommend colonoscopy to
rule out malignancy of the sigmoid colon when the patient is
clinically stable.
CHEST (PORTABLE AP) Study Date of ___
IMPRESSION:
Heart size and mediastinum are overall stable including mild
cardiomegaly. There is prominence of the azygos vein and
interstitial opacities consistent with mild interstitial
pulmonary edema. No appreciable pleural effusion or
consolidations or pneumothorax.
RENAL U.S. Study Date of ___
IMPRESSION:
Limited study, as the patient refused to complete the
examination. No
hydronephrosis. Right renal cysts.
MICROBIOLOGY:
=============
___ 9:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:00 am URINE Source: Catheter.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. LevETIRAcetam ___ mg PO BID
5. Divalproex (DELayed Release) 500 mg PO QAM
6. Divalproex (DELayed Release) 1000 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) 15 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID
4. Gabapentin 300 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
6. Aspirin 81 mg PO DAILY
7. Divalproex (DELayed Release) 500 mg PO QAM
8. Divalproex (DELayed Release) 1000 mg PO QHS
9. LevETIRAcetam ___ mg PO BID
10. Omeprazole 20 mg PO DAILY
11. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until talking with your doctors at
rehab
12. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until talking with
your doctors at rehab
13. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until talking with your doctors at
rehab
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
-E coli bacteremia
-Sepsis secondary to intraabdominal source
-Complicated diverticulitis
SECONDARY DIAGNOSES
=====================
-Vascular dementia
-Prior CVA
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hyoxia // hypoxia
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
The exam is suboptimal due to some respiratory motion and underpenetration
related to patient body habitus. Given this, there are relatively low lung
volumes. There is possible pulmonary vascular congestion. No definite focal
consolidation is seen, although this would be difficult to exclude. No large
pleural effusion or evidence of pneumothorax is seen. The cardiac silhouette
is enlarged. Enlargement of the cardiomediastinal silhouette is likely
accentuated by AP portable technique.
IMPRESSION:
Suboptimal due to respiratory motion and underpenetration related to patient
body habitus. Given this, there are relatively low lung volumes. Possible
pulmonary vascular congestion.
No definite focal consolidation, although this would be difficult to exclude.
Enlargement of the cardiac silhouette.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with large left adnexal mass visualized on CT
A/P // further assess adnexal mass
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach.
COMPARISON: Reference CT ___
FINDINGS:
This is a very limited transabdominal study demonstrating an approximately 10
x 15 cm fluid filled mass in the pelvis. Neither the uterus nor ovaries could
be adequately visualized and transvaginal approach was not a possible given
the patient's body habitus and state of mentation.
IMPRESSION:
Very large incompletely evaluated cystic mass. Further evaluation with either
contrast-enhanced CT scan or MRI is recommended as the lesion can not be fully
characterized by ultrasound.
Radiology Report
EXAMINATION: SECOND OPINION CT ABD/PELVIS
INDICATION: ___ year old woman with CT A/P from ___. Images in
OMR. Read as having colovesicular fistula. // second opinion of CT A/P
without contrast
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: 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: None.
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis in the visualized lung fields. No
focal consolidation or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no focal lesion within the limitations of an unenhanced scan. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout. There is no
evidence of focal lesion, within the limitations of an unenhanced scan. There
is no pancreatic ductal dilation or peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
renal lesions, within the limitations of an unenhanced scan. Multiple
hypoattenuating lesions are seen in bilateral kidneys, the largest of which is
in the right kidney interpolar region and measures 7.2 x 5.0 cm. The largest
lesion in the left kidney is exophytic and in the interpolar region and
measures 2.7 x 2.5 cm. There is no perinephric abnormality. There is
left-sided hydronephrosis and hydroureter. There is a right lower pole
non-obstructing renal stone (series 2, image 46).
The urinary bladder is decompressed, and there is a Foley in place. There are
multiple locules of air within the bladder.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness. There is asymmetric wall thickening of the
sigmoid colon with multiple diverticula, along with adjacent mesenteric
stranding and multiple prominent lymph nodes (series 3, images 49-65). There
is also a locule of air between the sigmoid colon in the left adnexal lesion
described above. The appendix is normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. There is a large left
adnexal lesion measuring 11.8 x 11.9 x 9.6 cm. There is air in the vaginal
vault.
LYMPH NODES: There are prominent mesenteric lymph nodes surrounding the
inflamed sigmoid colon.
VASCULAR: There is extensive atherosclerotic disease. There is no abdominal
aortic aneurysm.
BONES: Degenerative changes are seen in the thoracolumbar spine, most
prominent in the lower thoracic spine. Sclerotic foci in the right iliac bone
likely represent bone islands.
SOFT TISSUES: There is a tiny fat containing umbilical hernia.
IMPRESSION:
1. There are locules of air in the bladder and vaginal vault, raising the
possibility of colovesicular or colovaginal fistula. Recommend CT with IV,
P.O., and rectal contrast to assess for fistula.
2. There is asymmetric wall thickening of the sigmoid colon and multiple
diverticula, along with surrounding mesenteric fat stranding and multiple
prominent lymph nodes. These findings raise concern for acute diverticulitis,
however malignancy can not be excluded in the patient should have colonoscopy
when clinically stable.
3. There is a locule of air between the inflamed sigmoid colon and a left
adnexal lesion, raising further concern for perforation of acute
diverticulitis.
4. Left-sided hydronephrosis and hydroureter
5. Large left adnexal lesion. Further characterization is limited in the
absence of contrast.
7. Right lower pole nonobstructing renal stone.
RECOMMENDATION(S): Recommend CT with IV, P.O., and rectal contrast to assess
for fistula. Also recommend colonoscopy to rule out malignancy of the sigmoid
colon when the patient is clinically stable.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:02 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxia. // Does this patient have
pulmonary edema? Does this patient have pulmonary edema?
IMPRESSION:
Heart size and mediastinum are overall stable including mild cardiomegaly.
There is prominence of the azygos vein and interstitial opacities consistent
with mild interstitial pulmonary edema. No appreciable pleural effusion or
consolidations or pneumothorax.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with a PMHx of vascular dementia, HTN, DMII, COPD, CKD III,
prior CVA (residual R sided weakness), morbid obesity, now with new L sided
hydronephrosis compared to ___ CT and ___ on CKD // renal U/S with dopplers
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
Limited study, as the patient refused to complete the examination.
Limited views of both kidneys demonstrates no hydronephrosis.
The right kidney measures 13.4 cm. Multiple right renal cysts are
demonstrated, largest measuring 5.6 x 5.5 x 5.4 cm, and better evaluated on
prior CT.
The left kidney measures 11.6 cm. No further images were taken.
IMPRESSION:
Limited study, as the patient refused to complete the examination. No
hydronephrosis. Right renal cysts.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Altered mental status
Diagnosed with Sepsis, unspecified organism
temperature: 98.3
heartrate: 84.0
resprate: 24.0
o2sat: 96.0
sbp: 136.0
dbp: 91.0
level of pain: UTA
level of acuity: 2.0 | BRIEF SUMMARY OF ADMISSION
==========================
Ms ___ is a ___ F PMHX HTN, DMII, COPD, CKD III, prior stroke,
morbid obesity who presented to an OSH with AMS and abdominal
pain, CT abdomen pelvis initially concerning for colovesicular
or colovaginal fistula, for which she was transferred to ___
for further management, briefly admitted to the MICU for
transient hypoxia requiring BiPAP. Course was complicated by
___, precluding CT with IV contrast. Ultimately it was felt that
symptoms were secondary to complicated diverticulitis and given
patient's significant agitation and fear when CT scan was
attempted, along with her clinical improvement on antibiotics,
this was deferred. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
Right shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with sickle cell disease with known R shoulder avascular
necrosis, and recurrent pain crises in that shoulder, presents
with right shoulder pain. He was feeling well until 2 days ago
when he began to have worsening R shoulder pain. He took his
usual pain medication, including methadone and oxycodone, but he
reports that this was not sufficient. He reports that movement
and palpation increase the pain and that pain medication
alleviates the pain. He denies numbness or weakness. He reports
minor tingling sensation in the affected arm while in the ED. He
denies fever, chills, chest pain, cough, abdominal pain, or
other joint pain. He denies trauma and dehydration. He reports
that he drinks ~1L of fluids per day. Of note, he was last
admitted at the ___ ___ for pleuritic lower back and
R shoulder pain. At that admission, he was placed on a PCA, but
it was discontinued when the patient began displaying
"concerning behavior." He was discharged home on po pain
medications, and encouraged to follow up with his PCP,
___, and an orthopedic surgeon. He reports that he has
not seen any of these outpatient providers. He also previously
been hospitalized with pain crisis every ___ weeks, usually in
his shoulders and sometimes in the chest as well.
In the ED, initial vital signs were: T 97.6 HR 85 BP 122/66 RR
16 O2sat 99% on RA. Labs were remarkable for HCT 30.4 (MCV 67),
which is his baseline. R shoulder XR demonstrated sclerosis
along the right superior humeral head, most likely relating to
patient's known avascular necrosis (no priors were available for
comparison). CXR demonstrated no acute process.
On the floor patient reports ___ R shoulder pain.
Past Medical History:
- Sickle Cell Disease (SC) c/b priaprisim, AVN of shoulders (on
MRI ___ and hips, multiple hospitilization, never been on
hydroxyurea, no previous blood transfusions
- Asthma
- TTE with Trace MR, trivial pericardial effusion ___
- Anemia (baseline hct ___
- Gastritis on EGD/biopsy ___
Social History:
___
Family History:
Mother and brother have sickle cell, both with AS.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98 BP: 105/63 P: 55 R: 20 O2: 99% RA
General: keeps eyes closed, appears uncomfortable, holds R arm
close to body. Hyperventilating at times, normal respiration
with distraction.
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: port in place on left
Abdomen: Abd is soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Arm is tender to palpation and with motion.
Non-erythematous, non-edematous, atraumatic. Warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: strength ___ with handgrip bilaterally, sensation intact
to light touch bilaterally
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.1 BP 105-112/63-65 HR 55-70 RR18 O2sat 100% RA
Exam unchanged.
Pertinent Results:
ADMISSION LABS:
___ 03:05PM BLOOD WBC-7.6 RBC-4.56* Hgb-11.0* Hct-30.4*
MCV-67* MCH-24.2* MCHC-36.2* RDW-16.7* Plt ___
___ 03:05PM BLOOD Neuts-70.2* ___ Monos-3.7 Eos-1.4
Baso-0.3
___ 03:05PM BLOOD ___ PTT-34.6 ___
___ 03:05PM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-25 AnGap-16
___ 03:05PM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
INTERVAL/DISCHARGE LABS:
___ 05:00AM BLOOD WBC-6.4 RBC-4.37* Hgb-10.5* Hct-30.0*
MCV-67* MCH-25.3* MCHC-35.6* RDW-16.6* Plt ___
___ 05:00AM BLOOD Ret Aut-2.8
___ 05:00AM BLOOD TotBili-1.0
___ 05:00AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-139
K-3.6 Cl-105 HCO3-26 AnGap-12
___ 05:00AM BLOOD Calcium-8.3* Phos-5.1* Mg-2.0
RADIOLOGY
___ Shoulder XR
No acute fracture or dislocation. Sclerosis along the right
superior humeral head most likely relates to patient's known
avascular necrosis; no priors for comparison to assess for
interval change.
___ CXR
Left-sided Port-A-Cath is again seen terminating in the low
SVC/cavoatrial junction. The cardiomediastinal silhouette is
stable. Opacity at the left lung base is stable and most likely
represents atelectasis or confluence of vascular structures.
The appearance of the left lung base is similar dating back to
___. No focal consolidation is seen. There is no
pleural effusion or pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Methadone 10 mg PO TID
4. Omeprazole 20 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h:prn shortness of breath, wheeze
7. Senna 1 TAB PO BID
8. Lidocaine 5% Ointment 1 Appl TP BID
9. OxycoDONE (Immediate Release) 25 mg PO Q4H:PRN Pain
10. ZOFRAN ODT *NF* (ondansetron) 4 mg Oral Every 8 hours as
needed nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Methadone 10 mg PO TID
4. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth twice per day Disp #*60 Capsule Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h:prn shortness of breath, wheeze
7. Senna 1 TAB PO BID
8. Lidocaine 5% Ointment 1 Appl TP BID
9. ZOFRAN ODT *NF* (ondansetron) 4 mg ORAL EVERY 8 HOURS AS
NEEDED nausea
RX *ondansetron [ZOFRAN ODT] 4 mg ___ tablet,disintegrating(s)
by mouth every 8 hours Disp #*10 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 25 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
shoulder pain
secondary diagnosis:
avascular necrosis of the shoulder
sickle cell anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Sickle cell, shoulder pain.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided Port-A-Cath is again seen terminating in the low SVC/cavoatrial
junction. The cardiomediastinal silhouette is stable. Opacity at the left
lung base is stable and most likely represents atelectasis or confluence of
vascular structures. The appearance of the left lung base is similar dating
back to ___. No focal consolidation is seen. There is no pleural
effusion or pneumothorax.
Radiology Report
HISTORY: Sickle cell and known avascular necrosis of right shoulder,
presenting with severe right shoulder pain.
TECHNIQUE: 2 views of the right clavicle and 3 views of the right shoulder.
COMPARISON: None.
FINDINGS:
No evidence of acute fracture or dislocation is seen. There is sclerosis seen
along the superior humeral head which likely relates to patient's known
avascular necrosis. There is no prior for comparison to assess for interval
change. The right glenohumeral joint is intact. The visualized right upper
outer hemithorax is unremarkable.
IMPRESSION:
No acute fracture or dislocation. Sclerosis along the right superior humeral
head most likely relates to patient's known avascular necrosis; no priors for
comparison to assess for interval change.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R SHOULDER PAIN
Diagnosed with HB-SS DISEASE W/CRISIS
temperature: 97.6
heartrate: 85.0
resprate: 16.0
o2sat: 99.0
sbp: 122.0
dbp: 66.0
level of pain: 7
level of acuity: 3.0 | ___ with sickle cell disease with known R shoulder avascular
necrosis, and recurrent pain crises in that shoulder, presents
with right shoulder pain.
ACTIVE DIAGNOSES
# R shoulder pain- represents pain crises vs. acute on chronic
shoulder pain unrelated to vasocclusive event. Given hct at
baseline, lack of evidence for acute hemolysis, and lack of
fever, chest pain, abd pain, decreased oxygen saturation, or
triggers for pain crises this episode likely represents
non-vasoocclusive shoulder pain, possibly rebound pain secondary
to opiate dependence. Given history of frequent admissions for
pain, and absence of HR and BP elevation consistent with
physiologic response to pain, likely a component of opiate
dependence contributing. He was treated with home dose of
methadone 10 mg TID and IV hydromorphone 2 mg Q3H and IVF
overnight. He required 1 additional po hydromorphone 2mg PRN.
Given good po intake, he was then transitioned to po 30 mg
oxycodone Q4H. He decided he was ready to be discharged at that
point. He was continued on home bowel regimen. He was asked to
see outpatient specialists.
CHRONIC DIAGNOSES
# Sickle Cell Anemia- the patient is on folate, but not on
hydroxyurea. He has not seen his hematologist or primary care
provider in ___ months. He reports good hydration at home, but
has frequent pain episodes requiring admission and opiate
escalation. He currently denies fevers or chest pain, and clear
lungs on exam and CXR are reassuring for no signs of acute
chest. Bilirubin and reticulocytes were not elevated, making
hemolysis less likely.
# Asthma- he was continued on home doses of albuterol PRN.
TRANSITIONAL ISSUES
# CODE: full
# CONTACT: patient
# Issues to discuss at followup:
-pain medication titration
-R shoulder avascular necrosis management
-sickle cell anemia management |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
================================
MICU ADMISSION NOTE
Date of ICU Admission: ___
Reason for ICU Admission: pulmonary embolism
================================
HISTORY OF PRESENT ILLNESS:
================================
Ms. ___ is a ___ woman with a history of HTN, HLD,
CVA (___), DM2, hypothyroid, obesity, GERD, Crohn's, recent C.
diff, osteoarthritis with a recent admission to ___ from ___
- ___ for elective L hip replacement surgery, discharged to
rehab facility. She was taking ASA 81mg BID at rehab. She
initially presented to ___ with mild BLE swelling,
fatigue, SOB on exertion and severe back pain. She was
transferred from ___ to ___ given her surgery was at
___. After the patient had been transferred, a CTA chest
performed at ___ resulted as a "large amount of pulmonary
embolus in the interlobar pulmonary artery and right lower lobe
pulmonary artery extending into multiple segmental and
subsegmental right lower pulmonary artery branches w/ large R
lower lobe pulmonary infarction." BNP was negative at ___
and EKG showed no signs of right heart strain. Other labs
notable for Hgb 8.5, WBC 12, K 3.1, Procalcitonin normal
Upon arrival to the ___ ED, the patient was HDS and was
satting 100% on 2L NC with RR 18. MASCOT and orthopedics were
consulted. Orthopedics recommended therapeutic lovenox and
1mg/kg dose was given (90mg) at 00:00. MASCOT agreed to see the
patient the following morning.
At transfer to ICU, vitals were T 97.7, P 77, RR 18, BP 116/53,
SpO2 97%, SpO2 97% on 2L NC.
Past Medical History:
PMH/PSH:
Arthritis
C. diff colitis
CVA
Diabetes
Hypertension
Thyroid disease
THA
Bladder surgery
Thyroid surgery
Cholecystectomy
Social History:
___
Family History:
No family history of clotting disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: afebrile, HR 85, Spo2 100% on 2L, BP 119/57
GEN: conversant, in no acute distress
HEENT: oropharnyx clear without exudate
NECK: no adenopathy
CV: tachycardic, systolic flow murmur greatest LUSB
RESP: breathing comfortably, no wheezes/rales/rhonci
GI: no abdominal tenderness
MSK: mild ___ edema R > L
SKIN: no rashes or excoriations, incision site without evidence
of infection on left extremity. Painless range of motion of hip
and knee. No pain with compression of calf
NEURO: alert and oriented x 3, conversant, no focal deficits.
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, no m/r/g
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, but peripheral edema, L>R
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 06:04AM BLOOD WBC-12.9* RBC-3.08* Hgb-8.4* Hct-27.0*
MCV-88 MCH-27.3 MCHC-31.1* RDW-15.4 RDWSD-48.9* Plt ___
___ 06:04AM BLOOD ___ PTT-32.6 ___
___ 06:04AM BLOOD Glucose-148* UreaN-12 Creat-0.6 Na-137
K-3.6 Cl-97 HCO3-24 AnGap-16
___ 06:04AM BLOOD ALT-6 AST-14 LD(LDH)-269* AlkPhos-94
TotBili-1.2
___ 06:04AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.0 Mg-1.6
___ 06:15AM BLOOD calTIBC-200* Ferritn-551* TRF-154*
___ 06:17AM BLOOD ___ pO2-28* pCO2-45 pH-7.39
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 06:17AM BLOOD Lactate-1.5
___ 12:34PM BLOOD WBC-4.8 RBC-3.06* Hgb-8.4* Hct-26.8*
MCV-88 MCH-27.5 MCHC-31.3* RDW-15.6* RDWSD-49.9* Plt ___
___ 05:40AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-142
K-3.7 Cl-105 HCO3-24 AnGap-13
___ 06:15AM BLOOD ALT-6 AST-15 AlkPhos-80 TotBili-0.8
___ 05:40AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.6
___ 06:15AM BLOOD calTIBC-200* Ferritn-551* TRF-154*
___ TRANSTHORACIC ECHO:
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg. There
is normal left ventricular wall thickness
with a normal cavity size. There is normal regional and global
left ventricular systolic function. Overall
left ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection
fraction is >=75%. Left ventricular cardiac index is high (>4.0
L/min/m2). There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Normal right ventricular cavity
size with normal free wall motion. The aortic sinus diameter is
normal for gender with a normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve
stenosis. The increased velocity is due to high stroke volume.
There is trace 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. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness,
biventricular cavity sizes, and
hyperdynamic regional/global biventricular systolic function. No
valvular pathology or pathologic
flow identified. Mild pulmonary artery systolic hypertension.
___
CXR
IMPRESSION:
Pulmonary edema has improved. Cardiomediastinal silhouette is
stable. There
is no pleural effusion. No pneumothorax.
___ 1:28 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ -
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Atenolol 25 mg PO QHS
7. Atorvastatin 40 mg PO QPM
8. Cilostazol 100 mg PO BID
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 3 Days
Last day ___
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
2. Apixaban 5 mg PO BID Duration: 1 Month
Please do not start reduced dose until ___
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Ferrous GLUCONATE 324 mg PO EVERY OTHER DAY
RX *ferrous gluconate 324 mg (38 mg iron) 1 tablet(s) by mouth
every other day Disp #*15 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Atenolol 25 mg PO QHS
6. Atorvastatin 40 mg PO QPM
7. Cilostazol 100 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
13. Senna 8.6 mg PO BID
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
15. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until reassess if needed
16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until reassess if
needed
17. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until decide if
needed
Discharge Disposition:
Home With Service
Facility:
___
services of ___
Discharge Diagnosis:
Primary:
Pulmonary embolism
Osteoarthritis
Iron deficiency anemia
Secondary:
HTN
HLD
PAD
Hypothyrodism
GERD
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: ___ year old woman with know pulmonary embolization, now with
fevers positive blood culture // ?infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Pulmonary edema has improved. Cardiomediastinal silhouette is stable. There
is no pleural effusion. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Dyspnea, unspecified
temperature: 97.7
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of HTN, HLD,
CVA (___), DM2, hypothyroid, obesity, GERD, who presented with
provoked pulmonary embolism in the setting of hip surgery.
Patient managed with anticoagulation and discharged on apixaban. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ cough syrup / Prempro / pollen
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
___ - Intubated
___ - CVL placed
___ - Meningeal biopsy
___ - Trach/PEG placement
___ - ___ Placement
History of Present Illness:
The patient is a ___ year-old ___ woman(speaks proficient
___ with a recent finding of CSF pleocytosis and
leptomeningeal enchancement who presented to the ED with
generalized weakness. History is obtained from the patient who
is a very limited historian, even with a ___ phone
translator, and OMR.
Apparently, the patient was at home today when she felt
generally weak and sat down to the ground and was unable to get
up. EMS was activated (unclear how if she lives alone and could
not get up) and found her incontinent of urine. She also
endorsed decreased po intake as she didnt have the energy to
prepare food for herself. She was brought to the ED where she
complained of generalized weakness, but no new focal symptoms.
She did report a longstanding headache that is currently ___
bifrontally with associated photophobia, phonophobia. No nausea
or vomiting. She is inconsistent about whether this gets worse
when she lays down or sits up. No increased headache with cough
or bowel movement.
Of note, Ms. ___ was recently admitted to ___ medicine service
from ___ for headaches. She was found to have CSF
lymphocytic pleocytosis (WBC 450, RBC 188, protein 152, glucose
39) with low glucose and pachymeningeal enhancement on MRI (done
post LP). There was also a small subcortical lacunar stroke.
Cytology showed reactive lymphocytosis and flow cytometry also
favored a reactive process. An extensive battery of CSF studies
returned negative including, but not limited to, HIV, RPR, Tb
PCR x2, HZV, HSV, Arbovirus, fungal culture. She was seen by
neurooncology and the differential was felt to be wide including
the following entities: "idiopathic hypertrophic
pachymeningitis, large granular lymphocytic leukemia,
vasculitis, sinus thrombosis, or intravascular lymphoma."
I telephoned her cousin who last saw her 5 days ago. Cousin does
not know much of the ___ medical history, but relays that
over the past week she has been having more trouble with memory
and may not have been able to take care of herself at home.
ROS: positive as above. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or retention. Denies difficulty with gait. The patient denies
fevers, rigors, night sweats, or noticeable weight loss. Denies
chest pain, palpitations, dyspnea, or cough. Denies nausea,
vomiting, diarrhea, constipation, or abdominal pain. No recent
change in bowel or bladder habits. Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
- ___'s thyroiditis, with subclinical hypothyroidism
- Hypertension
- Hyperlipidemia
- Hypertension
- RLL lung mass: evaluated at ___, biopsy (___) with
fibrosis, hyalinized tissue with dystrophic calcification, no
AFB, no malignant cells
- Osteoporosis
- Quantiferon Gold positive
- Hyponatremia, thought secondary to SIADH
- Pacchymeningitis
Social History:
___
Family History:
Uncle with history of TB (per WebOMR)
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals - 98.6 77 101/55 100% on CMV, assist mode FiO2 0.4 and
PEEP 5
HEENT - left pupil sluggish (4 to 3 mm), right eye difficult to
open, pupil minimally or nonresponsive; sclerae anicteric
Cardiac - RRR. S1 and S2. ___ diastolic murmur loudest at ___
Pulmonary - CTAB
Abdomen - soft, normal bowel sounds
Extremities - warm, DP pulses 2+ bilaterally, without edema
Skin - no obvious skin abnormalities
Neurologic - unresponsive to pain/sternal rub, pupil exam as
above
DISCHARGE PHYSICAL EXAM:
============================
VS:98.2 98/57 88 24 100% TM
General: laying in bed with eyes closed, does not respond to
questions
HEENT: MMM, horizontal line of staples across L frontal scalp
without surrounding erythema or drainage, hair recently shaved,
pupils are minimally reactive to light and do not track, but do
move spontaneously when eyes are manually opened
Neck: supple
Lungs: Clear to auscultation bilaterally, anteriorly, no
wheezes, rales, rhonchi
CV: RRR
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Pneumo boots in place, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Skin: WWP, some healing abrasions across dorsal aspect of feet
Neuro: corneal reflex intact, nonresponsive at baseline
Pertinent Results:
ADMISSION LABS:
============================
___ 11:24AM BLOOD WBC-14.7*# RBC-4.58 Hgb-14.4 Hct-40.4
MCV-88 MCH-31.4 MCHC-35.6 RDW-14.6 RDWSD-46.3 Plt ___
___ 11:24AM BLOOD Neuts-87.6* Lymphs-2.5* Monos-9.2
Eos-0.1* Baso-0.1 Im ___ AbsNeut-12.88*# AbsLymp-0.36*
AbsMono-1.35* AbsEos-0.01* AbsBaso-0.02
___ 11:24AM BLOOD ___ PTT-24.7* ___
___ 11:24AM BLOOD Glucose-156* UreaN-45* Creat-1.1 Na-128*
K-3.8 Cl-90* HCO3-20* AnGap-22*
___ 11:24AM BLOOD ALT-19 AST-25 AlkPhos-56 TotBili-0.6
___ 11:24AM BLOOD Albumin-4.3 Calcium-8.8 Phos-4.0 Mg-2.9*
___ 10:50PM BLOOD TSH-0.11*
___ 11:24AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 11:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:30AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:30AM URINE RBC-61* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
CSF STUDIES:
=======================
CSF (___): No PMNs, no microorganisms, no growth in culture, no
enterovirus on culture.
___ 11:30PM CEREBROSPINAL FLUID (CSF) WBC-495 RBC-15*
Polys-2 ___ ___ 11:30PM CEREBROSPINAL FLUID (CSF) TotProt-232*
Glucose-26 LD(LDH)-55
___ 11:30PM CEREBROSPINAL FLUID (CSF) WBC-575 RBC-23*
Polys-1 ___ ___ PARANEOPLASTIC ANTIBODIES PANEL: negative.
___ HSV PCR: negative.
___ TB PCR not detected.
___ Borrelia ___ Ab: not performed by lab, despite
clinician request, given negative serum Ab
___ Mycoplasma IgG - Equivocal
___ Mycoplasma IgM - Negative
___ AntiCCP IgG - Negative
DISCHARGE LABS:
___ 06:17AM BLOOD WBC-8.0 RBC-2.78* Hgb-8.7* Hct-27.9*
MCV-100* MCH-31.3 MCHC-31.2* RDW-16.3* RDWSD-59.6* Plt ___
___ 01:30AM BLOOD Neuts-79.3* Lymphs-9.8* Monos-8.1 Eos-1.2
Baso-0.3 Im ___ AbsNeut-5.96 AbsLymp-0.74* AbsMono-0.61
AbsEos-0.09 AbsBaso-0.02
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-123* UreaN-21* Creat-0.3* Na-139
K-3.9 Cl-101 HCO3-29 AnGap-13
=== MICROBIOLOGY, SEROLOGY:
C. difficile DNA amplification assay (___): POSITIVE
URINE CULTURE (___): Yeast > 100k
URINE CULTURE (___): All negative.
BLOOD CULTURE (___): All negative.
SPUTUM CULTURE (___): All negative or
commensal respiratory flora.
___ BLOODLYME SEROLOGY-FINAL: NO ANTIBODY TO B.
BURGDORFERI DETECTED BY EIA.
___ BLOODLYME SEROLOGY-FINAL: NO ANTIBODY TO B.
BURGDORFERI DETECTED BY EIA.
___ MYCOPLASMA Ab: IgG+, IgM-
___ ANTI-CCP: negative.
___ ACE: normal
___ EBV serologies (blood): VCA-IgG AB-Positive; VCA-IgM
AB-Negative; EBNA IgG AB-Positive
___ FUNGAL/MTB BLOOD CX: negative.
___ SPUTUM CX X3: negative for AFB
___ SEROLOGY/BLOODCRYPTOCOCCAL ANTIGEN-FINALINPATIENT
___ SEROLOGY/BLOODRPR w/check for
Prozone-FINALINPATIENT
___ TISSUEGRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC
CULTURE-FINAL; FUNGAL CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID
FAST CULTURE-FINAL
___ Operative cultures negative except for Coagulase
negative staph from meninges.
=== EEG RECORDINGS ===
- ___ EEG:
This continuous recording captured a poorly organized and slow
background, consistent with a moderate encephalopathy of toxic,
metabolic, and/or anoxic etiology. A small number of right
frontocentral sharp and slow wave discharges were seen, but
these were not rhythmic nor repetitive. Interim results were
conveyed intermittently to the treatment team during this
recording period to assist in ___ medical decision-making.
- ___ EEG:
This continuous recording period captured a few left central
epileptiform discharges that were neither rhythmic nor
repetitive, and did not represent electrographic seizure
activity. In general, the tracing is consistent with a moderate
encephalopathy of toxic, metabolic, and/or anoxic etiology.
Interim results were conveyed to the treating team
intermittently during this recording period to assist in
___ medical decision-making.
- ___ EEG:
This continuous recording is significantly improved over the
previous day's tracing in that the epileptiform discharges
occurred only rarely, superimposed upon a slower than normal and
disorganized background. Interim findings were transmitted to
the treatment team intermittently throughout this recording
period to assist in ___ medical decision-making.
- ___ EEG:
At the beginning of this recording, epileptiform activity was
abundant, seen in a generalized or bifrontally predominant
pattern. As the recording progressed, resolution of the
discharges occurred, and was replaced by a slower than average
background, consistent with a moderate encephalopathy. Interim
findings were transmitted to the treatment team
intermittently throughout this recording period to assist in
___ medical decision-making.
- ___ EEG:
This tracing demonstrated an encephalopathic background with
frequent generalized discharges sometimes occurring rhythmically
at
frequencies of ___ Hz concerning for electrographic seizures. No
appreciable change was seen over the 24 hour period of
monitoring. Interim findings were
conveyed to the treating team intermittently during this
recording period to assist with real- time medical decision-
making.
- ___ EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of generalized delta/theta slowing with interspersed one
to two second
suppressions consistent with a severe encephalopathy
non-specific with regards to etiology. There are no epileptiform
discharges or seizures.
=== IMAGING ===
- ___ CT HEAD W/O CONTRAST
No significant change. Persistent hyperdensity in the distal
left transverse sinus reflecting thrombus, without evidence of
venous infarction.
- ___ MRI/MRA BRAIN
1. Diffuse leptomeningeal FLAIR hyperintense signal involving
the brainstem, basilar cisterns, the cranial nerves, anterior
temporal lobes and hippocampal formations, as well as orbital
frontal lobes and cerebellar folia with associated
leptomeningeal enhancement. There is FLAIR hyperintense signal
of the anterior bilateral temporal lobes and hippocampal
formations with associated diffusion-weighted hyperintense
signal with scattered foci of associated ADC hypointensity. The
constellation of findings are compatible with encephalitis,
particularly HSV. Although considered less likely,
paraneoplastic syndrome such as limbic encephalitis may be
considered if HSV has been excluded.
2. Superimposed punctate foci of diffusion-weighted hyperintense
signal some of which demonstrate associated ADC hypointensity as
described above are compatible with infarct of varying
chronicity.
3. Re-identified is a nonocclusive thrombus of the left
transverse sinus/
sigmoid sinus junction.
___ CT HEAD W/O CONTRAST
1. Status post placement of a right transfrontal EVD without
change to
ventricle size.
2. Unchanged thrombus in the left distal transverse sinus.
___ MENINGEAL BIOPSY
1. Meninges, biopsy (___):
Dura with patchy acute and chronic inflammation, see note.
2. Brain, right, biopsy (2A):
Brain with mild meningeal chronic inflammation. There are no
granulomas in sections examined. There is no evidence of
vasculitis. Note: AFB, Gram, GMS, and Treponema stains performed
on blocks 1B and 2B show no definite infectious organisms.
However, clinical and microbiological correlation is required to
exclude an infectious process. There are no changes suggestive
of spongiform encephalopathy.
___ CT HEAD W/O CONTRAST
1. Interval removal of right frontal approach ventriculostomy
catheter, with gas and blood products along the ventriculostomy
catheter tract. Hemorrhagic material is layering in the
occipital horn of the right lateral ventricle. Allowing for
differences in head position, ventricles are stable to slightly
increased in size.
2. Unchanged thrombus in the left distal transverse sinus.
___ MRI/MRA BRAIN
Severe vasospasm compatible with meningitis. Extensive
leptomeningeal enhancement, similar to the prior studies. Post
surgical changes at the right frontal biopsy site.
___ MRI/MRA BRAIN
1. Slight interval increase in the intensity with stable
distribution of the
pachymeningeal and leptomeningeal enhancement, likely secondary
to meningitis.
2. Interval resolution of previously seen vasospasm.
3. Stable postsurgical changes related to right frontal biopsy.
4. Interval decrease in the size of nonocclusive left venous
sinus thrombus.
5. Stable 3 mm aneurysm at the bifurcation of left middle
cerebral artery.
___ MRI/MRA BRAIN:
1. Stable abnormal high signal in and around the suprasellar
cisterns extending along the bilateral gyrus rectus and left
medial temporal lobe. Of note, contrast was not administered in
this study.
2. Stable 3 mm left MCA bifurcation aneurysm, otherwise
unremarkable MRA of the brain.
___ CXR:
Since a recent radiograph of ___, the patient has
undergone
placement of a tracheostomy tube, in standard position, with no
evidence of
pneumomediastinum or pneumothorax. There has also been interval
placement of
a PEG in the left mid abdomen, which likely accounts for
development of marked
pneumoperitoneum. Exam is otherwise similar to the recent study
except for
removal of a nasogastric tube and endotracheal to.
___ Pathology Report - Second Opinion of Nasal Biopsy
from ___:
LEFT TURBINATE LESION, EXCISION (slides labeled ___
procedure date ___.
Submucosal tissue with dense lymphoplasmacytic infiltrate,
scattered eosinophils, and fibrosis (see note).
Note: While lymphocytes, plasma cells, and eosinophils are
present around vessels, the diffuse nature of the inflammatory
infiltrate in the specimen makes it difficult to establish a
definite diagnosis of vasculitis in the two H&E slides submitted
for our review; multiple histologic levels and special stains
may be helpful for evaluation for vasculitis. There is no
evidence of ischemic-type necrosis or granulomatous
inflammation.
Per report, immunohistochemical stains performed at the
referring institution (not reviewed at ___ show a mixed
population of CD3+ T cells, CD20+ B cells, plasma cells with
polytypic light chain expression, and only rare cells positive
for EBV-encoded RNA (___). Per report, approximately half of
the IgG-positive plasma cells are noted to be positive for IgG4.
The overall morphology is not specific. The findings are not
characteristic for granulomatosis with polyangiitis (Wegener's
granulomatosis), but correlation with serum ANCA levels may be
helpful for further characterization. An additional diagnostic
consideration includes eosinophilic angiocentric
fibrosis, which some authorities consider to be in the spectrum
of IgG4-related sclerosing disease. Correlation with clinical
findings and serum IgG4 levels is required.
___: PICC Placement XRAY
As compared to ___, the patient has received a
left-sided PICC
line. The course of the line is unremarkable, the tip of the
line projects
over the mid SVC. No complications, notably no pneumothorax.
Otherwise
unchanged radiograph.
___: MRI Head w/wo Contrast
IMPRESSION:
1. Leptomeningeal enhancement at the basal cisterns is slightly
more nodular, but similar in distribution as compared to MRI
dated ___. There is slight increased enhancement
of the right trigonal choroid plexus and to new areas of nodular
enhancement of the cranial nerves when compared to prior exam of
___.
2. Significantly interval decreased cortical (frontal and
parietal sulci) leptomeningeal FLAIR hyperintense signal.
3. New areas of restricted diffusion at the left caudate
putamen. New foci of restricted diffusion at the right medial
temporal lobe.
4. Resolution of left venous sinus thrombosis
___: CT Head w/o Contrast
IMPRESSION:
1. New intraparenchymal hemorrhage in the left frontal and
temporal lobes with surrounding vasogenic edema. There is no
shift of midline structures. Patient is status post brain
biopsy.
2. Pneumocephalus is minimal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Sodium Chloride 1 gm PO TID
3. Calcium Carbonate 650 mg PO QHS:PRN hypocalcemia
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 1250 mg PO QHS
2. Sodium Chloride 2 gm PO BID
3. Acetaminophen 1000 mg PO Q8H:PRN fever / pain
4. Atorvastatin 80 mg PO QPM
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Ethambutol HCl 800 mg PO DAILY
7. Famotidine 20 mg PO Q12H
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Glucose Gel 15 g PO PRN hypoglycemia protocol
10. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
11. Isoniazid ___ mg PO DAILY
12. LACOSamide 100 mg PO BID
13. LeVETiracetam ___ mg PO BID
14. Levofloxacin 750 mg PO Q24H
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Miconazole Powder 2% 1 Appl TP QID:PRN groin rash
17. Midodrine 5 mg PO Q8H
18. PredniSONE 30 mg PO DAILY Duration: 7 Days
19. Pyrazinamide 1000 mg PO DAILY
20. Pyridoxine 50 mg PO DAILY
21. Rifampin 600 mg PO Q24H
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
23. Vancomycin Oral Liquid ___ mg PO Q6H
24. Vitamin D 1000 UNIT PO DAILY
25. Heparin 5000 UNIT SC BID
26. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
pachymenigitis of unclear etiology
Secondary Diagnosis:
Hyponatremia/SIADH
S/p prolonged respiratory failure w/ trach and PEG
Hypothyroidism vs Sick Euthyroid Syndrome
C difficile
H/o status epilepticus: continue lacosamide and keppra
Hypotension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with ___ year old woman with falls, HA,
meningitis new found L CVST. Worsening mental statusQuestions to be answered:
PLEASE EVALUATE for infarction or progressing hydrocephalus in setting of new
CVST L transverse // eval for ETT and NGT placement
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The ETT terminates 3 cm above the carina. There is an NG tube, which is below
the diaphragm and curls in the left upper quadrant. There are metallic clips
in the supraclavicular region bilaterally.
The previously identified partially calcified right lower lobe mass appears
unchanged. The lungs are otherwise clear. Heart size is normal. The
mediastinal and hilar contours are normal. The pulmonary vasculature is
normal. No pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities.
IMPRESSION:
1. Appropriate positioning of the ETT and NG tube.
2. Unchanged partially calcified right lower lobe mass.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with falls, HA, meningitis new found L CVST.
Worsening mental status - now obtunded // Questions to be answered: PLEASE
EVALUATE for infarction or progressing hydrocephalus in setting of new CVST L
transverse
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Comparison is made with prior head CT from ___ and CTA
head from ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage,or edema. The previously
noted small hyperdense focus in the distal left transverse sinus appears
unchanged without evidence of extension, compared to the prior exam from ___.
Ventriculomegaly is also stable compared to prior exam from ___.
Ill defined periventricular white matter hypodensities are seen representing a
sequela of chronic ischemic small vessel changes.
There is no evidence of fracture. Bilateral ethmoid sinuses have moderate
mucosal thickening. The sphenoid and maxillary sinuses appear clear. The
bilateral mastoid air cells appear clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
No significant change. Persistent hyperdensity in the distal left transverse
sinus reflecting thrombus, without evidence of venous infarction.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman with acute AMS, dilated and fixed pupils w/o
evidence of ventriculomegaly on CT // evaluate for brainstem ischemia or
other cause of AMS.
TECHNIQUE: Phase contrast MRV was performed through the brain. Sagittal and
axial T1 weighted imaging were performed along with diffusion imaging.
After administration of 6 mL of Gadavist intravenous contrast, axial imaging
was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CT head without contrast of ___, CTA head and CTA of
the head with without contrast of ___, MRI head with without
contrast ___.
FINDINGS:
MRI BRAIN:
When compared to the prior exam ___ there is now interval development
of diffuse bilateral leptomeningeal cerebellar and cerebral hemispheric FLAIR
hyperintense signal as well as FLAIR hyperintensity signal of the anterior
bilateral temporal lobes and hippocampal formations. There is thickening and
FLAIR hyperintense signal of the ventricular ependyma particularly along the
temporal and occipital horns. Postcontrast enhancement leptomeningeal
enhancement of the brainstem/pons, bilateral left greater than right 7 eighth
cranial nerve complexes extending into the internal auditory canals, bilateral
trigeminal nerves, 6 cranial nerve and the bilateral oculomotor nerves,
basilar cisterns, medial frontal lobes and orbital frontal lobes as well as
leptomeningeal enhancement of the bilateral cerebellar folia are identified.
There is also diffusion-weighted hyperintense signal with scattered foci of
associated ADC hypointensity of the bilateral anterior temporal lobes and
hippocampal formations, leptomeningeal medial frontal and orbital frontal
lobes, leptomeningeal brainstem, anterior septum pellucidum, right anterior
genu, posterior left occipital horn periventricular white matter, anterior
right superior frontal gyrus and scattered foci of the cerebellar hemispheres
predominately on the left some of which are compatible with infarct of varying
chronicity.
At the junction of the left distal transverse sinus and sigmoid sinus is
identified corresponding to a 1.4 x 0.6 cm (TRV, AP) nonocclusive central
filling defect noted on postcontrast MP rage sequences corresponding to
previously described thrombus on prior examinations. The remainder the dural
venous sinuses are patent.
Superimposed subcortical and periventricular white matter hyperintensities are
similar in distribution in configuration from prior exam and are nonspecific,
potentially representing sequela of chronic microangiopathy in a patient of
this age. The major intracranial flow voids are preserved. There is no
intracranial hemorrhage. The paranasal sinuses are essentially clear. The
orbits are unremarkable. The mastoid air cells are clear. The patient is
intubated. Sulci, ventricles cisterns are within expected limits given the
patient's age related global cerebral volume loss.
MRV brain: There is lack of flow related signal of the or left transverse
sinus, sigmoid sinus and visualized portions of the internal jugular vein
compatible with slow flow from the above described 1.4 x 0.6 cm (TRV, AP)
nonocclusive central filling defect at the transverse/sigmoid sinus junction
as postcontrast MP RAGE sequences demonstrates enhancement of the remainder of
the left transverse, sigmoid and left internal jugular vein.
IMPRESSION:
1. Diffuse leptomeningeal FLAIR hyperintense signal involving the brainstem,
basilar cisterns, the cranial nerves, anterior temporal lobes and hippocampal
formations, as well as orbital frontal lobes and cerebellar folia with
associated leptomeningeal enhancement. There is FLAIR hyperintense signal of
the anterior bilateral temporal lobes and hippocampal formations with
associated diffusion-weighted hyperintense signal with scattered foci of
associated ADC hypointensity. The constellation of findings are compatible
with encephalitis, particularly HSV. Although considered less likely,
paraneoplastic syndrome such as limbic encephalitis may be considered if HSV
has been excluded.
2. Superimposed punctate foci of diffusion-weighted hyperintense signal some
of which demonstrate associated ADC hypointensity as described above are
compatible with infarct of varying chronicity.
3. Re-identified is a nonocclusive thrombus of the left transverse sinus/
sigmoid sinus junction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with communicating hydrocephalus, ?infectious,
evaluate EVD positioning.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 18.4 cm; CTDIvol = 54.6 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT head performed on ___
FINDINGS:
Patient is status post placement of a right transfrontal EVD which terminates
in the body of the right lateral ventricle. The size of the ventricle is
grossly unchanged since prior study. For example the left temporal horn
measures 9 mm on today's study, previously 9 mm. There is persistent
hyperdensity at the distal left transverse sinus compatible with known
thrombus. There is no acute hemorrhage, large vascular territorial
infarction, mass effect, or shift of normally midline structures. The basal
cisterns appear patent and there is preservation of gray-white matter
differentiation.
No osseous abnormalities seen. There is mucosal thickening in the bilateral
ethmoid air cells and right maxillary sinus. The remaining visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1. Status post placement of a right transfrontal EVD without change to
ventricle size.
2. Unchanged thrombus in the left distal transverse sinus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS, intubated, meningitis // confirm
ETT, look for PNA.
IMPRESSION:
As compared to recent radiograph of 1 day earlier a nasogastric tube has been
advanced and now coils in the proximal stomach. No other relevant change
since the recent study.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with new CVL placement. // confirm ETT
placement Contact name: ___: ___
IMPRESSION:
As compared to previous radiograph of earlier the same date, a right internal
jugular central venous catheter is been placed, terminating at the cavoatrial
junction, with no visible pneumothorax. No other relevant change since recent
study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: This is a ___ year old woman with a medical history of ___'s
thyroiditis, RLL fibrothorax (non-malignant, non-mycobacterial), history of
IGRA positivity and IgG4 nasal turbinate disease, and recent hospitalization
for headache with imaging showing pachymeningeal enhancement and CSF studies
showing lymphocytic pleiocytosis, with negative TB NAAT, presented to this
hospital on ___ for generalized weakness and had imaging concerning for
possible sinus venous thrombous, who had an acute change in mental status on
the morning of ___ (became unresponsive) without changes in vital signs,
prompting MICU transfer.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiac size normal. The aorta is tortuous. ET tube is in standard position.
Right IJ catheter tip is in the cavoatrial junction. NG tube is coiled in the
stomach.
The previously identified partially calcified right lower lobe mass appears
unchanged. The lungs are otherwise clear. There is no pneumothorax or
enlarging effusions
.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p EDV placement, removed ___. // evaluate
for ICP
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 844 mGy-cm.
COMPARISON: CT head dated ___ and ___.
FINDINGS:
There has been interval removal of the right frontal approach ventriculostomy
catheter. Allowing for differences in head position, the ventricles appear
stable to slightly increased in size. Gas and blood products are seen along
the ventriculostomy catheter tract, and hemorrhagic material is seen layering
the occipital horn of the right lateral ventricle.
Persistent high-density material in the distal left transverse sinus is
compatible with known thrombus.
There is no acute large vascular territorial infarction, mass effect, or shift
of the normally midline structures.
Mild mucosal thickening or layering fluid is seen in the right maxillary
sinus. Remaining visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval removal of right frontal approach ventriculostomy catheter, with
gas and blood products along the ventriculostomy catheter tract. Hemorrhagic
material is layering in the occipital horn of the right lateral ventricle.
Allowing for differences in head position, ventricles are stable to slightly
increased in size.
2. Unchanged thrombus in the left distal transverse sinus.
NOTIFICATION: Wet read was discussed with Dr. ___ by Dr. ___
telephone at 14:25 on ___, 5 min after discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with failed RSBI // eval for interval change
eval for interval change
COMPARISON: Chest radiographs and CT scans since ___, most recently
___.
IMPRESSION:
Right upper lung and left lung essentially clear aside from mild linear
scarring or atelectasis at the base. The unusual calcific right pleural
parenchymal abnormality is chronic. Normal cardiomediastinal silhouette. No
evidence of pleural effusion. No pneumothorax.
ET tube, right internal jugular line and transesophageal drainage tube in
standard placements respectively.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new fever, hypotension, on ventilator
x1wk, c/f VAP // evaluate for VAP evaluate for VAP
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Left lung and right upper lung are clear. Large region of chronic calcific
consolidation in the right midlung could obscure adjacent pneumonia. Right
pleural calcification and elevation of the right lung base due to scarring are
chronic. No left pleural abnormality. Normal cardiomediastinal silhouette.
Right jugular line ends in the region of the superior cavoatrial junction and
nasogastric drainage tube ends in the upper stomach. No pneumothorax.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: ___ year old woman with pachymeningitis DDX TB, IgG4 disease,
vasculitis // eval for interval change in pachymeningitis
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Maximum intensity projection reconstructions and segmented views were
generated. Sagittal and axial T1 weighted imaging were performed along with
diffusion imaging. After administration of 6cc of Gadavist intravenous
contrast, axial imaging was performed with gradient echo, FLAIR, T2, and T1
technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and
coronal orientations.
COMPARISON: Brain MR ___ and head CT ___ CTA head ___
FINDINGS:
MRI Brain: Again seen is extensive leptomeningeal enhancement in the supra
and infratentorial compartments and particularly dramatic in the suprasellar
cistern. White matter hyperintensity on FLAIR appears unchanged.
There is a right frontal craniotomy defect with underlying postsurgical
changes, new since ___ would compatible with postoperative changes after
biopsy. There is a small amount of hemorrhage in the occipital horns of the
lateral ventricles bilaterally. This may be postoperative.
MRI brain: There is severe narrowing and irregularity of the intracranial
arteries bilaterally. This involves the middle and anterior cerebral arteries
to a greater extent than the basilar and posterior cerebral arteries.
Again seen is an approximately 3 mm aneurysm at the bifurcation of the left
middle cerebral artery.
The nonocclusive thrombus in the left transverse and proximal sigmoid sinuses
appears smaller than on the prior brain MR.
___:
Severe vasospasm compatible with meningitis.
Extensive leptomeningeal enhancement, similar to the prior studies.
Post surgical changes at the right frontal biopsy site.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman with basilar meningitis vs. Vasculitis. Eval
for interval change
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: Prior MRI/ MRA of brain from ___.
FINDINGS:
MR BRAIN:
Again seen is extensive leptomeningeal and pachymeningeal thickening, FLAIR
signal abnormality and enhancement in the supra and infratentorial
compartments, especially in the suprasellar cistern, slightly worse compared
to the prior study in intensity but similar in distribution. Previously seen
associated slow diffusion has significantly decreased in conspicuity.
Stable postsurgical changes related to recent prior right frontal craniotomy
with underlying resection cavity containing small amount of hemorrhagic blood
products and small extra-axial collection. There is minimal stable residual
enhancement surrounding the resection cavity, likely postsurgical in nature.
Stable small amount of layering hemorrhage in the occipital horn of right
lateral ventricle, possibly postoperative in nature.
There is stable FLAIR signal hyperintensity in bilateral subcortical,
periventricular and deep white matter, nonspecific.
Right frontal approach ventriculostomy catheter tract is seen in place with
hemorrhage and FLAIR signal abnormality surrounding it.
The ventricles, cisterns and sulci are stable and prominent. No midline shift
or mass effect is seen. The orbits are unremarkable. Nonspecific partial
fluid opacification of bilateral mastoid air cells. The visualized paranasal
sinuses are clear.
MRA brain: There has been interval resolution of the previously seen vasospasm
involving the intracranial arteries and anterior circulation bilaterally. The
middle and anterior cerebral arteries appear unremarkable on today's study.
Stable 3 mm aneurysm at the bifurcation of left middle cerebral artery is
again seen on image 3:65. The previously seen nonocclusive thrombus involving
the left transverse sinus is significantly decreased in size compared to the
prior study.
IMPRESSION:
1. Slight interval increase in the intensity with stable distribution of the
pachymeningeal and leptomeningeal enhancement, likely secondary to meningitis.
2. Interval resolution of previously seen vasospasm.
3. Stable postsurgical changes related to right frontal biopsy.
4. Interval decrease in the size of nonocclusive left venous sinus thrombus.
5. Stable 3 mm aneurysm at the bifurcation of left middle cerebral artery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pachymeningitis, ?TB with ongoing
seizures. Newly febrile // ? PNA, infiltrate, aspiration
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiac size is normal. The mediastinum is unchanged with tortuous aorta. ET
tube is in standard position. Right IJ catheter tip is in the cavoatrial
junction. The left lung is grossly clear. Right pleural calcification and
right pleural thickening is stable. There is no pneumothorax. large region
of chronic calcific consolidation in the right mid lung is a slightly denser
could be increasing atelectasis, pneumonia cannot be excluded. NG tube tip
is coiled in the stomach the tip is pointing to the EG junction
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with meningitis and intubated // ?interval
change ?interval change
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
The slight increase in pulmonary vascularity since ___, and no
definite edema or pleural effusion. Heart size normal. Enlarge calcified
abnormality in the right midlung is chronic.
ET tube in standard placement. Right jugular line ends in the upper right
atrium. Nasogastric drainage tube coils in the upper stomach with the tip
pointing back to the gastroesophageal junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with meningitis and intubated // ? interval
change
TECHNIQUE: Portable chest
___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old female with pachymeningitis, TB meningitis vs
vasculitic etiology. Biopsy planning.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: Multiple MRIs, most recent on ___.
FINDINGS:
MR BRAIN:
A small right frontal craniotomy defect is seen with minimal FLAIR
hyperintense signal in the underlying right frontal lobe with associated
susceptibility, consistent with the prior biopsy site. There is increased
FLAIR hyperintense signal in and around the suprasellar cisterns extending
into the bilateral gyrus rectus and left medial temporal lobe, stable since
the prior MRI. Diffuse pachymeningeal FLAIR hyperintense signal is seen,
particularly along the supratentorial convexity, stable since ___.
Stable periventricular and subcortical white matter hyperintensities are seen.
The ventricles are prominent but stable in size.
Interval decreased conspicuity of the foci of restricted diffusion in the left
corona radiata is seen.
Fluid is seen in the bilateral mastoid air cells. There is fluid in the
posterior nasopharynx from the intubated status. Partially visualized OG and
ET tubes are seen. Mucosal thickening in the ethmoid sinuses is seen.
MRA brain: There is stable appearance of the 3 mm left MCA bifurcation
aneurysm. Otherwise, the intracranial vertebral and internal carotid arteries
and their major branches appear normal without evidence of stenosis,
occlusion, or additional aneurysm formation.
IMPRESSION:
1. Stable abnormal high signal in and around the suprasellar cisterns
extending along the bilateral gyrus rectus and left medial temporal lobe. Of
note, contrast was not administered in this study.
2. Stable 3 mm left MCA bifurcation aneurysm, otherwise unremarkable MRA of
the brain.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new PEG placement and Trach placement.
Please perform xray to assess both trach and PEG. // assess trach/PEG
placement
IMPRESSION:
Since a recent radiograph of ___, the patient has undergone
placement of a tracheostomy tube, in standard position, with no evidence of
pneumomediastinum or pneumothorax. There has also been interval placement of
a PEG in the left mid abdomen, which likely accounts for development of marked
pneumoperitoneum. Exam is otherwise similar to the recent study except for
removal of a nasogastric tube and endotracheal to.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ w/ pachymeningitis c/f TB vs GPA vs IgG4-RD, also with
non-convulsive status epilepticus, central diabetes insipidus, the team is
questioning repeat biopsy at sites of greatest leptomeningeal signal.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRA dated ___
MRI dated ___.
FINDINGS:
Status post appearance of right trans frontal biopsy with linear hemosiderin
product along the biopsy tract. Residual enhancement and blood products
remain at the biopsy site. The degree of by a hemispheric nonenhancing
cortical leptomeningeal FLAIR hyperintense signal, particular on the
convexities and vertex, has significantly decreased since MRI dated ___.
The basal cistern leptomeningeal enhancement is similar in distribution but
slightly more nodular in morphology as compared to MRI dated ___.
The leptomeningeal enhancement continues to involve predominantly the
suprasellar, pre pons and perimesencephalic cisterns; extending to the
suprasellar cisterns, bilateral rectus gyri and bilateral medial temporal
lobes. There remains nodular enhancement of the cranial nerves, including
left trigeminal nerve root entry zone. When compared to the prior exam there
is also increased nodular enhancement of the left CN IX-XI (series 1200b,
image 32)
There is apparent increased enhancement of the right choroid plexus in the
track on (series 1200b, image 51).
There are areas of restricted diffusion in the left caudate head, left
putamen, new since MRI dated ___. An additional area of
restricted diffusion is present adjacent to the right temporal horn (602:12).
The major dural venous sinuses are without thrombus.
IMPRESSION:
1. Leptomeningeal enhancement at the basal cisterns is slightly more nodular,
but similar in distribution as compared to MRI dated ___. There
is slight increased enhancement of the right trigonal choroid plexus and to
new areas of nodular enhancement of the cranial nerves when compared to prior
exam of ___.
2. Significantly interval decreased cortical (frontal and parietal sulci)
leptomeningeal FLAIR hyperintense signal.
3. New areas of restricted diffusion at the left caudate putamen. New foci of
restricted diffusion at the right medial temporal lobe.
4. Resolution of left venous sinus thrombosis
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC // L DL Power PICC 43cm
___ ___ Contact name: ___: ___ L DL Power PICC 43cm
___ ___
IMPRESSION:
As compared to ___, the patient has received a left-sided PICC
line. The course of the line is unremarkable, the tip of the line projects
over the mid SVC. No complications, notably no pneumothorax. Otherwise
unchanged radiograph.
Radiology Report
INDICATION: ___ year old woman with pachymeningitis, need to assess for
vasculitis versus TB meningitis.
COMPARISON: None
TECHNIQUE: The patient was brought to the angio suite and positioned on the
angio table. Patient was already intubated and continuous sedation was
administered. The right femoral artery was localized using anatomic landmarks
and a 5 ___ short sheath was placed. A ___ 2 diagnostic catheter was
used to select the right internal carotid artery, left internal carotid artery
and left vertebral artery. AP, lateral, and oblique views of the intracranial
circulation were obtained. At the end the procedure diagnostic catheter was
removed and the arteriotomy site was closed with Angio-Seal. The patient was
transferred back to the intensive care unit.
DEVICES: ___ 2, 0.038 hydrophilic wire
PROCEDURE:
1. Three-vessel cerebral angiogram
FINDINGS:
Right internal carotid artery: The right anterior intracranial circulation is
unremarkable. There is some slight narrowing of the distal internal carotid
artery, A1 and M1 segments possibly consistent with basilar meningitis. No
signs of vasculitis.
Right internal carotid artery: The right anterior intracranial circulation is
unremarkable. There is some slight narrowing of the distal internal carotid
artery, A1 and M1 segments possibly consistent with basilar meningitis. No
signs of vasculitis.
Left vertebral artery: The posterior intracranial circulation is
unremarkable.
IMPRESSION:
Unremarkable three-vessel cerebral angiogram. Subtle narrowing of the distal
internal carotid artery, A1, and M1 segments bilaterally.
I, ___, participated in this procedure. I, ___
___, was present for the entirety of the procedure and supervised all
critical steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
Radiology Report
INDICATION: Missing needle, missing pack of needle
TECHNIQUE: Single lateral view of the skull: Additional image of a pack of
needles
COMPARISON: None.
FINDINGS:
No radiopaque structure with the appearance of a pack of suture needles is
seen. Numerous surgical clips are seen overlying the skull as well as
external fixation. Thin linear structure is seen projecting over the
nasopharynx, query external to the patient or related to a temperature probe.
IMPRESSION:
No radiopaque structure with the appearance of a pack of suture needles is
seen.
NOTIFICATION: Discussed with Dr. ___. ___ on ___ at 17:40
via telephone by Dr. ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ pachymeningitis c/f TB vs fungal (GPA vs IgG4-RD) vs CNS
lymphoma less likely given angiography not consistent with vasculitis), also
with non-convulsive status epilepticus, central diabetes insipidus,
hypotension of unclear etiology requiring levophed. S/p brain biopsy ___. //
please perform at 2200, 4 hours post craniotomy evaluating for bleed,
inflammation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: MR brain ___. CT head ___.
FINDINGS:
Patient is status post brain biopsy via left frontal craniotomy. There is
small amount of expected pneumocephalus along the left frontal and temporal
convexities. There are multiple moderate size foci of intraparenchymal
hemorrhage with surrounding vasogenic edema involving the left frontal and
temporal lobes and small amount of subarachnoid hemorrhage. Conglomerate of
hemorrhage in the left frontal lobe measures 3.5 x 3.2 cm (03:12). There is
mild mass effect on the frontal horn of the left lateral ventricle but no
shift of midline structures.
There is expected gas in the left scalp and extending inferiorly into the
masticator space. There is persistent opacification of left mastoid air
cells.
IMPRESSION:
1. New intraparenchymal hemorrhage in the left frontal and temporal lobes with
surrounding vasogenic edema. There is no shift of midline structures.
Patient is status post brain biopsy.
2. Pneumocephalus is minimal.
NOTIFICATION: The findings were telephoned to Dr. ___ By ___
___ at 23:46, ___, 5 min after discovery.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ pachymeningitis c/f TB vs fungal (GPA vs IgG4-RD less
likely given angiography not consistent with vasculitis), also with
non-convulsive status epilepticus, central diabetes insipidus, hypotension s/p
craniotomy ___ with brain biopsy and post op bleed in left frontal region
evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformatted images were obtained.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 18.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Post left frontal craniotomy with postop changes including pneumocephalus and
extracranial soft tissue swelling are present. The left frontal and temporal
lobe intraparenchymal hemorrhage with surrounding vasogenic edema and mass
effect effacing the left lateral ventricle is stable from previous
examination. There is 2 mm of rightward midline shift. The basal cisterns
are patent. Periventricular hypodensities are consistent with small vessel
ischemic changes. There is an air-fluid level in the right maxillary sinus
and opacification of the left mastoid air cells.
IMPRESSION:
1. Left frontal and temporal lobe intraparenchymal hemorrhage with surrounding
vasogenic edema and mass effect are unchanged.
2. Post left frontal craniotomy with postoperative changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fevers // eval for PNA
IMPRESSION:
Allowing for differences in technique and projection, there has not been a
relevant change in the appearance the chest since recent study of ___. Specifically, there are no new areas of consolidation to suggest
development of a pneumonia.
Radiology Report
INDICATION: ___ year old woman with pachymeningitis of unknown etiology,
depressed mental status, with hypothermia today concerning for sepsis //
please assess for evidence of pneumonia
COMPARISON: Radiographs from ___ and chest CT from ___
IMPRESSION:
Tracheostomy is unchanged in position. There is a left-sided central venous
line with the distal tip in the mid SVC however it is perpendicular to the SVC
wall. Large area of pleural base calcification and consolidation within the
right base is unchanged and better assessed on the prior CT scan. There is
atelectasis and volume loss on the left. There are no signs for overt
pulmonary edema or pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pachymeningitis unresponsive at baseline
with fever tachycardia tachypnea // pneumonia pneumonia
COMPARISON: Prior chest radiographs ___ through ___.
IMPRESSION:
Extensive chronic right pleural calcification obscures the right lower lobe.
Elsewhere there is No evidence of pneumonia.
Heart size normal. No appreciable pleural abnormality. Thoracic aorta is
generally large but not focally aneurysmal. No appreciable pleural effusion
or indication of pneumothorax
Left PIC line ends in the upper SVC. Tracheostomy tube midline.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with PHLEBITIS & THROMBOPHLEBITIS OF INTRACRANIAL SINUS
temperature: 97.9
heartrate: 102.0
resprate: 16.0
o2sat: 97.0
sbp: 128.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | PATIENT:
___ year old woman with a medical history of Hash___'s
thyroiditis, RLL fibrothorax (non-malignant, non-mycobacterial),
history of IGRA positivity and IgG4 nasal turbinate disease,
recent admission for headache with imaging showing
pachymeningeal enhancement and CSF studies showing lymphocytic
pleiocytosis but with negative TB NAAT, who was re-admitted on
___ for generalized weakness and imaging consistent with venous
sinus thrombosis. The patient had an acute worsening of mental
status the morning of ___ during which she became unresponsive
albeit without changes in her vital signs, prompting MICU
transfer and extended MICU course including chronic intubation
resulting in trach/peg placement with full course detailed
below. After stabilization, she was sent to the medicine floor
for further management. Patient remained stable on the medical
floor with stable respiratory status and unchanged neurological
status for 1 week after call out from MICU. At that time, felt
that patient safe for discharge to ___ for further
treatment where they will be able to continue monitor patient
and help her continue to heal neurologically as able.
ACUTE ISSUES
# PACHYMENINGITIS AND LYMPHOCYTIC PLEIOCYTOSIS:
- Patient was admitted between ___ for left-sided
frontal headaches x1 week. At that time she would shake her head
to Yes/No questions and would follow commands, but she would not
verbally communicate (even with a ___ interpreter). During
that admission she was found to have CSF with a lymphocytic
pleiocytosis (WBC 450, lymphocytes ~90%), elevated protein (191)
and low glucose (39). She also had pachymeningeal enhancement on
FLAIR MRI sequences, as well as a small left corona radiata
lacunar infarct. She had negative Lyme, HSV, VZV and arbovirus
serologies. CSF enterovirus culture was negative, as was CSF EBV
PCR and CSF TB PCR x3. RPR w/ prozone was negative for syphilis.
Flow cytometry was consistent with reactive lymphocytosis.
Patient was initially treated with ceftriaxone, acyclovir but
these were discontinued after workup for infectious etiologies
was unrevealing and patient made substantial recovery in terms
of her mental status. It was presumed that the etiology of her
meningitis with aseptic/viral and she was able to be discharged
home with follow up.
- The patient represented on ___ after sudden onset of
generalized weakness preventing her from standing. She was
incontinent of urine and endorsing ongoing headache. She was
encephalopathic, oriented to person and place only. She was
admitted and covered broadly for infectious etiologies of
meningitis (vancomycin, ceftriaxone and acyclovir) but continued
to rapidly decline in terms of her mental status, and within 1
day of admission she required transfer to the medical ICU and
intubation for airway protection in the setting of becoming
unresponsive (albeit with unchanged vital signs). Neurology,
neurosurgery, neuro-oncology and infectious disease services
were consulted. The differential for her presentation was felt
to include TB meningitis, IgG4-related disease, vasculitis,
venous sinus thrombosis, lymphoma, or an idiopathic hypertrophic
pachymeningitis.
- At time of transfer to the medical ICU, empiric treatment with
rifampin, isoniazid, pyrazinamide, ethambutol and levofloxacin
were started for empiric TB meningitis treatment. She was also
given methylprednisolone 500 mg IV daily x6 days for empiric
treatment of vasculitis and IgG4 related disease, however no
improvement was seen during this time. Acyclovir and ceftriaxone
were discontinued once CSF HSV PCR and cultures from CSF
returned negative. Plan to treat for 2 month course (end date
___
- The patient underwent right frontal craniotomy with meningeal
biopsy on ___. This biopsy was unrevealing (dura w/ patchy
acute and chronic inflammation, mild meningeal chronic
inflammation, no evidence of vasculitis), although the validity
of the biopsy result was uncertain due to difficulty obtaining
an area of the meninges with pachymeningeal enhancement. MRI/MRA
Brain on ___ revealed no significant change in the
leptomeningeal enhancement, while repeat on ___ showed slight
interval increase in the intensity with stable distribution of
the pachymeningeal and lepomeningeal enhancement. After
multidisciplinary meetings and given the differential diagnosis
centering on either TB meningitis or IgG4/Vasculitic disease, it
was decided to obtain angiography of the brain to assess for any
evidence of vasculitis. This was performed on ___ and did not
show significant findings: there was a mild narrowing of some
vessels which was consistent with meningitis, and not
vasculitis. Concomitantly outpatient pathologic samples were
examined by our rheumatology and pathology teams to assess for
evidence of IgG4 vasculitis. This analysis was inconclusive and
somewhat limited by the lack of multiple levels of biopsy sample
provided to ___. Repeat MRI showed new findings which were
concerning for an underlying infectious process, possibly
fungal. A repeat brain biopsy was performed on ___ which did
not reveal any clear etiology. Universal PCR from the second
brain biopsy was negative for mycobacterium tuberculosis, non Tb
mycobacterium, fungi and bacteria. Despite that, it was felt
from an infectious disease standpoint that the radiological
findings of pachymengitis were still consistent with Tb, which
would be treatable so they recommended completing the 2 month
course of RIPE+levofloxicin.
# VENOUS SINUS THROMBOSIS:
- ___ on ___ showed hyperdensity of distal left transverse
sinus consistent with venous sinus thrombosis. CTA/CTV confirmed
a focal thrombus in the left distal transverse sinus. Neurology
was consulted. No anticoagulation was initiated per their
recommendations, although she was continued on ASA 81mg qday.
The size of this thrombus was noted to progressively decrease on
follow up MRI/MRA imaging on ___ and ___.
# CEREBRAL VASOSPASM:
- MRI/MRA Brain on ___ revealed severe narrowing and
irregularity of the intracranial arteries bilaterally, involving
the middle and anterior cerebral arteries to a greater extent
than the basilar and posterior cerebral arteries. This was felt
to be consistent with severe vasospasm secondary to the
patient's underlying meningitic process. She was subsequently
started on nimodipine and atorvastatin per neurology's
recommendations. MRI/MRA on ___ revealed interval resolution of
vasospasm. On ___ the patient's Nimodipine was
discontinued and a repeat MRI/MRA brain was ordered which showed
nodular leptomeningeal enhancement.
# HYDROCEPHALUS:
- On ___, at time of the patient's rapid change in mental
status, neurosurgery was consulted emergently for consideration
of hydrocephalus secondary to meningitis. Patient was known at
that time to have communicating hydrocephalus. Neurosurgery
placed an EVD for ICP monitoring. Opening pressure was elevated
(___). EVD remained in place until ___ at which point it was
removed due to risk of infection.
# NON-CONVULSIVE STATUS EPILEPTICUS:
- Patient being found in non-convulsive status epilepticus on
___. Subsequently, a number of her medications were modified
including a discontinuation of metronidazole (previously on for
C.difficile infection). She was loaded with Keppra and later
lacosamide without complete suppressoin of seizure activity.
Propofol was therefore used for burst suppression. After several
days of propofol and ongoing maintenance dosing of Keppra and
lacosamide, propofol was able to be weaned without recurrence of
her seizures. There were no further episodes of status noted on
repeat EEG.
# PUPILLARY CHANGES:
- On admission, neurology recorded her exam as PERRL 4->2 brisk,
sharp discs on fundoscopy bilaterally, visual fields full to
number counting, EOMI, no nystagmus. However, on ___ (in
setting of acute worsening of her mental status shortly after
admission), she was noted to have developed dilated and fixed
pupils as well as intermittent horizontal nystagmus concerning
for either increased intracranial pressure or seizures. CT Head
at that time revealed no significant changes. Neurology felt
that imaging showed concerns for focal infarcts in the
brainstem. Over the subsequent 2 weeks, her neurological exam
was noted to fluctuate with intermittently asymmetric pupils and
presence of horizontal nystagmus.
- On ___, there appeared to be some improvement in her
neurological exam. She had intermittent spontaneous movement of
her extremities was observed although she still was not
withdrawing to painful stimuli. She was also noted to have a
new, albeit weak, gag reflex on ___.
# RESPIRATORY FAILURE:
- Patient was intubated on ___ for airway protection in setting
of rapidly worsening mental status and obtundation. For the
entirety of her stay she required only minimal ventilator
support, largely remaining on pressure support only. On ___,
however, the patient starting exhibiting periods of apnea that
required switching her to MMV.
- On ___ the patient underwent tracheostomy and percutaneous
endoscopic gastrostomy (PEG) with the Interventional Pulmonary
service given her inability to be weaned from the ventilator and
her family's desire to pursue ongoing maximally intensive care.
- On the floor she continued to have high oxygen saturation
(around 100%) on tracheal mask.
- Can consider downsizing trach and possible removal at ___ if
able
# HYPOTENSION:
- On ___, the patient's BP dropped to 87/52. SBPs had
previously between 100s-120s. Norepinephrine gtt was started at
that time to maintain MAP > 60. Etiology was hypotension
remained unclear, with extensive infectious workup negative.
Patient was also on high doses of steroids which made adrenal
insufficiency improbable. Patient was started on midodrine 10mg
PO TID on ___. Norepinephrine gtt was weaned and eventually
able to be discontinued on ___. On the floor she was maintained
on midorine 5mg every 8 hours with stable baseline SBPs ranging
___ systolic to 100.
.
# Sodium Handling Abnormalities:
- The patient had several episodes of extremely rapid
fluctuations in her serum sodium (as rapid as Na 138 to 161 in
10 hours). These were managed with a combination of D5W and
desmopressin. Central diabetes insipidus was definitively
diagnosed on ___ with steady rise in urine osmolality from 169
(pre-ddAVP) up to 840 (post-ddAVP) in setting of serum sodium
value in low 150s. Patient's central DI stabilized with a
regimen of 1mcg ddAVP qday which was started on ___. Prior to
transfer from the MICU to the floor, she developed hyponatremia
consistent with SIADH (elevated UOsm in setting of hyponatremia
to 129) which improved to 137 with 2g Na tablets and free water
restriction to 1.5L.
# ABNORMAL THYROID FUNCTION STUDIES:
- TSH was 0.082 on ___ with T4 being 6.3 at that time. Repeat
TSH on ___ was 1.6, with T4 and T3 being 3.8 and 55
respectively. Endocrinology was consulted and felt that these
changes were consistent with reactive changes to critical
illness (sick euthyroid syndrome). Nevertheless, given her
history of ___'s thyroiditis and subsequent risk of
developing true hypothyroidism (and given the setting of her
altered mental status and obtundation) they recommended started
levothyroxine 50mcg daily.
# C. Diff Infection: Patient with significant watery diarrhea
and tested positive for C. Diff infection. Started on PO
Vancomycin with plan to continue treatment for 2 weeks after
completion of TB treatment as above. Assume stop TB treatment on
___, continue PO Vancomycin until ___.
# GOALS OF CARE:
- Multiple goals of care discussions were conducted on
___ and ___ with the family desiring
ongoing maximally intensive care with understanding that patient
is DNR though ok for ventilation if needed given trach. During
meeting on ___, discussed with sister and nephew/HCP patients
overall clinical status as well as poor prognosis, specifically
explaining that patient's diagnosis remains elusive but best
chance is to treat for TB infection however with understanding
that the patient may not regain significant cognitive or
functional status.
CHRONIC ISSUES
# HYPERTENSION: Hypotensive this admission. Losartan stopped
during last hospitalization.
# S/P LACUNAR STROKE: ASA daily. Started atorvastatin 80 mg
daily.
TRANSITIONAL ISSUES
- 4mm aneurysm at left M1/M2 bifurcation seen on CTA Head from
___
- Will need thyroid panel rechecked as outpatient to distinguish
euthyroid sick syndrome from true hypothyroidism
- Please have neurology follow with her once a week at the ___.
- Continue slow prednisone taper decreasing 10mg/week. Currently
30 mg; decrease to 20mg ___, 10mg ___ for 7 days and stop
___
- Continue SS Bactrim while on steroid taper
- Continue RIPE + Levofloxacin for full 2 month course (last
dose date ___ can discuss with ID doctors after
___ and follow up scheduled
- Note: patient with intermittent fevers and mild tachypnea. Low
suspicion for true infectious etiology and feel Central fevers.
However, lower for aspiration. Consider changing PEG to J tube
once tract matures (___) if continued concern for aspiration;
can coordinate with ___ as outpatient procedure if needed
- Continue PO Vancomycin for C. Diff infection. Continue dosing
until 2 weeks after completion of TB treatment
- f/u with ID specialist at ___. Will call facility with
appointement
- continue ___ rehab at ___
- Monitor Na weekly to ensure Na stable as stable SIADH this
admission but treating with Na tabs |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tetanus / Penicillins / Augmentin / Fosamax / Edta (Edetic Acid)
Attending: ___
Chief Complaint:
Left facial droop, seizure
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
Neurology at bedside after Code Stroke activation within: 3 mins
Time/Date the patient was last known well: ___ on ___
___ Stroke Scale Score: 33
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: outside window
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: no large vessel
occlusion
NIHSS performed within 6 hours of presentation at: 19:51,
___
NIHSS Total: 31
1a. Level of Consciousness: 3
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 4
6a. Motor leg, left: 4
6b. Motor leg, right: 4
7. Limb Ataxia: U
8. Sensory: U
9. Language: 3
10. Dysarthria: U
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: left facial droop, slurred speech,
mute, seizure
HPI:
This is a ___ year old woman with a history of frequent
mechanical falls, hyperlipidemia, DM2, who was brought in by EMS
after her sons noticed that she was altered this morning, with
slurred speech and left facial droop. Last known normal was ___
on the night prior to presentation (son spoke to her on phone at
that time). History obtained by chart review and per sons at
bedside.
Reportedly, the patient has been suffering from several
mechanical falls over the past few months and was recently
discharged from rehab only to have suffered an additional
mechanical fall on ___ when she fell by reaching out for
something in the closet. She landed on her right shoulder. She
was subsequently able to pull herself up to the chair and went
about her typical business, watching tv and sleeping through the
night. She did not tell anyone that she hit her head. She
received xray of right shoulder and ribs on ___ that were
negative. She did recently suffer pubic fracture for which she
went to rehab and was still working on rehabilitating with home
___. She has been taking Tylenol 3 times a day and ibuprofen for
her shoulder pain since falling on ___. in all of her fall
events over the past few months, she has not had a typical fall
to one side or the other.
She was otherwise reportedly in her usual state of health up
until the morning of presentation, when she called her son to
ask him to help her because she couldn't figure out how to turn
on the TV. The son immediately became concerned, as this is
atypical for her. He went to see her and noted that she was also
having trouble using objects in general. For example, she told
him she
was thirsty and then attempted to go to the bathroom to get a
cup of water instead of the kitchen. While attempting to go to
the bathroom, she struggled to use the walker, navigating it
initially sideways and trying to backup with it into the
bathroom rather than mechanically move it as intended. The son
then went to get her a glass of water and when he brought it to
her from her left side, she did not see it was there and did not
reach out to grab it. He then became very concerned and called
his brother who is a Pathologist. They video chatted on his
phone and the brother noticed that the patient had a left facial
droop. This was reportedly unchanged since the first son had
arrived,
suggesting that it was present on his arrival and not a new
development. She was talking through this episode and did not
have slurred speech. She did not think anything was wrong except
for that fact that she was aware that she was having more
difficulty using objects. She did not know that she had
decreased
left peripheral vision, although her son pointed it out to her.
Notably, when she walked in the house (she reportedly requested
to use the bathroom alone when EMS arriving), she had no
asymmetry with walking and was able to use the facility without
trouble navigating self-care.
EMS arrived and brought her to ED. ED resident went to evaluate
her and noticed left nasolabial fold flattening. The patient was
reportedly talking fluently and then developed worsening slurred
speech with reported dense left hemiplegia. Neurology was
consulted. On arrival to CT suite, patient found to be in
generalized tonic-clonic convulsions, with RIGHT eye deviation,
mouth chewing, bilateral upper extremities flexed, lower
extremity stiffening. Vitals notable for desat to 80% during
event despite NRB placed on CT bed. Patient was taken back to
room as unstable for CT and out of concern for imminent
intubation. Her left eye became deviated inward as her
right-gaze resolved. Given unresponsiveness and out of concern
for ongoing seizure and length of GTC in someone without history
of seizures, she was given 2mg IV Ativan. Vitals remained stable
on NRB at that time and she was re-taken to CT scan for stat
NCHCT and CTA head and neck, which were unrevealing.
In ED:
- 1x 2mg IV Ativan
- 1x 1g IV Keppra
- IVF ordered
- 1x ceftriaxone, Flagyl, vanc
- intubated for airway protection out of concern for increasing
respiratory distress/tachypnea
- sedated with fentanyl/propofol
Arrived to ICU intubated on fentanyl/prop with IVF NS @50cc/hr
(started just prior to arrival to ICU).
ROS:
Symptoms leading up to presentation as reported by sons were
negative for fever, chills, cough, dysuria, dizziness, headache.
She did endorse some back pain since her fall.
Negative for staring spells, episodes of slurred speech or
word-finding difficulty, incontinence, mouth lacerations,
lethargy.
Past Medical History:
DM2
Osteoarthritis
Tinnitus
Hyperlipidemia
Hearing Loss
Asthma
Social History:
Lives alone at home.
Used to work as ___ of sorts
Has multiple ___ Degrees
Fromer tobacco use
drinks 1.5 oz scotch on weekends
MRS
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Mother - stroke (___)
Father - stroke (___)
MGM - breast cancer
Aunt - breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: appears well-groomed and younger than stated age
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
*Examined after 3 min GTC and 2mg IV Ativan*
-Mental Status: Obtunded, unarousable to voice, no eye opening
-CN: No VOR; left skew deviation with left eye deviated inward,
does not cross midline with movement of head, left pupil is
ovoid
minimally reactive; right pupil is 2>1.5 and sluggish; left
nasolabial fold flattening at rest, no asymmetry with facial
grimace, + bilateral corneal
-Motor: does not withdraw from noxious in all extremities, tone
is decreased, bulk is normal
-Reflexes: 1+ throughout, toes mute
DISCHARGE PHYSICAL EXAM:
============================
General: Sitting upright, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple
Pulmonary: Lungs clear, normal work of breathing.
Cardiac: RRR, warm, well-perfused, no m/r/g.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Psych: + visual hallucinations
Neurologic:
-Mental Status: Patient alert, reading newspaper. Conversant and
interactive. Oriented to date, month, president. Not oriented to
year or place. Naming/Repetition intact.
-CN: PERRL at 2.5mm with minimal though brisk reaction to 2mm
(post surgical). Slight left NLFF with symmetric activation.
-Sensory/Motor- ___ strength throughout, no drift
-Coordination- FNF intact ___
Pertinent Results:
LABS:
___ 04:30AM BLOOD WBC-7.8 RBC-3.59* Hgb-11.6 Hct-34.1
MCV-95 MCH-32.3* MCHC-34.0 RDW-14.3 RDWSD-49.8* Plt ___
___ 03:12AM BLOOD ___ PTT-28.7 ___
___ 04:30AM BLOOD Glucose-130* UreaN-7 Creat-0.5 Na-140
K-3.5 Cl-100 HCO3-27 AnGap-13
___ 04:30AM BLOOD ALT-18 AST-23 LD(LDH)-257* CK(CPK)-95
AlkPhos-106* TotBili-0.8
___ 09:35AM BLOOD CK-MB-12* MB Indx-4.0 cTropnT-<0.01
___ 09:35AM BLOOD T3-75* Free T4-1.3
___ 11:00PM BLOOD TSH-5.8*
IMAGING:
CT/CTA ___:
CT head: No acute intracranial abnormality. Please note that MRI
is more
sensitive for the detection of acute infarction.
CTA head and neck: There is no occlusion, dissection, aneurysm
(greater than 3
mm), or significant stenosis of the anterior circulation,
posterior
circulation, circle of ___, bilateral vertebral arteries, and
bilateral
internal carotid arteries. Final read pending 3D
reconstructions.
MRI:
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are
enlarged in an atrophic pattern
as expected for age. There is periventricular white matter
hyperintensity on
FLAIR. Although nonspecific, this is often attributed to
chronic small vessel
ischemia. There is no abnormal enhancement after contrast
administration.
IMPRESSION:
1. Atrophy. Otherwise normal study.
2. No evidence of mass, hemorrhage or infarction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY stuffiness
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Simvastatin 10 mg PO QPM
4. SITagliptin 50 mg oral DAILY
5. Aspirin 81 mg PO MWF
6. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. LevETIRAcetam 500 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO MWF
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY stuffiness
5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Simvastatin 10 mg PO QPM
8. SITagliptin 50 mg oral DAILY
9. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Generalized tonic clonic seizure
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with worsening slurred speech. L sided weakness,
facial droop// ? CVA
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.0 mGy (Body) DLP =
7.5 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 569.0
mGy-cm.
Total DLP (Body) = 577 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT of the head dated ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are prominent, consistent with global cerebral volume
loss. Patchy hypodensities in the periventricular white matter are most
consistent with chronic microvascular ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
The patient is status post bilateral cataract surgery.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. Incidental
notes are made of a fetal origin of the right PCA and near fetal origin of the
left PCA. Infundibular origin of the left PCOM measures 2 mm. The dural
venous sinuses are patent.
CTA NECK:
Atherosclerotic changes of the aortic arch and its major branching vessels are
seen. The carotid and vertebral arteries and their major branches appear
normal with no evidence of stenosis or occlusion. Mild calcified
atherosclerotic changes of the left carotid bifurcation are seen. There is no
evidence of internal carotid stenosis by NASCET criteria.
OTHER:
Biapical pleural thickening and calcifications are seen. The visualized
portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. Moderate cervical spondylosis is seen.
IMPRESSION:
1. Unremarkable CTA of the head.
2. No acute intracranial abnormalities on noncontrast head CT. Specifically
no large territory infarct or intracranial hemorrhage.
3. No narrowing of the internal carotid arteries, by NASCET criteria.
Allowing for mild atherosclerotic disease, unremarkable CTA of the neck.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with new hypoxia// eval PNA/ CHF
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
There is mild bibasilar atelectasis. The aorta is calcified and unfolded.
The cardiac silhouette size is borderline to mildly enlarged. Right
paratracheal opacity may be due to vasculature, but underlying right upper
lung consolidation is difficult to exclude. No overt pulmonary edema is seen.
IMPRESSION:
Right paratracheal opacity may be due to vasculature, but underlying right
upper lung consolidation is difficult to exclude. Dedicated PA and lateral
views of the chest would be helpful for further evaluation if/when patient
able.
No pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with s/p intubation// s/p intubation
TECHNIQUE: Single frontal view of the chest
COMPARISON: Earlier today, ___ at 19:05
FINDINGS:
Interval placement of an endotracheal tube, which terminates 3.5 cm above the
carina. Enteric tube has also been placed in the interval, and courses below
the diaphragm, terminating in the left abdomen, presumably within the stomach.
There is bibasilar atelectasis. Small bilateral pleural effusions are
difficult to exclude. Cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Endotracheal tube terminates 3.5 cm above the carina.
Enteric tube courses below the diaphragm, terminating in the left abdomen,
presumably within the stomach.
Bibasilar atelectasis. Small bilateral pleural effusions are difficult to
exclude.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old woman with apraxia, left facial droop and GTC seizure
in ED. now intubated on EEG// assess for stroke
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: Head CT ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are enlarged in an atrophic pattern
as expected for age. There is periventricular white matter hyperintensity on
FLAIR. Although nonspecific, this is often attributed to chronic small vessel
ischemia. There is no abnormal enhancement after contrast administration.
IMPRESSION:
1. Atrophy. Otherwise normal study.
2. No evidence of mass, hemorrhage or infarction.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Facial droop, L Weakness
Diagnosed with Weakness
temperature: 98.2
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 167.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year old woman who presented with
confusion at home & left sided facial droop with reported left
sided plegia in the ED, GTC in ED requiring intubation.
#ICU Course
CTH did not show any hemorrhage or large volume acute infarct.
Patient was admitted to the neuro ICU after intubation in the ED
for airway protection in the setting of receiving 4mg of Ativan
for seizure. Patient was weaned off sedation, and was notably
moving all 4 extremities spontaneously and pulling adequate
tidal volumes despite not following commands. The decision was
made to extubate patient as she was agitated with ETT in place
and would require significant sedation to continue ETT. Patient
was extubated at 8:30AM ___, and she did well with face tent O2
and was quickly weaned to NC only. She remained on NC as she had
desaturations while sleeping, consistent with her known sleep
apnea. Her continued altered mental status and inability to
follow commands was attributed to medication effect, as she had
received 4mg of Ativan in the ED, followed by multiple boluses
of propofol overnight while intubated. Her EEG showed no
seizures and no epileptiform discharges. An MRI was done, which
showed no acute stroke. Although patient initially received a
dose of antibiotics out of clinical concern for pneumonia, there
was no consolidation seen on chest x-ray, she was afebrile with
no leukocytosis so antibiotics were not continued. Her sodium on
admission to the NICU was 129, when corrected for glucose was
131. This was unchanged from her prior sodium in ___, so no
changes were made, and this hyponatremia was not thought to be
the source of her seizure. She was noted to have a new elevation
of her LFTs, with rising CK thought to be related to seizure;
these values trended down to normal. Patient had improving
mental status overnight until ___ AM, at which point she was
answering questions and following commands appropriately albeit
sleepy. Etiology of her event was thought to be a partial
seizure followed by secondary generalization with post-ictal
___ and subsequent agitation likely complicated by multiple
sedating medications. Seizure thought to be secondary to a
contribution of several things including patient's age, alcohol
use, and possibly recent trauma (fall 3 days prior). She was
started on Keppra 500mg PO BID for seizure prophylaxis. Since
she did not have a stroke, she was continued on her home aspirin
regimen which was 81mg ___, and ___. She was
stable for discharge from the ICU, and was transferred to the
step-down unit on ___.
#Floor course (___):
No events except brief formed visual hallucination in setting of
poor sleep. Received 1 time dose of fosfomycin for UTI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
erythromycin / Levaquin / Sulfa (Sulfonamide Antibiotics) /
Shellfish Derived / Iodine / IV Dye, Iodine Containing Contrast
Media / cyclobenzaprine
Attending: ___.
Chief Complaint:
Left face drooping
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The ___ is a ___ RH F with a PMHx significant for
provoked DVT (see below for details) and other chronic medical
issues as listed below who presents to the ___ ED for L lip
drooping x2 days.
Pt reports awakening ___ with L lip drooping. She noticed
this while she was putting on her lip liner. Later in the day,
she saw her accupuncturist who also commented on the drooping
and advised her to call her doctor. She emailed her PCP on
___ he then referred her to the ED for further
evaluation.
Pt has multiple chronic symptoms including pain and tingling in
her legs and left arm and numbness in both her hands (also
documented in ___ note). She did drop a cup out
of her R hand on the day that she noticed her lip was drooping.
She denied any weakness in the R hand at the time; however, it
was unusual for her to drop a cup she reports. She has had no
other new symptoms including new weakness or numbness, double
vision, or face numbness since developing the facial droop.
At the time of my assessment, pt reports an improvement in the
drooping but that her face is still not back to its normal
appearance. She has no other new complaints. She was able to
work with ___ ___ and is at her baseline.
Otherwise, pt is on coumadin following a club foot surgery on
___. She has a history of a provoked DVT (see below) and
her podiatrist started her on coumadin prophylactically as she
would have limited mobility following the surgery. She reports
still being on this medication because she still has limited
mobility. She now walks with a walker at baseline and works
frequently with ___.
On neurologic review of systems, the ___ reports insomnia
over 2 weeks. Pt reports chronic pain and tingling in her legs,
chronic LLE weakness, and chronic bilateral hand intermittent
numbness. Pt denies headache, lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech. Denies
loss of vision, blurred vision, or diplopia.
On general review of systems, the ___ reports tearing in
eyes for 1.5 weeks and L foot pain. Pt denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
LLE DVT ___, followed by Heme prior who felt provoked when
she was relatively sedentary following SI joint injections,
negative ACA, B2GP, and antiphospholipid Abs)
Severe scoliosis with ___ rod placement at the age of ___
at ___
Cervical spondylosis
Lumbar spinal stenosis with chronic pain and tingling in her
legs
Clubbed feet since birth, now s/p L club foot repair ___
GERD
IBS
Fibromyalgia
Myofascial pain
Cognitive dysfunction (thought to be related to attentional
issues, she had undergone neuropsych testing in ___
Left rotator cuff tendinitis
Asthma
Fibroids
Menorrhagia
Raynaud's phenomenon
Chronic rhinitis
Nephrolithiasis
TMJ
Allergic rhinitis
Eczema
Osteopenia
Social History:
___
Family History:
Dad: ___ in early ___, tic deloreux, prostate cancer
Mom: ___
___ Exam:
Admission Exam:
Vitals: 98.8 91 141/78 16 100% RA
General: NAD, comfortable
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: No edema, L foot warmer than R foot, both with 2+
DP pulses
Skin: No rashes or lesions
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent but tangential and circumferential 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
dysarthria. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. Subtle L NLFF but face activates symmetrically.
Hearing intact to finger rub bilaterally. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
R 5 ___ ___ 5 5 5 5 5 5
*Unable to perform as pt reports sciatica pain and pain at the
foot where she has had surgery
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Able to ambulate independently with a walker.
Discharge Exam: Unchanged
Pertinent Results:
Admission Labs:
___ 01:45AM GLUCOSE-97 UREA N-18 CREAT-1.1 SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
___ 01:45AM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.1
___ 01:45AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 01:45AM WBC-6.7 RBC-4.34 HGB-12.2 HCT-38.6 MCV-89
MCH-28.1 MCHC-31.6* RDW-13.6 RDWSD-44.2
___ 01:45AM NEUTS-52.6 ___ MONOS-7.7 EOS-2.1
BASOS-0.5 IM ___ AbsNeut-3.50 AbsLymp-2.45 AbsMono-0.51
AbsEos-0.14 AbsBaso-0.03
___ 01:45AM PLT COUNT-222
___ 01:45AM ___ PTT-40.9* ___
___ 01:35AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ 01:35AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:35AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:35AM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-3
Imaging:
MRI/MRA head and neck
1. No acute intracranial process. Patent anterior and posterior
circulation without evidence of stenosis, occlusion, or
aneurysm.
2. Nonspecific subcortical hyperintense foci most likely
representing small vessel ischemic changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. Warfarin 6 mg PO DAILY16
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
4. Lidocaine 5% Patch 1 PTCH TD QAM PRN pain
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Ranitidine 150 mg PO BID
7. Ropinirole 0.5 mg PO TID pain
Discharge Medications:
1. ClonazePAM 0.5 mg PO QHS:PRN anxiety
2. Lidocaine 5% Patch 1 PTCH TD QAM PRN pain
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Ranitidine 150 mg PO BID
5. Ropinirole 0.5 mg PO TID pain
Discharge Disposition:
Home
Discharge Diagnosis:
Possible Bell's palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) due to left foot post-surgical pain.
Neuro exam: subtle, equivocal left NLFF. Symmetric activation of
facial musculature. Rest normal.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with recent R foot surgery with cool R foot
compared to L // ? arterial thrombus
TECHNIQUE: Grayscale ultrasound, color Doppler, and spectral Doppler
waveforms of the right lower extremity were obtained.
COMPARISON: None
FINDINGS:
There is no bilateral lower extremity artery plaque. The bilateral common
femoral, femoral, popliteal, peroneal, posterior tibial, and dorsalis pedis
arteries are patent with normal color doppler flow, triphasic spectral doppler
waveforms, and peak systolic velocities.
IMPRESSION:
Normal bilateral lower extremity arteries
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with left facial droop // hilar adenopathy?
hilar adenopathy?
IMPRESSION:
As compared to ___, no relevant change is seen. ___ device
for vertebral stabilization. No hilar or mediastinal lymphadenopathy. Normal
size of the heart. No pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with L facial droop for several days on coumadin.
// e/o head bleed. R/o infection from PNA
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Reference MR head dated ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. A 1 cm soft tissue density nodule is
seen in the left posterior scalp, unchanged from ___, possibly of sebaceous
cyst.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old woman with left facial droop evaluate for stroke.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 13 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 3.0T MRI.
COMPARISON: ___ noncontrast head CT.
___ brain MRI with and without contrast.
FINDINGS:
MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration. Scattered subcortical hyperintense foci on T2 and inversion
recovery sequences are nonspecific and may reflect small vessel ischemic
changes. A left parietal extracranial soft tissue nodule measuring 9 mm
(7:21, 14:16) is suggestive of sebaceous cyst.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm larger than 3 mm in size.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
The origins of the great vessels, subclavian and vertebral arteries appear
normal bilaterally.
IMPRESSION:
1. No acute intracranial process. Patent anterior and posterior circulation
without evidence of stenosis, occlusion, or aneurysm.
2. Nonspecific subcortical hyperintense foci most likely representing small
vessel ischemic changes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Facial droop, R Hand weakness
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, FACIAL WEAKNESS
temperature: 98.8
heartrate: 91.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | The ___ is a ___ RH F with a PMHx significant for provoked
DVT (on Coumadin) and chronic pain syndromes who presents to the
___ ED for L lip drooping x2 days. The ___ underwent a
brain CT without contrast which was unremarkable for hemorrhage.
She also had a brain MRI which did not reveal any acute
ischemia. On neurological exam, she had a subtle flattening of
the left nasolabial fold. Otherwise, she had full strength of
her facial muscles. The ___ mental status, motor exam,
sensory exam, and coordination exam were without deficits. Lyme
titers were sent and pending at discharge, however the ___
has no history of tick exposure.
Per her covering podiatrist ___ at ___
___, Ms. ___ was started on Coumadin postoperative
after a club foot surgery ___ to her history of
provoked DVTs. However, since the ___ was now ambulatory
with a walker, she may be taken off of Coumadin. The ___
Coumadin was discontinued on this hospital course.
She was to be discharged with the diagnosis of possible subtle
Bell's palsy pending bilateral lower extremity imaging. However
she decided to leave the hospital as was not pleased with her
care. She was given discharge instructions and the number to
call for a follow up appointment with the neurology service. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
chest pain, dyspnea, cardiac arrest
Major Surgical or Invasive Procedure:
___ pericardiocentesis
History of Present Illness:
The patient is a ___ year old woman with remote Hodgkin's
lymphoma
(s/p radiation to chest and pelvis in ___ without recurrence)
and hypothyroidism who presents with chest pain and dyspnea. She
is transferred from ___ ED after apparent LOC and
pulselessness followed by 2 minutes of CPR with ROSC.
Going back 3 months, she started feeling inspiratory
sternal-area
chest pain. She presented to her PCP at this time and was
prescribed with short burst of prednisone for "pleurisy" as she
describes it. Per her report, this was diagnosed with CXR. The
pain resolved after taking the steroids but returned a few days
after stopping. She again presented with the same complaint, had
a CXR and was given a longer course of prednisone. Again the
pain
went away, but returned about 3 days after stopping the course.
She presented a third time, and had the same work-up and
treatment, this time with 2 weeks of steroids. Then this past
___ she had fevers and general malaise as well as new
bilateral leg swelling. Her PCP prescribed azithromycin and
recommended she go to ___ ED for evaluation on ___.
There, her vital signs were stable, and no diagnostic work-up
was
performed. She was set to be discharged with outpatient work-up.
Prior to leaving the ED she went to the restroom, and felt
nauseated and lightheaded, and had syncopal event and was helped
to floor by nursing. She then apparently lost pulse and had 2
minutes of CPR performed with ROSC. After awakening she reports
having dyspnea (which was new) and chest pain (from the
compressions she says), but was not confused. She was briefly
started on heparin for suspected PE but this was discontinued
prior to transfer.
Workup at ___ was notable for:
-CBC: 9.0, 10.3/___.5, 304
-Chemistry: 139, 3.5, 100, 27, 15, 0.52, 112
-LFTs ALT 45, AST 38, T bili 0.5, alk phos 176
-Troponin T less than 0.01
-VBG 7.40/___
-ProBNP 271
-EKG: New right bundle branch block
At ___ ED
- Initial vitals were: 98.4, 98, 122/76, 22, 89% NRB
- Exam notable for:
Pulsus paradoxus less than 10.
No acute distress. No jugular venous distention. Cardiac exam
unremarkable. Pulmonary exam with diminished breath sounds at
bases; desaturating to low ___ on nonrebreather, but in no acute
respiratory distress. Abdomen soft and nontender. Lower
extremities: Well perfused without edema. AOx3, following all
commands.
With respect to the hypoxia, despite sats around 90% on NRB, she
was not in distress, and felt danger of intubation in this
patient with suspicion of PE and preload dependence outweighed
benefits.
TTE showed small to moderate pericardial effusion with
invagination of the right ventricle in diastole consistent with
early tamponade physiology. She was sent to cath lab for
pericardial drainage, where 220cc of serosanginous fluid was
drained and sent for studies. Drain was left in place.
On arrival to the CCU, she was sat'ing 92% on NRB and
complaining
of mild dyspnea with inspiratory chest pain. She also describes
recent early satiety.
Past Medical History:
1. CVD Risk Factors
- None
2. Cardiac History
- None
3. Other PMH
-Hypothyroidism
-Hodgkin's lymphoma, s/p chest and pelvic radiation in ___
-Splenectomy
-Parathyroidectomy for adenoma (___)
-Hip replacement (___)
Social History:
___
Family History:
Mother: CHF died in ___
Otherwise not significant
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: see Metavision
Gen: NRB in place but calm, well-appearing, no increased WOB
CV: Tachycardic, II/VI diastolic harsh murmur
PULM: Markedly decreased breath sounds diffusely in mid and
lower
lung fields, no wheezing
ABD: soft, NT, ND
EXT: b/l nonpitting edema with sock marks, no calf tenderness,
negative ___ sign
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1107)
Temp: 98.4 (Tm 98.7), BP: 136/72 (131-142/72-84), HR: 92
(83-96), RR: 18, O2 sat: 95% (88-95), O2 delivery: Ra
General: Alert, oriented, no acute distress. Looks less fatigued
than yesterday. Currently off O2.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Patient with ok air movement overall, less cough with
inspiration. Less coarse crackles overall, no new crackles in
lung bases. No wheezes, rales, rhonchi.
CV: Mildly tachycardic. III/VI harsh holosystolic murmur heard
throughout precordium. 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
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
ADMISSION LABS:
___ 06:28AM BLOOD WBC-15.5* RBC-3.82* Hgb-11.1* Hct-34.0
MCV-89 MCH-29.1 MCHC-32.6 RDW-16.6* RDWSD-53.3* Plt ___
___ 06:28AM BLOOD Neuts-88.7* Lymphs-7.8* Monos-2.5*
Eos-0.1* Baso-0.3 NRBC-0.1* Im ___ AbsNeut-13.75*
AbsLymp-1.20 AbsMono-0.39 AbsEos-0.01* AbsBaso-0.04
___ 06:28AM BLOOD ___ PTT-150* ___
___ 06:28AM BLOOD Glucose-162* UreaN-16 Creat-0.5 Na-140
K-3.3* Cl-99 HCO3-20* AnGap-19*
___ 06:28AM BLOOD ALT-49* AST-47* CK(CPK)-282* AlkPhos-199*
TotBili-0.6
___ 06:28AM BLOOD Lipase-31
___ 06:28AM BLOOD cTropnT-<0.01
___ 06:28AM BLOOD CK-MB-1
___ 06:28AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.1 Mg-1.9
___ 06:33AM BLOOD pO2-38* pCO2-41 pH-7.41 calTCO2-27 Base
XS-0
___ 06:33AM BLOOD Lactate-1.8
MICRO/OTHER PERTINENT LABS:
___ 10:00AM PERICARDIAL FLUID TNC-1546* ___
Polys-9* Lymphs-54* ___ Macro-32* Other-5*
___ 10:00AM PERICARDIAL FLUID TotProt-4.6 Glucose-124
LD(LDH)-1792 Albumin-2.6
CYTOLOGY FOR PERICARDIAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
- Abundant blood.
- Mesothelial cells, lymphocytes, and histiocytes.
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-8.4 RBC-3.63* Hgb-10.5* Hct-32.3*
MCV-89 MCH-28.9 MCHC-32.5 RDW-17.0* RDWSD-54.9* Plt ___
___ 05:10AM BLOOD Glucose-104* UreaN-12 Creat-0.6 Na-141
K-4.1 Cl-101 HCO3-28 AnGap-12
___ 05:10AM BLOOD ALT-27 AST-32 AlkPhos-132*
IMAGING/STUDIES:
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism.
2. Multilobar pneumonia and bilateral small pleural effusions,
worse on the right.
3. Trace of pericardial effusion.
4. Splenectomy.
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Cardiovascular ___ MD ___
Using the ___ approach the pericardial space was accessed
and a drain placed. 220 cc of bloody fluid was removed and sent
for studies. Initial pericardial pressure was 14 and final was
0. The drain was left in place for monitoring in the ICU.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The estimated right atrial pressure is >15mmHg. Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection fraction is 75%. The right
ventricle has normal free wall motion. The aortic valve leaflets
(3) are mildly thickened. There is mild [1+] aortic
regurgitation. The mitral valve leaflets appear structurally
normal. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is a small to moderate
circumferential pericardial effusion measuring up to 1.5 cm in
greatest dimension (inferolateral to left ventricle). Anterior
to the right ventricle the effusion measures up to 1.1 cm and
anterior to the right atrium the effusion measures up to 1.2 cm.
There is invagination of the right ventricle during diastole
consistent with early tamponade physiology. No clinically
significant ___ or tricuspid inflow respiratory variation is
appreciated.
IMPRESSION: Small to moderate pericardial effusion with
invagination of the right ventricle in diastole consistent with
early tamponade physiology.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The estimated right atrial pressure is ___ mmHg. Overall left
ventricular systolic function is hyperdynamic.
The right ventricle has normal free wall motion. The aortic
valve leaflets (?#) are mildly thickened. There is mild to
moderate [___] tricuspid regurgitation. There is a trivial
pericardial effusion. The effusion is echo dense, c/w blood,
inflammation or other cellular elements.
Compared with the prior TTE ___, mild to moderate
tricuspid regurgitation is now appreciated; its severity was not
assessed previously (focused study).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Sertraline 100 mg PO DAILY
3. Liothyronine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO FOR FEVER
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Take for fever >100.5 and present to urgent care for
evaluation Disp #*1 Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H pneumonia
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once in the evening
of ___ Disp #*2 Tablet Refills:*0
3. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS:
==================
Pericardial effusion
Cardiac Tamponade
Multifocal pneumonia
Hypoxemic respiratory failure
Secondary Diagnosis
==================
Asplenia
Anemia
Transaminitis
Depression
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 postasrrest// eval for pneumothoreax
TECHNIQUE: Portable AP chest
COMPARISON: None
IMPRESSION:
Combination of bibasilar consolidation and small to moderate pleural effusion
is responsible for obscuration of the diaphragmatic pleural interface and
prominent air bronchograms in the lower lobes. This could be atelectasis or
pneumonia. Heart size is hard to assess because the cardiac contours are
obscured by pleuroparenchymal abnormalities. Upper lungs clear. No
pneumothorax. No pulmonary or mediastinal vascular engorgement.
Radiology Report
INDICATION: ___ year old woman with h/o Hodgkin's pw pericardial effusion and
hypoxia// PE? pericardial effusion
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 281 mGy-cm.
COMPARISON: None
FINDINGS:
Substernal approach of a pericardial draining catheter with trace of
pericardial effusion. Surgical clips are seen in the right side of the upper
aspect of the sternum. A pleomorphic hyperdensity is seen in the anterior
mediastinum, most likely corresponds to contrast in a vein.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main, left and right pulmonary arteries
are normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
Partially imaged thyroid gland appears normal. There is an narrowing of the
space between the right clavicle and the first rib, which could be positional.
Bilateral small pleural effusions greater on the right.
There is almost complete consolidation of the right lower lobe with air
bronchogram and hepatization of the right lower lobe, and partially of the
left lower lobe. Ground-glass opacities are seen in the apical and posterior
segments of the right upper lobe, right lower lobe, right middle lobe and left
lower lobe. The airways are patent to the subsegmental level.
Limited images of the upper abdomen show splenectomy. Otherwise unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multilobar pneumonia and bilateral small pleural effusions, worse on the
right.
3. Trace of pericardial effusion.
4. Splenectomy.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 13.45 pm, 15 minutes
after the discovery of the findings. Formal impression was discussed again
later after revision of the case with the attending physician.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with hx Hodgkins lymphoma s/p radiation
presenting with new pericardial effusion with tamponade physiology s/p drain,
hypoxia, pleural effusion// evidence of 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.
There are pulsatile waveforms which are not unexpected in the setting of the
known tamponade physiology.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx/lymphoma s/p radiation treatment,
splenectomy who p/w ?cardiac arrest in setting of pericardial effusion.//
?pleural effusion re-accumulated?
IMPRESSION:
In comparison with the study ___, there is little change in the bilateral
pleural effusions with underlying compressive atelectasis, more prominent on
the right. Cardiomediastinal silhouette is stable and there is no evidence of
appreciable vascular congestion.
Radiology Report
INDICATION: ___ year old woman with multifocal pneumonia and pleural
effusion// evaluate for pleural effusion progression
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There are small bilateral pleural effusions with subjacent
atelectasis/consolidation, mildly decreased since prior. No new focal
consolidation or pneumothorax. The size of the cardiac silhouette is within
normal limits.
IMPRESSION:
Slight interval decrease in size of the small bilateral pleural effusions.
Overlying atelectasis/consolidation persists.
Radiology Report
EXAMINATION: Chest PA and lateral
INDICATION: ___ year old woman with multifocal pneumonia and pleural effusion
and ongoing hypoxia// evaluate for pleural effusion progression, interval
change in size cardiac silhouette
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs most recently ___
FINDINGS:
In comparison to the previous film on ___, the bilateral pleural
effusions are decreased in size. Bilateral atelectatic changes are decreased.
There are no focal consolidations consistent with pneumonia. The cardiac
silhouette is within normal limits. There is no pneumothorax.
IMPRESSION:
1. Mild improvement of bilateral pleural effusions. Atelectatic changes have
improved..
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p cardiac arrest, Transfer
Diagnosed with Pericardial effusion (noninflammatory), Hypoxemia, Cardiac arrest, cause unspecified, Chest pain, unspecified
temperature: 98.4
heartrate: 98.0
resprate: 22.0
o2sat: 89.0
sbp: 122.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY STATMENT:
=====================
___ year old woman with remote Hodgkin lymphoma s/p radiation to
chest and pelvis in ___ and hypothyroidism who presents with 3
months of recurrent pleuritic chest pain and more recent
systemic symptoms and leg swelling, with apparent loss of pulse
at ___ s/p 2 minutes of CPR with ROSC, neurologically
intact after CPR, found to have pericardial effusion of unclear
etiology with early tamponade physiology s/p drainage, hospital
course also notable for treatment for multifocal pneumonia, now
clinically much improved with O2 Sats 92-94% on RA, with ongoing
asymptomatic desaturations to ~88% with ambulation.
ACUTE ISSUES ADDRESSED:
=======================
# Hypoxemic respiratory failure:
# Community acquired pneumonia
Likely multifactorial in etiology with multifocal pneumonia and
pleural effusions contributing. CTA negative for PE.
Additionally patient with evidence of small pleural effusions
persistent on CXR and received IV diuresis. ID was consulted
given concern for atypical organisms given asplenic status.
Legionella Ag was negative, Strep pneumo antigen negative.
Patient was treated with Azithromycin (___) and
Ceftriaxone (___), then transitioned to oral
cefpodoxime (___). Last chest x-ray ___ with bilateral
improvement of pleural effusions.
# Pericardial effusion:
S/p drainage of 220cc serosanginous fluid on ___ with drain
left in place. TTE showed an EF 75% and mild AR. Concern for
recurrence of malignancy with multiple processes (pleural and
pericardial effusions) and systemic symptoms, however cytology
negative for malignant cells. Alternative DDx: delayed
post-radiation process, effusion ___ viral infection, autoimmune
process. Cell studies not suggestive of infectious process and
culture negative. Cardiology followed the patient and did not
recommend further intervention, but recommended a repeat echo in
___ weeks time. Will establish appointment with cardiologist to
follow up after echo.
# Anemia - borderline:
Decreased TIBC, transferritin, iron and increased Ferritin,
likely reflective of anemia of chronic disease. Possibly a mixed
picture with iron deficiency anemia as well. No overt signs of
bleeding. Monitored with plan for transfusion in Hgb <7 but did
not require transfusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HFpEF, IDDM2, HTN, CKD IV, who presents for
acute shortness of breath and orthopnea.
Yesterday morning he developed new shortness of breath while
resting at home, worse when lying flat, and better when he sat
up
in the chair. Denies any chest pain or cough. He likes to add
salt to his meals and has been doing this more frequently of
late. Prior to yesterday, he had been in usual state of health.
He doesn't do much physical activity, but is able to walk up and
down the stairs in his house without any new DOE. He's had
issues
with peripheral edema and on ___ heart failure clinic visit,
torsemide dose was increased by cardiologist from 40mg BID to
60mg qAM and 40mg qPM. His dry weight is thought to be less than
160lbs.
I regards to his heart failure history, he has had 1
hospitalization in ___ for exacerbation. At that time,
pharmacologic nuclear stress test showed possible small
partially
reversible perfusion defect in basal inferolateral wall, versus
artifact. It was recommended he get a cardiac MRI to assess for
amyloidosis or other infiltrative disease, but he has not
scheduled this. He has had a history of symptomatic junctional
bradycardia for which it was recommended he hold beta blocker,
but he's been taking carvedilol without any subsequent issues.
In the ED initial vitals were:
- 97.8 64 171/65 20 100% RA
- Exam: b/l crackles, b/l ___ edema
- Labs: Trop-T 0.04->0.02, MB 4, ProBNP 558, BUN 4, Cr 3.5
- CXR: Mild pulmonary vascular congestion, without interstitial
edema.
- EKG: sinus rhythm. New TWI V5-6.
- He received 80mg IV Lasix to which he diuresed 750cc. He then
received Torsemide 60mg PO. ALso received home
antihypertensives:
Imdur 30, Losartan 100, Nifedipine 90, Carvedilol 6.25)
- Discussed with primary cardiologist who recommended admission
to heart failure service for IV diuresis
On arrival to the floor, he reports shortness of breath is much
improved after Lasix. He continues to deny chest pain. He has no
other complaints currently.
Past Medical History:
PAST ___ MEDICAL HISTORY:
Diastolic congestive heart failure
Type 2 Diabetes Mellitus
Hypertension
OTHER PAST MEDICAL HISTORY:
Chronic Kidney Disease IV c/b diabetic nephropathy
GERD
Osteoarthritis
BPH
Diverticulosis
Bilateral complex renal cysts
Social History:
___
Family History:
Father had coronary artery disease, cerebrovascular disease,
hypertension and diabetes. Mother had a stroke.
No reported history of premature coronary artery disease,
cardiomyopathies, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
___ 1115 Temp: 97.5 PO BP: 186/77 HR: 60 RR: 18 O2 sat:
100%
O2 delivery: r/a Dyspnea: 0 RASS: 0 Pain Score: ___
Admission weight; 158.5lb
GENERAL: Well developed, well nourished, lying in shallow angle
in no acute distress
HEENT: MMM, EOMI
NECK: JVP 12cm
CARDIAC: RRR, S1, S2, soft systolic murmur
LUNGS: bibasilar rales
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ edema to knees
SKIN: No significant skin lesions or rashes.
PULSES: 2+ radials
NEURO: moves all extremities with full and symmetric strength;
no
focal deficits
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1144)
Temp: 98.5 (Tm 99.1), BP: 152/75 (131-194/53-78), HR: 62
(58-68), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: RA
Fluid Balance (last updated ___ @ 1015)
Last 8 hours Total cumulative 245ml
IN: Total 620ml, PO Amt 620ml
OUT: Total 375ml, Urine Amt 375ml
Last 24 hours Total cumulative -200ml
IN: Total 800ml, PO Amt 800ml
OUT: Total 1000ml, Urine Amt 1000ml
GENERAL: Well appearing, sitting in a chair, pleasant, in NAD
NECK: JVD at 7-8 cm, +HJR
CARDIAC: RRR, ___ systolic murmur at ___, nl s1/s2, no rubs,
gallops, or thrills
LUNGS: CTAB, no wheezes, crackles, or rhonchi
ABDOMEN: Soft, non tender, non distended, BS+
EXTREMITIES: Warm, well perfused, no lower extremity edema
SKIN: No significant skin lesions or rashes
Pertinent Results:
ADMISSION LABS
___ 11:22PM BLOOD WBC-9.5 RBC-4.35* Hgb-11.4* Hct-35.6*
MCV-82 MCH-26.2 MCHC-32.0 RDW-16.1* RDWSD-48.1* Plt ___
___ 11:22PM BLOOD Neuts-63.8 ___ Monos-5.1 Eos-3.1
Baso-0.5 NRBC-0.3* Im ___ AbsNeut-6.06 AbsLymp-2.42
AbsMono-0.48 AbsEos-0.29 AbsBaso-0.05
___ 11:22PM BLOOD Glucose-159* UreaN-44* Creat-3.5* Na-143
K-3.8 Cl-102 HCO3-29 AnGap-12
___ 11:22PM BLOOD ALT-11 AST-15 AlkPhos-97 TotBili-0.4
___ 11:22PM BLOOD cTropnT-0.04* proBNP-558
___ 11:22PM BLOOD Albumin-3.4*
PERTINENT/DISCHARGE LABS
___ 07:15AM BLOOD WBC-11.8* RBC-4.26* Hgb-11.3* Hct-35.1*
MCV-82 MCH-26.5 MCHC-32.2 RDW-17.0* RDWSD-50.4* Plt ___
___ 07:15AM BLOOD Glucose-66* UreaN-50* Creat-4.1* Na-143
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 07:15AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.4
IMAGING/STUDIES
CXR ___- Mild pulmonary vascular congestion, without
interstitial edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Gabapentin 600 mg PO QHS
3. Carvedilol 6.25 mg PO BID
4. NIFEdipine (Extended Release) 90 mg PO DAILY
5. linaGLIPtin 5 mg oral DAILY
6. Atorvastatin 80 mg PO QPM
7. Glargine 30 Units Bedtime
8. Torsemide 60 mg PO QAM
9. Torsemide 40 mg PO QPM
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. Dose is Unknown BOTH EYES
QHS
12. Aspirin 81 mg PO DAILY
13. Calcitriol 0.25 mcg PO EVERY OTHER DAY
14. Calcitriol 0.5 mcg PO EVERY OTHER DAY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. HydrALAZINE 100 mg PO Q8H
RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Torsemide 100 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.25 mcg PO EVERY OTHER DAY
7. Calcitriol 0.5 mcg PO EVERY OTHER DAY
8. Carvedilol 6.25 mg PO BID
9. Gabapentin 600 mg PO QHS
10. Glargine 30 Units Bedtime
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. linaGLIPtin 5 mg oral DAILY
13. Losartan Potassium 100 mg PO DAILY
14. NIFEdipine (Extended Release) 90 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Heart failure, preserved EF, exacerbation
Hypertensive emergency
Chronic kidney disease
Secondary diagnoses:
Type II Diabetes
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 lateral
INDICATION: History: ___ with sob, h/o chf// ?edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph dated ___
FINDINGS:
There is no focal consolidation. Eventration of the left hemidiaphragm is
re-demonstrated. The cardiomediastinal and hilar silhouettes are unchanged.
There is mild pulmonary vascular congestion, without interstitial edema. No
pleural effusions. No pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion, without interstitial edema.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Heart failure, unspecified
temperature: 97.8
heartrate: 64.0
resprate: 20.0
o2sat: 100.0
sbp: 171.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | ___ with HFpEF (EF 65%) HTN, IDDM2, CKD IV who presented with
dyspnea, orthopnea and lower extremity edema due to acute on
chronic heart failure exacerbation likely ___ uncontrolled blood
pressures.
ACTIVE ISSUES:
==============
# Hypertensive emergency
Presented w/SBPs in the 170s and had difficult to control blood
pressures on the floor with persistent hypertension. Hydralazine
held due to concern for poor renal perfusion. Isosorbide
mononitrite was increased from 30 mg daily to 120 mg daily.
Nifedipine 90 mg was continued. Hydralazine was restarted and
increased to 100 mg TID daily. Losartan was briefly held due to
rise in renal function, but then restarted at 100 mg daily.
Carvedilol was continued at 6.25 mg PO BID and not increased due
to history of symptomatic bradycardia.
Presented w/elevated BPs with acute HF exacerbation. Torsemide
was increased to 100 mg qd.
# Acute diastolic heart failure:
Volume overloaded on admission with JVP elevation, rales,
and leg edema to knees. Weight (after diuresis) 158lb, from last
clinic weight 165lb 5 weeks ago. Trigger likely multifactorial
given self-endorsed dietary indiscretion and liberal fluid
intake as well as poor blood pressure control and concern for
poor compliance. Pt initially treated with IV diuretic and then
transitioned to PO torsemide at 100 mg qd. Her
anti-hypertensives were changed as above.
# CKD IV:
Creatinine slightly elevated compared to last check, but
essentially within his recent range. Presumed secondary to
longstanding HTN and DM2. Given persistently elevated Cr and
hypertension, nephrology consulted who recommended BP management
and follow-up with them.
# IDDM2: Continued on home insulin
**TRANSITIONAL ISSUES**
Discharge weight: 70.1 kg
Discharge Cr: 4.1
Discharge diuretic: Torsemide 100 mg qd |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
iodine / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ transferred after fall with LOC. Patient was walking down
the steps and lost her balance and fell down 4 steps. +LOC, does
not remember what happened. Next thing she remembers is being on
the floor. This is her ___ fall. Six months ago she fell down
the stairs and broke a rib. She was initially evaluated at ___.
___, where she was found to have possible R tentorial SDH, no
acute cervical spine injury, R 11th rib fracture, R transverse
process fractures of L2 nd L5, and b/l sacral fractures. No
intraabdominal or intrathoracic pathology. She was found to be
hypotensive to the ___ and started on levophed. A RIJ was
placed. Subsequently levophed was weaned. Also desated and was
transferred on nonrebreather, now on 2L NC. Currently
complaining of pain lower and upper back. Not drinking or eating
well last few days per son.
Past Medical History:
CAD, MI, hypothyroidism, HLD, HTN
Past Surgical History:
R frontotemporal craniotomy for R intracranial aneurysm clipping
Cardiac stent ___ years ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission,
Vitals: 97.2, 119, 103/51, 24, 92%NC
GEN: A&O, NAD, sleepy
HEENT: No scleral icterus, R pupil (3mm) > L pupil
(2mm),reactive b/l
CV: tachycardic, tender to palpation over sternum
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender
Ext: No ___ edema, ___ warm and well perfused, tender over T and L
spine
On discharge,
VS: 98.8 100 128/89 18 98%3LNC
General: well-appearing, in no acute distress
Cardiopulmonary: RRR, normal S1 and S2. No murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally, although
decreased. No chest wall tenderness
Abdomen: Soft, non-tender, non-distended
Back: Mild tenderness to palpation over sacrum
Extremities: atraumatic, well-perfused. No clubbing, cyanosis or
edema
Neurologic: Grossly intact. Alert and oriented x3
Pertinent Results:
___ 05:30AM BLOOD WBC-8.2 RBC-3.51* Hgb-10.3* Hct-30.6*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.0 Plt ___
___ 05:30AM BLOOD Neuts-84.7* Lymphs-10.4* Monos-4.3
Eos-0.1 Baso-0.5
___ 05:30AM BLOOD ___ PTT-29.6 ___
___ 05:30AM BLOOD Glucose-173* UreaN-30* Creat-1.5* Na-136
K-4.2 Cl-104 HCO3-21* AnGap-15
___ 05:30AM BLOOD CK(CPK)-129
___ 05:30AM BLOOD CK-MB-5
___ 05:30AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
___ 05:34AM BLOOD Lactate-3.5*
___ 05:50AM BLOOD WBC-5.1 RBC-3.20* Hgb-9.3* Hct-28.6*
MCV-89 MCH-29.0 MCHC-32.5 RDW-15.5 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-96 UreaN-15 Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-28 AnGap-13
___ 01:26AM BLOOD CK(CPK)-97
___ 05:30AM BLOOD cTropnT-0.22*
___ 12:21PM BLOOD CK-MB-5 cTropnT-0.24*
___ 12:40AM BLOOD CK-MB-4 cTropnT-0.18*
___ 12:22PM BLOOD CK-MB-3 cTropnT-0.08*
___ 05:00PM BLOOD CK-MB-2 cTropnT-0.08*
___ 01:26AM BLOOD CK-MB-2 cTropnT-0.08*
___ 05:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
CXR (___)
The cardiac silhouette is within normal limits. There is no
pneumothorax. No pleural effusion, pulmonary hemorrhage or focal
consolidation noted.
Cardiac echocardiography (___)
Dilated right ventricle with mild global systolic dysfunction
(LVEF >55%). Normal global and regional left ventricular
systolic function. Moderate to severe functional tricuspid
regurgitation. At least moderate pulmonary hypertension
Lower extremity Doppler U/S (___)
No evidence of DVT in either the right or the left lower
extremity
CT Head (___)
No evidence of new hemorrhage or territorial infarction.
Appearance of right tentorial subdural hematoma is largely
unchanged.
CXR (___)
As compared to the previous radiograph, no relevant change is
seen. The lung volumes remain low. Right pleural effusion with
mild right basal atelectasis. Mild cardiomegaly with signs of
mild-to-moderate fluid overload. Moderate enlargement of the
right hilus continues to be present. Bilateral apical
thickening, symmetrical in distribution.
Medications on Admission:
metoprolol tartrate 25 mg BID
simvastatin 40 mg daily
amitriptyline 25 mg daily
celexa 10 mg daily
levothyroxine 112 mcg daily
lorazepam 1 mg BID
Aspirin 81 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H wheeze
3. Amitriptyline 25 mg PO HS
4. Citalopram 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ipratropium Bromide Neb 1 NEB IH Q4H wheeze
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Senna 8.6 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. Heparin 5000 UNIT SC TID
12. Aspirin 81 mg PO DAILY
13. Lorazepam 1 mg PO BID:PRN anxiety
14. Morphine Sulfate ___ mg IV Q4H:PRN pain
RX *morphine 2 mg/mL ___ mg IV every 4 hours Disp #*7 Cartridge
Refills:*0
15. Metoprolol Tartrate 25 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mechanical fall resulting in:
-Right 11th rib fracture
-Sacral fractures
-Right transverse process L2 and L5 fractures
-Small right tentorial subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: CVL placement.
COMPARISON: Prior outside chest radiograph and chest CT from ___.
TECHNIQUE: Portable AP chest radiograph.
FINDINGS:
A right-sided central venous catheter project over the expected location of
the upper SVC. The cardiac silhouette is within normal limits. There is no
pneumothorax. No pleural effusion, pulmonary hemorrhage or focal consolidation
noted.
Radiology Report
HISTORY: Hypoxemia.
COMPARISON: None.
FINDINGS:
Grayscale, color, and spectral Doppler evaluation was performed of the
bilateral lower extremity veins. There is normal phasicity of the common
femoral veins bilaterally. There is normal compression and augmentation of
the bilateral common femoral, proximal femoral, mid femoral, distal femoral,
popliteal, and posterior tibial veins. The peroneal veins are not visualized.
IMPRESSION:
No evidence of DVT in either the right or the left lower extremity.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New shortness of breath, evaluation for pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there are newly appeared
bilateral pleural effusions as well as an enlarged cardiac silhouette,
associated to signs indicative of bilateral atelectasis. Signs of
mild-to-moderate pulmonary edema are present.
No focal parenchymal opacities suggesting pneumonia.
At the time of dictation and observation, 12:02 p.m., on ___, the
referring physician ___ was paged for notification.
Radiology Report
CHEST RADIOGRAPH
INDICATION: look for pulmonary edema
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-existing pleural
effusions are stable. Signs indicative of pulmonary edema have moderately
increased since the previous examination. The cardiac silhouette has also
slightly increased in size. Subsequent areas of atelectasis at the lung bases
are unchanged. Well-ventilated lung parenchyma. No evidence of pneumonia is
currently present. No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman s/p fall with R right tentoral subdural
hemorrhage, mental status not improving // interval change
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: DLP: ___ MGy-cm
CTDI: 54. 63
COMPARISON: HEAD CT ON ___.
FINDINGS:
A right tentorial subdural hematoma is again seen on the right, with
redistribution of blood and postsurgical changes on the right. There is no
evidence of new hemorrhage or large territorial infarction. Areas of low
attenuation in the subcortical white matter likely represent chronic small
vessel ischemia. A vascular clip is seen anteriorly producing a significant
artifact, but unchanged in appearance from the prior study.
The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
No evidence of new hemorrhage or territorial infarction. Appearance of right
tentorial subdural hematoma is largely unchanged.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hypoxemia, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
The lung volumes remain low. Right pleural effusion with mild right basal
atelectasis. Mild cardiomegaly with signs of mild-to-moderate fluid overload.
Moderate enlargement of the right hilus continues to be present. Bilateral
apical thickening, symmetrical in distribution.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with TRAUMATIC SUBDURAL HEM, FX LUMBAR VERTEBRA-CLOSE, FX SACRUM/COCCYX-CLOSED, UNSPECIFIED FALL
temperature: 97.2
heartrate: 120.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 105.0
level of pain: 5
level of acuity: 2.0 | Patient was transferred from outside hospital after sustaining
mechanical fall down four steps with positive loss of
consciousness. At outside hospital, she was found to have a
small right tentorial SDH, a right 11th rib fracture, transverse
process fractures of L2 and L5 and bilateral sacral fractures.
CT c-spine was negative of injury and CT torso was negative for
solid organ injury. On presentation to the OSH she was noted to
be hypotensive to the ___'s and was started on levophed via a RIJ
TLC however the pressor has been weaned off. She also briefly
desated and had to be place on a non-rebreather. She was
transferred to our institution for further evaluation and
management of her injuries.
On admission to the trauma ICU patient was on a non-rebreather
mask but satting well on 2L NC. She denied any palpitations,
dyspnea or chest pain prior to the fall. On initial labs her
troponins rose from 0.03 to 0.22 however her MB was normal at 5.
She had a lactate of 3.5 and a Cr of 1.4. Orthopaedics, spine
and neurosugery were consulted for evaluation of injuries, all
of which were deemed non-operative. She was noted to be
hypotensive and thus started on pressors, and resuscitated with
cristalloids, and later colloids. On HD#2 she was started on
Keppra for seizure prophylaxis per neurosurgery recommendations.
A bedside echocardiogram showed good ejection fraction. On HD#3
patient worked with physical therapy. Haldol was given for
increasede aggitation and physical restraints ordered. Pressors
were weaned off. On HD#4, patient developed tachypnea when
haviing breakfast, wheezy. Albuterol neb was initiated and
respiratory rate dropped from 35 to 20. EKG showed T wave
inversion at I, avL, avF, V2, and poor R progression in
comparison with previous EKG, ABG ___. Cycled
troponins were negative. Furosemide 20 IV and ~1.5L urinary
output afterwards with improved respiration. Cardiology team was
consulted and did not make further recommendations. On HD#5 she
was given another dose of intravenous lasix with good response.
Keppra was discontinue due to altered mental status. A repeat
head CT was performed and found to be unchanged from that
obtained on admission. Scheduled nebs every 4 hours added due to
wheezing on exam and oxygen requirement.
On HD#6 she was transferred to the floor. Anticipating
discharge, she was once again evaluated by physical therapy who
recommended recovery at a rehabilitation facility. Case
management was involved in the screening process. On HD#7 Foley
catheter was removed. Given improvement, patient was deemed
suitable for discharge. She would remain touchdown
weight-bearing on right lower extremity. Follow-up appointments
with Neurosurgery, Orthopedic Surgery and Acute Care Surgery
were scheduled.
At the time of discharge patient still complained of
mild-to-moderate lower back pain, controlled with medications.
She was tolerating a regular diet and on 2L of oxygen via nasal
cannula. Destination ___ rehabilitation facility was
updated on patient's status. Patient and family memebers
received teaching and follow-up instructions, with verbalized
understanding and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Cephalosporins
Attending: ___
Chief Complaint:
Difficulty tolerating POs
Major Surgical or Invasive Procedure:
PEG placement ___
History of Present Illness:
Ms. ___ is a very pleasant ___ lady who has a history
of anaplastic thyroid cancer diagnosed recently presenting with
poor PO intake for the past 2 weeks in the setting of nausea and
vomiting following eating.
In terms of her anaplastic thyroid cancer, she initially
presented in ___ with a right thyroid nodule (see oncologist
history below, under past medical history). Since discovery of
her anaplastic thyroid cancer, she is s/p near total
thyroidectomy, radiation, and is on cycle 4 of chemotherapy.
Since starting chemotherapy, she has dealt with significant
nausea and vomiting which has worsened over the past two weeks,
and even more significantly so, over the last two days,
prompting her current admission. She has not had a solid meal in
2 weeks; even drinking water sometimes prompts emesis. She is
intermittently able to keep down water. She denies dizziness or
lightheadedness. She lives in ___ by herself and is able to
manage on her own, although her two daughters help out and have
asked she move in with them, however she prefers to remain at
home and live independantly.
Review of systems is negative for chest pain, shortness of
breath, abdominal pain. She has not moved her bowels in 2 weeks
except for watery diarrhea today. Denies jaundice. Denies
dysuria. Denies fevers, chills. Endorses headache that began
today.
Her past medical history is significant for malignant melanoma,
GERD,
___ Syndrome ___ variant), breast cancer,
osteopenia, hypertension, osteoporosis, hyperlipidemia.
Past Medical History:
Oncologist History:
In ___ this year, she had a routine physical exam, noticed
to have a right thyroid nodule. She had an ultrasound, which
found a 5.5 x 2.7 cm x 2.8 cm right lobe mass, three nodules
identified and they were complex cystic, measuring 0.7 and 1.2
and 3.5 cm in maximum dimension and the left lobe measured 4.4
cm. On ___, she had a thyroid scan with multinodular
uptake. The iodine uptake was 27% and there were mixed hyper
and hypofunction nodules. An ultrasound-guided needle
aspiration showed poorly differentiated primary thyroid cancer
with metastasis, and the patient had seen ___,
MD ___ and Neck, ENT surgery on ___. Dr. ___
___ examined her and took her to the operating room on
___ to do a near total thyroidectomy. Her tumor had to be
peeled off the recurrent laryngeal nerve for voice preservation.
She recovered very well from her surgery. Postoperatively, she
did have I123 iodine uptake followed by ablative 50 mCi of
radioactive iodine.
She has since initiated radiation and chemotherapy (she receives
chemo at ___.
Other past medical history:
Malignant melanoma
arthritis, gastroesophageal reflux disease, ___
syndrome, breast cancer, osteopenia, macular degeneration,
hypertension, osteoarthritis, hyperlipidemia, cataracts,
hyperthyroidism, ___ syndrome.
Social History:
___
Family History:
Her brother had thyroid cancer.
Physical Exam:
Admission
temp 98.2, HR 82, BP 130/70, RR 12
Gen: Pleasant, Caucasian female, resting comfortably in bed
Neck: supple
Cardiac: Nl s1/s2 regular rate, no appreciable murmurs
Pulm: clear in anterior lung fields
Abd: soft and nontender with normoactive bowel sounds
Ext: no edema noted
Discharge
Vitals: 98.8 109/53 85 16 92% RA I/O 905/550
GENERAL: NAD
SKIN: Rash under armpits and at groin- red raised resolving
HEENT: AT/NC,OP clear with no lesions
NECK: anterior neck erythematous/dry, no LAD, elevated JVP
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no wheezes/rhonchi, rales left base
ABDOMEN: nondistended, non-tender, +BS, PEG tube in place with
dressing c/d/i.
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3
Pertinent Results:
I. Laboratory
A. Admission
___ 08:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-MOD
___ 08:00PM URINE RBC-5* WBC-50* BACTERIA-NONE YEAST-NONE
EPI-1
___ 08:00PM URINE MUCOUS-RARE
___ 07:20PM GLUCOSE-74 UREA N-16 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 07:20PM estGFR-Using this
___ 07:20PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.1
___ 07:20PM WBC-3.8* RBC-3.78* HGB-12.1 HCT-33.9* MCV-90
MCH-31.9 MCHC-35.7* RDW-13.7
___ 07:20PM NEUTS-76.9* LYMPHS-12.9* MONOS-6.6 EOS-2.9
BASOS-0.8
___ 07:20PM PLT COUNT-140*
B. Discharge
___ 11:15AM BLOOD WBC-2.6* RBC-3.07* Hgb-10.1* Hct-28.7*
MCV-94 MCH-32.8* MCHC-35.1* RDW-15.6* Plt ___
___ 11:15AM BLOOD Glucose-127* UreaN-10 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
___ 11:15AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
II. Microbiology
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
III. Imaging
None
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Calcitriol 0.25 mcg PO DAILY
3. Calcium Carbonate 1000 mg PO TID
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Dexamethasone 4 mg IV Q8H
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Calcitriol 0.25 mcg PO DAILY
3. Calcium Carbonate 1000 mg PO TID
4. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine [Levothroid] 125 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hours
Disp #*60 Capsule Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
7. Ondansetron 8 mg PO BID
RX *ondansetron 8 mg 1 tablet,disintegrating(s) by mouth every
12 hours Disp #*60 Tablet Refills:*0
8. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth every 12 hours
Disp #*60 Tablet Refills:*0
9. Lorazepam 0.5 mg PO Q6H:PRN nausea, anxiety
Do not drive, drink alcohol, or perform activities that require
concentration
RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
10. Metoclopramide 2.5 mg PO BID
can increase to QID as needed
RX *metoclopramide HCl 5 mg 2.5 mg by mouth twice a day Disp
#*120 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: dehydration; protein-calorie malnutrition, severe
Secondary: T4b anaplastic thyroid cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: chemotherapy and respiratory symptoms.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
No focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable. There is no overt
pulmonary edema.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: VOMITTING
Diagnosed with VOMITING
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 147.0
dbp: 54.0
level of pain: 0
level of acuity: 3.0 | ___ with clinical T4b anaplastic thyroid cancer status post
total thyroidectomy, radioactive ablation, and currently on
concurrent chemoradiotherapy with carboplatin AUC 2 weekly and
Taxol 50 mg presenting with poor PO intake for more than 2
weeks. Patient had peg tube placed on ___. Hospital course is
summarized by problems below:
#Nutrition: Patient presented with poor oral intake for over 2
weeks secondary to pain associated with swallowing. Her
baseline nausea is likely related to chemotherapy. Her dysphagia
is likely secondary to radiation or related to site of tumor.
Swallow study on ___ showed no abnormalities. Patient had PEG
inserted on ___. She continued to have nausea with tube feeds
requiring trying several feed formulations. It was unclear
whether nausea was truly related to tube feed formulations.
Patient was started on omeprzaole for possible acid reflux and
standing zofran. Overall, patient had difficulty with tolerating
tube feeds, which seemed to be related to formula and gastric
accomodation. Nutrition was consulted multiple times, and the
patient finally was able to tolerate peptamen cycled feeding
with an anti-emetic and pro-motility regimen. Plan will be to
see if she continues to tolerate and convert to bolus feeding
per nutrition recommendations.
# Anaplastic thyroid cancer: Patient received radiation therapy
while in house. She will be getting chemotherapy with
carboplatin and taxol as an outpatient. She was continued on
home levothyroxine.
# Rash: Patient presented with rash underneath armpits and groin
area. Likely rash was secondary to candidal skin infection.
Patient was treated with fluconazole from ___ to ___
with improvement in rash.
# Leukopenia and thrombocytopenia - Patient presented
pancytopenia likely in setting of chemotherapy and poor
nutrition. Counts were monitored and remained stable.
# Borderline hypocalcemia: This is favored to be secondary to
thyroid radiation with resultant parathyroid dysfunction. She
was continued on calcitriol and calcium carbonate.
# Hypothyroidism: Stable, continued on levothyroxine
# Code Status - FULL
# EMERGENCY CONTACT:
Name of health care proxy: ___ (daughter)
Phone number: ___
Cell phone: ___
# Transitional issues
- continue chemoradiation therapy for thyroid cancer as
outpatient
- consider conversion from cycled to bolus tube feeds if patient
continues to tolerate tube feeds
- titrate of anti-emetic and pro-motility regimen as needed for
tube feeds |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Dizziness and Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMhx of ___ s/p living kidney transplant ___ on
cyclosporine, cellcept, prednisone, CREST, PE previously on
warfarin, CAD (s/p ___ and OM ___ who presents for
hypotension and prescyncope in the setting of recent
up-titration of her home blood pressure medications.
Of note, she was recently discharged from the ET service for an
admission related to a new ___ for which she underwent renal bx.
Initial concern was for possible acute rejection of her
transplant, but bx was reassuring in this regard, showing
advanced changes associated with diabetic nephropathy.
Additionally during her stay, she was noted to have volume
overload in the setting of her ___, and she was started on a
number of different medications for hypertension management,
volume control and diuretics, as well as an aggressive insulin
regimen recommended by the ___.
Since her discharge, she has felt overall well until in the
middle of the night she awoke and felt dizzy. She notes this was
prior to taking her AM medications. She went back to bed
following this incident, and when she awoke she was notably
lightheaded and dizzy. She went to her PCP office for routine
follow-up, and was noted to have blood pressures ranging from
60-80 systolic, and thus was sent to the ED for further
evaluation. She denies any fevers, chills, CP, SOB, cough,
diarrhea, abd pain, or dysuria.
In the ED, initial vitals were:
97.1 71 110/56 19 93% RA
- Labs notable for: SCr 2.0, stable from recent admission
- Imaging was notable for:
Absent diastolic flow in transplanted kidney
The patient was given 1L NS and her home nifedipine and Lasix
were held. SBPs improved to 150s overnight and patient is
hypertensive to 180s this morning.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: Afeb, 120-180/60, 80-90, ___, 94% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1, 158/71, 80, 18, 99% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10AM PLT COUNT-323
___ 06:10AM WBC-7.3 RBC-2.76* HGB-8.3* HCT-25.9* MCV-94
MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5*
___ 06:10AM CYCLSPRN-168
___ 06:10AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9
___ 06:10AM GLUCOSE-85 UREA N-49* CREAT-2.0* SODIUM-138
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
___ 05:45PM PLT COUNT-272
___ 05:45PM NEUTS-92.0* LYMPHS-3.0* MONOS-4.2* EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-7.47* AbsLymp-0.24* AbsMono-0.34
AbsEos-0.02* AbsBaso-0.01
___ 05:45PM WBC-8.1 RBC-2.74* HGB-8.2* HCT-26.1* MCV-95
MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.3*
___ 05:45PM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-3.9
MAGNESIUM-2.0
___ 05:45PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-81 TOT
BILI-0.3
___ 05:45PM GLUCOSE-231* UREA N-48* CREAT-2.0* SODIUM-134
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 05:52PM LACTATE-1.3
DISCHARGE LABS:
===============
___ 05:24AM BLOOD WBC-6.1 RBC-2.43* Hgb-7.5* Hct-23.2*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.4 RDWSD-46.5* Plt ___
___ 05:24AM BLOOD Glucose-166* UreaN-42* Creat-1.8* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-14
___ 07:44AM BLOOD ALT-17 AST-12 LD(LDH)-257* AlkPhos-75
TotBili-0.2
___ 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 05:24AM BLOOD Cyclspr-204
MICROBIOLOGY:
=============
None
IMAGING:
========
___ (PA & LAT)
Stable mild cardiomegaly, decreased right pleural effusion, now
tiny.
___ TRANSPLANT U.S.
The left lower quadrant transplant renal morphology is normal
measuring 13.2 cm in length. Specifically, the cortex is of
normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and
renal sinus fat is normal. There is no hydronephrosis and no
perinephric fluid collection.
Doppler: There is absent diastolic flow main renal artery as
well as the intralobar branches, which is more convincing on
todays exam compared with prior. The main renal vein is patent.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with hx of renal txp with weakness, hypotension// eval for
pna, renal txp functioning
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. There is a residual tiny right
pleural effusion decreased from prior with persistent minimal linear
atelectasis in the right lower lung. Otherwise lungs are clear. The heart
remains mildly enlarged. Mediastinal contour is stable. Bony structures are
intact.
IMPRESSION:
Stable mild cardiomegaly, decreased right pleural effusion, now tiny.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with hx of renal txp with weakness, hypotension
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Prior recent exam from ___
FINDINGS:
The left lower quadrant transplant renal morphology is normal measuring 13.2
cm in length. Specifically, the cortex is of normal thickness and
echogenicity, pyramids are normal, there is no urothelial thickening, and
renal sinus fat is normal. There is no hydronephrosis and no perinephric
fluid collection.
Doppler: There is absent diastolic flow main renal artery as well as the
intralobar branches, which is more convincing on todays exam compared with
prior. The main renal vein is patent.
IMPRESSION:
Absent diastolic flow within the left lower quadrant transplant kidney is
concerning for rejection. Please correlate with results from recent biopsy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Hypotension
Diagnosed with Hypotension, unspecified
temperature: 97.1
heartrate: 71.0
resprate: 19.0
o2sat: 93.0
sbp: 110.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with PMhx of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
presents for hypotension and prescyncope in the setting of
up-titrating her anti-hypertensives. On admission, the patient
was given 1L NS and her nifedipine and Lasix were held. Her
symptoms resolved. She remained significantly orthostatic,
likely ___ longstanding diabetes and autonomic dysfunction.
Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO
QPM and Lasix 20mg PO daily with plans to continue to adjust her
blood pressure medications as an out-patient and possible
outpatient ABPM.
#Presyncope/hypotension:
Patient presented with hypotension i/s/o starting multiple
antihypertensives and a new diuretic regimen. Held
antihypertensives and diuretics for ___ and gave IVF with
improvement of blood pressure. Likely d/t medication effect, as
no evidence of infection. See "Hypertension" for discharge
regimen.
#Hypertension/Orthostasis:
Essential hypertension in the setting of tacrolimus therapy with
very poorly controlled blood pressures and difficult medication
titration given orthostasis and hypotension. Patient initially
hypotensive on admission but quickly became hypertensive to SBPs
of 200s with IVF and holding antihypertensives. However patient
was very orthostatic with drop to SBPS of 120s from 200s with
standing, despite being asymptomatic. Concern for diabetes
induced dysautonomia. Patient was maintained on carvedilol
12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with
SBPs in the 160s-170s. Plan is forcontinued titration of BP meds
and monitoring of orthostatics as an out-patient with ABPM.
# CKD
# S/p living unrelated donor kidney transplant ___:
Recent admission with renal bx showing diabetic changes without
signs of rejection. Her immunosuppressive regimen was increased
and she was discharged with a more aggressive antidiabetic
regimen and antihypertensive regimen.
- Decreased cyclosporine to 50mg BID given levels
- Continued home prednisone 5mg PO daily
- Continued home MMF 500mg BID
- Continued home diabetes regimen as below
# DM1, hyperglycemia: A1C 7.5% (___), had issues with
hypoglycemia d/t poor intake.
- Continued prior discharge regimen:
* Lantus 22 units qAM and 17 units qhs
* Humalog 8 units TID with meals
* Humalog sliding scale TID with meals
* ___ c/s
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69
- Continued home levothyroxine 125 mcg QD
# PE. Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# CAD. S/p ___ and OM ___. Completed 6 months on Plavix
- Continued home ASA 81 mg QD
- Continued home Ranexa ER 500 mg BID
# Nausea
- Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID
# Gout
- Continued home allopurinol ___ mg QD
# HLD
- Continued home atorvastatin 20 mg QD
# CREST:
- Held home esomeprazole 40 mg capsule BID
- Pantoprazole 40 mg BID while inpatient
# PVD
- Continued home cilostazol 100 mg QAM, 50 mg QPM |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
implant AICD
History of Present Illness:
Mr. ___ ___ year old male with a PMHx of atrial
fibrillation not on AC and recent hospitalization at ___
for colitis who is presenting to ___ after a cardiac arrest.
Earlier today, he was found by his wife after she heard a crash.
She found him at the bottom of the stairs, he was unresponsive,
and she called ___. She started CPR with rescue breaths. After
EMS arrived, he was found to be in VFib, was shocked once and
received epinephrine with ROSC. En route to the hospital he was
found to be in AFib with RVR to the 150s and was loaded with
amiodarone. He was intubated at ___ and ___ Unasyn. A CT
head and CT neck did not show acute processes. His initial
Trop-T was < 0.01 and K was noted to be 2.8 which was repleted
prior to his transfer to ___ for post-arrest care.
He was recently hospitalized at ___ with colitis and
severe diarrhea. After discharge, he continued to have diarrhea
to the point where he was apparently sleeping in a different bed
due to waking frequently to use the bathroom.
In the ED here, he was broadened to vancomycin and cefepime. A R
femoral CVL and A-line were placed under sterile conditions. He
was found to have guaiac positive brown stool. He did not have
signs of trauma on exam. A bedside ultrasound by the ED provider
did not show regional WMAs.
Initial vitals: T 36.5, HR 60, BP 112/66, RR 17, O2 100% Vent
Pertinent Labs:
WBC 9.2; Hgb 12.4
Normal coags
proBNP 2528, Trop-T 0.12 -> 0.10
K 3.3, CO2 22, Cr 0.9, Mg 1.7
VBG 7.29/51 -> 7.34/46
Negative serum toxicology screen.
Patient was given:
The post-arrest care team was consulted. Cardiology felt this
was unlikely to be ACS and deferred catheterization. Cooling to
35C was recommended.
On arrival to the MICU, he was intubated and sedated.
Review of systems: Per HPI.
Past Medical History:
Atrial Fibrillation
Colitis - unclear if infectious or inflammatory, suspect
infectious
Hernia
Stage ___ Melanoma
Social History:
___
Family History:
Mother with ___ disease. Unknown medical history for
father.
Physical Exam:
ON ADMISSION:
====================
Vitals: T: 35.7 BP: 124/72 P: 70 R: 13 O2: 100% on ventilator
GENERAL: intubated and sedated, unresponsive
HEENT: Sclera anicteric, small reactive pupils, MMM
NECK: C-collar in place
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Cool, 2+ edema on the shins bilaterally
NEURO: deeply sedated
ON DISCHARGE:
LABS: WBC 6.9, Hgb 11.9, Hct 35.8, Plts 349,BUN 14, Creat 0.8,
Na 135, K+ 4.0, Cl 98, HC03 24
Weight: 78.6kg (weight ___
I/O: 24 hour ___ + unmeasured amounts
Tele: AP, VS
VS: 97.7, 135/78, HR 69, RR 20, 02 sat 94% RA
Physical Exam:
Gen: sitting up in a chair, in no acute distress
Neuro: A/O x3. Speech clear. Takes time to process next
thought and repeats himself. Tongue is midline, no facial droop.
Minimal word finding difficulty.
Neck: supple, no JVD.
CV: RRR, S1S2, no m/r/g
Chest: Diminished in bases. Nonlabored breathing.
ABD: non-tender with + BS x4
Extr: Radial pulses: 2+ b/l. ___: 2+ b/l. no ___ edema
Skin: small reddened dots on back, no pustules, no clusters
Pertinent Results:
ON ADMISSION
==================
___ 12:48PM BLOOD WBC-9.2 RBC-4.14* Hgb-12.4* Hct-37.0*
MCV-89 MCH-30.0 MCHC-33.5 RDW-12.9 RDWSD-42.5 Plt ___
___ 12:48PM BLOOD ___ PTT-22.0* ___
___ 12:48PM BLOOD Glucose-193* UreaN-10 Creat-0.9 Na-139
K-3.3 Cl-103 HCO3-22 AnGap-17
___ 02:04AM BLOOD ALT-37 AST-56* CK(CPK)-1167* AlkPhos-48
TotBili-0.7
___ 12:48PM BLOOD Calcium-7.0* Phos-2.6* Mg-1.7
___ 01:29PM BLOOD Glucose-177* Na-139 K-3.2* Cl-106
calHCO3-25
PERTIENT LABS:
==================
Serum tox:
___ 12:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
proBNP-2528* (___)
Trop CK/MB
___ 12:48PM BLOOD cTropnT-0.12*
___ 06:07PM BLOOD CK-MB-14* MB Indx-3.3
___ 06:07PM BLOOD cTropnT-0.10*
___ 02:04AM BLOOD CK-MB-26* MB Indx-2.2 cTropnT-0.05*
___ 08:55AM BLOOD CK-MB-26* cTropnT-0.03*
___ 06:19AM BLOOD Ret Aut-1.8 Abs Ret-0.06
___ 12:48PM BLOOD ___
MICRO:
===========
URINE CULTURE (Final ___: NO GROWTH.
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
IMAGING:
=========
CT abd/pelvis (___)
1. Ascending colitis possibly reflecting arrest-related
hypoperfusion and a degree of ischemic bowel versus
infectious/inflammatory etiology. No pneumoperitoneum.
2. Moderate perihepatic and intrapelvic ascites. However no rim
enhancing
intra-abdominal collection seen.
CT Chest (___)
1. Increased large right and moderate left pleural effusions
with bilateral lower lobe consolidations potentially reflecting
pneumonia with aspiration a possibility.
2. Multiple nondisplaced bilateral anterior rib fractures
reflecting
resuscitation.
TTE (___)
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis (LVEF = 30 %). Right ventricular
chamber size is normal with moderate global free wall
hypokinesis. 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 no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with moderate global biventricular hypokinesis. No
valvular pathology or pathologic flow identified.
CLINICAL IMPLICATIONS: The left ventricular ejection fraction is
<40%, a threshold for which the patient may benefit from a beta
blocker and an ACE inhibitor or ___.
CXR (___)
Comparison to ___. The patient has received a
feeding tube. The course of the tube is unremarkable, the tip
is not visualized on the image. No complications, notably no
pneumothorax. Unchanged appearance of the endotracheal tube and
of the lung parenchyma and the cardiac silhouette.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dronedarone Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever or dropping water
temp
2. Amiodarone 400 mg PO BID
___ PO BID until ___ then reduce dose to 400mg PO daily X 2
weeks then 200mg PO daily
3. Atorvastatin 20 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
This can be discontinued when midline IV is discontinued.
6. Metoprolol Tartrate 50 mg PO QHS
7. Metoprolol Tartrate 75 mg PO BID AT ___ AND 1600
8. Ramelteon 8 mg PO DAILY at 1800
9. Rivaroxaban 20 mg PO DINNER
10. Vancomycin 1000 mg IV Q 12H post ICD Duration: 3 Doses
Only 1 more dose due tonight ___ at 11pm then can
discontinue.
11. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p vfib arrest
non obstructive CAD
s/p placement of AICD
infectious colitis
PNA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man intubated s/p cardiac arrest // ET placement,
interval change effusions, edema, infection
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___
FINDINGS:
Endotracheal tube terminates overlying the upper thoracic trachea.
Nasogastric tube terminates below the left hemidiaphragm and out of view.
There is mild pulmonary interstitial edema. There are bilateral right greater
than left pleural effusions. Ill-defined opacities overlying both lower lobes
are compatible with subsegmental atelectasis. There is no pneumothorax.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
1. Bilateral right greater than left small pleural effusions.
2. Bibasilar atelectasis.
3. Mild pulmonary interstitial edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulm edema, recent cardiac arrest and
pleuritic CP // eval for infiltrate, interval change in pleural effusions
TECHNIQUE: Chest single view
COMPARISON: ___ 04:24
FINDINGS:
Right pleural effusion has mildly worsened, left is stable. Bibasilar
consolidations, stable, likely atelectasis. Pulmonary vascular congestion,
heart size and pulmonary edema have mildly worsened. No pneumothorax.
IMPRESSION:
Mild interval worsening.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p cardiac arrest, afib, systolic heart
failure with continued cough, O2 requirement, SOB this morning // review for
interval changes for effusion, pulmonary edema review for interval changes
for effusion, pulmonary edema
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild pulmonary edema has worsened. The large right and moderate left pleural
effusion and severe bibasilar atelectasis are stable. Component of pneumonia,
particularly in the left lower lung is indeterminate, but could be
considerable. Cardiac silhouette is partially obscured, probably mildly
enlarged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with VF arrest s/p dual chamber ICD // lead
placement
COMPARISON: Chest radiograph since ___ the most recent ___
FINDINGS:
PA and lateral views of the chest provided.
Newly placed left chest wall ICD is noted with leads terminating in the right
atrium and right ventricle. There has been interval resolution of pulmonary
edema. Moderate bilateral pleural effusions, improved on the right side.
Improvement of severe bibasilar atelectasis. Cardiomediastinal silhouette is
otherwise within normal limits.
IMPRESSION:
1. Newly placed left chest wall ICD with leads terminating in the right atrium
and right ventricle.
2. Interval resolution of pulmonary edema. Moderate bilateral pleural
effusions, improved on the right side. Improvement of severe bibasilar
atelectasis.
Radiology Report
INDICATION: ___ s/p intubation at OSH for cardiac arrest // ___ s/p
intubation at OSH for cardiac arrest
TECHNIQUE: Portable AP chest radiograph of the chest and upper abdomen
COMPARISON: None available
FINDINGS:
Portable AP chest radiograph demonstrates an endotracheal tube, its tip which
projects approximately 6.8 cm above the level of the carina in appropriate
position. Perihilar airspace opacities are present. There is no pleural
effusion or pneumothorax. Heart is upper limits of normal in size.
IMPRESSION:
Perihilar opacities in this patient status post cardiac arrest may reflect
pulmonary edema or alternatively contusions in the event of chest
compressions. No displaced rib fracture identified.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with multiple cardiac arrests, needs OG access
for electrolyte repletion // eval OG placement eval OG placement
IMPRESSION:
Comparison to ___. The patient has received a feeding tube. The
course of the tube is unremarkable, the tip is not visualized on the image.
No complications, notably no pneumothorax. Unchanged appearance of the
endotracheal tube and of the lung parenchyma and the cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with multiple cardiac arrests, worsening hypoxia
// eval for interval changes eval for interval changes
IMPRESSION:
Comparison to ___. No relevant change is noted. Monitoring and
support devices are stable. Mild cardiomegaly. Moderate bilateral pleural
effusions and signs of mild to moderate pulmonary edema. No new focal
parenchymal changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cardiac arrest s/p arrest // interval
change in ET tube, infection, pleural effusions interval change in ET
tube, infection, pleural effusions
IMPRESSION:
Comparison to ___. Minimal left and moderate right pleural
effusion persist. The appearance of the lung parenchyma is unchanged. Stable
position of the endotracheal tube and the nasogastric tube. No pneumonia.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast.
INDICATION: ___ year old man with diarrhea and infectious colitis now s/p
polymorphic VT arrest x2 // Assess for evidence of intra-abdominal infection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 958 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A small subcentimeter cyst is noted in the upper pole of the left kidney.
Otherwise bilateral kidneys demonstrate normal morphology without focal
lesions. There is no perinephric abnormality.
GASTROINTESTINAL: Esophageal enteric catheter tip is within the distal gastric
body. Otherwise the stomach is mildly distended with ingested material and
oral contrast. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. There is moderate fat stranding about the
ascending colon reflecting colitis. Sigmoid diverticulosis without definite
diverticulitis is also identified. The appendix is not visualized.
PELVIS: The urinary bladder is decompressed by Foley catheter an otherwise
appears unremarkable. The distal ureters appear unremarkable as well. A
moderate amount of free fluid is noted within the pelvis, in contiguity with
right pericolonic fat stranding.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Right femoral arterial and central venous catheters are noted.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: There is mild diffuse body wall edema. Intra pelvic ascites is
seen extending into a right inguinal hernia.
IMPRESSION:
1. Ascending colitis possibly reflecting arrest-related hypoperfusion and a
degree of ischemic bowel versus infectious/inflammatory etiology. No
pneumoperitoneum.
2. Moderate perihepatic and intrapelvic ascites. However no rim enhancing
intra-abdominal collection seen.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: Polymorphic ventricular tachycardia and arrest. History of
diarrhea and infectious colitis.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and X maximal intensity projection
images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 958 mGy-cm.
COMPARISON: CT chest ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of dissection or intramural hematoma. The heart, pericardium, and
great vessels are within normal limits. No pericardial effusion is seen.
There is mild calcific atherosclerosis of the coronary arteries.
Pulmonary vasculature is grossly patent.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is a large right and moderate left pleural effusion,
increased from prior.
LUNGS/AIRWAYS: Consolidations of bilateral lower lobes, right greater than
left, with air bronchograms may reflect relaxation atelectasis although
pneumonia is not excluded. Calcified granulomas are identified within the
consolidated portion of the lower lobes. The right right and mild left lower
lobe relaxation atelectasis is identified Lungs are clear without masses or
areas of parenchymal opacification.
Endotracheal tube tip is 7.7 cm above the carina. Secretions are noted within
the right mainstem bronchus, extending into the right lower lobe bronchus.
The airways are otherwise patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Esophageal enteric catheter traverses below the diaphragm and its
tip is below the field-of-view. Included portion of the upper abdomen
demonstrates mild perihepatic ascites. Mild intrahepatic biliary duct
dilatation is also identified.
BONES: No suspicious osseous abnormality is seen.? minimally displaced
fractures of multiple bilateral anterior ribs, slightly greater on the left,
are consistent with resuscitation efforts.
IMPRESSION:
1. Increased large right and moderate left pleural effusions with bilateral
lower lobe consolidations potentially reflecting pneumonia with aspiration a
possibility.
2. Multiple nondisplaced bilateral anterior rib fractures reflecting
resuscitation.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Cardiac arrest, Transfer
Diagnosed with Cardiac arrest, cause unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 1.0 | BRIEF SUMMARY STATEMENT:
================================
Mr. ___ is a ___ year old male with a PMHx of atrial
fibrillation who presented after a cardiac arrest in the setting
of recent colitis and diarrhea. Cardiac arrest was in the
setting of hypokalemia and ventricular fibrillation, and had
ROSC in the field. He was extubated, stabilized on amiodarone,
and transferred from the ICU to the floor on ___.
#. VFIB arrest
- ROSC after 1 shock and epinephrine.
- cath on ___ showed LAD 30% stenosis, diag 50%, LCX
40-50%, RCA minor irregularities
- on amio, asa, metoprolol, statin
#. PAF
-Continue Xarelto. Copay will be $20/month.
-Amiodarone 400 mg BID for 2 weeks (from start date in CCU
___ then 400 mg QD x 2 weeks then 200 mg daily.
- Continue Metoprolol
- ___ dual AICD placed yesterday: CXR this morning without
acute abnormalities. 3 days (___) of antibiotics
(vancomycin). Device interrogated this morning- functioning
well.
#. Systolic HF s/p VF arrest
- initial EF was 30% now on repeat echo on ___ EF 60%,
trivial MR, moderate pericardial effusion without signs of
tamponade
- continue Lasix, metoprolol
-weights, labs, I&Os daily
- no need for repeat echo unless tamponade signs
#. Pneumonia
-Completed Ceftriaxone course
#. Colitis
- CT on ___ showed ascending colitis potentially reflecting
arrest related hypoperfusion/ischemic bowel versus
infectious/inflammatory. No abscess seen.
-Last dose of Flagyl is ___
#. Cognitive changes post VF arrest and resuscitation
-___ consult/OT consult. - recommended rehab
- neurology consulted- initially recommended MRI with contrast
however new AICD and can't have MRI for at least 6 weeks post
implant of device (it is MRI compatible). Recs were to follow up
outpatient with neuro in 3 months. If symptoms persist then will
undergo outpatient neuropsych testing.
#. Pruritic rash on back
- improving. Cont gold bond powder as needed.
#. PROPHYLAXIS:
- DVT ppx with NOAC
- Pain management with tylenol
- Bowel regimen with Senna/Colace (Hold for loose stools)
#.Dispo:
-Inpatient. Plan for rehab. Will need follow up with his
cardiologist Dr. ___ at ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ - Cardiac cath
___ - ___ catheter
History of Present Illness:
___ with CAD s/p MI and ischemic cardiomyopathy, CHB s/p PPM,
IDDM, HTN, HLD presenting with intermittent chest pain since
early AM ___. The pain was left of sternum, tight in nature,
and intermittent without provoking factors. An episode later in
the morning lasted ___ minutes, initially not resolving with
nitro x 3 taken an hour apart, but then resolved while en route
by EMS.
In the ED intial vitals were: Pain 0, 61 129/52 16 96% RA
EKG showed LBBB with STE by Sgarbossa criteria concerning for
STEMI.
Cardiology was called urgently to review and recommended medical
management with plan for cath if recurrent chest pain.
Labs notable for troponin negative x 2. Cr 1.1. Hgb 13. Plt 121.
INR 1.3.
Patient was given: Heparin gtt and nitro gtt.
At ~___ patient reported recurrent CP with EKG without STE seen
on previous.
Cardiology reevaluated pt. He was given morphine and nitro gtt
increased with improvement.
On the floor, patient arrived with ___ chest pain, which he
reports was tolerable and significantly better than earlier.
Repeat EKG on the floor again showed absence of earlier STE.
ROS: Positive for chronic stable angina reproducible with ___
minutes of activity (walking). No DOE, PND, orthopnea. No leg
swelling, palpitations, syncope, presyncope. All of the other
review of systems were negative or as above.
Past Medical History:
Hypertension
- Hyperlipidemia
- Complete Heart Block s/p PPM
- CAD s/p delayed presention of MI in ___ with mid-LAD
thrombux s/p DES, with jailed ___ s/p dilation. Mmoderate disease
in ramus OM1, proximal and mid RCA
- Unstable angina ___ - Cath showed 70% mid LAD lesion,
patent stent, and complete occlusion of D1 with very slow flow.
The lesion was not able to be crossed and the D1 was occluded at
the end of the procedure. There was a 90% OM1 lesion, 60%
ostial, and 70% distal right coronary artery narrowings.
Ejection fraction at that time was 35-40%.
- Ischemic cardiomyopathy with EF 40-45% in ___
- CKD stage 3
- BPPV s/p reported extensive evaluation at ___ ___
- GERD
- DM2 - A1c 8.3 in ___
- BPH
- Anemia
- Elevated PSA
Social History:
___
Family History:
Father: "old age"
Mother: "old age"
___: healthy
Daughter: healthy
Physical ___:
Admission Physical Exam:
===========================
VS: 97.4 121/63 p61 R16 95%RA ___ pain
GENERAL: NAD, lying in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple. No JVD
CARDIAC: S1, S2. regular. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
Discharge Physical Exam:
===========================
VS: Tm 98.3, 118/61 (SBP 91-120), 76-79, 20, 100%RA, discharge
weight 53.1kg
GENERAL: Middle aged man, A&Ox3, NAD
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple w/o discernible JVD sitting upright
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e
NEURO: CN II-XII intact, ___ strength diffusely
PULSES: 1+ radial pulses bilaterally
Pertinent Results:
ADMISSION LABS:
==================
___ 02:12PM BLOOD WBC-5.8 RBC-4.19* Hgb-13.0* Hct-36.6*
MCV-87 MCH-31.0 MCHC-35.4* RDW-12.7 Plt ___
___ 02:12PM BLOOD ___ PTT-25.8 ___
___ 02:12PM BLOOD UreaN-11 Creat-1.1
___ 03:10AM BLOOD Glucose-114* UreaN-9 Creat-1.1 Na-142
K-3.9 Cl-107 HCO3-25 AnGap-14
___ 03:10AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 02:25PM BLOOD Glucose-340* Lactate-1.5 Na-140 K-3.9
Cl-100 calHCO3-24
___ 02:12PM BLOOD ___
PERTINENT LABS:
==================
___ 02:12PM BLOOD cTropnT-<0.01
___ 08:30PM BLOOD cTropnT-<0.01
___ 03:10AM BLOOD cTropnT-<0.01
___ 11:08PM BLOOD CK-MB-25* MB Indx-5.9 cTropnT-0.15*
proBNP-1689*
___ 11:08PM BLOOD ALT-24 AST-39 CK(CPK)-427* AlkPhos-59
TotBili-0.7
___ 11:13PM BLOOD Type-ART pO2-65* pCO2-53* pH-7.37
calTCO2-32* Base XS-3
___ 12:42AM BLOOD Type-ART pO2-60* pCO2-37 pH-7.38
calTCO2-23 Base XS--2
___ 03:25AM BLOOD Type-ART pO2-78* pCO2-34* pH-7.41
calTCO2-22 Base XS--1
___ 11:13PM BLOOD Lactate-1.4
___ 03:25AM BLOOD Lactate-2.1*
___ 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative (OD
value 0.312)
DISCHARGE LABS:
=================
___ 04:55AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.1* Hct-33.3*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.3 Plt ___
___ 04:55AM BLOOD Glucose-74 UreaN-28* Creat-1.4* Na-142
K-4.2 Cl-106 HCO3-26 AnGap-14
___ 04:55AM BLOOD Mg-2.1
IMAGING/REPORTS:
==================
- CXR ___: Streaky opacity in the left lower lung could
represent atelectasis versus pneumonia.
- CXR ___: The patient has been intubated with the ET tube tip
being 4 cm above the carinal. NG tube tip is in the stomach.
Pacemaker leads are in unchanged position There is interval
development of bilateral perihilar relatively homogeneous
opacities most likely representing pulmonary edema and
associated shin with small amount of pleural effusion. Other
etiologies such as pulmonary hemorrhage or noncardiogenic
pulmonary edema would be a possibility. Infection would be
substantially less likely.
- CXR ___ opacities are improved from ___. Findings are most consistent with resolving mild pulmonary
edema.
- TTE ___:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe regional left ventricular
systolic dysfunction with focal severe hypokinesis to akinesis
of the mid to distal anterior wall, septum, and apex in addition
to hypokinesis of the entire lateral wall. Overall left
ventricular systolic function is severely depressed (LVEF= ___
%). A left ventricular mass/thrombus cannot be excluded. Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve is not well seen. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe regional left
ventricular systolic dysfunction c/w multivessel CAD. Normal
right ventricular cavity size and systolic function. Mild mitral
regurgitation.
- TTE ___:
No masses or thrombi are seen in the left ventricle.
IMPRESSION: Apical akinesis/aneurysm. No thrombus seen.
MICRO:
=======
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO QPM
4. Rosuvastatin Calcium 40 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Amlodipine 5 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Glargine 16 Units Bedtime
Humalog 5 Units Lunch
Humalog 9 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Glargine 16 Units Bedtime
Humalog 5 Units Lunch
Humalog 9 Units Dinner
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth qday Disp #*15 Tablet
Refills:*0
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Rosuvastatin Calcium 40 mg PO QPM
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth qday Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- NSTEMI
- Acute on chronic anemia
Secondary Diagnoses:
- Delirium
- Non-infectious antibiotic-associated diarrhea
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemic respiratory failure // please
eval for pulmonary edema
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
The patient has been intubated with the ET tube tip being 4 cm above the
carinal. NG tube tip is in the stomach. Pacemaker leads are in unchanged
position
There is interval development of bilateral perihilar relatively homogeneous
opacities most likely representing pulmonary edema and associated shin with
small amount of pleural effusion. Other etiologies such as pulmonary
hemorrhage or noncardiogenic pulmonary edema would be a possibility. Infection
would be substantially less likely.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute hypoxic respiratory failure, continued
poor oxygenation // ? pulmonary edema vs aspiration pneumonitis vs ARDS
COMPARISON: Chest radiograph ___
FINDINGS:
AP view of the chest provided. Left pacemaker is in stable position. ETT
ends 5.0 cm above the Carina. Transesophageal tube courses below the level of
the diaphragm and the tip projects over the proximal stomach. New Swan-Ganz
catheter ends in the right main pulmonary artery.
Perihilar opacities are improved.
No pneumothorax. Small, bilateral pleural effusions are unchanged. Minimal
bibasilar atelectasis is unchanged.
Hilar and cardiomediastinal contours are normal.
IMPRESSION:
Perihilar opacities are improved from ___. Findings are most
consistent with resolving mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man intubated in shock // eval for change from
previous eval for change from previous
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Following tracheal extubation, Moderate pulmonary edema has redistributed, now
more basilar, probably no more severe, lung volumes are smaller and moderate
cardiomegaly has increased. Right jugular central venous line ends in the low
SVC. 0 right transjugular Swan-Ganz catheter ends in the right pulmonary
artery in should not be advanced. Transvenous right atrial right ventricular
pacer leads in standard placements. Nasogastric drainage tube ends in the
stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Swan in place, agitated and pulled at
catheter // ? dislocation of Swan catheter ? dislocation of Swan
catheter
TECHNIQUE: Semi upright AP chest radiograph was obtained.
COMPARISON: Frontal chest radiograph ___
FINDINGS:
Cardiac device generator is in the left chest wall with intact leads in the
right atrium and right ventricle. Swan-Ganz catheter and nasogastric tube
have been removed. There is no pneumothorax.
Moderate cardiomegaly is unchanged. Lung volumes are low, but slightly
increased compared to prior examination resulting in improved bibasilar
aeration with there is persistent patchy opacities, likely atelectasis.
IMPRESSION:
1. Removal of Swan-Ganz catheter and nasogastric tube. No pneumothorax.
2. Decreased pulmonary edema with improved bilateral aeration.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chest pain // ?ptx
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Dual lead pacemaker is seen over the
left chest wall with leads extending into the heart. Overlying EKG leads are
present. Lung volumes are low limiting assessment. There is mild streaky
opacity in the left lower lung which could represent atelectasis versus
pneumonia. Otherwise the lungs appear clear. The heart size is within normal
limits allowing for technique. Mediastinal contours normal. No acute bony
abnormalities.
IMPRESSION:
Streaky opacity in the left lower lung could represent atelectasis versus
pneumonia.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: STEMI
Diagnosed with INTERMED CORONARY SYND
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year old male with PMH significant for CAD s/p MI with
ischemic cardiomyopathy, complete heart block s/p pacemaker
placement, T2DM and HTN who presented with episodes of chest
pain while at rest which were relieved by SL nitro.
# UA/NSTEMI: The patient has a history of chronic stable angina,
normally occurring with ___ctivity, but no
prior episodes of chest pain at rest. Initial EKG on admission
showed LBBB with STE by Sgarbossa criteria concerning for STEMI.
Labs notable for troponin negative x 2.
He was initially treated with medical management. He continued
to have episodes of chest pain, the decision was made to
proceded with cardiac catheterization on ___. In the cath
lab, he was found to have a narrow L circumflex, and a bare
metal stent was placed in the ostial left circumflex. Access was
R radial. He received 300 mg Plavix, and was placed on an
integril gtt for planned total course of 18 hours.
After the cardiac cath, the patient became acutely delirous. He
was given flumazenil without improvement. Also received haldol 5
mg x1. Of note, he has had similar reactions to benzos in the
past. He then became hypertensive and hypoxemic concerning for
flash pulmonary edema. He was subsequently intubated. He then
developed hypotension, thought secondary to propofol vs
cardiogenic shock, so he was transferred to the CCU for further
management.
In the CCU, he was started on dopamine and diuresed with IV
lasix boluses and later lasix drip in addition to metolazone.
Vasopressin was later added for persistent hypotension. Swan
catheter placed the following day on ___. In addition, while
in the CCU; though patient's hypoxia was thought to be ___ to
pulmonary edema and improved with diuresis above, patient was
empirically treated for a 5 day course (CTX and Azithromycin,
___ for CAP. Subsequently patient's pressors were
weaned and patient's swan and pressors were off by ___.
# ___ on CKD: Patient's Cr downtrended while in CCU from peak of
1.9 to 1.6, thought to be ___ to ___ on CKD in setting of poor
renal perfusion in the context of cardiogenic shock. 5 mg
lisinopril was started on ___ while Cr was downtrending.
Discharged on this dose of lisinopril but recommend titrating
this up as an outpatient once his creatinine returns to baseline
and as tolerated by his blood pressure.
# Thrombocytopenia: Patient had downtrending platelets
concerning for HIT (4T score = 4) so heparin was held. HIT
antibodies were negative (OD = 0.312).
# Diarrhea: Patient noted to have diarrhea on ___, C.
diff was sent and was negative. Patient was subsequently started
on loperamide for presumed non-infectious antibiotic-associated
diarrhea.
# Hematocrit drop: Patient was noted to have a downtrending
hemoglobin over several days (12.8 -> 12.0 -> 11.1 on ___. He
has never undergone a colonscopy. Repeat hemoglobin check in the
afternoon of ___ was 11.0 (stable). The patient expressed a
strong desire to be discharged home and since there were was no
acute change in his CBC, it was felt that close outpatient
follow up and re-checking his CBC by his primary care provider
___ 3 days was appropriate.
# Delirium: Patient exhibited several brief ___ hours)
episodes of delirium during his hospital stay during which he
A&Ox1 (self only). These tended to resolve with redirection and
non-pharmacologic measures to reduce delirium, although he did
receive one dose of seroquel 25mg during his stay.
==== TRANSITIONAL ISSUES ====
# Hematocrit drop: Last hemoglobin was 11.0 on ___.
- Patient has been instructed to see his PCP ___ ___ days of
discharge for repeat complete blood count.
- Please consider referral for outpatient colonoscopy given that
patient has never had one and his anemia raises concern for GI
bleeding.
# Hypertension and Systolic CHF
- Please titrate up lisinopril to his pre-hospitalization dose
of 40mg qday once his creatinine normalizes and as tolerated by
his blood pressure.
# Cardiology follow-up
- Patient instructed to schedule follow up appointment with
cardiologist with ___ weeks.
- Recommend considering ICD as outpatient if EF doesn't improve.
# Home Physical Therapy
- Patient will need to continue home ___ for his deconditioning
# Discharge weight: 53.1kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain and jaundice
Major Surgical or Invasive Procedure:
___ ERCP, sphincterotomy, stent placement
___ Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ y/o M w/ no significant past medical history
who initially presented to ___ for jaundice and
abdominal pain. He reports approximately one week of moderate to
severe epigastric and right upper quadrant pain that was worse
after eating, with radiation into right anterior chest.
Associated with increased jaundice and diffuse pruritis for past
2 days, and burning bilateral pain in the shoulder blades for
the past several days. No fevers or chills. Denies feeling
confused. He had vomiting for approximately 5 days, and was
trying to treat his symptoms at home. Says he took Dayquil,
Nyquil, Pepto bismol, and milk of magnesia for the past week
without any relief. Says the milk of magnesia caused him some
to have some blood in his stool, but that resolved prior to
admission. He reports that his stools have been gray in color
and his urine has been an orange/brown color. He denies any
recent alcohol use. He has not taken Tylenol specifically, but
per his report of use of Dayquil and Nyquil, he has had at least
some acetaminophen exposure. At ___ he had
LFTs that revealed an obstructive pattern and underwent a CT
scan of the abdomen which raised concern for a CBD stone and
transferred for further evaluation. In the ___ ED he underwent
RUQ u/s, was kept NPO, ERCP was consulted, and he was admitted
for ERCP and further treatment.
Past Medical History:
Denies any prior medical conditions.
Social History:
___
Family History:
No known family hx of gallstones or liver disease.
Maternal grandfather had DM
___ uncle has DM
Mother is healthy
Father's PMHx unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS pre-ERCP (09:45): 98.0 113/59 55 18 97% on RA
VS post-ERCP (13:25): 97.5 122/68 81 18 98% on RA
Gen: young man who appears comfortable
Head: no evidence of trauma
Eyes: + scleral icterus, EOMI
ENT: no oral lesions, normal dentition, + jaundice
Neck: normal ROM, no LAD
Chest: clear to auscultation and percussion bilaterally
Cards: RR, s1s2 present, no m/r/g
Abd: soft, minimally tender to firm palpation over RUQ,
otherwise not tender to palpation throughout, not distended, no
rigidity, no rebound tenderness, BS+
GU: no foley, no CVA tenderness
MSK: grossly normal aROM and strength throughout
Ext: no edema, WWP
Neuro: awake, alert, oriented to person, place, time, reason for
hospitalization, clear speech, no facial droop, tongue midline,
no tremor, coordination grossly intact
Discharge Physical Exam:
VS: 98.8, 72, 134/62, 18, 100 RA
HEENT: no deformity, PERRL, EOMI. Mucus membranes moist, pink.
Neck supple, trachea midline.
CV: RRR
Pulm: Clear to auscultation bilaterally
Abdomen: soft, mildly tender to palpation at surgical sites as
anticipated, mildly distended. Active bowel sounds x4 quadrants.
Skin: Multiple laparoscopic sites to abdomen with glue.
Ext: Warm and dry. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
==================
ADMISSION LABS: reviewed, notable for hyperbilirubinemia,
transaminitis
.
___ 04:15AM BLOOD WBC-7.3 RBC-4.83 Hgb-14.4 Hct-43.5 MCV-90
MCH-29.8 MCHC-33.1 RDW-13.3 RDWSD-43.8 Plt ___
___ 04:15AM BLOOD Neuts-60.6 ___ Monos-12.1 Eos-4.9
Baso-1.1* Im ___ AbsNeut-4.44 AbsLymp-1.54 AbsMono-0.89*
AbsEos-0.36 AbsBaso-0.08
___ 04:15AM BLOOD ___ PTT-33.2 ___
___ 04:15AM BLOOD Glucose-95 UreaN-13 Creat-1.0 Na-139
K-3.8 Cl-105 HCO3-25 AnGap-13
___ 04:15AM BLOOD ALT-217* AST-100* AlkPhos-264*
TotBili-6.7*
___ 04:15AM BLOOD Lipase-59
___ 04:15AM BLOOD Albumin-4.0
___ 05:00AM BLOOD Lactate-0.9
.
.
=================
IMAGING: reviewed.
.
___ CT abd/pelvis (___):
IMPRESSION (wet read):
1. Cholelithiasis and evidence of choledocholithiasis with mild
diffuse biliary ductal dilatation.
.
___ RUQ U/S:
IMPRESSION:
1. CBD is dilated to 8 mm as seen on recent CT. No stone is
seen within the visualized portion of the CBD,
2. Cholelithiasis with borderline wall thickening.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
.
___ ERCP:
Impression: The scout film was normal.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized. The course and caliber of the
structures are normal with no evidence of extrinsic compression,
no ductal abnormalities, and no filling defects.
A biliary sphincterotomy was performed.
After the sphincterotomy, significant oozing was noted.
Balloon sweeps were performed and no stones or sludge were
clearly identified though visualization was somewhat limited
secondary to oozing.
The CBD and CHD were swept repeatedly and no sludge or stones
were seen.
A 10 mm x 40 mm Wallflex fully covered metal stent (REF 7052,
LOT ___ was placed successfully to tamponade the bleeding
with hemostasis achieved.
Otherwise normal ercp to third part of the duodenum
Labs:
___ 05:30AM BLOOD WBC-10.1*# RBC-4.90 Hgb-14.6 Hct-44.0
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.6 RDWSD-44.4 Plt ___
___ 05:30AM BLOOD WBC-6.5 RBC-4.74 Hgb-14.4 Hct-41.6 MCV-88
MCH-30.4 MCHC-34.6 RDW-13.2 RDWSD-42.5 Plt ___
___ 05:10AM BLOOD WBC-8.4 RBC-4.69 Hgb-14.1 Hct-41.0 MCV-87
MCH-30.1 MCHC-34.4 RDW-13.2 RDWSD-41.6 Plt ___
___ 12:40AM BLOOD WBC-7.7 RBC-4.62 Hgb-14.0 Hct-40.6 MCV-88
MCH-30.3 MCHC-34.5 RDW-13.4 RDWSD-42.9 Plt ___
___ 05:05PM BLOOD WBC-7.8 RBC-4.74 Hgb-14.5 Hct-42.6 MCV-90
MCH-30.6 MCHC-34.0 RDW-13.5 RDWSD-44.4 Plt ___
___ 05:30AM BLOOD ___ PTT-36.0 ___
___ 05:10AM BLOOD ___ PTT-34.9 ___
___ 05:30AM BLOOD Glucose-72 UreaN-12 Creat-0.8 Na-139
K-3.5 Cl-102 HCO3-24 AnGap-17
___ 05:30AM BLOOD Glucose-93 UreaN-8 Creat-0.8 Na-132*
K-3.5 Cl-96 HCO3-25 AnGap-15
___ 05:10AM BLOOD Glucose-81 UreaN-9 Creat-0.8 Na-137 K-3.6
Cl-101 HCO3-23 AnGap-17
___ 04:15AM BLOOD Glucose-95 UreaN-13 Creat-1.0 Na-139
K-3.8 Cl-105 HCO3-25 AnGap-13
___ 05:30AM BLOOD ALT-162* AST-92* AlkPhos-299*
TotBili-4.0* DirBili-2.5* IndBili-1.5
___ 05:30AM BLOOD ALT-147* AST-63* LD(LDH)-159 AlkPhos-291*
TotBili-4.6* DirBili-3.1* IndBili-1.5
___ 05:10AM BLOOD ALT-164* AST-68* LD(LDH)-145 AlkPhos-273*
Amylase-69 TotBili-6.8* DirBili-5.4* IndBili-1.4
___ 04:15AM BLOOD ALT-217* AST-100* AlkPhos-264*
TotBili-6.7*
___ 06:50PM BLOOD Lipase-14
___ 05:10AM BLOOD Lipase-14
___ 04:15AM BLOOD Lipase-59
___ 05:30AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
___ 05:30AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.7
___ 05:10AM BLOOD Albumin-3.7 Calcium-9.3 Phos-2.3* Mg-1.6
___ 05:00AM BLOOD Lactate-0.9
Medications on Admission:
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN reflux
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Chronic cholecystitis.
2. Choledocholithiasis.
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: Right upper quadrant pain and obstructive LFT pattern.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Same-day CT abdomen and pelvis.
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: Mild central intrahepatic biliary dilatation as noted on prior CT
is not readily apparent on ultrasound. The CBD measures 8 mm. No stone is
seen within the visualized portion of the CBD.
GALLBLADDER: Cholelithiasis present with some focal areas of borderline
gallbladder wall thickening. No pericholecystic fluid.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.2 cm.
KIDNEYS: Limited sagittal view of the right kidney is grossly unremarkable
without hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. CBD is dilated to 8 mm as seen on recent CT. No stone is seen within the
visualized portion of the CBD,
2. Cholelithiasis with borderline wall thickening.
3. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Jaundice, RUQ abdominal pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 97.1
heartrate: 63.0
resprate: 18.0
o2sat: 99.0
sbp: 116.0
dbp: 59.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ yo M who presented to ___ emergency
department on ___ from an outside hospital with epigastric
and right upper quadrant pain with jaundice. On HD2 he underwent
an ERCP that showed no filling defects within the biliary ducts,
no stones or sludge were found with balloon sweeps. A
sphincterotomy was preformed resulting in significant oozing of
blood, requiring a 10 mm x 40 mm Wallfelx fully covered metal
stent. The Acute Care Surgery service was consulted post-ERCP
for consideration for laparoscopic cholecystectomy.
After successful ERCP, the patient was transferred to the Acute
Care Surgery Service for further management of his gallbladder
disease. His liver enzymes were decreasing and therefore to
extirpate the source of the common duct stones, he was taken to
the operating room on ___ for a laparoscopic
cholecystectomy. Procedure was tolerated without incident, he
was extubated and taken to the PACU in stable condition. He was
then transferred to the surgical floor for further management.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. He was prescribed a 5
day course of ciprofloxacin post ERCP.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMHx of DMII, HTN, glaucoma, dementia
and chronic constipation who is brought in by her granddaughter
for productive cough x 2 weeks. She notes that her grandmother
is usually ambulatory with a walker, but has become less so in
the past two weeks, noting she has appeared somewhat weak, along
with urinary incontinence. She denies falls or any trauma. She
is also complaining of abdominal pain.
In the ED, initial vitals were: 99.2 98 146/68 18 98% RA Gluc
269
- Exam notable for:
A&O x1 (name ___- did not correctly answer her granddaughter's
name)
Speaking ___ word sentences only. Poorly cooperative with neuro
exam
Chest: CTA bl. S1/S2, no m/r/g, no peripheral edema, warm ext,
no meningismus or concern for meningitis
- Labs notable for:
Flu swab negative,
WBC 7.5
Hgb 9.7
Plts 130s
Ca: 9.2 Mg: 2.1 P: 3.2
ALT: 13 AP: 102 Tbili: 0.3 Alb: 3.6 AST: 19
chem 7: ___
Lactate 1.1
pH: 7.39 pCO2 48 Hco3 30
___ blood, 100 protein, trace glucose, 3 RBCs
- Imaging was notable for:
CT abdomen/pelvis:
Aortic aneurysm at the diaphragmatic hiatus and infrarenal
appear similar tomarginally increased from prior CT. No adjacent
hematoma. No finding toaccount for pain.
CT head without contrast:
1. Subacute left cerebral subdural hematoma measuring 5 mm in
greatest axial thickness.
2. Chronic right cerebellar infarcts.
CXR ___
IMPRESSION:
In Comparison with study of ___, there again are low
lung volumes that accentuate the transverse diameter of the
heart. No vascular congestion, pleural effusion, or acute focal
pneumonia. Probable mild atelectatic changes at the left base.
Substantial degenerative changes seen in the thoracolumbar
spine. However, the
lateral view of the thoracic spine is of limited quality and
possible
sclerosis of vertebral bodies suggested on the prior examination
cannot be adequately assessed.
- Patient was given:
___ 17:30 IVF NS 500 mL
___ 18:16 IVF NS
___ 22:04 PR Acetaminophen 650 mg
___ 22:44 IV CeftriaXONE
___ 22:44 IVF NS ( 1000 mL ordered)
___ 23:25 IV Azithromycin (500 mg ordered)
___ 23:25 IV CeftriaXONE 1 g
Patient spiked a fever in the ED to 101.6
Neurosurgery was consulted:
"Neurologic examination appears to be consistently with
patient's baseline. CT shows very small L subacute SDH which
causes no mass effect. No neurosurgical intervention is
indicated. No indication for AED or Neurosurgical follow up.
Recommend admission to medicine for further workup of general
fatigue and respiratory symptoms."
Upon arrival to the floor, patient is able to note no current
pain, and no chest pain. Says 'yes' when asked if breathing is
difficult, but unable to obtain further history from patient.
Per granddaughter, patient has been more lethargic recently, and
she's noticed a cough, dry at first but recently with clear
sputum, but noted some pink sputum prior to coming to ED.
Past Medical History:
- HTN
- CKD stage 3
- DM2
- stroke
- obesity
- glaucoma, diabetic retinopathy, macular drusen
- dementia
- tremor
- HLD
- carpel tunnel syndrome
- appendectomy
- hysterectomy
- cataract surgery
Social History:
___
Family History:
No family history of COPD
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: 99.6 156/81 97 20 91% RA
GENERAL: Patient appears tired, intermittently sleeping and able
to respond to questions. Answers ___ to name, but doesn't
say last name. Unable to answer where she is or the year.
HEENT: MMM, no scleral icterus. Difficulty examining eyes, but
noted R eye with white film, possible cataract
NECK: No elevated JVP
CARDIAC: soft sounds, RRR, no murmurs appreciated
LUNGS: Good air movement, no crackles or significant wheezing
ABDOMEN: Soft, nontender, nondistended, normal bowel sounds
EXTREMITIES: Warm, well perfused. ___ bilaterally, no ___ edema
NEUROLOGIC: A&Ox1 to first name. ___. Able to move all
extremities to command. Moving face symmaterically. Left tongue
deviation noted on my exam, a change from recent exam in ED
DISCHARGE PHYSICAL EXAM:
=========================
VITALS - Tc 98.7, Tm 100.2 (overnight) | 122/75-150/81 | 84 | 18
| 99%/RA | 67.6 kg
GENERAL - elderly woman, in no distress, laying in bed,
somnolent but easily rousable
HEENT - moist mucous membranes, saliva leaking from mouth,
sclerae anicteric
NECK - supple
CARDIAC - regular, normal S1/S2, no murmur
LUNGS - no increased work of breathing, lungs clear though small
breaths
ABDOMEN - obese, soft, non-tender, non-distended, normal bowel
sounds
EXTREMITIES - warm, no peripheral edema
SKIN - dry, no rash
NEUROLOGIC - oriented to first & last name. ___. Moves
extremities on command. Laying on left side, head turned to
left, tongue deviated to left (as in admission note) with left
sided facial droop, though when awake and positioned centrally,
droop is absent
Pertinent Results:
ADMISSION LABS:
===============
___ 02:37PM BLOOD WBC-7.5# RBC-3.42* Hgb-9.7* Hct-30.3*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.0 RDWSD-48.8* Plt ___
___ 02:37PM BLOOD ___ PTT-28.1 ___
___ 02:37PM BLOOD Glucose-217* UreaN-23* Creat-1.4* Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
___ 02:37PM BLOOD ALT-13 AST-19 AlkPhos-102 TotBili-0.3
___ 02:37PM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.2 Mg-2.1
IMAGING:
========
- ___ CT ABDOMEN/PELVIS W/O CONTRAST
Aortic aneurysm at the level of the diaphragmatic hiatus and
infrarenal
segments appearing relatively size stable though measuring up to
6.4 cm at the level of the hiatus and up to 5 cm at the level of
the mid abdomen. No associated hematoma or signs of rupture.
Additional nonemergent findings described above.
- ___ CXR
In Comparison with study of ___, there again are low
lung volumes that accentuate the transverse diameter of the
heart. No vascular congestion, pleural effusion, or acute focal
pneumonia. Probable mild atelectatic changes at the left base.
Substantial degenerative changes seen in the thoracolumbar
spine. However, the lateral view of the thoracic spine is of
limited quality and possible sclerosis of vertebral bodies
suggested on the prior examination cannot be adequately
assessed.
- ___ CT HEAD W/O CONTRAST
Subacute left cerebral subdural hematoma measuring 5 mm in
maximal thickness. No significant mass effect. Chronic atrophy
with small vessel disease and chronic right cerebellar infarct.
- ___ CHEST X-RAY:
Compared to chest radiographs since ___ most recently
___.
Lungs are grossly clear. There are no findings to suggest
pneumonia.
Moderate cardiomegaly is chronic. There is no appreciable
pulmonary vascular
engorgement although the vascular enlargement of both hila is
long-standing.
There is no pulmonary edema or appreciable pleural effusion the
lateral view
would be required to detect a small amount of pleural fluid.
MICROBIOLOGY:
=============
- ___ BLOOD CX: NEGATIVE
DISCHARGE LABS:
===============
___ 06:48AM BLOOD WBC-7.7 RBC-3.41* Hgb-9.7* Hct-30.7*
MCV-90 MCH-28.4 MCHC-31.6* RDW-15.1 RDWSD-48.5* Plt ___
___ 06:48AM BLOOD Glucose-246* UreaN-21* Creat-1.4* Na-144
K-4.2 Cl-105 HCO3-21* AnGap-22*
___ 06:48AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 8.6-17.2 mg PO DAILY
2. Bisacodyl ___ mg PO DAILY:PRN constipation
3. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
4. Acetaminophen ___ mg PO QHS:PRN Pain - Mild
5. melatonin 5 mg oral QHS
6. Lactulose 15 mL PO BID:PRN constipation
7. amLODIPine 10 mg PO DAILY
8. Simvastatin 10 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
14. Pilocarpine 4% 1 DROP BOTH EYES Q8H
15. ___ 30 Units Breakfast
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Doses
2. Dextromethorphan-Guaifenesin (Sugar Free) 10 mL PO Q6H:PRN
COUGH
3. Docusate Sodium 100 mg PO BID
4. GuaiFENesin 10 mL PO Q6H
5. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once to
twice daily Refills:*0
7. Ramelteon 8 mg PO QHS:PRN insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth before bed
Disp #*30 Tablet Refills:*0
8. Bisacodyl 10 mg PR QHS
9. ___ 30 Units Breakfast
10. Senna 17.2 mg PO BID
11. Acetaminophen ___ mg PO QHS:PRN Pain - Mild
12. amLODIPine 10 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
15. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
16. Lactulose 15 mL PO BID:PRN constipation
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
18. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
19. Pilocarpine 4% 1 DROP BOTH EYES Q8H
20. Simvastatin 10 mg PO QPM
21. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses: viral URI, lethargy, constipation
Secondary diagnoses: chronic renal failure, anemia, chronic
diastolic heart failure, glaucoma, cataracts
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with viral URI and persistent low grade
fevers// Eval for pneumonia? Eval for pneumonia?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Lungs are grossly clear. There are no findings to suggest pneumonia.
Moderate cardiomegaly is chronic. There is no appreciable pulmonary vascular
engorgement although the vascular enlargement of both hila is long-standing.
There is no pulmonary edema or appreciable pleural effusion the lateral view
would be required to detect a small amount of pleural fluid.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough, Lethargy
Diagnosed with Altered mental status, unspecified
temperature: 99.2
heartrate: 98.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | This patient is a ___ year old woman with a PMH notable for type
II diabetes, hypertension, dementia and chronic constipation who
presented with progressive weakness without falls, and abdominal
pain.
ACTIVE ISSUES
# Acute bronchitis
# Lethargy - toxic/metabolic encephalopathy:
# Productive cough, low grade fevers: likely secondary to viral
URI, given absent findings on CXR. Unable to obtain full history
from patient, given dementia. Subacute SDH could be contributing
to lethargy, as could infection. UA negative and influenza PCR
negative. Did have initial low-grade fever, then persistent
temperatures in 99.5-100 range, but had no other localizing
signs/symptoms of sepsis or infection. She was started on
azithromycin empirically for 5 day course with ongoing clinical
improvement.
- Last day of azithromycin, ___
# Subdural hematoma
No midline shift or neurologic deficits appreciated.
Patient was seen by neurosurgery in the ED, and no further
imaging, evaluation, or treatment recommended
# Abdominal pain,
# Chronic constipation: CT unimpressive. Does have history of
chronic constipation with large stool burden noted on CT
abdomen/pelvis. UA unremarkable as well. Pain appears to have
resolved with increased bowel regimen resulting in large BM.
Continue bowel regimen aggressively.
CHRONIC ISSUES
# Chronic renal failure: baseline Cr 1.6-1.8. Cr 1.4 here.
# Hypertension: BP elevated to >150s here, even up to 190s.
Subacute SDH as well, based on imaging. Continued amlodipine 10
mg daily and hydralazine 10 mg PO Q8H (holding for SBP <130).
# Anemia: normocytic. Stable. No signs of bleeding or
hemodynamic instability.
# Chronic diastolic heart failure: Furosemide stopped as
outpatient. Continued to hold.
# Hyperlipidemia: Decreased simvastatin to 20 mg given
interaction with amlodipine, though would favor discontinuing
given lack of benefit at age ___.
# Glaucoma and Cataracts: continue home eye drops
================================
## TRANSITIONAL ISSUES ##
================================
-- Monitor temperatures. Has had elevated temperature, though
not fever (high 99, to 100.2, maximum) while in house, and on
azithromycin. No further localizing symptoms and no
leukocytosis. Repeated CXR just prior to discharge unchanged.
Continue to monitor for development of true fever (greater than
to 100.4F) and consider infectious evaluation if becomes truly
febrile.
-- Goals of care: DO NOT RESUSCITATE, DO NOT INTUBATE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Ambien
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with COPD, CHF, and arthritis. He
reports that he has gained about 5 pounds over the last 4 days.
He reports that his abdomen his become slightly distended during
this time. He also thinks his lower extremities may be slightly
more swollen L>R. He has not had a bowel movement in about one
week. He feels short of breath at baseline and has not had any
recent change. He has an occasional dry cough, but this is also
unchanged. He was referred to the ED by his PCP.
.
In the ED initial vital signs, 98.4 141/89 84 18 94% RA. He
received combivent, acetaminophen. His abdomen was slightly
tender to the touch. He had a CT of the abdomen which showed a
moderate amount of stool, but no acute process. A chest xray
also did not show anything acute and no overt pulmonary edema.
He had some bilateral wheezing which patient and daughter
confirmed as baseline. ED contacted his PCP who requested
admission out of concern for a CHF exacerbation. Vitals on
transfer: 98.5 155/93 68 16 93%RA.
.
Currently, he feels comfortable. He has slight pain around his
left elbow. He reports having it drained many months ago. He
also reports some general congestion. In the past he has had a
small amount of rectal bleeding from hemorrhoids, but none
currently.
Past Medical History:
DJD L/S spine, C-spine, C3-4 thru C7, knee (R)--s/p TKR
bilaterally w/re-do (R) ___, Spinal Stenosis L4-5
Asthma
Rheumatoid vs. inflammatory arthritis
BPH with dysfunctional voiding syndrome
Anxiety/depression
Gout
GERD
Venous insufficiency, Peripheral neuropathy
h/o ? seizure ___
COPD
Restless leg syndrome
Constipation
Gallstones
Cyst (L) kidney,
Sigmoid diverticulitis
Cognitive impairment
s/p Lacunar infarcts
Dysphagia
Hearing impairment
Hypertension
Insomnia
Social History:
___
Family History:
Father had liver cancer. His sister had diabetes. His brother
had CVD.
Physical Exam:
VS - Temp ___ F, BP 137/76, HR 64, R 18, O2-sat 93 % RA
GENERAL - well-appearing in NAD, comfortable, appropriate,
slightly hard of hearing
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - unable to appreciate JVD
LUNGS - bilateral wheezing
HEART - RR
ABDOMEN - +BS, soft, slightly tender to touch in lower
quadrants, no rebound, slightly distended
EXTREMITIES - warm, legs symmetric (compression stalkings in
place), slight tenderness of left calf. Left small effusion over
elbow, non-tender, no erythema.
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMIT LABS:
___ 04:15PM BLOOD WBC-5.2 RBC-4.05* Hgb-12.2* Hct-36.5*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.1 Plt ___
___ 04:15PM BLOOD Neuts-59.8 ___ Monos-5.7 Eos-4.7*
Baso-0.5
___ 04:15PM BLOOD ___ PTT-29.4 ___
___ 04:15PM BLOOD Glucose-106* UreaN-29* Creat-1.2 Na-131*
K-5.1 Cl-94* HCO3-27 AnGap-15
___ 04:15PM BLOOD ALT-25 AST-29 AlkPhos-81 TotBili-0.3
___ 04:15PM BLOOD Lipase-21
___ 04:15PM BLOOD proBNP-619
.
EKG ___:
Baseline artifact. Sinus rhythm. Left atrial abnormality. P-R
interval
prolongation. Right bundle-branch block. Since the previous
tracing of ___ atrial premature beat is now not seen.
.
KUB ___:
FINDINGS: Supine and upright views of the abdomen were obtained.
There is
gaseous distention of the stomach without an otherwise
obstructive bowel gas pattern. A moderate amount of stool is
seen in the colon. No definite
evidence of free air is seen. There are marked degenerative
changes along the lumbar spine. Degenerative changes are also
seen at the hip joints
bilaterally and at the pubic symphysis.
.
IMPRESSION: Moderate colonic fecal loading and gaseous
distention of the
stomach without otherwise evidence of bowel obstruction.
.
CXR ___:
FINDINGS: Frontal and lateral views of the chest are obtained.
Mild
bibasilar atelectasis is seen. No focal consolidation, pleural
effusion, or evidence of pneumothorax is seen. The cardiac
silhouette is top normal. The aorta remains calcified and
tortuous. There is diffuse osteopenia.
Degenerative changes are seen at bilateral shoulder and
acromioclavicular
joints. There are also degenerative changes along the spine
along with severe compression again seen in the lower thoracic
vertebral body.
.
IMPRESSION: No acute cardiopulmonary process.
.
CT Abd/Pelvis ___:
FINDINGS: The included portions of the lung bases demonstrate
mild bilateral dependent atelectatic changes. There are coronary
artery and aortic calcifications. There is a small hiatal
hernia.
.
The liver, spleen, pancreas and right adrenal gland appear
unremarkable.
There is mild thickening of the left adrenal gland. Dependent
hyperdensity
within the gallbladder is suggestive of stones or sludge. The
right kidney
appears grossly normal. The left kidney contains several
hypodensities. A
multiloculated cyst in the lower pole appears similar to prior
MRI
examinations. Hypodensities in the interpolar region likely
represent simple cysts. Within the upper pole of the left
kidney, there is a 1.2 x 1.3 cm hyperdense lesion (601B:45)
which previously measured 6 mm on the prior MRI exam. This is
incompletely characterized.
.
Loops of small and large bowel are normal in size and caliber.
There is
diverticulosis without evidence of diverticulitis.
.
There are atherosclerotic calcifications of the abdominal aorta
and major
branches. The aorta is tortuous without evidence of aneurysm.
.
A 1.2 x 1.0 cm cystic lesion in the mesentery (2:57) is
incompletely
characterized, however benign in appearance and of doubtful
clinical
significant in a patient of this age.
.
The bladder appears within normal limits. The prostate gland is
normal in
size. No free air, free fluid or lymphadenopathy is seen. There
is a small
fat-containing umbilical hernia.
.
There are bilateral pars defects at L5/S1 with grade 1
anterolisthesis of L5 on S1. Multilevel degenerative changes of
the lumbar spine are present.
There are remote fractures of the left ninth and tenth ribs.
There are
degenerative changes in the lumbar spine with compression
deformities at T11 and T12 vertebral, indeterminate age however
not associated with paraspinal edema or retropulsion of
fragments.
.
IMPRESSION:
1. No acute findings to explain left upper quadrant tenderness.
2. Renal cysts including multiloculated lower pole cyst on the
left. A
hyperdense lesion in the upper pole of the left kidney is
incompletely
characterized. This was smaller on the prior MR examination of
___ which was characterized as hyperdense cyst at that time. A
soft tissue lesion, however, cannot be entirely excluded on this
exam.
3. Cholelithiasis versus gallbladder sludge.
4. Grade 1 spondylolisthesis of L5 over S1.
5. Indeterminate age depression deformities of T11 and T12
vertebral bodies.
.
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-5.0 RBC-4.15* Hgb-12.6* Hct-37.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.4 Plt ___
___ 07:30AM BLOOD Glucose-99 UreaN-23* Creat-1.0 Na-134
K-4.1 Cl-96 HCO3-28 AnGap-14
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ male with history of constipation,
abdominal pain, cough.
___.
FINDINGS: Frontal and lateral views of the chest are obtained. Mild
bibasilar atelectasis is seen. No focal consolidation, pleural effusion, or
evidence of pneumothorax is seen. The cardiac silhouette is top normal. The
aorta remains calcified and tortuous. There is diffuse osteopenia.
Degenerative changes are seen at bilateral shoulder and acromioclavicular
joints. There are also degenerative changes along the spine along with severe
compression again seen in the lower thoracic vertebral body.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
EXAM: Abdomen supine and upright views.
CLINICAL INFORMATION: ___ male with history of constipation,
abdominal pain, cough.
COMPARISON: None.
FINDINGS: Supine and upright views of the abdomen were obtained. There is
gaseous distention of the stomach without an otherwise obstructive bowel gas
pattern. A moderate amount of stool is seen in the colon. No definite
evidence of free air is seen. There are marked degenerative changes along the
lumbar spine. Degenerative changes are also seen at the hip joints
bilaterally and at the pubic symphysis.
IMPRESSION: Moderate colonic fecal loading and gaseous distention of the
stomach without otherwise evidence of bowel obstruction.
Radiology Report
INDICATION: Abdominal distention and left upper quadrant tenderness.
TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was
obtained after the administration of 130 mL IV Optiray contrast. Coronal and
sagittal reformations were prepared.
COMPARISON: No direct examinations available. Correlation with MR of the
L-spine dated ___ and MRU dated ___.
FINDINGS: The included portions of the lung bases demonstrate mild bilateral
dependent atelectatic changes. There are coronary artery and aortic
calcifications. There is a small hiatal hernia.
The liver, spleen, pancreas and right adrenal gland appear unremarkable.
There is mild thickening of the left adrenal gland. Dependent hyperdensity
within the gallbladder is suggestive of stones or sludge. The right kidney
appears grossly normal. The left kidney contains several hypodensities. A
multiloculated cyst in the lower pole appears similar to prior MRI
examinations. Hypodensities in the interpolar region likely represent simple
cysts. Within the upper pole of the left kidney, there is a 1.2 x 1.3 cm
hyperdense lesion (601B:45) which previously measured 6 mm on the prior MRI
exam. This is incompletely characterized.
Loops of small and large bowel are normal in size and caliber. There is
diverticulosis without evidence of diverticulitis.
There are atherosclerotic calcifications of the abdominal aorta and major
branches. The aorta is tortuous without evidence of aneurysm.
A 1.2 x 1.0 cm cystic lesion in the mesentery (2:57) is incompletely
characterized, however benign in appearance and of doubtful clinical
significant in a patient of this age.
The bladder appears within normal limits. The prostate gland is normal in
size. No free air, free fluid or lymphadenopathy is seen. There is a small
fat-containing umbilical hernia.
There are bilateral pars defects at L5/S1 with grade 1 anterolisthesis of L5
on S1. Multilevel degenerative changes of the lumbar spine are present.
There are remote fractures of the left ninth and tenth ribs. There are
degenerative changes in the lumbar spine with compression deformities at T11
and T12 vertebral, indeterminate age however not associated with paraspinal
edema or retropulsion of fragments.
IMPRESSION:
1. No acute findings to explain left upper quadrant tenderness.
2. Renal cysts including multiloculated lower pole cyst on the left. A
hyperdense lesion in the upper pole of the left kidney is incompletely
characterized. This was smaller on the prior MR examination of ___ which was
characterized as hyperdense cyst at that time. A soft tissue lesion, however,
cannot be entirely excluded on this exam.
3. Cholelithiasis versus gallbladder sludge.
4. Grade 1 spondylolisthesis of L5 over S1.
5. Indeterminate age depression deformities of T11 and T12 vertebral bodies.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD DISTENTION
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.4
heartrate: 84.0
resprate: 18.0
o2sat: 94.0
sbp: 141.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a history of Chronic
Diastolic Heart Failure, COPD, who presented with increasing
abdominal distention and constipation.
.
# Abdominal Distension/Constipation: His CT showed (see report
above) stool in the colon and patient had not had a BM in
several days. Patient had increasing distension over the last
few days prior to presentation, minimal discomfort in his
abdomen. His CT did not reveal any acute infection, patient was
afebrile, no leukocytosis. The most likely cause of his
distension was thought to be constipation. The patient was put
on an aggressive bowel regimen with Miralax, lactulose, Senna,
Docusate, and a bisacodyl suppository. He had one very large BM,
no diarrhea, no blood in his stool. He reported that his
distension had decreased afterwards, without complaints prior to
discharge.
.
#Chronic Diastolic CHF: Last echo in ___ showed EF of 55%, but
a component of diastolic heart failure. His BNP was 619 on
admission, CXR without evidence of cardiomegaly. He did not
appear to be decompensated on exam, he was continued on his home
lisinopril and torsemide as an inpatient and will follow this
regimen at home.
.
#COPD: Patient reports shortness of breath and wheezing at
baseline. He had a mild non-productive cough throughout his
admission. He was given an increasing dose of tesselon perles,
and nebs PRN. Patient had good sats on room air 93-95%. He was
continued on his home COPD medications. He will stop tessalon
perles as an outpatient, as this has been known to numb the
throat and cause an increased risk of aspiration. Patient also
on lisinopril and has a chronic cough, we have notified the
patient that he should discuss switching his lisinopril due to
chronic cough (possible ___.
.
#Left elbow Effusion: Patient had a small left elbow effusion
(chronic per patient), non-erythematous, no signs of infection.
He was given Tylenol for pain control.
.
#Hyponatremia. Appears chronic per OMR and has been attributed
to SIADH. Hyponatremia had resolved prior to discharge
.
#BPH: Patient continued on his finasteride.
.
#Cognitive Impairment: Continued donepezil 5mg.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
Lap cholecystectomy
History of Present Illness:
Ms. ___ is a ___ female with no past medical history
presenting with acute onset abdominal pain two days ago. She
went to urgent care where she had her labs checked. They were
abnormal and thus she was referred to ___. She was then referred
to the ___. The patient does not report n/v. She has had a
similar pain intermittently for the past ___ years. The time in
between her pain episodes then was so infrequent that she did
not connect the instances. The pain that she had on the day of
presentation to the OSH was different from the pain she had had
before because it was so long in duration and so intense
radiating from her back to the stomach and it would take her
breath away. No fevers or chills or change in her bowel habits.
Pain associated with reflux and increased gas. Her pain was not
related to food intake. She went to the hospital and was found
to have elevated bilirubin and transaminitis with multiple
stones in her gallbladder concerning for cholecystitis. Surgery
was consulted who recommended ERCP prior to cholecystectomy at
___. She has not had weight loss or weight gain. Transferred
from ___ for ERCP per ___ surgery
there and confirmed by ACS here. . ROS: Pertinent positives and
negatives as noted in the HPI. All other systems were reviewed
and are negative.
PAST MEDICAL/SURGICAL HISTORY:
No PMH/PSH
Anxiety attack x 1.
SOCIAL HISTORY: ___
FAMILY HISTORY: No family history of gallstones. Grandmother
with ulcers in her
stomach.
Past Medical History:
See HPI
Social History:
___
Family History:
See HPI
Physical Exam:
ADMISSION:
=========
EXAM(8)
98.2 PO ___ 18 99 RA
Currently she has ___ pain in the epigastrum but it is not
worsened with palpation.
VITALS: Afebrile and vital signs stable (see eFlowsheet)
___: 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:
=========
Vitals: 24 HR Data (last updated ___ @ 2346)
Temp: 98.9 (Tm 98.9), BP: 108/73 (106-123/73-78), HR: 78
(74-85), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra
Fluid Balance (last updated ___ @ ___)
Last 8 hours Total cumulative -950ml
IN: Total 0ml
OUT: Total 950ml, Urine Amt 950ml
Last 24 hours Total cumulative -635ml
IN: Total 1520ml, PO Amt 120ml, IV Amt Infused 1400ml
OUT: Total 2155ml, Urine Amt 2150ml, EBL 5ml
Physical exam:
GEN: A&O, NAD
CV: RRR
PULM: not in respiratory distress, breathing comfortably
ABD: Soft, nondistended, minimal tenderness epigastric, no
rebound or guarding, incisions c/d/i
Wound: incision c/d/i
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
===========================
___ 01:40AM BLOOD WBC-8.0 RBC-4.39 Hgb-10.5* Hct-35.1
MCV-80* MCH-23.9* MCHC-29.9* RDW-16.0* RDWSD-45.8 Plt ___
___ 01:40AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-135 K-5.0
Cl-107 HCO3-18* AnGap-10
___ 01:40AM BLOOD ALT-345* AST-233* AlkPhos-190*
TotBili-1.2 DirBili-0.5* IndBili-0.7
MICRO:
=====
none
IMAGING/OTHER STUDIES:
======================
ABDOMINAL US:
Gallbladder is filled with stones. No wall thickening. There is
no sonographic ___ sign. No biliary ductal dilatation. CBD
measures 3 mm.
MRCP ___. Moderately motion degraded study.
2. Cholelithiasis without acute cholecystitis, biliary ductal
dilatation, or choledocholithiasis.
___ 05:30AM BLOOD WBC-7.2 RBC-4.26 Hgb-10.3* Hct-32.6*
MCV-77* MCH-24.2* MCHC-31.6* RDW-16.1* RDWSD-44.4 Plt ___
___ 05:30AM BLOOD Glucose-75 UreaN-7 Creat-0.6 Na-141 K-4.6
Cl-109* HCO3-21* AnGap-11
___ 05:30AM BLOOD ___ PTT-30.1 ___
___ 05:30AM BLOOD ALT-198* AST-60* AlkPhos-161* TotBili-0.5
___ 05:30AM BLOOD Lipase-26
___ 05:30AM BLOOD Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr prn Disp #*7 Tablet
Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
Please hold for diarrhea or loose stool.
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
Please hold for diarrhea or loose stool.
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic cholelithiasis
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: ___ year old woman with abdominal pain, cholelithiasis and
elevated ___ transferred from OSH.// ACS request repeat US to better evaluate
GB wall. OSH US deemed suboptimal.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: Multiple gallstones are seen, measuring up to 1.0 cm, as seen on
the ultrasound performed 1 day prior. There is no distension or wall
thickening of the gallbladder. Ultrasonographic ___ sign was negative.
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: 11.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 11.0 cm
Left kidney: 10.4 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Multiple gallstones seen within the gallbladder. No distension or wall
thickening of the gallbladder. Negative ultrasonographic ___ sign. No
evidence of acute cholecystitis.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ presented to OSH with acute onset RUQ pain and liver injury
in setting of gallstones.// please eval for presence of choledocholithiasis as
requested by general surgery prior to possible CCY on ___.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Liver gallbladder ultrasound dated ___.
FINDINGS:
Study is moderately degraded by respiratory motion.
Lower Thorax: There is no pleural or pericardial effusion.
Liver: The liver is normal in signal intensity and morphology without focal
lesion or steatosis. There is no suspicious lesion. The portal and hepatic
veins are patent.
Biliary: There is no intrahepatic or extrahepatic biliary ductal dilatation.
The gallbladder contains numerous stones and is otherwise unremarkable without
pericholecystic inflammatory changes. There is no choledocholithiasis.
Pancreas: Pancreas is normal in signal intensity and morphology without focal
lesion or ductal dilatation.
Spleen: Spleen is normal in size without focal lesion. A small accessory
spleen is noted.
Adrenal Glands: Unremarkable.
Kidneys: No suspicious lesion or hydronephrosis.
Gastrointestinal Tract: Visualized loops of large and small bowel are
unremarkable.
Lymph Nodes: No upper abdominal lymphadenopathy.
Vasculature: Unremarkable.
Osseous and Soft Tissue Structures: No suspicious osseous lesion.
IMPRESSION:
1. Moderately motion degraded study.
2. Cholelithiasis without acute cholecystitis, biliary ductal dilatation, or
choledocholithiasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cholecystitis, Transfer
Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction
temperature: 97.6
heartrate: 69.0
resprate: 18.0
o2sat: 97.0
sbp: 156.0
dbp: 78.0
level of pain: 1
level of acuity: 3.0 | Ms. ___ is a ___ female with the past medical history
and findings noted above who presents with RUQ pain, found to
have symptomatic cholelithiasis.
# SYMPTOMATIC CHOLELITHIASIS:
Patient presented to OSH following acute right-sided abdominal
pain with obstructive LFT pattern and gallstones observed on
RUQ. Patient transferred given concern for choledocholithiasis
requiring ERCP. Upon arrival, pain had resolved, LFTs
downtrending, and repeat RUQ with persistence of gallstones but
no CBD dilation, overall consistent with passed stone. Per
surgery team request, MRCP obtained and confirmed no persistent
choledocholithiasis. On ___, she was taken to the OR and
underwent a laparoscopic cholecystectomy. For details of the
procedure please see the surgeon's operative report.
Following a brief uneventful recovery in the PACU the patient
was transferred to the surgical floor. Her diet was advanced to
a regular diet which was well tolerated. Her pain was well
controlled with oral pain medication.
Prior to discharge the patient was tolerating a regular diet,
her pain was well controlled with oral pain medication. She
voided without issue, and was ambulating independently. She was
afebrile and hemodynamically normal, she was deemed medically
appropriate for discharge home with close follow up in the
surgery clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Cardiac Arrest
Major Surgical or Invasive Procedure:
Femoral a-line
Formal CVL
intuabtion
History of Present Illness:
___ year old male with reported history of alcohol abuse found
down at 7AM this morning. Per report he was not feeling well
since the night prior but was unclear as to the cause of this.
He was found by his family at 0700 to be unresponsive. The
family called EMS and they found the patient to be in
PEA/Asystole. Resusitation was started in the field and
continued at ___. He recieved several rounds of
epi, bicarb and calcium. ROSC was obtained after 39 minutes at
OSH. A crash femoral CVL was placed and a head CT was obtained.
Patient was placed on epi drip. CT scan reportedly with severe
edema and troponin of 15. Cooling initiated and patient
transferred to ___. On arrival to ___ the patient was
reported to have no movement or response to pain though not on
sedatives/paralytics, and reported to have unilateral fixed and
dilated pupil. He was placed on levophed and epi, with
improvement in his blood pressure. Per report from the ED all
lines and interventions were done without sedation. No family
member per the ED resident was with the patient. On repeat scan
in the ED he was noted to have uncle herniation and diffuse
swelling of the drain with lost of the grey white matter.
Neurosurgey was consulted who said no neurosurgical
intervention.
On arrival to the MICU, the patient is non-responsive with
painful stimuli. His SBP was in the ___ with a thready pulse.
Review of systems:
Unable to obtain due to patient being unresponsive
Past Medical History:
Unable to obtain due to patient being unresponsive
Social History:
___
Family History:
Unable to obtain due to patient being unresponsive
Physical Exam:
Admission Exam:
Vitals: T:32.8 C (activly being cooled) BP:72/40 P:86
Intubated on Assit Contol ventilation with rate of 22, sats of
100% on 50% FiO2.
General- Intubated and unresponsive not on sedation
HEENT- Edemadous boggy scleara, left eye blown and fixed, right
eye 6mm and non-responsive, Sclera anicteric, MMM
Neck- supple, unable to further assess
Lungs- Difuse ronchi bilaterally
CV- RRR, no murmurs, or gallops
Abdomen- soft, unable to assess tenderness, +BS, no rebound
tenderness or guarding, no organomegaly
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- non-responsive. left eye blown and fixed, right eye 6mm
and non-responsive
Death Exam:
No pulse, no respirations, no heart sounds. Pupils fixed and
non-reactive.
Pertinent Results:
ADMISSION LABS:
___ 01:23PM BLOOD WBC-19.0* RBC-4.06* Hgb-12.2* Hct-38.4*
MCV-95 MCH-30.2 MCHC-31.9 RDW-14.0 Plt ___
___ 01:23PM BLOOD ___ PTT-40.4* ___
___ 01:23PM BLOOD Glucose-564* UreaN-36* Creat-2.6* Na-136
K-3.3 Cl-100 HCO3-12* AnGap-27*
___ 05:45PM BLOOD ALT-693* AST-1169* LD(LDH)-___*
CK(CPK)-6553* AlkPhos-191* TotBili-0.9
___ 01:23PM BLOOD cTropnT-3.48*
___ 05:45PM BLOOD CK-MB-365* MB Indx-5.6 cTropnT-6.42*
___ 01:23PM BLOOD Albumin-3.1* Calcium-8.5 Phos-7.5*
Mg-2.8*
___ 01:16PM BLOOD Type-ART pO2-102 pCO2-56* pH-6.89*
calTCO2-12* Base XS--24
___ 06:04PM BLOOD Type-ART ___ Tidal V-500 PEEP-5
FiO2-60 pO2-76* pCO2-42 pH-6.94* calTCO2-10* Base XS--24
Intubat-INTUBATED
___ 01:16PM BLOOD Lactate-12.6*
___ 06:04PM BLOOD Lactate-11.5*
Imaging:
Head CT:
There is diffuse cerebral edema with loss of gray-white
differentiation.
There is effacement of the sulci. There is effacement of the
lateral
ventricles, basal cisterns and downward tonsillar herniation.
There is
increased density in the basilar cisterns likely related to
diffuse cerebral edema.
There is a possible fracture of the left medial orbital wall.
There is
opacification of the bilateral ethmoid air cells and mucosal
thickening of the bilateral sphenoid sinuses and right maxillary
sinus. The frontal sinuses and mastoid air cells are clear.
IMPRESSION:
Diffuse cerebral edema with loss of gray-white differentiation
and uncal and downward tonsillar herniation.
CXR:
Portable AP chest radiograph. The ETT now terminates 3.2 cm
above the carina. Lung volumes are very low with low with
bibasilar atelectasis.
There is no pneumothorax.
Medications on Admission:
Unable to obtain due to patient being unresponsive
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired s/p cardiac arrest.
Discharge Condition:
Expired
Followup Instructions:
___
Radiology Report
INDICATION: Intubated. Reevaluation of ETT position.
COMPARISON: Outside hospital radiograph from ___ at 8:44 a.m.
FINDINGS: Portable AP chest radiograph. The ETT now terminates 3.2 cm above
the carina. Lung volumes are very low with low with bibasilar atelectasis.
There is no pneumothorax.
Radiology Report
HISTORY: Status post arrested unknown cause. Evaluate for worsening edema/
herniation.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes were generated. Thin-section bone algorithm
reconstructed images were acquired.
COMPARISON: Reference head CT from ___ at 916.
FINDINGS:
There is diffuse cerebral edema with loss of gray-white differentiation.
There is effacement of the sulci. There is effacement of the lateral
ventricles, basal cisterns and downward tonsillar herniation.There is
increased density in the basilar cisterns likely related to diffuse cerebral
edema.
There is a possible fracture of the left medial orbital wall. There is
opacification of the bilateral ethmoid air cells and mucosal thickening of the
bilateral sphenoid sinuses and right maxillary sinus. The frontal sinuses and
mastoid air cells are clear.
IMPRESSION:
Diffuse cerebral edema with loss of gray-white differentiation and uncal and
downward tonsillar herniation.
NOTIFICATION: Telephone indications Dr. ___ by Dr. ___ at 215 on
___ at time of review of study.
Radiology Report
INDICATION: Status post cardiac arrest due to unknown cause. Evaluate for
pulmonary embolism or hemoperitoneum.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained through the chest after
administration of 100 mL of Visipaque intravenous contrast, timed for the
early arterial phase. (Of note, a discussion was had regarding patient's the
elevated creatinine, however, given overall clinical situation, medical team
wished to pursue contrast-enhanced CT). Followed by scanning through the
abdomen and pelvis in the portal venous phase. Multiplanar reformatted images
in coronal and sagittal axes were generated.
DLP: 1562 mGy-cm.
FINDINGS:
CTA CHEST: There is an endotracheal tube in appropriate position. An enteric
tube terminates in the stomach. The airways are patent to the subsegmental
level. There is no mediastinal or hilar lymphadenopathy by CT size criteria.
The heart, pericardium and great vessels are unremarkable.
Lung windows demonstrates a large portion of the lower lobes to be collapsed
with atelectasis of the dependent portions of the upper lobes. There is no
evidence of pneumothorax or pleural effusion.
The aorta and main thoracic vessels are well opacified. The aorta
demonstrates normal caliber throughout the thorax without intramural hematoma
or dissection. The pulmonary arteries are opacified to the subsegmental
level. There is no filling defect in the main, right, left, lobar or
subsegmental pulmonary arteries.
CT ABDOMEN AND PELVIS: The liver enhances homogeneously without focal lesions
or intrahepatic biliary dilatation. There is hyperdense material within the
gallbladder, possible sludge. The portal vein is patent. The pancreas, spleen
and right adrenal gland are unremarkable. There is a fat containing lesion of
the left adrenal gland, consistent with an adrenal myelolipoma. The kidneys
demonstrate numerous intermediate density lesions bilaterally, the largest of
which on the left in the interpolar region, measures 2.3 cm and the largest of
which on the right in the upper pole, measures 1.9 cm.
The stomach is distended with fluid. Stomach wall appears mildly thickened,
possibly due to third spacing from volume resuscitation. The small bowel and
large bowel are fluid filled, but nondilated. A rectal tube is noted. There
is trace perihepatic simple free fluid. There is no retroperitoneal or
mesenteric lymph node enlargement by CT size criteria. There is no free air.
The intra-abdominal vasculature is unremarkable.
The urinary bladder is decompressed with a Foley catheter. A mild urachal
remnant is noted. The prostate is normal in size. There is no pelvic free
fluid. There is no inguinal or pelvic lymphadenopathy.
OSSEOUS STRUCTURES: No lytic or sclerotic lesion suspicious for malignancy is
present. Multilevel degenerative changes of the lumbar spine are noted.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Largely collapsed bilateral lower lobes with atelectasis of the dependent
portion of the upper lobes as well.
3. No evidence of acute intra-abdominal process and no hemoperitoneum.
4. Small amount of perihepatic simple free fluid.
5. Multiple intermediate density lesions in the bilateral kidneys for which
non-emergent renal ultrasound could be considered if the clinical scenario
warranted it.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: POST ARREST
Diagnosed with CARDIAC ARREST, HYPOTENSION NOS, CEREBRAL EDEMA, COMPRESSION OF BRAIN
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with asystole -> PEA arrest with ROSC p/w cerebral edema and
herniation.
#Cardiac Arrest/Brain Herniation: The patient was found down in
the field and resusicated and had return of circulation after 39
minutues from the time of EMS arrival on the scene. He was
unresponsive and was placed on blood pressure support. His
troponin was elevated, indicating a likely cardiac source for
his arrest. He had a head CT that was notable for severe
cerebral edema at the outside hospital. He was transfered to
___ for further care. Here he required increased blood
pressure support and was ultimatly on maximum dose of 3
medications to raise blood pressure. He was unresponsive to
painful stimuli. He was noted to have a left pupil that was
fixed and dialated. He underwent repeat Head CT that was notable
for severe cerebral edema with efacement of the grey/white
matter and both tonsilar and uncal herniation. Neurosurgery was
consulted who did not believe that any surgical or medical
intervention would be successful in return of any type brain
function. Given these findings multiple family meetings were had
to explain the prognosis and that he would not improve.
Following the family discussions the family decided to make the
patient CMO and the pressors were stopped and he was extubated.
The patient quickly passed and was pronounced dead at 2240. The
family was informed and autopsy was declined. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Ambien / ciprofloxacin
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of Addison's
disease, RA and hypothyroidism, who was referred to the ED by
endocrinologist after recent labs showed K+ of 6.3. She reports
several days of weakness, feeling flushed, palpitations, and
having lower extremity discomfort. Of note, she had an Ecoli UTI
recently diagnosed ___ and treated with Bactrim DS 1 by mouth
twice a day for 3 days. She denies SOB, chest pain, N/V,
fevers/chills/night sweats, abdominal pain, changes in bowel
movements, or falls. She reports she has no continued dysuria,
put continues to have malaise.
She had similar symptoms in ___ from a UTI that resulted in
decompensation of her Addisons, urosepsis, and ICU admission.
During this admission she was treated with fluids and briefly on
norepinephrin drip due to hypotension unresponsive to fluids.
She was given stress-dose steroids with hydrocrotisone and
ceftriaxone, and narrowed to 7d course of bactrim when urine
culture from outpatient on ___ grew pan-sensitive E. coli.
In the ED, initial VS were T 97.4 HR 72 BP 154/100 RR 12 100%
___ on RA. Labs on presentation were significant for K+ of 6.3,
Na+ of 135, Cre 1.2, BUN 25, and lactate of 2.1. EKG was
significant for normal sinus rhythm and peaked T waves. CXR was
negative for an acute cardiopulmonary process. UA was negative.
In the ED she received 2L of NS, 2g calcium gluconate, IV
dextrose and 6U IV insulin, 100mg IV hydrocortisone. Repeat K+
in the ED showed downtrending to 4.9n and repeat EKG showed
slightly less peaked T waves. Her blood sugar dropped to 49
after IV insulin, but increased to 98 after eating. Transfer VS
were T 97.7 HR 79 BP 133/70 RR 18 100% ___ on RA. Decision was
made to admit to medicine for further management.
On arrival to the floor, patient reports feeling much better
with improved malaise, weakness, lower extremity discomfort, and
palpitations. She is noted to be often walking the halls, and
reports trouble sleeping.
Past Medical History:
PMH:
ADDISON'S DISEASE (Dx over ___ ago. on fludrocortisone 0.1 mg,
prednisone 5 mg tablet)
ADDISONIAN CRISIS
RHEUMATOID ARTHRITIS (on MTX 25mg/week)
COLLAGENOUS COLITIS (not active)
FIBROCYSTIC CHANGES IN BREAST
GERD (Rx. Nexium 40mg)
HYPERCHOLESTEROLEMIA
HYPOTHYROIDISM (Synthroid ___ mcg tablet)
IRON DEFICIENCY ANEMIA
MENOPAUSE (on estrogen cream, estradiol vaginal ring)
OSTEOPENIA (Rx. alendronate 70 mg tablet weekly)
SPINAL STENOSIS (baclofen, oxycodone, diazepam 5 mg, PRN)
LACTOSE INTOLERANCE
ANXIETY (Rx. clonazepam 0.5 mg tablet, PRN
HTN (metoprolol 25mg)
MIGRAINES
PSH:
BACK SURGERY
TUBAL LIGATION
Social History:
___
Family History:
Mother with OA and sister with RA.
No history of blood clots
Father- stroke in ___
No seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.4 HR 84 BP 129/73 RR 16 100% O2sat
General: NAD, in good spirits, pleasant
Cardio: RRR no mrg
Respiratory: CTAB
Abdominal: soft, slight suprapubic tenderness to palpation, no
rebound or guarding
Extremities: warm and well perfused
Skin: hyperpigmented skin noted on exposed areas
DISCHARGE PHYSICAL EXAM:
Vitals: Afebrile VSS SBP 116-130s
General: NAD, in good spirits, pleasant
Cardio: RRR no mrg
Respiratory: CTAB
Abdominal: soft, slight suprapubic tenderness to palpation, no
rebound or guarding
Extremities: warm and well perfused
Skin: hyperpigmented skin noted on sun-exposed areas; no
increased pigmentation of buccal mucosa or palmar creases
Pertinent Results:
LABS ON ADMISSION
___ 03:20PM BLOOD WBC-7.2 RBC-3.96* Hgb-12.6 Hct-37.8
MCV-96 MCH-31.8 MCHC-33.3 RDW-13.7 Plt ___
___ 03:20PM BLOOD Plt ___
___ 12:25PM BLOOD UreaN-25* Creat-1.2* Na-135 K-6.3* Cl-102
HCO3-23 AnGap-16
___ 03:20PM BLOOD ALT-27 AST-59* AlkPhos-44 TotBili-0.4
___ 03:20PM BLOOD Albumin-5.0 Calcium-9.9 Phos-3.5 Mg-2.2
___ 03:32PM BLOOD Lactate-2.1* K-6.1*
___ 03:35PM URINE Color-Straw Appear-Clear Sp ___
___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
LABS ON DISCHARGE
___ 07:15AM BLOOD WBC-10.7 RBC-3.56* Hgb-11.4* Hct-34.0*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.9 Plt ___
___ 07:15AM BLOOD Glucose-68* UreaN-25* Creat-1.0 Na-139
K-4.6 Cl-100 HCO3-23 AnGap-21*
___ 07:15AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0
MICRO
___ 3:35 pm URINE Site: NOT SPECIFIED
CHM S# ___ UCU ADDED ___.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
IMAGING
___ CXR: No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID:PRN symptoms of HSV
2. Alendronate Sodium 70 mg PO 1X/WEEK (___)
3. Baclofen 10 mg PO TID:PRN leg spasm
4. Clobetasol Propionate 0.05% Cream 1 Appl TP Frequency is
Unknown
5. ClonazePAM 0.5 mg PO BID:PRN anxiety
6. Diazepam 5 mg PO Q6H:PRN back pain
7. esomeprazole magnesium 40 mg oral BID
8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal as directed
9. Estring (estradiol) 2 mg vaginal q 12 weeks
10. Fludrocortisone Acetate 0.1-0.2 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Methotrexate 25 mg PO 1X/WEEK (___)
14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
15. PredniSONE 10 mg PO DAILY
16. Calcium Carbonate 500 mg PO DAILY
17. Vitamin D Dose is Unknown PO DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Baclofen 10 mg PO TID:PRN leg spasm
2. Calcium Carbonate 500 mg PO DAILY
3. ClonazePAM 0.5 mg PO BID:PRN anxiety
4. Fludrocortisone Acetate 0.1-0.2 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
9. PredniSONE 20 mg PO DAILY
20 mg on ___ and ___ 10 mg on ___ 5 mg on ___ and
afterwards as advised by endocrinologist
Tapered dose - DOWN
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Methotrexate 25 mg PO 1X/WEEK (___)
11. Estring (estradiol) 2 mg vaginal q 12 weeks
12. Acyclovir 400 mg PO BID:PRN symptoms of HSV
13. Alendronate Sodium 70 mg PO 1X/WEEK (___)
14. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
15. Esomeprazole Magnesium 40 mg ORAL BID
16. Diazepam 5 mg PO Q6H:PRN back pain
17. Vitamin D 400 UNIT PO DAILY
18. Estradiol (estradiol) 0.01 % (0.1 mg/gram) VAGINAL AS
DIRECTED
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hyperkalemia
Addison's Disease
Secondary diagnoses:
Rheumatoid arthritis
Hypothyroidism
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ PMH Addisons with recent fevers/chills // eval for
Pneumonia
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Prior right central venous line is no longer visualized. Lungs are clear of
focal consolidation, effusion, or pulmonary vascular congestion. The
cardiomediastinal silhouette is normal. No acute osseous abnormalities
identified.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Hyperkalemia
Diagnosed with GLUCOCORTICOID DEFICIENCY, HYPERKALEMIA, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 97.4
heartrate: 72.0
resprate: 12.0
o2sat: nan
sbp: 154.0
dbp: 100.0
level of pain: 6
level of acuity: 2.0 | Hospital course: ___ with history of Addison's disease,
rheumatoid arthritis, and hypothyroidism presented with weakness
and palpitations, hyperkalemia to 6.3 with associated ECG
changes after being treated for UTI with bactrim now status-post
4L IVF, IV lasix, and stress-dose IV hydrocortisone, discharged
with resolution of hyperkalemia, ECG changes, and symptoms with
plans to continue PO prednisone and fludricortisone and follow
up with primary care and endocrinology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Difficulty speaking
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old woman with no past medical history
who presents to the ED after an episode of difficulty speaking.
History is obtained primarily from her as well as her husband.
She was in her usual state of health today and going about her
business as usual, when at around 12 noon her husband shouted to
her from the next room. When she did not respond he went in to
check on her. Although she was trying to speak, she was unable
to
produce more than a sound or two (eg. "tuh, tuh..."). He tried
asking her various questions but she was unable to answer. She
seemed to know what she wanted to say, but was unable to get it
out. Ms ___ states that she very clearly remembers this and
could think of what she wanted to say, but was unable to produce
the words. She understood everything that was being said to her.
There was no facial droop, weakness, sensory change, or
headache.
She was able to walk around and carry objects in her hands
during
this time. After about 5 minutes of this, she seemed to be
improving, in that she was able to say things like ___ and
"okay". Thinking the episode was over, she and her husband
watched TV on the couch until about 1:30pm. During this time she
did not say anything more than one or two words.
At around 1:30pm her daughter arrived. When she did so, she
asked
Ms ___ several questions, and again she seemed to have
difficulty producing anything more than a single sound. As
above,
she knew what she wanted to say, and could understand what
people
were saying to her. Thinking that she needed to rest, she went
to
take a nap. When she awoke at about 3:30, she found that she was
again able to speak normally. However, as they were concerned
she
could have had a stroke, they presented to ___. There,
initial BP was 143/73. Due to concern for stroke, she was
transferred to ___.
She has never had an prior similar episodes. She denies any
pain,
difficulty speaking, weakness, or sensory change currently.
Past Medical History:
Osteoarthritis
Social History:
___
Family History:
Sister died of a heart attack at age ___
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 97.8 BP: 161/79 HR: 79 RR: 16 SaO2: 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. Able to register 3 objects and recall
___ at 5 minutes, and the third with category clue. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Slight flattening of the right nasolabial fold with good
activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Tone is slightly increased in the legs. No pronator
drift. No adventitious movements, such as tremor or asterixis
noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Mildly decreased sensation to vibration,
proprioception
in both feet. Otherwise normal. No extinction to DSS. Sways with
Romberg but does not fall.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAM:
===============
VS: Temp: 98.5 (Tm 99.1), BP: 136/71 (122-158/64-71), HR: 66
(54-73), RR: 18 (___), O2 sat: 97% (96-99), O2 delivery: Ra
Exam
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
No dysarthria. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Slight flattening of the right nasolabial fold with good
activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Tone is slightly increased in the legs. No pronator
drift. No adventitious movements, such as tremor or asterixis
noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Mildly decreased sensation to vibration,
proprioception
in both feet. Otherwise normal. No extinction to DSS. Sways with
Romberg but does not fall.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:04AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:31AM GLUCOSE-88 UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-11
___ 07:31AM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-169
CK(CPK)-24* ALK PHOS-76 TOT BILI-0.3
___ 07:31AM GGT-84*
___ 07:31AM CK-MB-<1 cTropnT-<0.01
___ 07:31AM TOT PROT-6.0* ALBUMIN-3.4* GLOBULIN-2.6
CHOLEST-166
___ 07:31AM VIT B12-229* FOLATE-5
___ 07:31AM %HbA1c-5.3 eAG-105
___ 07:31AM TRIGLYCER-77 HDL CHOL-59 CHOL/HDL-2.8
LDL(CALC)-92
___ 07:31AM TSH-5.7*
___ 07:31AM CRP-1.6
___ 07:31AM WBC-4.5 RBC-2.75* HGB-9.4* HCT-28.2* MCV-103*
MCH-34.2* MCHC-33.3 RDW-13.2 RDWSD-48.3*
___ 07:31AM NEUTS-43.5 ___ MONOS-9.8 EOS-2.0
BASOS-0.7 IM ___ AbsNeut-1.95 AbsLymp-1.94 AbsMono-0.44
AbsEos-0.09 AbsBaso-0.03
___ 07:31AM ___ PTT-34.7 ___
___ 07:31AM PLT COUNT-131*
___ 01:40AM cTropnT-<0.01
___ 01:40AM ___ PTT-33.2 ___
___ 12:35AM GLUCOSE-95 UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-19* ANION GAP-12
___ 12:35AM estGFR-Using this
___ 12:35AM ALT(SGPT)-13 AST(SGOT)-25 ALK PHOS-74 TOT
BILI-0.3
___ 12:35AM LIPASE-35
___ 12:35AM cTropnT-<0.01
___ 12:35AM ALBUMIN-3.4* CALCIUM-8.2* PHOSPHATE-3.4
MAGNESIUM-1.9
___ 12:35AM %HbA1c-5.6 eAG-114
___ 12:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 12:35AM WBC-5.1 RBC-2.74* HGB-9.3* HCT-28.3* MCV-103*
MCH-33.9* MCHC-32.9 RDW-13.1 RDWSD-48.3*
___ 12:35AM NEUTS-48.2 ___ MONOS-7.5 EOS-1.6
BASOS-0.6 IM ___ AbsNeut-2.44 AbsLymp-2.11 AbsMono-0.38
AbsEos-0.08 AbsBaso-0.03
___ 12:35AM PLT COUNT-141*
___ 11:30PM URINE HOURS-RANDOM
___ 11:30PM URINE HOURS-RANDOM
___ 11:30PM URINE HOURS-RANDOM
___ 11:30PM URINE GR HOLD-HOLD
___ 11:30PM URINE UHOLD-HOLD
___ 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
DISCHARGE LABS:
===============
___ 07:31AM BLOOD WBC-4.5 RBC-2.75* Hgb-9.4* Hct-28.2*
MCV-103* MCH-34.2* MCHC-33.3 RDW-13.2 RDWSD-48.3* Plt ___
___ 05:20AM BLOOD ___ PTT-35.5 ___
___ 05:20AM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-141
K-4.5 Cl-106 HCO3-25 AnGap-10
___ 07:31AM BLOOD ALT-12 AST-20 LD(LDH)-169 CK(CPK)-24*
AlkPhos-76 TotBili-0.3
___ 07:31AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:20AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
___ 07:31AM BLOOD VitB12-229* Folate-5
___ 07:31AM BLOOD %HbA1c-5.3 eAG-105
___ 07:31AM BLOOD TSH-5.7*
___ 12:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING:
========
CXR ___:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Slight haziness of the left
lung base on the frontal view does not have a correlate on the
lateral view and likely due to overlying known breast implant.
No focal consolidation is otherwise seen. No pleural effusion
or pneumothorax is seen. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality. Slight haziness of the
left lung base on the frontal view likely due to overlying known
breast implant.
CTA head/neck ___:
1. Multifocal atherosclerotic disease of the circle of ___
with no evidence of occlusion or aneurysm formation.
2. Mild atherosclerotic calcifications of the common carotid
artery
bifurcations without evidence of internal carotid artery
stenosis by NASCET criteria.
3. Atherosclerotic narrowing of the distal right vertebral
artery.
MRI head without contrast ___:
1. Small subacute infarction in the left posterior insular
cortex and tiny
infarction in the left temporal lobe.
2. No evidence of acute hemorrhage.
3. Mild-to-moderate parenchymal volume loss.
TTE ___:
The left atrial volume index is normal. There is no evidence for
a right-to-left shunt with agitated saline at rest and with
maneuvers. The estimated right atrial pressure is ___ mmHg.
There is normal left ventricular wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Quantitative 3D volumetric left
ventricular ejection fraction is 65 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18mmHg). Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is moderate mitral
annular calcification. There is mild [1+] mitral regurgitation.
Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is high
normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function. Mild mitral regurgitation with normal valve
morphology.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Every evening Disp
#*30 Tablet Refills:*3
3. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*3
4.Outpatient Physical Therapy
Home ___.
ICD: I63.9.
5.Cane
Straight cane. ICD I63.9.
Prognosis: Good.
Length of need: 13 months.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ female with transient aphasia concerning for TIA.
Stroke protocol.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head without contrast dated ___.
CTA head and neck with contrast dated ___.
FINDINGS:
There is hyperintense signal abnormality on the diffusion-weighted images
along the posterior aspect of the left insular cortex without corresponding
hypointensity on the ADC map. There is also a tiny focus of hyperintense
diffusion signal abnormality in the left temporal lobe peritrigonal region.
The findings likely represent subacute infarctions.
There is a tiny chronic microhemorrhage in the left centrum semiovale. There
is no evidence of acute hemorrhage.
Mild-to-moderate prominence of the ventricles and sulci is suggestive of
involutional changes. There is no mass effect or midline shift. Patchy areas
of T2 and FLAIR hyperintense signal abnormalities in the periventricular and
subcortical white matter are nonspecific, but likely reflect chronic small
vessel ischemic changes.
There is a partially empty sella. The major intracranial arterial and venous
flow voids are preserved. Mild mucosal thickening of the ethmoid sinuses.
Trace mastoid air cell effusions are noted. The intraorbital contents are
unremarkable.
IMPRESSION:
1. Small subacute infarction in the left posterior insular cortex and tiny
infarction in the left temporal lobe.
2. No evidence of acute hemorrhage.
3. Mild-to-moderate parenchymal volume loss.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Aphasia, Transfer
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 97.8
heartrate: 79.0
resprate: 16.0
o2sat: 96.0
sbp: 161.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
================
This is an otherwise healthy ___ year old woman who presented to
the ED after 2 episodes of inability to produce speech. Though
she describes two distinct episodes, it is not clear that she
ever returned to normal in between them. Alternatively, it is
possible that she had a single continuous episode lasting
several hours.
Neurologic exam is currently only notable for very slight right
facial asymmetry, and increased tone in the legs with loss of
large fiber sensation.
MRI shows a small subacute infarction in the left posterior
insular cortex and tiny infarction in the left temporal lobe.
Etiology thought to be cardioembolic vs. artery-to-artery given
moderate atherosclerotic calcifications at the carotid bulbs and
carotid siphons bilaterally.
She was started on aspirin 81 mg daily and atorvastatin 40 mg
daily while in house. She had an unremarkable TTE.
Patient found to have B12 deficiency in house. She was started
on vitamin B12 100 mcg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of dysphagia and ? GERD vs eosinophilic esophagitis,
s/p EGD on ___ around 1pm presenting with esophageal
perforation. Patient felt fine after EGD, tolerated soup, and
went home, however, over course of afternoon had increasing
chest pain and returned to ___. Denies nausea or vomiting. No
shortness of breath. Patient found to have mediastinal air on
CT,
no pneumo, no effusion and transferred to ___ for further
management. Patient has ___ year history of dysphagia with food.
Occasional regurgitation. Had EGD in ___ that saw white cells in
biopsies of distal esophagus and question of eosinophilic
esophagitis vs reflux so was placed on high dose PPI for 3
months
and underwent repeat EGD yesterday which was by report normal.
Past Medical History:
PMH: GERD
PSH: none
Social History:
___
Family History:
non contributory
Physical Exam:
VS: T: 97 70 ___ 98%Ra
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, no subq emphysema, some tenderness to palpation in
anterior chest
PULM: no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, no tenderness,
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ Ba swallow :
No frank esophageal leak
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 160 mg/5 mL 20 mls by mouth every six (6)
hours Refills:*0
2. Amoxicillin-Clavulanate Susp. 500 mg PO/NG Q8H
RX *amoxicillin-pot clavulanate 250 mg-62.5 mg/5 mL 10 mls by
mouth every eight (8) hours Refills:*1
3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole 30 mg 1 tablet(s) twice a day Disp #*28 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumomediastinum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with perforated esophagus// eval for perf
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 10 mGy; Accum DAP: 91.57 uGym2; Fluoro time: 1 minutes
12 seconds
COMPARISON: Outside CT chest from ___
FINDINGS:
With patient in the upright position, water-soluble contrast was administered
per mouth. In the frontal and lateral position, there was no suggestion of
esophageal leak. Patient was then asked to swallow thin barium liquid, also
in the upright position. Again, there was no evidence of extraluminal
contrast to suggest leak. Contrast cleared normally into the stomach without
evidence of obstruction.
IMPRESSION:
No frank esophageal leak.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, PERFORATED ESOPHAGUS, Transfer
Diagnosed with Chest pain, unspecified
temperature: 97.0
heartrate: 70.0
resprate: 16.0
o2sat: 98.0
sbp: 108.0
dbp: 82.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for observation.
She remained NPO and was hydrated with IV fluids. Her barium
swallow showed no perforation and Tylenol took care of her chest
discomfort. She was placed on broad spectrum antibiotics
prophylactically and her WBC was 12K at ___.
As she remained afebrile and her WBC trended down to normal,
clear liquids were started. She was able to swallow without
difficulty. Her IV antibiotics were changed to Augmentin
suspension which she will continue for a ___nd her
diet will be advanced to full liquids tomorrow. As she continues
to progress well, she was discharged to home on ___ and
will follow up with Dr. ___ week. She will also follow up
with her ___ physician but may want to be referred
here to the GI service. She will let us know at her follow up
visit. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ampicillin / cat scan dye /
aspirin
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 08:43PM BLOOD WBC-6.5 RBC-3.44* Hgb-6.6* Hct-24.9*
MCV-72* MCH-19.2* MCHC-26.5* RDW-19.9* RDWSD-47.2* Plt ___
___ 08:43PM BLOOD Neuts-64.8 ___ Monos-6.1 Eos-1.5
Baso-0.5 Im ___ AbsNeut-4.22 AbsLymp-1.73 AbsMono-0.40
AbsEos-0.10 AbsBaso-0.03
___ 08:43PM BLOOD ___ PTT-26.3 ___
___ 08:43PM BLOOD D-Dimer-632*
___ 08:43PM BLOOD Glucose-171* UreaN-32* Creat-1.4* Na-140
K-4.7 Cl-105 HCO3-20* AnGap-15
___ 08:43PM BLOOD ALT-12 AST-19 AlkPhos-73 TotBili-0.4
___ 08:43PM BLOOD proBNP-___*
___ 08:43PM BLOOD cTropnT-<0.01
___ 08:43PM BLOOD Albumin-4.3 Calcium-9.2 Phos-4.2 Mg-2.4
Iron-17*
___ 08:43PM BLOOD calTIBC-493* VitB12-373 Ferritn-9.7*
TRF-379*
DISCHARGE LABS
===============
___ 06:10AM BLOOD WBC-7.3 RBC-3.38* Hgb-8.1* Hct-26.8*
MCV-79* MCH-24.0* MCHC-30.2* RDW-25.0* RDWSD-57.3* Plt ___
___ 06:10AM BLOOD Glucose-120* UreaN-18 Creat-1.1 Na-145
K-4.8 Cl-111* HCO3-22 AnGap-12
___ 06:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2
___ 06:00AM BLOOD 25VitD-40
PERTINENT MICRO
================
___ 08:43PM URINE Color-Straw Appear-CLEAR Sp ___
___ 08:43PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-SM*
___ 08:43PM URINE RBC-10* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 08:43PM URINE CastHy-2*
___ 8:43 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:30PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
PERTINENT IMAGING
==================
EKG (___)
Sinus rhythm
Probable left atrial enlargement
When compared with ECG of ___ wave
abnormalities are less marked
CXR (___)
IMPRESSION:
1. Streaky right lower lobe opacities suggestive of bronchitis.
2. Mild cardiomegaly.
CT Chest (___)
IMPRESSION:
1. Findings concerning for multifocal aspiration pneumonia with
right lower lobe consolidation, and right upper lobe ___
nodules. Follow-up imaging may be performed with radiographs.
2. Additional multiple pulmonary nodules are also noted in the
left upper lobe and left lower lobe measuring up to 4 mm, may be
inflammatory.
3. Prominent mediastinal lymph nodes are likely reactive.
CT Neck (___)
IMPRESSION:
1. Evaluation for malignancy within the head and neck is limited
in the
absence of intravenous contrast media. Within the limitation,
there is no evidence of obstructing or non-obstructing
malignancy within the neck.
2. Paranasal sinus disease.
3. Please refer to the separately dictated CT chest for full
description of the intrathoracic findings.
4. Please also note that this examination is there is only is an
anatomical survey and does not assess the swallowing mechanism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
2. Sodium Bicarbonate 650 mg PO BID:PRN belching
3. Allopurinol ___ mg PO DAILY
4. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN postnasal
drip
6. amLODIPine 5 mg PO DAILY
7. melatonin 3 mg oral QHS:PRN insomnia
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
2. Cefpodoxime Proxetil 400 mg PO DAILY Duration: 10 Doses
3. Ferrous Sulfate 325 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
8. Allopurinol ___ mg PO DAILY
9. amLODIPine 5 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN postnasal
drip
11. melatonin 3 mg oral QHS:PRN insomnia
12. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
13. Sodium Bicarbonate 650 mg PO BID:PRN belching
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Community Acquired Pneumonia
================== Bronchiectasis
SECONDARY DIAGNOSIS: Iron deficiency anemia
==================== Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with cough x 2 weeks, fatigue // r/o pna
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and prior
FINDINGS:
Lungs appear mildly hyperinflated.Mild cardiomegaly. There is mild
atherosclerotic calcification and tortuosity of the thoracic aorta.
Redemonstrated is subsegmental atelectasis at the medial left lung base.
There are streaky right lower lobe opacities. There is osteopenia. There are
mild multilevel degenerative changes of the thumb thoracic spine.
IMPRESSION:
1. Streaky right lower lobe opacities suggestive of bronchitis.
2. Mild cardiomegaly.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old female with a history of DM, HTN, CKD presenting with
3 weeks of cough productive of clear sputum, wheezing, and decreased exercise
tolerance. CXR with RLL streaking and lungs diffusely rhonchorous, treating
empirically w/ abx. // evidence of parenchymal disease, other acute process
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: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 4.8 mGy (Body) DLP = 169.8
mGy-cm.
Total DLP (Body) = 170 mGy-cm.
COMPARISON: Chest radiograph ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Visualized thyroid appears
unremarkable. There is no supraclavicular lymphadenopathy. There is no
axillary lymphadenopathy.
UPPER ABDOMEN: Visualized portion of the upper abdomen demonstrate multiple
bilateral hypodensities within the kidneys, measuring up to 2.3 cm in the
right upper pole, likely renal cysts.
MEDIASTINUM: Multiple prominent mediastinal lymph nodes are seen, for example
a right paratracheal lymph node measuring 1.2 cm in short axis (302; 61).
HILA: No definite hilar lymphadenopathy is noted on this noncontrast scan.
HEART and PERICARDIUM: The heart is mildly enlarged. There is no pericardial
effusion. There are severe coronary artery calcifications. Mild aortic valve
calcifications and mitral annulus calcifications are also seen.
PLEURA: There is no pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Nodular opacities in the right lower lobe with ground-glass
opacities are concerning for pneumonia. Extensive ___ nodules are
noted in the right upper lobe anteriorly concerning for infection (302; 70).
There is increased interstitial septal thickening suggesting possible mild
pulmonary edema. A 4 mm geometric subpleural pulmonary nodule is noted in the
left upper lobe (302; 67), likely a pulmonary lymph node. Multiple 3-4 mm
pulmonary nodules noted in the left upper lobe (302; 43, 48, 145). A 4 mm
left lower lobe pulmonary nodule is noted. 3 mm pulmonary nodule is noted in
the right upper lobe.
2. AIRWAYS: There is diffuse bilateral bronchial wall thickening with mucous
plugging predominantly in the right lower lobe.
3. VESSELS: The aorta and pulmonary arteries are normal in caliber. There is
moderate atherosclerotic calcification of the aorta.
CHEST CAGE: Chronic fracture deformity of the right proximal humerus is noted.
Incidental sternal foramen is noted. No suspicious osseous lesion is
identified. Grade 1 retrolisthesis of L1 on L2 is noted.
IMPRESSION:
1. Findings concerning for multifocal aspiration pneumonia with right lower
lobe consolidation, and right upper lobe ___ nodules. Follow-up
imaging may be performed with radiographs.
2. Additional multiple pulmonary nodules are also noted in the left upper lobe
and left lower lobe measuring up to 4 mm, may be inflammatory.
3. Prominent mediastinal lymph nodes are likely reactive.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
INDICATION: ___ year old female with a history of DM, HTN, CKD presenting with
3 weeks of cough productive of clear sputum, wheezing, and decreased exercise
tolerance. CXR with RLL streaking and lungs diffusely rhonchorous, treating
empirically w/ abx. Also with new oropharyngeal dysphagia and suspected
aspiration. // r/o H N malignancy, obstructing lesion
TECHNIQUE: MDCT acquired helical axial images were obtained from the thoracic
inlet through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 26.5 cm; CTDIvol = 12.3 mGy (Body) DLP = 325.5
mGy-cm.
Total DLP (Body) = 326 mGy-cm.
COMPARISON: CT cervical spine without contrast of ___.
FINDINGS:
Evaluation for malignancy within the head and neck is limited in the absence
of intravenous contrast media. Within this limitation there is no evidence
mass lesion involving the nasopharynx or oropharynx. Some debris is noted at
the level of the epiglottis and vallecular folds. No evidence of mass at the
level of the vocal cords.
There is a mucous retention cyst in left maxillary sinus. There are no
suspicious lymph nodes within the neck.
Salivary glands are grossly normal without evidence of mass or adjacent fat
stranding. The thyroid gland appears normal.
Multilevel degenerative changes are noted within the cervical spine. No acute
osseous lesions.
Partially visualized intracranial structures are unremarkable without evidence
of midline shift. Visualized orbits within normal limits.
Prominent mediastinal lymph nodes, bronchial wall thickening and a right lower
lobe pneumonia are better evaluated on the concurrently performed CT chest.
IMPRESSION:
1. Evaluation for malignancy within the head and neck is limited in the
absence of intravenous contrast media. Within the limitation, there is no
evidence of obstructing or non-obstructing malignancy within the neck.
2. Paranasal sinus disease.
3. Please refer to the separately dictated CT chest for full description of
the intrathoracic findings.
4. Please also note that this examination is there is only is an anatomical
survey and does not assess the swallowing mechanism.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea, Wheezing
Diagnosed with Pneumonia, unspecified organism
temperature: 97.2
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 170.0
dbp: 41.0
level of pain: 2
level of acuity: 2.0 | SUMMARY:
====================
___ is a ___ year old female with a history of
DM, HTN, CKD presenting with 3 weeks of cough productive of
clear sputum, wheezing, and decreased exercise tolerance, found
to have Hgb ___ s/p 1u pRBC with appropriate response, as well
as multifocal pneumonia and concern for aspiration, treated with
antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ambien
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ yo F NSCL stage IIIB s/p chemoXRT admitted from ___
___ after she was found to have a 4cm L
occipital brain lesion with white matter edema and small
hemorrhage but without midline shift or herniation as well as a
L spine lesion. Patient presented initially to ___. Es with LLQ
pain and vomiting although she denies vomiting on my interview
along ___ back pain and vision disturbances primarily on the R
visual field. Say she woke up on the morning of admission with
severe abdominal pain prompting presentation to ___. Es ER. Of
note, she has been having increasingly severe back pain in the
mid back that is unrelated to activity and without radiation,
neurologic symptoms such as leg weakness, paresthesias, bowel or
bladder dysfunction although she does note intermittent
constipation and diarrhea although no urinary or fecal
incontinence. Says pain usually controlled with Tylenol but it
returns after 4 hours. Also notes some blurred vision on the
right side. Of note, she denies headaches, nausea, or focal
neuro motor/sensory complaints although she says she does feel
like she "walks to one side" occasionally. Denies night time
difficulties with ambulation. No recent falls.
In the ER at ___ vitals were: T 99.2 HR 97 BP 141/67 RR 18
SaO2 97% RA. Received 10mg IV dexamethasone. Films from ___ Es
uploaded to PACS system (brain MRI, spine MRI, and CT abdomen
pelvis). Admitted to Oncology for further eval and management.
On arrival to the floor patient says her back pain is
controlled. No specific complaints.
Past Medical History:
ONCOLOGIC HISTORY:
-Stage IIIB NSCLC with large right upper lobe mass with
mediastinal invasion, started on steroids, and having received
one cycle of chemotherapy (unclear date and type). Treated by
Dr. ___ at ___
-___ MEDICAL & SURGICAL HISTORY:
- hypertension
- hyperlipidemia
- anxiety
- s/p tonsillectomy
- s/p carpal tunnel surgery
Social History:
___
Family History:
Mother had malignancy ___ (unclear type) s/p partial
amputation.
Physical Exam:
On admission:
VS: T 98.2 HR 92 BP 102/58 RR 18 SaO2
GEN: Comfortable in NAD
Eyes: [x]WNL [x]EOMI [x]PERRL [x]Conjunctiva: [x]clear
[]injected []icteric
ENT: [x]WNL []Moist MM []dry MM []poor dentition []edentulous
[]ulcers []erythema []exudate []thrush []swelling []JVD ___cm
CV: [x]WNL []tachy/brady []regular []irregular []nl s1 []nl s2
[]S3 []S4 []mumurm []rub []RLE edema []LLE edema []vascular
access:
Respiratory: [x]WNL []CTAB [] rales []rhonchi []wheeze
[]diminished []dullness []comfortable []percussion []egophony
Gastrointestinal: mild diffuse tenderness to palpation without
guarding . nl active bowel sounds. no masses palpated. Difficult
to appreciate liver or splenic edge due patient discomfort with
palpation.
Musculoskeletal-Extremities: [x]WNL []Tone WNL []Upper extremity
strength __/5 and symmetric ___ strength __/5 and symmetric
[]bulk WNL []Normal gait []No cyanosis []No clubbing []No joint
swelling
Neurological: Alert and oriented x2. Vision notable for reduced
vision of the right side (could not identify a moving finger to
her right at all past the midline). ___ motor strength ___ and
distal upper and lower extremities bilaterally. Nl finger to
nose and heel to shin testing. Gross sensation intact. Downgoing
toes bilaterally. Fluent speech.
Integument: [x]WNL []warm []cool []dry []moist []cyanotic
[]mottled []rash []ulcer
Psychiatric: [x]WNL []appropriate []pleasant []flat affect
[]depressed []anxious []agitated []manic []psychiatric
[]intoxicated []combative
Hematologic: []WNL []No cervical ___ []No supraclavicular ___
[]No axillary ___ []No inguinal ___ []Thyroid WNL []Other:
Genitourinary: []WNL []Normal genitalia []Catheter present
[]Other:
At discharge:
Vital signs: 98.3, 97.7, 112/70, 97, 16, 97% RA
General: thin appearing female in NAD
HEENT: EOMI, PERRLA, MMM. Right temporal homonymous hemianopia.
Neck: Supple, no JVD, no lymphadenopathy
Chest: CTABL, no wheezes, rhonchi, crackles, rales
___: RRR, no MRG
GI: Abdomen soft, non-tender, non-distended.
Extremities: no rash, edema, erythema, asymmetry.
Neuro: Temporal right hemianopia as above, otherwise CN intact.
Tone, power, reflexes, coordination, sensation intact and equal
in all extremities.
Pertinent Results:
ADMISSION LABS
___ 08:05PM BLOOD WBC-5.7 RBC-3.13* Hgb-9.5* Hct-30.1*
MCV-96 MCH-30.4 MCHC-31.6 RDW-14.2 Plt ___
___ 08:05PM BLOOD Neuts-79.6* Lymphs-13.5* Monos-4.6
Eos-1.6 Baso-0.8
___ 08:05PM BLOOD Plt ___
___ 08:05PM BLOOD Glucose-83 UreaN-22* Creat-1.5* Na-143
K-3.9 Cl-106 HCO3-27 AnGap-14
___ 08:05PM BLOOD estGFR-Using this
___ 08:05PM BLOOD ALT-16 AST-33 AlkPhos-59 TotBili-0.3
___ 08:05PM BLOOD Albumin-4.1
___ 08:05PM BLOOD GreenHd-HOLD
DISCHARGE LABS
___ 06:40AM BLOOD WBC-5.7 RBC-2.99* Hgb-9.1* Hct-28.5*
MCV-95 MCH-30.4 MCHC-31.9 RDW-14.6 Plt ___
___ 06:40AM BLOOD Neuts-77.2* Lymphs-14.5* Monos-5.9
Eos-2.2 Baso-0.2
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-113* UreaN-24* Creat-1.4* Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
___ 06:40AM BLOOD ALT-13 AST-23 LD(LDH)-256* AlkPhos-63
TotBili-0.3
___ 06:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
MICROBIOLOGY
___ 2:43 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 10:04 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).
___ Complete GU USS
1. 4 mm non-obstructing stone in the left kidney. Small cysts
in the right and left kidney.
2. Protrusion at the inferior portion of the bladder at midline
may represent extrinsic compression from vagina or cervix;
however, a mass within the bladder cannot be ruled out. Suggest
GU evaluation.
___ MR ___ w/ and w/o contrast
1. An area of T2/FLAIR hyperintensity with thick gyral
enhancement in left occipital lobe, which likely represents an
area of late subacute infarct. Follow-up MRI is advised after
few weeks.
2. Generalized cerebral volume loss with changes of chronic
small vessel
ischemic disease.
___ TTE
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. The estimated right atrial pressure is ___ mmHg.
There is LVH. Apical LVH cannot be excluded (LV apex not well
seen). The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal to hyperdynamic (LVEF>55%). There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No masses
or vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
There are no echocardiographic signs of tamponade.
IMPRESSION: No cardiac source of embolism seen. LVH with
possible apical LVH. If indicated, a repeat study with echo
contrast may better define LV apical anatomy.
___ MRA Brain and Neck with Contrast
1. No evidence of stenosis or occlusion in the major arteries of
___ and
neck.
2. An outpouching is noted arising from the cavernous segment of
the left
internal carotid artery on reconstructed images, which is not
visualized well on source images. This may be due to tortuous
vessel. Attention on follow up imaging is advised.
___ Colonoscopy with biopsy
Findings:
Mucosa: Nodularity, edema, erythema and ulceration with contact
bleeding were noted in the distal ileum. Cold forceps biopsies
were performed for histology at the ileum.
Excavated Lesions Several diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be of moderate severity.
Impression: Diverticulosis of the sigmoid colon
Erythema and ulceration in the distal ileum (biopsy)
Otherwise normal colonoscopy to ~15-20 cm into the ileum
___ GI Biopsy
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___/___
DIAGNOSIS:
Ileum biopsy: Minute foci of poorly differentiated carcinoma in
a background of fibrinopurulent exudate. Tumor cells mark with
keratin cocktail, CK7 and TTF1, consistent with a metastasis
from the patient's known lung carcinoma. Tumor cells do not mark
for CK20, chromogranin or synaptophysin.
Clinical: Abnormal CT scan. Abdominal pain.
Gross: The specimen is received in one formalin filled
container labeled with the patient's name ___,
medical record number and additionally labeled "small bowel".
It consists of multiple tissue fragments measuring up to 0.3 cm
entirely submitted in cassette A.
___ MRI Brain with and without contrast
1. Multiple bilateral small acute/early subacute embolic
infarction not
present in the prior exam.
2. Left occipital lobe area of gyriform enhancement, also
demonstrating
increased T2 FLAIR signal with decreased blood volume and blood
flow, likely representing an evolving infarction rather than
metastasis, since there are new bilateral infarcts. Follow up is
recommended as clinically warranted.
Medications on Admission:
Medications
From OMR note ___: (patient could not remember exactly)
Medications - Prescription
AMLODIPINE-VALSARTAN [EXFORGE] - (Prescribed by Other Provider)
- 5 mg-160 mg Tablet - one Tablet(s) by mouth daily restart
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - one
Tablet(s) by mouth daily
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg
Tablet - one Tablet(s) by mouth daily
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet -
1.5
(One and a half) Tablet(s) by mouth daily
FAMCICLOVIR - (Prescribed by Other Provider) - Dosage uncertain
FAMOTIDINE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
LOPERAMIDE - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth twice a day as needed for diarrhea Take this
pill three times a day on the day after you are discharged then
go to twice a day. If you do not have a bowel movement for 24
hours hold this medication.
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet -
one
to two Tablet(s) by mouth three times per day as needed for
anxiety
MAALOX:BENADRYL:2%LIDOCAINE - (Prescribed by Other Provider) -
- 1:1:1 mixture Take 1 tablespoon via straw 15 minutes before
meals and bedtime as needed.
MORPHINE - (Prescribed by Other Provider) - Dosage uncertain
NYSTATIN - (Prescribed by Other Provider) - 100,000 unit/mL
Suspension - by mouth
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage
uncertain
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other
Provider) - Dosage uncertain
SENNOSIDES [SENNA] - (Prescribed by Other Provider) - 8.6 mg
Tablet - 1 (One) Tablet(s) by mouth twice a day as needed
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
5. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: hold for sedation, hr<50, rr<12.
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety, nausea.
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for fever or pain.
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day.
11. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Abdominal pain
Subacute Left Occipital Infarct
Secondary: Stage IIIB non-small cell lung cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Non-small cell lung cancer, back pain and acute kidney injury,
diffuse lymphadenopathy, evaluate for obstructive uropathy.
COMPARISON: CT abdomen and pelvis on ___.
FINDINGS: The right kidney measures 9.0 cm. There is a cyst in the lower
pole of the right kidney measuring 8 x 5 x 8 mm. There is no hydronephrosis
or mass seen. There is mild cortical thinning of the kidneys bilaterally.
The left kidney measures 9.7 cm. There is a small echogenic focus measuring 4
mm in the interpolar region of the left kidney that likely represents a
non-shadowing stone. A cyst in the left kidney measures 8 x 10 x 9 mm. There
is no hydronephrosis.
At the inferior portion of the bladder, there is a bulge/protrusion in the
midline that may represent extrinsic compression from the vagina or cervix;
however, a mass cannot be excluded. Post-residual volume is 2 cc. There are
bilateral ureteral jets seen.
IMPRESSION:
1. 4 mm non-obstructing stone in the left kidney. Small cysts in the right
and left kidney.
2. Protrusion at the inferior portion of the bladder at midline may represent
extrinsic compression from vagina or cervix; however, a mass within the
bladder cannot be ruled out. Suggest GU evaluation.
Radiology Report
CLINICAL HISTORY: ___ woman with NSCLC with new occipital mass.
STUDY: MRI head without and with contrast.
COMPARISON STUDY: Outside MRI head dated ___.
TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, gradient echo, and
diffusion-weighted images were obtained of the brain prior to administration
of contrast. Axial T1 and sagittal MP-RAGE images were obtained after
administration of contrast with axial and coronal reconstructions.
FINDINGS: An area of T2/FLAIR hyperintensity is noted in the left occipital
lobe which appears predominantly hypointense on T1-weighted images. It shows
mild slow diffusion. It shows gyral hyperintensity on T1-weighted images,
which likely represents changes of cortical laminar necrosis. It shows thick
gyral enhancement on post-contrast images. This has not significantly changed
since the study of ___. This likely represents an area of late
subacute infarct.
There is prominence of ventricles, cortical sulci, and extra-axial CSF spaces
suggestive of generalized cerebral volume loss. Focal and confluent T2/FLAIR
hyperintensities are noted in periventricular and subcortical white matter of
bilateral cerebral hemispheres, which likely represent changes of chronic
small vessel ischemic disease.
Brainstem and cerebellum appear normal. The major intracranial flow voids are
maintained.
Fluid is noted in the left inferior mastoid air cells. The visualized
paranasal sinuses are clear. The orbits are unremarkable. Degenerative
changes are noted in the visualized cervical spine.
IMPRESSION:
1. An area of T2/FLAIR hyperintensity with thick gyral enhancement in left
occipital lobe, which likely represents an area of late subacute infarct.
Follow-up MRI is advised after few weeks.
2. Generalized cerebral volume loss with changes of chronic small vessel
ischemic disease.
These findings were discussed with Dr ___ by Dr ___
telephone at 11:13 AM on ___.
Radiology Report
CLINICAL HISTORY: ___ year old woman with NSCLC, left occipital lesion
concerning for infarct.
COMPARISON STUDY: MRI head dated ___.
STUDY: MRA head and neck without contrast.
TECHNIQUE: 3D TOF MR angiography of the head was performed. 2D TOF MRA of the
neck was performed. Multiplanar reconstructions were performed. Some of the
images are degraded by motion artefact.
FINDINGS:
MRA HEAD: The arteries of the anterior circulation including bilateral
intracranial internal carotid arteries, anterior and middle cerebral arteries
are patent.
An outpouching is noted arising from the cavernous segment of the left
internal carotid artery on reconstructed images (series 302, image 5), which
is not visualized well on source images. This may be due to tortuous vessel.
The arteries of posterior circulation including bilateral vertebral arteries
and posterior cerebral arteries appear patent.
There is no evidence of stenosis or occlusion.
MRA NECK. Three-vessel aortic arch is noted. The origins of the great vessels
and vertebral arteries are patent. Bilateral common, internal and external
carotid arteries and cervical vertebral arteries appear normal.
There is no evidence of stenosis or occlusion.
IMPRESSION:
1. No evidence of stenosis or occlusion in the major arteries of head and
neck.
2. An outpouching is noted arising from the cavernous segment of the left
internal carotid artery on reconstructed images, which is not visualized well
on source images. This may be due to tortuous vessel. Attention on follow up
imaging is advised.
Radiology Report
INDICATION: ___ woman with known small cell lung cancer with new left
occipital lobe lesion, right temporal hemianopsia. Evaluate for metastasis.
COMPARISON: MRI from ___ and priors.
TECHNIQUE: Multiplanar, multisequence images of the head were performed with
and without contrast. Perfusion sequences were also obtained using ASL
perfusion on post-contrast images.
FINDINGS:
There are punctate areas of slow diffusion involving the right cerebellum and
left cerebellum, right occipital lobe, right caudate and bilateral corona
radiata, likely representing infarctions embolic in nature. There is no
evidence of acute hemorrhage. Again noted, there is an area of T2 FLAIR
hyperintensity with corresponding gyriform enhancement the left occipital lobe
without significant change since the prior exam. This area demonstrates
decreased blood volume and blood flow on perfusion sequences respect to the
contralateral side.
There are bilateral subcortical and periventricular T2 FLAIR hyperintensities
likely representing microangiopathic chronic ischemic changes. There is
diffuse volume loss. No other areas of suspicious enhancement is noted. The
major intracranial flow voids are preserved. The orbits are unremarkable.
There is fluid in the left mastoid air cells. The paranasal sinuses are
clear.
IMPRESSION:
1. Multiple bilateral small acute/early subacute embolic infarction not
present in the prior exam.
2. Left occipital lobe area of gyriform enhancement, also demonstrating
increased T2 FLAIR signal with decreased blood volume and blood flow, likely
representing an evolving infarction rather than metastasis, since there are
new bilateral infarcts. Follow up is recommended as clinically warranted.
Findings were discussed with Dr. ___ at 9.45 am on ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLQ PAIN
Diagnosed with SECONDARY MALIG NEO NEC, ABDOMINAL PAIN LLQ, HYPERTENSION NOS, SEC MAL NEO BRAIN/SPINE, SECONDARY MALIG NEO BONE
temperature: 99.2
heartrate: 97.0
resprate: 18.0
o2sat: 97.0
sbp: 141.0
dbp: 67.0
level of pain: 3
level of acuity: 3.0 | ___ yo F with history of lung cancer admitted with abdominal
pain, back pain, visual deficits found to have 4cm L lesion in
occiptal lobe now thought to be subacute stroke. She also had
abdominal ___ vs. metastatic disease, and ileal thickening all
suggestive of metastatic cancer, possibly due to lung vs. ___
primary.
.
#Brain lesion: Ms. ___ was transferred to ___ with new
right temporal hemianopia, imaging from OSH concerning for
metastatic deposit in left occipital lobe, as well as in the
L-spine. She was started on dexamoethasone for these processes
and admitted to the neuro-onocology service for furtehr
management. She was seen by radiation-oncology. However,
review of imaging of L-spine was nnot consistent with
metastasis. she underwent MRI with gadolinium here, which was
read as being more consistent with subacute infarct than with
metastatic deposit. Repeat imaging on ___ confirmed that
the imaging was more consistent with stroke. TTE with bubble
study was normal. MRA ___ and neck showed only toruosity of
ICA in cavernous sinus, no other vascular abnormalities. We
stopped dexamethasone, started aspirin and she will need to
followup with repeat MRI with Dr. ___.
# Metastatic lung carcinoma: Ms. ___ presenting symptom
was abdominal pain. While here, she continued to have
intermittent pain, poor oral intake, intermittent diarrhea and
constipation. C. diff toxin was negative. She was found to
have diffuse abdominal lymphadenopathy and ileal thickening on
CT from OSH. She was seen by gastroenterology, and underwent a
colonoscopy with biopsy on ___, which showed encroaching and
ulcerated ileal lesion. The biopsy was consistent with
metastatic lung cancer. We discussed this finding with the
patient and her family, as well as with her oncologist Sr.
___. Per Dr. ___, she was evaluated by
general surgery who felt that they would not offer her any
surgerym but that she would be a candidate for G-tube to help
improve her nutritional status, and to avert any issues with
intestinal obstruction. The patient declined this option at
present. She will followup with Dr. ___ after
discharge, and also with surgery.
# Acute renal failure, most likely pre-renal, but will need to
consider obstructive process as well given the numerous lymph
nodes in the abdomen. We gave her some hydration during her
hospital stay, but her creatinine remained elevated around 1.4.
She will require ongoing monitoring of her renal function by her
oncologist.
# Hypertension: Had been holding home atenolol given elevated
creatinine, but hypertensive with SBP in 160s-180, have started
metoprolol. We discontinued her home antihypertensives and
maintained her on metoprolol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___
Chief Complaint:
Aphasia, IPH
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angio - positive for Pial AVM
History of Present Illness:
___ male with afib, HTN, DM and mild dementia, on Aspirin and
Eliquis presented as Medflight from ___ with large
left IPH. Patient was found down by family same day around 1pm;
last seen well previous night 9pm. He was confused/aphasic and
brought to an OSH where non contrast head CT showed large IPH.
He was given K Centra to reverse Eliquis, started on nicardipine
for SBP 220 and transferred to ___ for further care.
Patient was awake but non-verbal and unable to give any history.
Past Medical History:
-Atrial fibrillation (diagnosed ___
-Diabetes mellitus
-Mild cognitive impairment vs dementia
-Anxiety
-Hypertension
-Urinary incontinence
-GERD
Social History:
___
Family History:
Several family members with dementia
Physical Exam:
=============
On admission:
=============
Gen: elderly male, awake
HEENT: Pupils: ___ EOMs does not follow
Extrem: Warm and well-perfused.
Date and Time of evaluation: ___
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[x]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[ ]6 Obeys commands
__10__ Total
ICH Score:
GCS
[ ]2 GCS ___
[x]1 GCS ___
[ ]0 GCS ___
ICH Volume
[x]1 30 mL or Greater
[ ]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[x]0 Absent
Infratentorial ICH
[ ___ Yes
[x]0 No
Age
[x]1 ___ years old or greater
[ ]0 Less than ___ years old
Total Score: ___3___
Neuro:
Mental status: Awake, tracks examiner to left, does not follow
commands or answer questions
Language: nonverbal except rare "ouch" or slight moan
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. unable to assess visual fields
III, IV, VI: left gaze preference; does not cross midline to
right
V, VII: slight right facial asymmetry; corneals present
bilaterally
VIII: unable to assess
IX, X: unable to assess
XI: unable to assess
XII: unable to assess
Motor: Normal bulk and tone bilaterally. mild tremor when lift
left arm. holds left arm>leg antigravity when lifted. localizes
left arm. withdraws right arm and slightly right leg
Sensation: responds to noxious stimuli x 4
=============
ON DISCHARGE:
=============
General: Lying in bed, pleasant interactive
HEENT: Sclerae anicteric, MMM
Neck: HOB at 30 degrees, no JVD.
CV: irregular rhythm, regular rate, variable S2, no m/r/g
Lungs: CTAB anteriorly, no wheezes
GI: soft, NT/ND, no rebound tenderness or guarding.
Extremities: warm, well perfused, pulses 2+. No edema.
Neuro: Opens eyes spontaneously, alert but not oriented. Does
not speak today.
Pertinent Results:
Admission
=========
___ 08:05PM BLOOD WBC-3.7* RBC-1.55* Hgb-4.8* Hct-14.9*
MCV-96 MCH-31.0 MCHC-32.2 RDW-13.4 RDWSD-46.0 Plt Ct-70*
___ 08:05PM BLOOD ___ PTT-86.5* ___
___ 08:34PM BLOOD Glucose-240* UreaN-19 Creat-0.9 Na-143
K-3.4* Cl-101 HCO3-24 AnGap-18
___ 08:05PM BLOOD cTropnT-<0.01
___ 12:26AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 Cholest-100
___ 12:26AM BLOOD %HbA1c-7.0* eAG-154*
___ 12:26AM BLOOD Triglyc-71 HDL-33* CHOL/HD-3.0 LDLcalc-53
Discharge
=========
___ 05:35AM BLOOD WBC-10.5* RBC-3.84* Hgb-11.5* Hct-34.7*
MCV-90 MCH-29.9 MCHC-33.1 RDW-13.6 RDWSD-44.7 Plt ___
___ 07:32AM BLOOD ___ PTT-27.3 ___
___ 05:35AM BLOOD Glucose-159* UreaN-19 Creat-0.8 Na-142
K-3.7 Cl-99 HCO3-29 AnGap-14
___ 05:35AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.1
Imaging & Studies
=================
CT Head ___
IMPRESSION:
1. Expected interval evolution of the large intraparenchymal
hematoma with
surrounding edema involving the left temporal and parietal
lobes, now
measuring 6.1 x 3.6 cm in greatest axial dimension compared to
previous
measurement of 6.5 x 4.2 cm.
2. Minimally improved associated mass effect, with 2 mm
rightward shift of
midline structures.
3. Similar effacement of the left lateral ventricle and adjacent
sulci.
4. No evidence of new hemorrhage or infarction.
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CXR ___
IMPRESSION:
1. Interval removal of a Dobhoff tube and placement of an
enteric tube. The side port of the enteric tube projects just
beneath the left hemidiaphragm. Consider advancement by 1-2 cm
to be definitively beneath the gastroesophageal
junction.
2. Unchanged mild pulmonary vascular congestion without
pulmonary edema.
3. There is persistent retrocardiac consolidation, which may
represent
infectious consolidation in the appropriate clinical context. No
volume loss to suggest atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Desmopressin Acetate 0.2 mg PO QHS
4. Fluvoxamine Maleate 100 mg PO BID
5. GlipiZIDE 5 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. LORazepam 0.5 mg PO Q6H:PRN anxiety
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. RisperiDONE 0.5 mg PO DAILY
13. RisperiDONE 1 mg PO QHS
14. Sertraline 75 mg PO DAILY
15. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Docusate Sodium 100 mg PO BID
4. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
5. Labetalol 400 mg PO Q8H
6. Lansoprazole Oral Disintegrating Tab 30 mg NG DAILY
7. Senna 8.6 mg PO BID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Desmopressin Acetate 0.2 mg PO QHS
10. Fluvoxamine Maleate 100 mg PO BID
11. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY
12. Lisinopril 40 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Sertraline 75 mg PO DAILY
15. HELD- RisperiDONE 1 mg PO QHS This medication was held. Do
not restart RisperiDONE until meet with your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left IPH
Pial AVM
Hypertension
Acute hypoxemic respiratory failure
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with head bleed, found down, temp of 103.6*** WARNING ***
Multiple patients with same last name!// Pneumonia
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph dated earlier same day.
FINDINGS:
Lung volumes are low. There is no focal consolidation. The cardiomediastinal
and hilar silhouettes are within normal limits. There is no pulmonary edema.
No pleural effusions. No pneumothorax.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with large L sided IPH*** WARNING *** Multiple
patients with same last name!// underlying aneurysm?
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.9 mGy (Body) DLP =
12.5 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 617.7
mGy-cm.
Total DLP (Body) = 630 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
A 6.4 x 3.6 cm intraparenchymal hematoma is seen in the left temporal lobe
with surrounding edema, unchanged. There is sulcal effacement of the left
temporal lobe with mass effect on body of the left lateral ventricle. There
is 3 mm rightward midline shift.
The ventricles and sulci are otherwise normal in size and configuration.
Patchy periventricular hypodensities are most consistent with chronic
microvascular ischemic disease.
There is mild mucosal thickening of the ethmoid sinuses. A small right
mastoid effusion is seen. The patient is status post bilateral cataract
surgery.
CTA HEAD:
There is a tangle of vessels anterolateral to the intraparenchymal hematoma
along the left anterior temporal region (3:286). These suggest an
arteriovenous malformation.
Atherosclerotic changes of the cavernous and supraclinoid segments of the
bilateral internal carotid arteries are seen without stenosis.
There is fetal origin of the right PCA with severe focal narrowing at the
junction of the right posterior communicating and posterior cerebral arteries.
There is patency seen distally.
There is severe focal narrowing the distal right vertebral artery with patency
seen distally.
Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
Atherosclerotic changes of the carotid bifurcations are seen without
narrowing of the internal carotid arteries, by NASCET criteria. The vertebral
arteries appear normal with no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. A 3.3 cm x 2.3 cm
low-attenuation lesion is seen in the left thyroid lobe.. There is no
lymphadenopathy by CT size criteria. Degenerative changes of the cervical
spine are seen.
IMPRESSION:
1. Unchanged large intraparenchymal hematoma in the left temporal lobe with
surrounding edema. 3 mm rightward midline shift.
2. Tangle of vessels seen anterolateral to the hematoma overlying the left
anterior temporal region suggest an arteriovenous malformation.
3. The fetal origin of the right PCA with severe focal narrowing at the
junction of the right PCOM and PCA. Patency seen distally.
4. Severe focal narrowing of the distal right vertebral artery with patent
distal run-off.
5. No stenosis or occlusion of the cervical vessels.
6. 3 cm low-attenuation lesion in the left thyroid lobe.
RECOMMENDATION(S):
1. Vascular neurosurgery consult.
2. Thyroid nodule. Ultrasound follow up recommended.
___ College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
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.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with This is a ___ year old male with history of
afib on aspirin and apixiban who was last known well at 9 pm on ___. with
large left IPH// pna
TECHNIQUE: Portable semi-erect radiograph the chest.
COMPARISON: Radiograph of the chest performed 7 hours prior.
FINDINGS:
Lung volumes are low resulting in mild bibasilar atelectasis as well as
crowding of the cardiomediastinal structures however heart size is normal. No
focal consolidations concerning for pneumonia are identified. There is no
large pleural effusion or pneumothorax. Visualized osseous structures are
unremarkable.
IMPRESSION:
No focal consolidations concerning for pneumonia identified. Mild bibasilar
atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with large left IPH// please perform at 05:00
request of neurosurgery, assess size of hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDI vol = 46.7 mGy (Head) DLP =
934.1 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CTA head dated ___. CT head dated ___.
FINDINGS:
Again seen is a large intraparenchymal hemorrhage involving the left parietal,
occipital and temporal lobes, slightly increased in size from prior, now
measuring 6.7 x 4.0 cm in greatest axial dimension, previously 6.4 x 3.6 cm.
There is surrounding vasogenic edema. No significant change in mild rightward
midline shift measuring 4 mm, as well as effacement of the left lateral
ventricle and of the adjacent sulci in the left parietal, occipital and
temporal lobes. Atherosclerotic calcifications in the distal vertebral
arteries and carotid siphons remain unchanged.
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:
Slight interval increase in size of large intraparenchymal hemorrhage
involving the left parietal, occipital and temporal lobes, now measuring 6.7 x
4.0 cm in greatest axial dimension, previously 6.4 x 3.6 cm. There is no
substantial change in mass effect, with 4 mm of rightward midline shift and
effacement of the left lateral ventricle and adjacent sulci.
Radiology Report
EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM
INDICATION: ___ year old man with IPH// eval NGT placement
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph of the chest performed 7 hours prior.
FINDINGS:
Heart size is normal. Hilar and mediastinal contours are normal. Enteric
tube is coiled within the upper esophagus. Bibasilar atelectasis is
persistent. No evidence of pleural effusion or pneumothorax.
IMPRESSION:
Enteric tube is coiled within the upper esophagus and must be repositioned.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 11:40 am, 10 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH// NGT placement
TECHNIQUE: AP portable chest radiograph.
COMPARISON: Chest radiograph ___ through ___. CTA
head and neck ___
FINDINGS:
Lung volumes are low accentuating the pulmonary vasculature. There is no
pulmonary edema, pleural effusion or pneumothorax. Cardiomediastinal
silhouette is enlarged, but stable. Enteric tube is seen with its tip in the
distal stomach. Rightward deviation of the trachea is related to a large left
thyroid nodule better evaluated on the prior CTA head and neck.
IMPRESSION:
Enteric tube tip is in the distal stomach. No acute cardiopulmonary process.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for evaluation of left
intraparenchymal hematoma
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Left common carotid artery
Left external carotid artery
Left internal carotid artery
Three-dimensional rotational angiography of the left internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Right common carotid artery
Right common femoral artery
Ultrasound-guided access to right common femoral artery
INDICATION: This ___ gentleman who was found altered aphasic was
found have a left temporal IP H. CTA was performed was concerning for
increased vascularity in the region of the hemorrhage. The angiogram was
planned to rule out underlying vascular lesion.
ANESTHESIA: Patient was maintained under moderate sedation by the anesthesia
team throughout the entirety of the procedure. Please see their
documentation. Patient's hemodynamic and respiratory parameters were
monitored continuously throughout the entirety of the case by a trained and
independent observer. Anesthesia was present in the event of the need for
intubation for embolization.
TECHNIQUE: Diagnostic cerebral angiogram, bilateral carotid
COMPARISON: CTA
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. He was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. A time-out was performed. The right common femoral
artery was identified using anatomic and radiographic landmarks. The right
common femoral artery was accessed using standard micropuncture technique
after infiltration of local anesthetic using ultrasound guidance. A long 6
___ sheath was introduced, connected to continuous heparinized saline
flush, and secured.
Next a stiff ___ 2 diagnostic catheter was introduced. It was connected
to continuous heparinized saline flush as well as the power injector. It was
advanced over 038 glidewire through the aorta into the aortic arch. The wire
was used to select the left common carotid artery. The catheter was
positioned over the wire into the left common carotid artery. The wire was
removed. Vessel patency was confirmed via hand injection. Standard AP and
lateral views were obtained.
A roadmap was obtained. The catheter was advanced into the left external
carotid artery over the wire using roadmap guidance. The wire was removed.
Vessel patency was confirmed via hand injection. Standard AP and lateral
views were obtained.
The catheter was withdrawn to the left common carotid artery. A new roadmap
was performed. The catheter was advanced into the left the internal carotid
artery over the wire using roadmap guidance. The wire was removed. Vessel
patency was confirmed via hand injection. Standard AP and lateral as well as
three-dimensional rotational images were obtained.
The catheter was reconfigured into the ___ shape and used to select the
right common carotid artery. A roadmap was performed. The catheter was
advanced more distal into the right common carotid artery over the wire using
roadmap guidance. The wire was removed. Vessel patency was confirmed via
hand injection. Standard AP and lateral views were obtained.
Several attempts were made to access the left vertebral artery without
success. Was determined to conclude the case at that time by Dr. ___.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. The patient was removed
from the fluoroscopy table and remained at his neurologic baseline without any
evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Ultrasound the right common femoral artery: There is a single noncompressible,
arterial, pulsatile lumen. There is evidence of access of the wire into the
lumen. Images were saved to the patient's permanent medical record.
Left common carotid artery: Vessel caliber smooth and regular. There is
opacification of the anterior middle cerebral arteries and their distal
territories. There is filling by distal MCA branches a peel arteriovenous
malformation with venous drainage into the vein ___ and ___. There
is no evidence of aneurysm. The right transverse sinus is dominant. There is
minimal stenosis of the internal carotid artery based on roadmap images and
NASCET criteria, consistent with less than 20%.
Left external carotid artery: Vessel caliber smooth and regular. There is
opacification of the distal external carotid artery branches. There is no
evidence of AV shunting or contribution to the fistula.
Left internal carotid artery: Vessel caliber smooth and regular. Once again
there is demonstrated filling of the anterior middle cerebral arteries no
distal territories. There is slight shifting of the middle cerebral artery
candelabra in light of the left IPH. The distal MCA branches supply a pial
AVM in the temporal region. This is a diffuse feathery AVM. Venous drainage
is via the vein ___ and ___.
Right common carotid artery: Vessel caliber smooth and regular. There is no
evidence carotid stenosis in the cervical region based on roadmap images and
NASCET criteria. There is opacification of the anterior middle cerebral
arteries and their distal territories. There is a fetal configuration the PC
om with evidence of some atherosclerotic disease. There is no evidence of
aneurysm or AVM or contribution to the fistula. Venous phase is unremarkable.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
Left temporal lobe pial AVM fed by MCA branches that is responsible for the
intraparenchymal hemorrhage. Venous drainage is via the vein ___ and
___ of ___. The nidus is difficult to measure secondary to diffuse
appearance but probably approximates 2 cms in diameter.
RECOMMENDATION(S):
1. No large vessel feeders that would facilitate embolization. Repeat
angiogram in 1 month with plans for definitive therapy with likely
radiosurgery.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with IPH// please eval ___ at 0500, 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 =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
No substantial change in size of large intraparenchymal hemorrhage involving
the left parietal, and left temporal lobes, measuring 6.5 x 4.2 cm in greatest
axial dimension, previously 6.7 x 4.0 cm. Surrounding vasogenic edema is
again seen. There is slight decreased mass effect, with 2 mm of rightward
midline shift. Similar effacement of the adjacent sulci in the left parietal,
occipital and temporal lobes, and of the left lateral ventricle. Unchanged
atherosclerotic calcifications of the distal vertebral arteries and carotid
siphons. There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No substantial change in size of large intraparenchymal hemorrhage involving
left parietal, occipital and temporal lobes, now measuring 6.5 x 4.2 cm in
greatest axial dimension, previously 6.7 x 4.0 cm. Slight decrease in
rightward midline shift, now 2 mm, previously 4 mm. Similar effacement of the
left lateral ventricle and adjacent sulci.
Radiology Report
INDICATION: ___ year old man with stroke and new fever// Assess for pulmonary
congestion or pneumonia
COMPARISON: Radiographs from ___
IMPRESSION:
There is a nasogastric tube whose tip and side port are within the body of the
stomach. Heart size is upper limits of normal. There are mildly low lung
volumes. There is no overt pulmonary edema, definite consolidation, or
pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke// assess for pulmonary edema
assess for pulmonary edema
IMPRESSION:
NG tube tip is in the stomach. Heart size and mediastinum are unchanged.
Lungs overall clear. Left basal opacity is noted, new and might represent
aspiration or developing infection in the left lower lobe.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with IPH/AVM rupture with fever ___, treating
for possible PNA// evaluate for PNA evaluate for PNA
IMPRESSION:
Comparison to ___. In the interval, the patient has developed
mild to moderate pulmonary edema. In addition, there is a new retrocardiac
atelectasis. No pleural effusions. No pneumonia. Stable mild cardiomegaly.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with large left IPH from AVM, now with increased
oxygen demands// Evaluate for clots
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: There is no prior imaging available for comparison.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the 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: CR - CHEST PORTABLE AP
INDICATION: ___ year old man s/p NGT placement// Assess NGT placement
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 11:23.
IMPRESSION:
There has been interval placement of a nasogastric tube, which terminates in
the right mainstem bronchus. There is no other significant interval change
compared to study from earlier today.
NOTIFICATION: The findings were discussed with ___, nurse by ___
___, M.D. on the telephone on ___ at 6:28 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE LINE TUBE PLACEMENT 3 EXAMS
INDICATION: ___ year old man with altered mental status// NG tube placement
TECHNIQUE: Three sequential AP radiographs of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
The new nasogastric tube terminates in the body of the stomach on the final
image. Low lung volumes are noted. There are small bilateral pleural
effusions. No focal consolidation or pneumothorax is identified. There is
unchanged cardiomegaly and mild to moderate pulmonary edema. There are no
acute osseous abnormalities.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with altered mental status// S/p NGT placement
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 19:08.
IMPRESSION:
The nasogastric tube terminates in the body of the stomach. No significant
interval change.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with newly placed NG Tube. CXR to evaluate for
proper placement.// ___ year old man with newly placed NG Tube. CXR to evaluate
for proper placement.
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph dated ___
FINDINGS:
2 sets of sequential radiographs provided, demonstrating progressive
advancement of an enteric tube. The side-port of the enteric tube was advanced
from the level of the left hemidiaphragm to just beneath the left
hemidiaphragm. The Dobhoff tube has been removed.
Low lung volumes. There is persistent retrocardiac consolidation, which may
represent infectious consolidation in the appropriate clinical context. There
is no volume loss to suggest atelectasis. No large pleural effusions or
pneumothorax. Unchanged mild pulmonary vascular congestion without pulmonary
edema. Moderate cardiomegaly is unchanged.
IMPRESSION:
1. Interval removal of a Dobhoff tube and placement of an enteric tube. The
side port of the enteric tube projects just beneath the left hemidiaphragm.
Consider advancement by 1-2 cm to be definitively beneath the gastroesophageal
junction.
2. Unchanged mild pulmonary vascular congestion without pulmonary edema.
3. There is persistent retrocardiac consolidation, which may represent
infectious consolidation in the appropriate clinical context. No volume loss
to suggest atelectasis.
RECOMMENDATION(S): Consider enteric tube advancement by 1-2 cm to be
definitively beneath the gastroesophageal junction.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 10:52 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ y/o man with history of DMII, HTN, atrial fibrillation on
apixaban here with large IPH, with course complicated by fevers, hypertension,
and hyperglycemia. Now with increased somnolence. Evaluation for interval
change, worsening intracranial bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 924 mGy-cm.
COMPARISON: Comparison to noncontrast head CT from ___.
FINDINGS:
Redemonstration of large intraparenchymal hemorrhage with surrounding edema
involving the left temporal and parietal lobes, with expected interval
evolution of blood products, now measuring 6.1 x 3.6 cm in greatest axial
dimension (03:26), compared to previous measurement of 6.5 x 4.2 cm. There is
no evidence of new hemorrhage.
There is unchanged rightward shift of midline structures measuring 2 mm,
perhaps minimally improved from prior study. Similar degree of effacement
involving the adjacent sulci in the left parietal, temporal, and occipital
lobes, as well as effacement of the left lateral ventricle. There is no
evidence of infarction, or mass. Prominence of the right lateral ventricle
may be secondary to involutional change. Periventricular and subcortical
hypodensities are nonspecific, though likely sequela of chronic small vessel
ischemic disease.
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. Expected interval evolution of the large intraparenchymal hematoma with
surrounding edema involving the left temporal and parietal lobes, now
measuring 6.1 x 3.6 cm in greatest axial dimension compared to previous
measurement of 6.5 x 4.2 cm.
2. Minimally improved associated mass effect, with 2 mm rightward shift of
midline structures.
3. Similar effacement of the left lateral ventricle and adjacent sulci.
4. No evidence of new hemorrhage or infarction.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: SDH, Transfer
Diagnosed with Other nontraumatic intracerebral hemorrhage
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: critical
level of acuity: nan | ===================
Neurology Course
===================
Mr. ___ presented to ___ ED with a large left IPH. He was
evaluated by neurosurgery in the ED and was admitted to the
neuro ICU under the stroke neurology service for spontaneous
IPH.
#IPH/AVM
The patient's aspirin and apixaban were held. He received
KCentra at OSH. He underwent a CTA head and neck which showed
unchanged large left temporal IPH with surrounding edema and 3
mm rightward midline shift. It also revealed tangle of vessels
adjacent to the hemorrhage which appear to drain into a cortical
vein, and is concerning for an AVM or dural AV fistula. He
underwent another CT on the following day which showed slight
interval increase in the left IPH, now with 4mm of rightward
shift and effacement of the left lateral ventricle. His sodium
was kept at a goal of 140-150. His son at the beside stated he
was his HCP and made the patient DNR/DNI. Later when 3 sisters
were visiting they said they were all Health Care Proxys and
said he should be full code for now. Patient went for a cerebral
angiogram on ___ which revealed a small pial arteriovenous
malformation. Please see separately dictated angio report by Dr.
___ complete details of the procedure. Post-operatively
he returned to the neuro ICU and was transferred from the
neurology service to the neurosurgery service for further
management. He was not a surgical candidate due to the location
of the AVM in the speech center and the vessels were not
amenable to embolization given small size. The plan was made for
repeat angio in 1 month and likely radiation thereafter. He was
transferred out to the ___ on ___. His BP goal was
liberalized to SBP less than 160 on ___.
#Fever
On ___ overnight patient was noted to be febrile to 102.9. He
was initiated on empiric Vancomycin and Ceftriaxone. Blood
cultures were sent which revealed ***. UA was also sent on ___
which was negative for infection. EKG at that time with slight
ST depression, troponins were cycled 0.01 and 0.02. Likely
demand ischemia. MRSA swab sent on ___ due to recurrent fevers
that was negative. Antibiotics were discontinued ___ per
Medicine recommendations given no clear infectious source.
Repeat CXR ___ showed new pulmonary edema and worsening
atelectasis, but no consolidation.
#Hypertension
Home meds were held on admission but gradually resumed. He
required Nicardipine gtt was discontinued after his SBP goals
were liberalized to less than 160. He was started on PO
labetalol and amlodipine which were titrated but per Medicine
recommendations.
#Diabetes
Home metformin and glipizide were held. He was started on
insulin sliding scale. He was started on glargine ___ per
Medicine recommendations.
#Hypoxia
On ___, the patient's SpO2 was 91% on 5L NC following his chest
x-ray, and he was temporarily put on a non-rebreather. After a
couple hours, he was weaned back down to supplemental oxygen via
nasal cannula and his SpO2 was mid-high 90%. When he required a
NRB, an ABG was drawn that revealed high pO2. He was given Lasix
20mg IV x 1 and diuresed to a goal of -500cc-1000cc daily for
fluid overload per Medicine's recs. A foley was placed for UOP
monitoring and BMPs were checked twice-a-day to follow his
electrolytes.
#Nutrition
The patient was evaluated by SLP and made NPO. A NGT was put in
place for tube feedings and medications. On ___, SLP again
evaluated the patient, but was unable to complete the evaluation
secondary to lethargy. ACS was consulted to place a PEG on ___.
=======================
Medicine Course
=======================
Mr. ___ is a ___ y/o man with history of DMII, HTN, atrial
fibrillation on apixaban who presented with a large
intraparenymal hemorrhage with underlying cause believe to be a
parieto-occipital AVM. Patient was deemed not to be a candidate
for surgical intervention. He will follow up with neurosurgery
after his discharge from rehab for consideration of radiotherapy
for treatment of AVM.
# Patient developed instability to speak and presented to
___ where he was found to have a large left IPH.
CTA demonstrated findings concerning for AVM or dural AV
fistula. He underwent angiogram on ___ that demonstrated
pial AVM. He was deemed not to be a surgical candidate due to
location and age/comorbidities. Recommended SBP < 160, holding
home ASA and eliquis indefinitely. Also recommended neurosurgery
follow up after discharge from rehab facility for consideration
of radiotherapy. *** There is no plan for radiation or
chemotherapy while patient is in rehab ***
# HTN
Multifactorial including IPH, pain, and essential hypertension.
Goal SBP < 160 per neurosurgery. He was continued on amlodipine,
HCTZ, and lisinopril with good BP control.
# Volume overload
# Acute hypoxemic Respiratory Failur
New onset ___, likely secondary to pulmonary edema and
mucous
plugging. Oxygen requirement rapidly decreased with diuresis and
was euvolemic prior to discharge. He will need a voiding trial
at rehab. He was not discharged on a diuretic. Will need close
monitoring and restart Lasix 20mg daily if his weight increases.
# Fevers
Most likely non-infectious etiologies of IPH and/or aspiration
pneumonitis over pneumonia. MRSA swab neg, cultures neg.
# Dysphagia
Due to stroke. A PEG tube was placed as he failed speech and
swallow evaluation. Will need close monitoring after discharge.
# DM
Baseline A1c 7.0%. On ___ with full tube feeds, required 36U
regular insulin. Will restart metformin after discharge and
adjust insulin.
Transitional Issues
====================
# Discharge weight: 101.5kg
[ ] Discharged with foley catheter. Please conduct voiding trial
in ___ hours and if fails replace and refer to urology
[ ] Follow up in 1 month with Dr. ___ Will need
a repeat NCHCT at the time of this appointment. Call
___ with questions. You may need a repeat diagnostic
angiogram in the future.
[ ] After discharge from rehab, consider radiotherapy for
treatment of AVM per neurosurgery. There are no plans for chemo
or radiation while patient is in rehab.
[ ] Follow up daily weights and consider restarting Lasix 20mg
daily if patient starts to retain fluid
[] Cardiology follow up as outpatient for consideration of
further work-up of TWI including stress test, though notably
patient is contraindicated from taking aspirin or
anti-coagulation given recent IPH.
[] PEG tube placed for dysphagia. Patient will need follow up
with speech and swallow and re-evaluation to determine if he has
recovery.
[ ] Stopped glipizide and started insulin. Please monitor blood
glucose carefully and can likely restart glipizide upon
discharge from rehab
[ ] Stopped metoprolol and replaced with labetolol 400mg TID for
blood pressure control. Consider started carvedilol as
outpatient.
[ ] Increased HCTZ to 25mg daily and amlodipine to 10mg daily
[ ] Stopped aspirin and apixaban. Patient should not be
restarted on these medications given IPH
[ ] Stopped risperadone given encephalopathy and sedation.
Consider restarting if patient is agitated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
gabapentin / zolpidem
Attending: ___.
Chief Complaint:
Left femur fracture
Major Surgical or Invasive Procedure:
___: Left long TFN
History of Present Illness:
___ female with HTN, HLD, and osteoporosis, who presents with
the above fracture s/p mechanical fall. The patient slipped and
fell in the parking lot, immediately c/o L leg pain with visible
deformity. No headstrike or LOC, not c/o pain anywhere else.
She does take a baby aspirin daily (last dose was two days ago),
no other blood thinners.
Past Medical History:
PRE-DIABETES
DEPRESSION
HYPERLIPIDEMIA
HYPERTENSION
OSTEOPOROSIS
ALLERGIC RHINITIS
ABDOMINAL PAIN
ANXIETY
MEMORY LOSS
GOITER
BACK PAIN
VITAMIN D DEFICIENCY
MIGRAINE HEADACHES
NECK PAIN
SHOULDER PAIN
SLEEP APNEA
PELVIC DYSSYNERGY
OBGYN
POST-MENOPAUSAL BLEEDING
MASS WITHIN THE RIGHT BREAST AT 9 O'CLOCK, 6 CM FROM THE
CONSTIPATION
ANAL FISSURE
Social History:
___
Family History:
N/A
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
- L hip dressing c/d/i
- Fires ___
- SILT s/s/sp/dp/t n dist
- Toes WWP
Pertinent Results:
see omr.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. HydrOXYzine 10 mg PO BID
3. Diazepam 2.5-5 mg PO QHS:PRN anxiety/insomnia
4. Alendronate Sodium 70 mg PO QSUN
5. amLODIPine 5 mg PO DAILY
6. linaCLOtide 145 mcg oral DAILY
7. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic (eye) BID
8. Ranitidine 150 mg PO BID
9. Atorvastatin 20 mg PO QPM
10. diclofenac sodium 1 % topical BID
11. Aspirin 81 mg PO DAILY
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Vitamin D 1000 UNIT 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 QHS
Take for 4 weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp
#*28 Syringe Refills:*0
5. Milk of Magnesia 30 ml PO BID:PRN Constipation - Second Line
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Partial fill ok. Wean. No driving/heavy machinery.
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed for pain Disp #*30 Tablet Refills:*0
7. Senna 8.6 mg PO DAILY
8. Alendronate Sodium 70 mg PO QSUN
9. amLODIPine 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic (eye) BID
13. Diazepam 2.5-5 mg PO QHS:PRN anxiety/insomnia
14. diclofenac sodium 1 % topical BID
15. Hydrochlorothiazide 12.5 mg PO DAILY
16. HydrOXYzine 10 mg PO BID
17. linaCLOtide 145 mcg oral DAILY
18. Losartan Potassium 25 mg PO DAILY
19. Ranitidine 150 mg PO BID
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS IN O.R. LEFT
INDICATION: ___ female with a midshaft fracture of the femur
TECHNIQUE: 7 intraoperative images were taken.
COMPARISON: Prior radiograph of the left femur from ___
FINDINGS:
7 intraoperative images were acquired without a radiologist present.
Images show intramedullary nail and screw fixation of the left hip, traversing
the mid-diaphyseal fracture of the left femur. A distal interlocking screws
seen in the distal femur..
IMPRESSION:
Intraoperative images were obtained during ORIF of a left femoral diaphysis
fracture. Please refer to the operative note for details of the procedure.
Radiology Report
INDICATION: ___ year old woman with SOB // ? PNA
COMPARISON: Prior radiographs ___
IMPRESSION:
Cardiac monitoring leads overlying the chest wall mild cardiomegaly, unchanged
from prior. Tortuous aorta. Mildly prominent interstitial markings,
unchanged from prior may represent mild edema. Widening of the mediastinum
may be secondary to rotation of the patient. Large calcification projecting
at the left thoracic inlet may represent the large thyroid calcified nodule
last seen on the prior cervical spine CT. There are no pneumothoraces.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with a hip fracture s/p fixation. // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler 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: FEMUR (AP AND LAT) LEFT
INDICATION: ___ year old woman s/p L hip fracture s/p long IMN // Assess
component positioning
TECHNIQUE: Two views left femur
COMPARISON: Left femur radiographs ___ and intraoperative images
___
FINDINGS:
The patient is status post open reduction internal fixation of a transverse
proximal femoral diaphyseal fracture with placement of an extended gamma nail
construct transfixing the fracture. Alignment is near anatomic with
persistent mild anterior displacement by approximately 5 mm. Surgical
hardware is intact. No new fracture seen. Soft tissue calcification adjacent
to the greater trochanter unchanged from the prior study, possibly reflecting
calcific tendinitis.
IMPRESSION:
Improved alignment following open reduction internal fixation of a proximal
femoral diaphyseal fracture.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: L Leg pain, s/p Fall
Diagnosed with Displaced transverse fracture of shaft of left femur, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.0
heartrate: 62.0
resprate: 20.0
o2sat: 100.0
sbp: 161.0
dbp: 103.0
level of pain: 9
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left midshaft femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for surgical fixation left 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
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Amoxicillin
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a ___ PMH DM2, PVD, HTN, HLD, COPD w/recent admission
for NSTEMI and foot impaction brought to ED for fall with head
strike.
Patient returned home from rehab facility yesterday. This
afternoon she was visiting with a friend who is helping her out
at home and she slipped while walking to the kitchen. She hit
her head when she fell, but did not lose consciousness. Patient
denies dizziness or palpitations prior to the fall and no
seizure activity was witnessed. Friend immediately called EMS
and she was brought to ED. Of note, patient on ASA and
Clopidogrel.
Patient walks with a cane at baseline and has history of several
mechanical falls over many years, resulting in two hip
fractures. She reports that she fell on her right arm a few days
prior to this fall. She states that her balance has been
progressively worsening, but she denies any dizziness,
light-headedness, or syncope. She feels "top heavy". Her
independence is extremely important to her, and she says she
would rather die than be in a nursing home. She understands the
need to maximize her safety at home but also does not want to
sacrifice all of her freedom.
Patient initially had some posterior head pain but now has no
complaints. She did not sustain any additional injuries in the
fall. CT head on arrival showed no intracranial bleed.
In the ED, initial vitals were: 98.4 73 151/63 16 93% RA
Labs were notable for hyponatremia of 124 and thrombocytosis to
408.
UA was notable for leukocytes and 23 WBCs.
CT head was negative for acute intracranial process.
In the ED, he was given:
___ 00:10 IV CefTRIAXone 1 gm
___ 00:10 IVF 250 mL NS 250 mL
___ 09:00 PO/NG Clopidogrel
___ 09:00 PO Pantoprazole
___ 09:00 PO/NG Sucralfate
___ 09:16 PO Moexipril 7.5 mg
___ 09:16 IH Tiotropium Bromide 1 CAP
___ 09:16 IH Fluticasone-Salmeterol Diskus (250/50)
___ 10:27 PO Aspirin 81 mg
___ 10:27 PO Atenolol 50 mg
___ 10:27 PO BusPIRone 5 mg
___ 10:27 PO/NG Furosemide 20 mg
___ 10:27 PO/NG MetFORMIN (Glucophage) 500 mg
___ walked with patient and she was only able to walk thirty feet
and felt exhausted. She was admitted for primarily safe
disposition.
On the floor, patient is comfortable. On ROS, she says she has
mild, chronic DOE, and has had diarrhea for the past two weeks
consisting of large watery bowel movements, but since ___
has not had a bowel movement. No headache, CP, cough, abd pain,
N/V. Has chronic urinary retention with foley in place for the
last ___ weeks. No numbness or weakness.
Past Medical History:
Peripheral vascular disease. Mod b/l SFA stenoses with
claudiaction
Chronic dyspnea on exertion
HTN
HLD
DM2
Emphysema
Melanoma
Left total hip replacement
Prior hysterectomy and b/l cataract surgery
Social History:
___
Family History:
No family history of premature CAD. Father (deceased at ___),
brother (deceased at ___) and mother (deceased at ___) all died of
CHF.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 97.7 132/63 64 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD. Head normocephalic, no
e/o trauma.
CV: Very distant heart sounds, RRR no m/r/g based on limited
exam
Lungs: poor air movement throughout, no wheezes, rales, or
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place draining yellow urine
Ext: No TTP in ___ b/l. No e/o trauma
Neuro: CNII-XII intact, preserved strength, moving all
extremities spontaneously
DISCHARGE EXAM
==============
Vital Signs: 98.2 ___ 18 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI
CV: Very distant heart sounds, RRR no m/r/g based on limited
exam
Lungs: poor air movement throughout, no wheezes, rales, or
rhonchi
Abdomen: Soft, mildly distended, high pitched bowel sounds
present, no organomegaly, no rebound or guarding
GU: foley in place draining yellow urine
Ext: no cyanosis, clubbing, or edema
Neuro: CNII-XII grossly intact, moving all extremities
spontaneously
Pertinent Results:
ADMISSION LABS
==============
___ 09:03PM BLOOD WBC-9.3 RBC-3.81* Hgb-11.7 Hct-34.4
MCV-90 MCH-30.7 MCHC-34.0 RDW-12.5 RDWSD-41.0 Plt ___
___ 09:03PM BLOOD Neuts-76.9* Lymphs-11.7* Monos-8.8
Eos-1.3 Baso-0.5 Im ___ AbsNeut-7.18*# AbsLymp-1.09*
AbsMono-0.82* AbsEos-0.12 AbsBaso-0.05
___ 09:03PM BLOOD ___ PTT-27.3 ___
___ 09:03PM BLOOD Glucose-139* UreaN-30* Creat-1.1 Na-124*
K-4.4 Cl-86* HCO3-26 AnGap-16
___ 09:03PM BLOOD CK(CPK)-73
___ 08:24PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 08:24PM URINE RBC-6* WBC-23* Bacteri-FEW Yeast-NONE
Epi-<1
___ 08:24PM URINE Color-Yellow Appear-Hazy Sp ___
DISCHARGE LABS
==============
___ 06:26AM BLOOD WBC-5.9 RBC-3.57* Hgb-11.0* Hct-33.2*
MCV-93 MCH-30.8 MCHC-33.1 RDW-12.9 RDWSD-43.2 Plt ___
___ 06:26AM BLOOD Glucose-105* UreaN-11 Creat-0.8 Na-134
K-4.6 Cl-100 HCO3-26 AnGap-13
___ 06:26AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
IMAGING
=======
CT head w/o contrsat ___
IMPRESSION:
1. No acute intracranial hemorrhage.
2. New focal hypodensity in the pons since ___, which
may be
artifactual or related to prior infarct.
3. Aerosolized secretions in the paranasal sinuses as described
above, which may represent acute sinusitis in the correct
clinical setting.
CXR portable AP ___
IMPRESSION:
1. New subtle right mid lung opacity, which in the appropriate
clinical
context, may be related to aspiration or pneumonia.
2. A more discrete nodular opacity in the right midlung, which
may be due to the same process. Follow-up chest radiograph is
recommended to document
resolution and to exclude the less less likely possibility of a
lung cancer as a cause of this finding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO 3X/WEEK (___)
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. BusPIRone 5 mg PO BID
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Moexipril 15 mg PO QAM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
9. Furosemide 20 mg PO DAILY
10. glimepiride 4 mg ORAL DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO 3X/WEEK (___)
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. BusPIRone 5 mg PO BID
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Moexipril 15 mg PO QAM
8. Tiotropium Bromide 1 CAP IH DAILY
9. Docusate Sodium 100 mg PO BID
10. Psyllium Powder 1 PKT PO TID:PRN constipation
11. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
12. glimepiride 4 mg ORAL DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Levofloxacin 500 mg PO Q48H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
DIAGNOSES
=========
#mechanical fall
#urinary tract infection
#hyponatremia
#urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall with head strike.
TECHNIQUE: Contiguous axial images from skull base to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, or edema. Interval
development of a pontine hypodensity may represent artifact or may be the
sequela of prior infarct (series 2, image 9). Ventricles and sulci are
prominent, consistent with age-related atrophy. Periventricular white matter
hypodensities are nonspecific but consistent with small vessel ischemic
changes.
No osseous abnormalities seen. Mucosal thickening with aerosolized secretions
are seen in the maxillary sinuses bilaterally. There are also aerosolized
secretions in bilateral ethmoid air cells. There is also mucosal thickening in
the right frontal sinus. Partial opacification right mastoid air cells is
noted. The left mastoid air cells and middle ear cavities bilaterally are
clear.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. New focal hypodensity in the pons since ___, which may be
artifactual or related to prior infarct.
3. Aerosolized secretions in the paranasal sinuses as described above, which
may represent acute sinusitis in the correct clinical setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Hypoxia. Evaluate for pneumonia.
TECHNIQUE: Portable chest x-ray.
COMPARISON: ___, CTA chest dated ___
FINDINGS:
The cardiac silhouette is unremarkable. Emphysematous changes are seen
throughout the lungs. Reticular opacities are seen in the bilateral lower
lung fields. Somewhat increased opacity is noted in the right mid lung in
comparison to the recent CT chest including a peripheral nodular opacity, not
definitively seen on prior examination. No large pleural effusion or
pneumothorax is present.
IMPRESSION:
1. New subtle right mid lung opacity, which in the appropriate clinical
context, may be related to aspiration or pneumonia.
2. A more discrete nodular opacity in the right midlung, which may be due to
the same process. Follow-up chest radiograph is recommended to document
resolution and to exclude the less less likely possibility of a lung cancer as
a cause of this finding.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Urinary tract infection, site not specified, Fall on same level, unspecified, initial encounter, Chronic obstructive pulmonary disease, unspecified, Essential (primary) hypertension, Type 2 diabetes mellitus without complications
temperature: 98.4
heartrate: 73.0
resprate: 16.0
o2sat: 93.0
sbp: 151.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | BRIEF SUMMARY
=============
___ PMH DM2, PVD, HTN, HLD, COPD w/recent admission for NSTEMI
and urinary retention with chronic foley brought to ED for fall
with head strike. A NCHCT was performed, which was negative for
acute process. Her CXR on admission was concerning for
pneumonia, although she had little to no respiratory symptoms. A
UA showed evidence of a UTI, and she was treated with
ceftriaxone then transitioned to levaquin to complete a 7-day
course to cover both UTI and CAP. She was also found to have
hyponatremia and dehydration clinically, which resolved with
fluid administration. Because of her recent falls, she was
discharged to rehab for ___.
ACUTE ISSUES
============
# FALL: Patient has history of recurrent falls, with bilateral
hip fractures from prior falls in the past. The patient reports
that she fell a few days prior to her admission, she fell and
injured her arm. On the day of admission, she fell again and hit
her head. She reports that both were related to loss of balance;
no syncope. The etiology of her fall may be related to
dehydration and/or infection, in combination with likely
age-related balance issues (several year hx of balance
problems). She reports that she has had diarrhea for the past
two weeks and felt dehydrated; she was given IVF with
resolution. On admission, she was noted to have a UA positive
for infection, likely related to her chronic foley for urinary
retention. She was treated as below. A CXR also showed a right
middle lobe opacity concerning for aspiration or pneumonia; she
had no respiratory symptoms but her abx coverage would cover CAP
as well. EKG showed no evidence of cardiac event. CT head
negative. The patient reports that independence is her number
one priority, even if her health is at risk because of it. Due
to this desire, she was discharged to rehab for physical
therapy, with home services to help mitigate her fall risk at
home.
# Urinary tract infection: The patient was found to have a
positive urinalysis while in the ED. She was asymptomatic but
has a chronic foley catheter, so was treated with ceftriaxone
then transitioned to levofloxacin to complete a 7-day course
(also to cover CAP given possible PNA)
# Lung nodule: Patient was noted to have a right mid-lung nodule
noted on CXR on admission. This may represent either aspiration
or underlying pneumonia, but repeat CXR is warranted in the near
future to assess for resolution. If this fails to resolve,
consider further evaluation for malignancy.
# HYPONATREMIA: Patient's admission sodium was 124, likely due
to poor PO intake and diarrhea. Normalized with IVF.
# URINARY RETENTION: Patient has been intermittently
straight-cathed at her extended care facility. She was seen in
___ clinic where she was unable to do this herself. We
continued her foley, and she will follow up with urology as an
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lipitor / Zetia
Attending: ___.
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p DDRT ___ c/b delayed graft function (received ___, discharged home ___, p/w n/v. Pt reported feeling
well until 8pm the day prior to admission, when he started
vomiting. He reported emesis was green and constant; he had
been unable to keep anything down. He stopped vomiting about 3
hours prior to Transplant Consultation. He reported he had been
bloated, but that this had resolved. He denied f/c, n/v, abd
pain. +regular flatus, but last BM was 4 days prior to admission
and was somewhat difficult to pass. Of note, pt has
gastroparesis at baseline.
Past Medical History:
PMH: ESRD, DM2 w/ retinopathy & neuropathy, HTN, IgA
nephropathy, CAD (NSTEMI ___ HTN urgency, EF 60%, 1+ MR),
hypercholesterolemia, diabetic foot ulcer/osteomyelitis of R
hallux, lumbar spinal stenosis, erectile dysfunction,
gastroparesis, s/p R patellar fracture
PSH: R wrist ex fix, amputation L hallux (___), L radiocephalic
AVF (___), L brachiocephalic AVF (___), R hallux IP joint
arthroplasty (___), R ___ toe amputation (___), DDRT (___)
Social History:
___
Family History:
Father w/ HTN & DM. Mother w/ breast ca. Brothers w/ HTN, DM.
Physical Exam:
On admission:
97.6 85 152/72 16 100%RA
Gen: nontoxic appearance, appears tired
___: RRR, holosystolic ejection murmur
Pulm: CTA b/l
Abd: soft, ND, appropriately tender over incision, no graft
tenderness, no rebound/guarding, +BS, incision c/d/i without
erythema/drainage, JP w/ thin serous fluid
Ext: no c/c/e
-----------
On discharge:
afebrile, VSS
Gen - NAD, alert
Heart - RRR, systolic murmur
Lungs - CTAB
Abdomen - soft, non-distended, appropriately TTP over incision,
no rebound, no guarding
Extrem - no graft TTP, no edema
Pertinent Results:
On Admission ___ -
WBC-5.2# RBC-3.27* Hgb-9.7* Hct-30.1* MCV-92 MCH-29.8 MCHC-32.3
RDW-15.0 Plt ___
Neuts-88.4* Lymphs-5.0* Monos-4.9 Eos-0.9 Baso-0.7
Glucose-166* UreaN-51* Creat-2.9* Na-144 K-4.9 Cl-107 HCO3-23
AnGap-19
URINE Color-Yellow Appear-Clear Sp ___
URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub- Urobiln-NEG pH-6.0 Leuks-SM
RBC-44* WBC-13* Bacteri-NONE Yeast-NONE Epi-0
URINE CastHy-1*
On Discharge ___ -
WBC-3.1* RBC-2.84* Hgb-8.6* Hct-26.0* MCV-92 MCH-30.2 MCHC-33.0
RDW-15.1 Plt ___
Glucose-177* UreaN-36* Creat-2.4* Na-141 K-4.3 Cl-109* HCO3-21*
AnGap-15
tacroFK-11.1
___ KUB: Supine and upright views of the abdomen. Surgical
drains and double-J stents seen in the right hemipelvis.
Overlying skin staples are also noted. There is a nonspecific
bowel gas pattern. Stool is identified throughout the colon.
There are no air-filled dilated loops of small bowel noting an
overall paucity of gas within the small bowel loops. There is
no free intraperitoneal air nor air-fluid levels. No acute
osseous abnormality detected.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Gabapentin 100 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO TID
4. Nystatin Oral Suspension 5 mL PO QID
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Tacrolimus 8 mg PO Q12H
7. ValGANCIclovir 450 mg PO 2X/WEEK (___)
8. Aspirin 325 mg PO DAILY
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Gabapentin 100 mg PO DAILY
4. Mycophenolate Mofetil 500 mg PO TID
5. Nystatin Oral Suspension 5 mL PO QID
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Senna 1 TAB PO BID
10. ValGANCIclovir 450 mg PO EVERY OTHER DAY
11. Hecoria *NF* (tacrolimus) 7 mg Oral q12H Duration: 2 Doses
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
12. GlipiZIDE 2.5 mg PO DAILY
do not take if hypoglycemic, check BS daily
Discharge Disposition:
Home
Discharge Diagnosis:
constipation, gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male status post renal transplant ___ with vomiting.
COMPARISON: ___.
FINDINGS:
Supine and upright views of the abdomen. Surgical drains and double-J stents
seen in the right hemipelvis. Overlying skin staples are also noted. There
is a nonspecific bowel gas pattern. Stool is identified throughout the colon.
There are no air-filled dilated loops of small bowel noting an overall paucity
of gas within the small bowel loops. There is no free intraperitoneal air nor
air-fluid levels. No acute osseous abnormality detected.
IMPRESSION:
Nonspecific bowel gas pattern. Gas and stool seen throughout the colon with
overall paucity of small bowel gas therefore limiting assessment.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with CHEST PAIN NOS, KIDNEY TRANSPLANT STATUS, DIABETES UNCOMPL ADULT
temperature: 97.6
heartrate: 85.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | Pt was admitted with constipation & gastroparesis on ___. He
was placed on sips, IVF, IV Zofran, scopalamine patch, and a
bowel regimen. On HD2, he was advanced to clears. He was also
given milk of magnesia, Dulcolax PR, and a tap water enema; he
did have bowel movements. Tacrolimus was continued and dosed
daily.
The patient had been started on glipizide 5 mg QD one day prior
to admission by Dr. ___ was consulted for glucose
control and an insulin sliding scale was started in-house. His
Valcyte was changed to QOD. He reported chills, so he was
pan-cultured (NGTD.) A UA was positive, so he was started on
ciprofloxacin; urine culture showed no growth. On HD 3, he was
advanced to regular diet and heplocked. At the time of
discharge, he was AVSS and tolerating PO without n/v.
The patient was discharged home on decreased dose of Tacro ___.
Patient is a free care patient and currently has no access to
insulin, syringes, or testing supplies at home, so he was
discharged on a decreased dose of glipizide (2.5 mg QD) while on
1 week course of ciprofloxacin for UTI. He will follow up in
clinicon ___ with labs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
persistent cough, trouble sleeping
Major Surgical or Invasive Procedure:
___ - Upper endoscopy
History of Present Illness:
This is a ___ old Male with PMH significant for metastatic
esophageal adenocarcinoma (s/p esophagectomy with gastric pull
through and chemoradiation - surgery complicated by ___ with
laparoscopic reduction of hiatal hernia and J-tube placement,
___ now presenting with hypoxia and persistent cough.
The patient was recently admitted ___ to ___ thoracic
surgery service with gastric outlet obstruction - of unclear
etiology per Dr. ___ (? longstanding pyloric spasm).
EGD ___ was without evidence of esophageal obstruction -
biopsies were negative for malignancy. Repeat EGD was performed
___ and he underwent dilation of the pylorus to improve
gastric emptying. Trialed with metoclopramide dosing. Given his
ongoing symptoms he underwent hiatal hernia repair and J-tube
placement for these symptoms this admission (___). Tube feeds
were tolerated post-op. He had noted pulmonary nodules on
imaging that admission with CT-guided biopsy on ___ positive
for metastatic disease. He also required a Foley catheter for
urinary retention - which was maintained at discharge. In
addition, he was treated with a 5-day course of ciprofloxacin.
He was discharged home with ___ on ___.
On ___ he was tolerating oral feeds and Ensure well and
discontinued J-tube feeds. At follow-up with Dr. ___
thoracic surgery on ___ a CXR demonstrated a very dilated
conduit with large PTX and effusion? but the patient was not
symptomatic. On ___ had a PET-CT ___ ___ had MRI of
the head, both at the mobile imgaging unit at ___,
to evaluate his malignancy burden. Results are not yet
available.
The patient then notified the thoracic surgery team on ___
in the evening with complaints of persistent productive cough
and trouble sleeping. He stated that the symptoms had been
present for several weeks. Pt tried nyquil with little effect.
Pt also reports nausea/vomiting as a result of coughing. Per
patient, he was referred to clinic or ___ ED for earlier
evaluation and chose earlier evaluation because he was coughing
violently every night with extensive sputum production that
looks like a combination of mucus and his feeding material.
On arrival to the ED today, oxygen saturation was 96%, but then
he
desaturated in the ED to 88%, and started receiving oxygen by
nasal canula. He remained asymptomatic, denying SOB. CXR
significant for RML collapse and moderate right pleural effusion
and CT PE protocol was negative for pneumothorax or PE, but also
suggested that the dilated conduit is causing compression of the
right lung, per preliminary reads for both.
ED course:
- initial VS 98.9 95 97/70 19 96% RA (desats to 88% on RA)
- Labs notable for WBC 16.7, Hgb 13.6, platelets 363
- Creatinine 0.6, lactate 1.2; INR 1.1
- LFTs: AST 41, ALT 21, AP 89 and albumen 3.4
- CXR and CTA chest obtained
- Blood cultures obtained
- Received 1L LR
- Evaluated by thoracic surgery
REVIEW OF SYSTEMS: See HPI for pertinent details.
Denies fevers or chills; no nightsweats. No headaches or visual
changes. No chest pain or difficulty breathing. Denies abdominal
pain. No changes in bowel habits. No dysuria or hematuria. Mild
extremity swelling after standing for prolonged period. Has lost
over 80lbs since the diagnosis of esophageal adenocarcinoma.
Past Medical History:
PAST MEDICAL HISTORY:
Metastatic esophageal adenocarcinoma, s/p esophagectomy with
gastric pull through and chemoradiation - surgery complicated by
GOO with pyloric dilatation, then laparoscopic reduction of
hiatal hernia and J-tube placement
PAST SURGICAL HISTORY:
- Laparoscopic reduction of hiatal hernia and J-tube insertion,
___
- Laparoscopic colon polypectomy, ___
- Esophagectomy and gastric pull through, ___
Social History:
___
Family History:
Mother HTN
Father Died of MI ___
Uncle with leukemia
Physical Exam:
ADMISSION EXAM
===============
Vitals: 98.9 97/70 95 16 92%RA
General: NAD. Appears stated age. Non-toxic appearing.
HEENT: PERRL. EOMI. Nares clear. Oropharynx with white exudate
on hard palate and poor dentition. Neck supple. No
lymphadenopathy.
___: RRR. No murmurs, audible rubs. S1 and S2 noted.
Respiratory: Mild increase in work of breathing. Reduced airway
sounds on the R with good air movement on the L and rub noted in
L base. No rhonchi or rales appreciated.
Abdomen: Soft, NTND with normoactive bowel sounds; no
hepatosplenomegaly or palpable masses; J-tube intact in LLQ.
Extremities: Warm, well-perfused distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing or peripheral edema.
Derm: Skin appears intact with no significant rashes or lesions
Neuro: AOx3. Cranial nerves II-XII are intact. Normal bulk and
tone. Motor and sensory function are grossly normal. Gait
deferred.
DISCHARGE EXAM
===============
Vitals: 98.3 101/62 72 18 92% RA (amb sat 88% yesterday)
I/Os: TFs 1820 | IV 550 | 1470 | 175 from NGT
General: NAD. Appears stated age. Non-toxic appearing.
HEENT: PERRL. EOMI. MMM. OP clear. NGT with brownish food debris
and liquid material consistent with stomach contents.
___: RRR. No murmurs.
Respiratory: Some decreased breath sounds and faint inspiratory
crackles at left base, right lung with bowel sounds. No wheezes.
Abdomen: soft, NTND with normoactive bowel sounds; J-tube intact
in LLQ without erythema. TFs leaking around site mildly.
Extremities: WWP with no c/c/e. 2+ distal pulses b/l.
Neuro: Motor, and sensory functions all grossly normal. Gait
deferred.
Pertinent Results:
ADMISSION LABS
===============
___ 11:35AM LACTATE-1.2
___ 11:20AM GLUCOSE-130* UREA N-17 CREAT-0.6 SODIUM-140
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-35* ANION GAP-12
___ 11:20AM ALT(SGPT)-21 AST(SGOT)-41* ALK PHOS-89 TOT
BILI-0.6
___ 11:20AM LIPASE-36
___ 11:20AM ALBUMIN-3.4* CALCIUM-9.5 PHOSPHATE-2.9
MAGNESIUM-2.3
___ 11:20AM WBC-16.7* RBC-4.67 HGB-13.6* HCT-41.0 MCV-88
MCH-29.1 MCHC-33.1 RDW-14.4
___ 11:20AM NEUTS-85.3* LYMPHS-5.7* MONOS-6.1 EOS-1.5
BASOS-1.4
___ 11:20AM PLT COUNT-363
___ 11:20AM ___ PTT-30.2 ___
DISCHARGE LABS
===============
___ 07:00AM BLOOD WBC-8.8 RBC-4.08* Hgb-11.8* Hct-36.0*
MCV-88 MCH-28.9 MCHC-32.8 RDW-14.4 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-127* UreaN-16 Creat-0.6 Na-143
K-3.8 Cl-105 HCO3-33* AnGap-9
___ 07:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.1
MICROBIOLOGIC DATA
===================
___ Urine culture - pending
___ Blood culture - pending
IMAGING STUDIES
================
CXR ___:
1. Right lower lobe collapse and small-to-moderate right
pleural effusion.
2. Mild left basilar atelectasis, new from prior.
3. No definite pneumothorax, although evaluation is limited due
to esophageal conduit on the right.
CTA Chest ___:
1. No acute aortic abnormality or pulmonary embolus.
2. Several bilateral pulmonary nodules, similar in appearance
to ___ compatible with metastatic disease.
3. Hazy ground-glass opacity in the left lower lobe with
adjacent small pleural effusion is unchanged since ___. Ground-glass opacity is nonspecific but may represent
focal edema.
4. Status post esophagectomy with gastric pull-up with
prominent distention of the intrathoracic stomach, similar in
degree ___ suggestive of outlet obstruction.
5. Distended gastric pullup as well as the large bowel loops
and associated fat herniating into the thoracic cavity causes
significant mass effect upon and contributes to the
atelectasis/collapse of the lungs.
6. Unchanged right thyroid nodule measuring 1.8 cm.
7. Large left central diaphraghmatic hernia, unchanged.
8. Coronary artery calcifications.
EGD ___
Esophagitis was seen in the upper third of the esophagus.
Evidence of an esophago-gastric anastomosis was seen at 23 cm
from the incisors.
Stomach: Gastric deformity was noted, with massive dilation of
the proximal stomach. There was excessive fluid and food debris
in the proximal stomach. The distal stomach was less dilated and
without much fluid or food debris. There was no discrete
intrinsic lesion or extrinsic compression visualized to account
for this discrepancy. There appeared to be a twist in the lumen
at the level of the pylorus/gastric outlet. This could be
traversed with the gastroscope into the duodenum, which appeared
normal. There was again no discrete intrinsic lesion or
extrinsic compression visualized at this level. Excavated
Lesions A few large, irregular, superficial, ischemic-appearing
ulcers were found in the stomach body. Cold forceps biopsies
were performed for histology at the stomach ulcer, to rule-out
malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Metoclopramide 10 mg PO QID
3. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Tamsulosin 0.4 mg PO HS
2. Metoclopramide 10 mg PO QID
3. Omeprazole 20 mg PO DAILY
we recommend that you take this medication twice daily.
4. Oxygen
Home oxygen @ 2 LPM continuous via nasal cannula, conserving
device for portability.
5. Hospital bed
Please provide with hospital bed to allow for head of bed
elevation to 40-degrees given chronic aspiration concerns.
ICD-9 code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Chronic aspiration
- Gastric outlet obstruction
- Metastatic esophageal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of esophageal conduit, now with dyspnea, here to evaluate
for acute cardiopulmonary process.
COMPARISON: ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: Suture material projecting vertically over the right lung on the
frontal view is compatible with the patient's esophageal conduit. An
air-fluid level in the right lung apex is also related to the conduit. There
is no definitive evidence of pneumothorax. Complete opacification of the
right lung base suggests right lower lobe collapse. Mild left basilar
atelectasis is new from the prior exam. A small-to-moderate right pleural
effusion is probably not changed from ___. A left pleural effusion is
small, if any. The pulmonary vasculature is not engorged, and there is no
overt pulmonary edema. The cardiomediastinal contours are within normal
limits. The right hilus is obscured by opacification in the right chest. The
left hilar contours are within normal limits.
IMPRESSION:
1. Right lower lobe collapse and small-to-moderate right pleural effusion.
2. Mild left basilar atelectasis, new from prior.
3. No definite pneumothorax, although evaluation is limited due to esophageal
conduit on the right.
Radiology Report
HISTORY: Esophagectomy and pull-up, presenting with shortness of breath.
COMPARISON: CT interventional ___, outside CT chest ___.
TECHNIQUE: Axial helical MDCT images were obtained of the chest after the
administration of IV contrast in the arterial phase. Multiplanar reformats
were generated in the coronal and sagittal planes as well as bilateral oblique
maximum intensity projection images.
DLP: 428.74 mGy-cm.
FINDINGS:
CTA CHEST: There is a heterogeneous right-sided thyroid nodule measuring 1.8
cm, unchanged in size compared to ___. Heart size is normal with trace
physiologic pericardial fluid. Coronary artery calcifications are noted. The
thoracic aortic arch is normal in caliber without focal aneurysmal segment or
dissection. The main pulmonary artery is normal in caliber. There is no
pulmonary embolus to the segmental level. There are several scattered
calcified mediastinal lymph nodes. A borderline enlarged 1.1 x 1.0 cm AP
window lymph node has increased in size compared to prior study where it
measured 6 mm (3:38). A right hilar lymph node conglomerate measuring 2.1 x
1.4 cm has minimally increased, previously measuring 1.6 x 1.5 cm. There is
no axillary or supraclavicular lymphadenopathy by CT size criterion.
The patient is status post esophagectomy and gastric pull-up. The
intrathoracic stomach is prominently dilated, similar to extent from ___,
containing a large amount of food material which is suggestive of an outlet
obstruction. There is angling of the gastric outflow as it moves from the
thoracic to the abdominal cavity. There is redemonstration of a large
left-sided diaphragmatic hernia containing a few loops of small and large
bowel.
There is a small left-sided pleural effusion. The airways are patent to the
subsegmental level. There is prominent right lower lobe atelectasis likely
compressive from the gastric pull-up. There are several bilateral pulmonary
nodules redemonstrated, appearing roughly similar compared to ___. The
largest on the right side is in the inferior portion of the right upper lobe
adjacent to the gastric pull-up, measuring 2.0 x 1.6 cm (3:45). The largest
on the left is in the upper lobe measuring 1.0 x 0.9 cm (3:22). Additional
nodules are again noted in the left upper lobe (3:40, 54). There is a
prominent nodule in the left inferior lingular segment, measuring 2.3 x 1.8 cm
(3:92). Additional nodules are seen in the right lower lobe and right upper
lobe. No new nodule is identified. Subtle ground-glassing in the left lower
lobe is unchanged since ___. There is no pneumothorax.
OSSEOUS STRUCTURES: There are no focal lesions in the visualized osseous
structures concerning for malignancy.
IMPRESSION:
1. No acute aortic abnormality or pulmonary embolus.
2. Several bilateral pulmonary nodules, similar in appearance to ___ compatible with metastatic disease.
3. Hazy ground-glass opacity in the left lower lobe with adjacent small
pleural effusion is unchanged since ___. Ground-glass opacity is
nonspecific but may represent focal edema.
4. Status post esophagectomy with gastric pull-up with prominent distention
of the intrathoracic stomach, similar in degree ___ suggestive of
outlet obstruction.
5. Distended gastric pullup as well as the large bowel loops and associated
fat herniating into the thoracic cavity causes significant mass effect upon
and contributes to the atelectasis/collapse of the lungs.
6. Unchanged right thyroid nodule measuring 1.8 cm.
7. Large left central diaphraghmatic hernia, unchanged.
8. Coronary artery calcifications.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New nasogastric tube, evaluation of placement.
COMPARISON: ___.
FINDINGS: A nasogastric tube has been placed in the neoesophagus. The tip is
at the bases of the neoesophagus, approximately at the level of the right
hemidiaphragm. The atelectatic and postoperative changes on the right have
decreased in severity and extent. However, an atelectasis at the left lung
bases has newly developed. Unchanged appearance of the cardiac silhouette.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with HYPOXEMIA
temperature: 98.9
heartrate: 95.0
resprate: 19.0
o2sat: 96.0
sbp: 97.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH significant for metastatic esophageal
adenocarcinoma (s/p esophagectomy with gastric pull through and
chemoradiation - surgery complicated by GOO with pyloric
dilation and laparoscopic reduction of hiatal hernia then J-tube
placement, ___ who presented with hypoxia and persistent
cough.
# Likely chronic aspiration, leading to hypoxia with persistent
productive cough - Imaging suggestive of impaired lung function
in the setting of markedly dilated gastric conduit (with
evidence of air-fluid level and food material in the thorax -
suggesting chronic gastric outlet obstruction). Patient
presented complaining of productive cough attributed to chronic
aspiration and GERD. CTA chest showed no pulmonary embolism or
PTX but severe dilated of the intrathoracic stomach. No evidence
of consolidation. Thoracic surgery was consulted, relaying he
was not a surgical candidate given his metastatic disease. He
was placed on aspiration precautions and GI was consulted who
performed an EGD on ___ which demonstrated gastric volvulus
that was managed with NG tube decompression. We recommended
strict NPO and only sips for comfort - using a J-tube for
primary nutrition. He was also discharged on home oxygen given
some ambulatory desaturations.
# Gastric outlet obstruction - Patient developed gastric
obstruction after total esophagectomy with gastric pull through.
Etiology unclear to primary surgeon, but there is a suggestion
of longstanding pyloric spasm. Attempts to improve the
obstruction with pyloric dilatation and hiatal hernia reduction
have not provided relief and he now has a J-tube for nutrition.
Imaging on admission revealed significant distention of gastric
conduit, as patient had been eating food recently. Of note, he
enjoys eating and expressed desire to keep eating. He was placed
on aspiration precautions and GI was consulted who performed an
EGD on ___ which demonstrated gastric volvulus that was
managed with NG tube decompression. We recommended strict NPO
and only sips for comfort - using a J-tube for primary
nutrition. He continued on once daily PPI therapy. Thoracic
surgery did mention that aggressive head of bed elevation to
___ degrees will be important to prevent GERD and aspiration -
thus a hospital bed was requested for home.
# Leukocytosis - WBC elevated to 16.7 on admission with
neutrophilia, but resolved spontaneously without intervention.
He had no localizing symptoms and imaging (CXR and CT) without
consolidation. Urine culture with coagulase negative Staph and
he had no symptoms - antibiotics were deferred.
# Metastatic esophageal adenocarcinoma - Patient is s/p
esophagectomy with gastric pull through with chemoradiation in
___. Esophageal adenocarcinoma found to be Her 2+ and recently
with bilateral pulmonary lung nodules also found to be Her 2+,
supporting metastatic disease. Dr. ___ (primary
oncologist from ___ was made aware of his hospitalization and
is planning for palliative chemotherapy after hospitalization
with follow-up scheduled the week of his discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral adnexal masses, fevers
Major Surgical or Invasive Procedure:
CT-guided drainage of bilateral tubo-ovarian abscesses
History of Present Illness:
___ yo G0 transferred from ___ with bilateral adnexal
masses and persistent fevers. Patient reports for approximately
past two months has had fevers and abdominal pain. Reports high
fevers at home starting beginning of ___. Initially no other
symptoms other than fevers and body aches. Was evaluated by PCP
and had "multiple blood tests" done. Reports continued to have
almost daily fevers since that time. Has been taking ibuprofen
amost daily for fevers. Reports started to develop diffuse lower
abdominal pain associated with fevers several weeks prior. PCP
ordered pelvic ultrasound which was done on ___ and revealed
bilateral pelvic masses right 9.2x5.6x5cm and left sided
13.1x12x10.6cm. An MRI was performed on ___ and revealed a
10.3x8.7x7.8cm complex left adnexal mass, 4.5cm right adnexal
mass. CT scan was done at ___ on ___ which showed
bilateral adnexal masses with spetations and an air filled
portion of right sided loculation adnexal masses measuring 15cm
together. Patient transferred to ___ for further management
given concern of air in mass and possible fistula with bowel.
Patient reports decreased appetite for past two months, stools
softer more frequent. Denies any nausea, vomiting, blood in
stools. Reports periods normal.
Past Medical History:
OB/GYN Hx:
- G0
- LMP ___
- Reports periods q29-30days, x5days, reports cramping pain with
periods
- Denies any history of abnormal Pap
- Denies any history of STI, pelvic infections
- Denies any history of fibroids, ovarian cysts
PMHx:
- Denies
- Denies HTN, asthma, clotting disorders
PSHx:
- Denies
Medications:
- ibuprofen PRN
Allergies:
- NKDA
Social History:
___
Family History:
- Denies any history of breast, colon, uterine or ovarian cancer
- Denies any history of clotting disorders, HTN, asthma
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally, normal work of
breathing
Abd: soft, appropriately tender, nondistended, three lower
abdominal drains without evidence of skin infection continuing
to drain small amounts of yellow-colored material, no
rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ CT-Interventional Procedure: Successful CT-guided
placement of 2 ___ pigtail catheters into the right lower
quadrant and left lower quadrant tubo-ovarian abscesses. Samples
sent for microbiology evaluation.
___ Abscess culture: Mixed bacterial flora including
pseudomonas aeruginosa (rare growth, pan-sensitive), bacteroides
fragilis (moderate growth, + beta-lacatamase), prevotella
(moderate growth, - beta-lactamase)
___ Blood culture: no growth
___ CT Pelvis:
1. Bilateral adnexal collections with pigtail catheters an
appropriate
position.
2. The left adnexal collection was aspirated to completion
based on the
images from the prior CT interventional procedure. However, in
the intervening days, the collection has reaccumulated.
3. Possible fistula between the sigmoid colon in the left
adnexal collection is identified.
___ Blood culture: no growth
___ CT-Interventional Procedure:
1. Successful CT guided exchange of left adnexal catheter.
2. Successful placement of additional right adnexal pigtail
catheter as
described above.
3. Limited preprocedure CT demonstrates enteric contrast within
the left
adnexal collection, confirming the presence of a fistula with
the sigmoid
colon. The left adnexal collection contains dense material,
compatible
with enteric contrast from the colonic fistula identified on the
prior CT.
___: Duplex left upper extremity: Nonocclusive thrombus
within the left basilic vein, surrounding the PICC
___: CT Abdomen/Pelvis:
1. 2 right-sided and 1 left-sided transabdominal drains within
significantly smaller adnexal collections. 6 x 6.5 cm left
adnexal collection, just inferior and anterior to the left
pigtail drain and 4 x 4.1 cm right anterolateral collection
anterolateral to the lower right-sided pelvic drain, in addition
to a smaller 1.6 x 2 cm adjacent collection. These collections
demonstrate T1 hyperintensity and T2 shading on the prior MRI,
compatible with patient's known endometriomas.
2. Small right larger than left pleural effusions.
Medications on Admission:
ibuprofen prn
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. Ciprofloxacin HCl 750 mg PO/NG Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every 12 hours
Disp #*20 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*1
4. Lorazepam ___ mg PO QHS:PRN insomnia
Do not drive while using this medication.
RX *lorazepam 1 mg 1 tablet by mouth at bedtime Disp #*5 Tablet
Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive or drink alcohol, causes sedation
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
bilateral tubo-ovarian abscesses
left tubo-ovarian abscess with colonic fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-guided abscess drainage.
INDICATION: ___ year old woman with bilateral TOAs // drainage of TOAs
COMPARISON: CT from ___ and MRI from ___.
PROCEDURE: CT-guided percutaneous bilateral pelvic abscess drainage.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist, who was present and supervising throughout the total procedure
time.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, 18G ___ needle was inserted
into the right lower quadrant collection. 0.038 ___ wire was placed
through the needle and needle was removed. A sample of fluid was aspirated,
confirming needle position within the collection. Tract dilatation was
performed over the wire with 6, 7 and ___ dilators. This was followed by
placement of an ___ ___ catheter into the connection. The plastic
stiffener and the wire were removed. Pigtail was deployed, and the position of
the pigtail was confirmed within the collection via CT fluoroscopy. The
process was repeated for the left lower quadrant collection.
Approximately 50 cc of purulent fluid was drained from the right lower
quadrant collection and 150 cc of purulent fluid from the left lower quadrant
collection. Samples were sent for microbiology evaluation. The catheters was
secured by a StatLock. The catheters was attached to bags. 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
3.5 mg Versed and 200 mcg fentanyl throughout the total intra-service time of
40 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Bilateral tubo-ovarian abscesses with multiple air-fluid levels. Bilateral
endometriomas avoided.
IMPRESSION:
Successful CT-guided placement of 2 ___ pigtail catheters into the right
lower quadrant and left lower quadrant tubo-ovarian abscesses. Samples was
sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with new PICC line // new L 45cm POWER PICC
Contact name: ___: ___
FINDINGS:
Newly placed left-sided PICC line. The course of the line is unremarkable,
the tip of the line projects over the low SVC. No evidence of complications,
notably no pneumothorax. Otherwise normal chest radiograph.
Radiology Report
INDICATION: ___ year old woman with bilateral ?TOAs with recurrent fever,
increasing WBC // PLEASE EVALUATE DRAIN PLACEMENT, INTERVAL CHANGE IN ABSCESS
AND POSSIBILITY OF FISTULA
TECHNIQUE: Multidetector axial CT images were acquired through the pelvis
after the administration of oral contrast only. Subsequently, images were
acquired through the pelvis after the administration of rectal and IV
contrast.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
DOSE: DLP: 246.90 mGy-cm (pelvis)
IV Contrast: 100 mL Omnipaque
COMPARISON: CT performed on ___. MRI performed on ___.
FINDINGS:
PELVIS:
8 x 7.4 x 8 cm fluid collection in the right adnexa which is grossly stable in
size when compared to the previous exam. There is a anterior approach pigtail
catheter within the collection which contains an air-debris level.
7.9 x 7.3 x 8.1 cm collection in the left adnexa, which has re-accumulated
since the prior CT intervention were the collection was completely aspirated.
There is an anterior approach pigtail catheter coiled which appears within
this air containing collection. After the administration of IV and rectal
contrast, there appears to be a fistula connecting the collection to the
adjacent sigmoid colon. This is best seen on series 12, image 38 and 42.
In the right anterior adnexa, there is a well-circumscribed homogeneous 4.5 x
4.8 cm mass (series 9, image 23) and a similar mass on the left measuring 6.3
x 5.3 cm (series 9, image 32), both of which represent endometriomas based on
prior MRI.
There is no pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: There is mass-effect on the uterus from the bilateral
adnexal collections however the uterus is otherwise normal on CT.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. Bilateral adnexal collections with pigtail catheters an appropriate
position.
2. The left adnexal collection was aspirated to completion based on the
images from the prior CT interventional procedure. However, in the intervening
days, the collection has reaccumulated.
3. Possible fistula between the sigmoid colon in the left adnexal collection
is identified.
Radiology Report
INDICATION: ___ female with bilateral TOAs.
COMPARISON: CT performed on ___. MRI performed on ___.
PROCEDURE: CT-guided drainage of bilateral tubo-ovarian abscesses.
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 the supine position on the CT scan table. A limited
preprocedure CT of the pelvis demonstrated bilateral adnexal collections, both
with catheters in place. On further evaluation, the left collection could not
be aspirated. The decision was made to at increase the size of the left
adnexal catheter to 12 ___.
LEFT DRAIN EXCHANGE:
Under CT fluoroscopic guidance, a 0.038 ___ wire was placed through the
existing 8 ___ left pigtail catheter. The catheter was removed and serial
dilation was performed over the tract. Subsequently, a 12 ___ pigtail
catheter was replaced over wire into the left adnexal collection. A total of
180 cc of thick, foul-smelling feculent material was aspirated to collapse the
abscess cavity. Passes cavity was gently irrigated with approximately 50 cc
of sterile saline.
RIGHT DRAIN ADJUSTMENT:
8 ___ right adnexal catheter was flushed with sterile saline. A total of
30 cc of thick, feculent material was aspirated. Limited noncontrast CT of
the pelvis demonstrated a collection medial to the right adnexal collection
which appeared to communicate with the drained collection on prior exams
however did not collapse with aggressive flushing, aspiration or patient
repositioned. Decision was made at this point to place an additional catheter
into this medial right adnexal collection.
RIGHT ADNEXAL CATHETER PLACEMENT:
The patient was placed in a supine position on the CT scan table. Based on
the CT findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
pigtail catheter into the collection. The plastic stiffener and the wire were
removed. The pigtail was deployed. The position of the pigtail was confirmed
within the collection via CT fluoroscopy.
Approximately 20 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. CT fluoroscopic images obtained after aspiration
demonstrates collapse of this abscess cavity.
All catheters were by a StatLock. The catheter was attached to bag. Sterile
dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 265.2 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 120
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
PREPROCEDURE CT:
Noncontrast CT performed for preprocedure evaluation demonstrates a 6.4 x 7.7
cm left adnexal collection. An anterior approach pigtail catheter is coiled
within this collection. The collection contains dense material, compatible
with enteric contrast from the colonic fistula identified on the prior CT.
There is a pigtail catheter coiled within the right adnexa. Medial to this
catheter, there is a 5.4 x 5.9 cm collection containing air-fluid level.
POST CATHETER EXCHANGE CT:
Limited noncontrast CT of the pelvis performed after exchange of the left
adnexal catheter and with the patient and right decubitus position
demonstrates complete collapse of the left adnexal collection. The right
adnexal collection was aspirated however there continues to be a medial right
adnexal collection which was targeted for drainage as described above.
IMPRESSION:
1. Successful CT guided exchange of left adnexal catheter.
2. Successful placement of additional right adnexal pigtail catheter as
described above.
3. Limited preprocedure CT demonstrates enteric contrast within the left
adnexal collection, confirming the presence of a fistula with the sigmoid
colon.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL RIGHT
INDICATION: Evaluate for clot at left PICC site, in a patient with worsening
numbness, tingling, and throbbing pain of the left arm x2 days.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular and axillary veins are patent and compressible with
transducer pressure.
The left brachial veins are patent compressible with transducer pressure and
show normal color flow and augmentation. A PICC is seen within the left
basilic vein, which is not compressible with transducer pressure, consistent
with a nonocclusive thrombus. The left cephalic vein is not well visualized.
IMPRESSION:
Nonocclusive thrombus within the left basilic vein, surrounding the PICC.
NOTIFICATION: These findings were communicated via telephone by Dr. ___
___ to Dr. ___ at 23:09 on ___.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with b/l TOAs s/p drainage with 3 drains in
place. // Please perform drain study and interval assessment of her abscesses
TECHNIQUE: Spiral acquisition was performed during single phase after
administration of IV contrast. Oral contrast was also administered.
Multiplanar reformats were created.
DOSAGE: TOTAL DLP This study involved 3 CT acquisition phases with dose
indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3)
Spiral Acquisition 4.4 s, 53.1 cm; CTDIvol = 5.7 mGy (Body) DLP = 276.5
mGy-cm. Total DLP (Body) = 277 mGy-cm.mGy-cm
COMPARISON: Multiple prior studies, most recent CT procedure ___
FINDINGS:
Small right larger than left pleural effusions with passive atelectasis.
Focal fatty change adjacent to falciform ligament. Decompressed gallbladder.
Normal appearance of the pancreas without main ductal dilation. Normal spleen
and adrenals.
Decompressed stomach. Contrast extends through the rectum. No small bowel
dilation. No definite enteric contrast is demonstrated within the adnexal
collections on the current study.
Normal caliber abdominal aorta. There is mild generalized stranding of
mesenteric fat.
Anteverted uterus. 2 right-sided and 1 left-sided transabdominal drains are
demonstrated within the adnexal collections, significantly decreased in size
compared to prior. A 6 x 6.5 cm left adnexal collection, just inferior and
anterior to the left pigtail drain, is present, prior 6.1 x 6.5 cm. A 4 x 4.1
cm right anterolateral collection is demonstrated anterolateral to the lower
right-sided pelvic drain, prior 4.8 x 4.4 cm, in addition to a smaller 1.6 x 2
cm adjacent collection. Generalized pelvic stranding.
Presumed small bone island within the right femoral head. No suspicious
osseous lesions.
IMPRESSION:
-2 right-sided and 1 left-sided transabdominal drains within significantly
smaller adnexal collections. 6 x 6.5 cm left adnexal collection, just
inferior and anterior to the left pigtail drain and 4 x 4.1 cm right
anterolateral collection anterolateral to the lower right-sided pelvic drain,
in addition to a smaller 1.6 x 2 cm adjacent collection. These collections
demonstrate T1 hyperintensity and T2 shading on the prior MRI, compatible with
patient's known endometriomas.
-Small right larger than left pleural effusions.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:40 ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Pelvic pain
Diagnosed with ABDOMINAL PAIN GENERALIZED, FEVER, UNSPECIFIED
temperature: 99.0
heartrate: 120.0
resprate: 20.0
o2sat: 100.0
sbp: 136.0
dbp: 68.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ was admitted to the gynecologic oncology service
at the ___ after transfer from
___ on ___ for bilateral pelvic masses,
fever, and pain.
On hospital day #1, she underwent CT-guided drainage of
bilateral collections with drainage of foul-smelling material
and she was started on gentamycin and clindamycin for suspected
tubo-ovarian abscesses bilaterally.
On hospital day #3,she was transitioned to ceftriaxone and
flagyl after consultation with Infectious Disease given gram
stain and drain output concerning for feculent material.
Infectious disease was consulted; the patient was started on IV
ceftriaxone/flagyl then transitioned to meropenem.
On hospital day #4, Ms. ___ had a fever to ___ and her
antibiotics were then changed to meropenem. She underwent a
repeat CT of her abdomen and pelvis which revealed
re-accumulation of the abscesses bilaterally to their
pre-drainage size as well as contrast extravasation from the
sigmoid colon to the left tubo-ovarian abscess. Colorectal
surgery was consulted and recommended repeat drain placement and
conservative management. The patient then underwent CT-guided
exchange of the previous 2 drains with larger drains and
placement of a third drain by interventional radiology. Enteric
contrast from her previous CT scan was aspirated from the left
adnexal collection, confirming the presence of a colonic
fistula.
On hospital day #6, Ms. ___ received 2 units of packed
red blood cells as well as vitamin K for a hematocrit of 20.6
and INR of 1.8. There was no evidence of bleeding and she had an
appropriate rise in her hematocrit and improvement in her INR.
On hospital day #9, Ms. ___ experienced numbness and
tingling in her left upper extremity. Ultrasound revealed a
non-occlusive basilic vein thrombosis around her PICC. The PICC
was removed and she was continued on prophylactic lovenox.
Repeat imaging on hospital day #10 showed interval improvement
in drainage of bilateral adnexal collections without active
drainage of enteric contrast into the collection.
During her admission, Social Work was consulted for assessment
and support in coping with this unexpected hospitalization and
diagnosis. The patient was found to have adequate social support
and coping mechanisms for self care and was given resources for
further support as an outpatient.
By hospital day #11, she was afebrile with stable vital signs,
tolerating oral intake and ambulating independently. Her
infectious disease doctors agreed with ___ to oral
ciprofloxacin and flagyl and the gynecology oncology team, in
conjunction with the colorectal surgery service, felt the
patient was safe for discharge home with continued antibiotics
and close outpatient followup. She was then discharged home in
stable condition with home nursing services and close outpatient
followup scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Inderal
Attending: ___
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with T2DM (A1c=6.3%), CHF (EF=50-60%), CAD s/p CABGx4, HepB,
asthma, and h/o CVA who presents with hypoglycemia. She was
found unresponsive to minimally responsive by her son and
husband this morning. She was thought to have been this was for
at least an hour, but the family is not sure how long this
lasted. EMS was called and was found to have a ___ of 11. Her
mental status reportedly improved after receiving 1 amp of D50
in the ambulance and she reports that she initially felt sleepy
after waking up but now feels back to normal. ___ after dextrose
was 152.
She states that she ate a normal dinner last night at 7pm but
did not have a snack before bed, which she usually does. She
takes Humulin U500 on a sliding scale 3 times per day at home
and she reports taking between ___ units last night with
dinner, which was the amount she was prescribed to take for a ___
in the low 100s (she cannot remember the exact ___ or amount of
insulin she took). She states that over the past few weeks her
___ have raged from 50-170.
In the ED, initial VS: 96.9 87 173/69 99%. ___ was in 170s upon
arrival. EKG showed no ischemia and initial trop was negative.
SHe was admitted to the floor for hypoglycemia.
Currently, she is feeling well. She states that she has some
dyspnea on exertion, althogh she is occasionally SOB at baseline
given her asthma and CHF. She denies any chest pain, N/V,
headache, dizziness or lightheadedness.
Past Medical History:
-T2DM, diagnosed in ___, last A1c in ___ was 6.3%
-CAD s/p CABGx4 in ___
-Chronic Hepatitis B - viral load 69x10^6 in ___, on Viread
-CHF (EF 50-60%)
-HTN
-H/o CVA ___ years ago
-Asthma
-CKD - stage 2, from nephrotic syndrome
-Raynaud's
Social History:
___
Family History:
Diabetes in her nephew and some other family members, unsure
which ones
Physical Exam:
Admission exam:
Vitals: T 97.3 BP 155/75 HR 80 RR 20 SpO2 100/4L
___ (arrival to floor) = 279
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Shallow breaths, otherwise clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, appears distended with increased
tympany to percussion. + bowel sounds. no rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing. Trace to 1+
edema of ___, L>R, vein harvest scars on L ___.
Neuro: CN II-XII intact. ___ strength in upper extremities. L ___
is ___ strength in proximal and distal muscle groups. R ___ is
___ in hip flexion and ___ in plantarflexion/dorsiflexion.
Discharge exam: Same as above
Pertinent Results:
Labs:
___ 05:00AM BLOOD WBC-6.5 RBC-4.03* Hgb-12.4 Hct-37.4
MCV-93 MCH-30.8 MCHC-33.3 RDW-13.4 Plt ___
___ 05:00AM BLOOD Neuts-54.4 ___ Monos-8.1
Eos-18.3* Baso-0.7
___ 05:00AM BLOOD Glucose-105* UreaN-23* Creat-1.2* Na-141
K-4.1 Cl-108 HCO3-21* AnGap-16
___ 05:00AM BLOOD ALT-40 AST-30 LD(LDH)-224 AlkPhos-86
TotBili-0.2
___ 03:45PM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD cTropnT-<0.01 proBNP-663*
Imaging:
-CXR (___) - Pulmonary vasculature is more engorged, but
there is no pulmonary edema or pleural effusion. Moderate
cardiomegaly and mediastinal vascular engorgement are chronic.
No pneumothorax. No focal pulmonary consolidation.
Medications on Admission:
-Insulin U-500 sliding scale tid with meals
-amlodipine 5mg PO daily
-bumetanide 1mg PO daily
-clonazepam 0.5mg PO qHS PRN
-Advair 250/50 1 inh bid
-isosorbide mononitrate ER 15mg PO daily
-metoprolol tartate 50mg PO bid
-pantoprazole 20mg PO daily
-simvastatin 40mg PO daily
-tenofovir 300mg PO daily
-acetaminophen 650mg PO q4h PRN
-ASA 81mg PO daily
-Colace 100mg PO bid
-Senna 1 tab PO bid
-Lisinopril 10mg PO daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. insulin regular hum U-500 conc 500 unit/mL Solution Sig:
sliding scale units Injection three times a day: New sliding
scale:
Sugar-breakfast-lunch-dinner
___
81 to 180 - ___
181 to 280 - ___
281 to 380 - ___
381 to 480 - ___
>480 - ___.
15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
Inhalation
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hypoglycemia
Type 2 diabetes
Secondary diagnoses:
Chronic systolic heart failure
CAD s/p CABGx4
HTN
Asthma
Chronic kidney disease
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 ___ woman with CHF now with hypoglycemia.
IMPRESSION: AP and lateral chest compared to ___:
Pulmonary vasculature is more engorged, but there is no pulmonary edema or
pleural effusion. Moderate cardiomegaly and mediastinal vascular engorgement
are chronic. No pneumothorax. No focal pulmonary consolidation.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by AMBULANCE
Chief complaint: HYPOGLYCEMIA
Diagnosed with DIAB W MANIF NEC ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 96.9
heartrate: 87.0
resprate: nan
o2sat: 99.0
sbp: 173.0
dbp: 69.0
level of pain: 13
level of acuity: 2.0 | ___ with T2DM (A1c=6.3%), CHF (EF=50-60%), CAD s/p CABGx4, HepB,
asthma, and h/o CVA who presents with hypoglycemia.
#Hypoglycemia - Thought to be related to lower than usual PO
intake the night before admission. She took her normal amount
of evening insulin but then did not have her usual pre-bedtime
snack. She rapidly improved after receiving dextrose
pre-hospital. On the floor, she was no longer hypoglycemic.
___ was consulted and we changed her home U-500 sliding scale
to lower the amount of insulin she takes in the evening.
#CAD s/p MI - No anginal sx this admission. Trop x1 was neg in
the ED.
#HTN - BP was slighly elevated upon arrival but she missed her
AM meds when she was taken by ambulance to the hospital. She
was continued on her home antihypertensive regimen.
#H/o CVA - Has baseline asymmetric weakness in her ___ after
stroke ___ years ago. No recent neurological changes. She was
continued on her home ASA 81mg and Plavix.
#Chronic CHF (EF=50-60%) - Has some evidence of vascular
congestion on CXR, but did not appear significantly volume
overloaded on exam. She was continued on her home Bumex as well
as ACEi and beta blocker, no aldosterone antagonist on her med
list.
#HepB - high viral load on last lab work and she was continued
on her home dose of Ciread.
#CKD (baseline Cr 1.1-1.3) - Creatinine at baseline upon arrival
to the ED
#Asthma - Had some dyspnea on exertion but maintained her O2 sat
on room air. She was continued on her home Advair and inhalers.
#Code status this admission - FULL CODE
#Transitional issues:
-Has follow-up arranged with her PCP and with ___ need
her evening blood sugar followed and her insuln dosing adjusted
as necessary |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pedestrian struck
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M was struck by a car this AM. He sustained a
headstrike and posterior scalp laceration without LOC. He had
back pain following the accident, but denied weakness, numbness,
tingling, loss of bowel or bladder function. He was taken to an
OSH where a CT scan of the head showed no ICH. MRI of T/L spine
showed a T12 burst fracture. The head laceration was repaired.
The patient was stable and was transferred to ___ for further
management. Neurosurgery was consulted for spine evaluation.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 98.2 BP: 113/71 HR: 58 R 18 O2Sats 100% RA
Gen: comfortable, NAD.
HEENT: occipital laceration s/p repair
Neck: no cervical midline tenderness
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT
Back: tenderness to palpation in thoracic spine
Extrem: Warm
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor: full strength upper and lower extremities bilaterally
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Right toe downgoing, left toe equivocal
Discharge exam:
he is pleasant and cooperative
Speaks ___ only
Strength is ___ and sensory intact bilaterally
Babinski is flexor
Reflexes are 2+ throughout
rectal tone intact
no ___ or clonus
Pertinent Results:
___ 11:45AM GLUCOSE-136* UREA N-36* CREAT-1.7* SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
___ 11:45AM estGFR-Using this
___ 11:45AM ALT(SGPT)-35 AST(SGOT)-55* ALK PHOS-67 TOT
BILI-1.1
___ 11:45AM LIPASE-44
___ 11:45AM CALCIUM-9.9 PHOSPHATE-2.6* MAGNESIUM-2.2
___ 11:45AM WBC-12.2*# RBC-4.75 HGB-14.2 HCT-40.9 MCV-86
MCH-29.9 MCHC-34.7 RDW-12.8
___ 11:45AM NEUTS-94.2* LYMPHS-2.0* MONOS-3.2 EOS-0.5
BASOS-0.1
___ 11:45AM PLT COUNT-266
___ 11:45AM ___ PTT-30.3 ___
Ct Torso ___. T12 burst Chance fracture extending into the
posterior elements (unstable fracture) with retropulsion. MR of
the spine is recommended to evaluate the cord and posterior
ligaments.
2. Cystic lesion in the left thyroid, incompletely
characterized. Thyroid
ultrasound in a non-urgent setting as an outpatient is
recommended for
evaluation.
3. Renal hypodensities are too small to be characterized on CT.
Consider
renal ultrasound in outpatient setting for further evaluation,
if clinical
concern.
4. Small pulmonary nodules, largest measuring ___hest in six months for followup.
Renal U/S ___ - simple renal cysts noted.
Thoracic X-ray ___ - slight kyphosis at T12 and mild loss of
height at this level.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. acetaminophen-codeine 300-15 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
T12 chance fracture
Renal Lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: T12 Chance fracture and hard abdomen.
TECHNIQUE: CT torso without IV contrast due to high creatinine. Oral
contrast was not administered. Coronal and sagittal reformatted images
provided.
Limitation of the study due to lack of IV contrast was discussed with Dr.
___ prior to scanning by Dr. ___.
COMPARISON: No prior.
FINDINGS:
CT CHEST: There is a cystic lesion in the left thyroid lobe measuring 2.5 x
2.5 cm (2:8), incidental and incompletely characterized. The airways are
patent up to subsegmental level. There are few small pulmonary nodules, as
follows: RUL, 3 mm, (2:15); LUL, 5 mm, (2:31); LUL, 2 mm, (2:31); RLL, 2 mm,
(2:40). There are minimal bibasilar atelectasis at the lung bases. There is
no evidence of lung contusion or laceration. No pleural effusion or
pneumothorax is seen. The ascending aorta measures 4 cm. No pathologically
enlarged lymph nodes in the mediastinum, hilum or axilla according to CT size
criteria. There is no pericardial effusion.
CT ABDOMEN: The evaluation of solid organs and vessels is suboptimal due to
lack of IV contrast. With this limitation in mind, the liver, spleen,
pancreas, and bilateral adrenal glands are normal. There is a 10-mm
hypodensity in interpolar region of the right kidney (2:67) and interpolar
region of the left kidney (2:68), incompletely characterized. No
hydronephrosis. There is no free fluid or free air. Loops of large and small
bowel appear within normal limits. No pathologically enlarged lymph nodes are
seen in the retroperitoneum or mesentery according to CT size criteria.
Scattered calcifications are seen in the abdominal aorta.
CT PELVIS: The rectum, sigmoid and urinary bladder appear within normal
limits. The prostate is not enlarged. The seminal vesicles appear within
normal limits on a non-contrast scan. There is no free fluid in the pelvis.
There are no pathologically enlarged lymph nodes in the pelvic or inguinal
area according to CT size criteria.
OSSEOUS STRUCTURES: There is a T12 burst Chance fracture extending into the
posterior elements (unstable fracture) with retropulsion. Additionally, there
is a nonspecific sclerosis in the right pubic bone and left ischium (2:127 and
123).
IMPRESSION:
1. T12 burst Chance fracture extending into the posterior elements (unstable
fracture) with retropulsion. MR of the spine is recommended to evaluate the
cord and posterior ligaments.
2. Cystic lesion in the left thyroid, incompletely characterized. Thyroid
ultrasound in a non-urgent setting as an outpatient is recommended for
evaluation.
3. Renal hypodensities are too small to be characterized on CT. Consider
renal ultrasound in outpatient setting for further evaluation, if clinical
concern.
4. Small pulmonary nodules, largest measuring 5 mm. Consider CT chest in six
months for followup.
Findings were discussed with ___ at 3:20 p.m. by phone by Dr.
___ on ___.
Radiology Report
RENAL ULTRASOUND
CLINICAL INDICATION: Renal hypodensity seen on non-contrast CT scan of
___.
Scans of the kidneys were performed in the prone position as excessive bowel
gas limited visualization with the patient supine. Left kidney measures 8.2
cm in length and is normal in echogenicity with no stones or hydronephrosis.
In the middle third of the right kidney, there is a simple cyst measuring 1.7
x 1.3 x 1.1 cm. No solid masses are seen.
The left kidney measures 8.3 cm in length and again shows no evidence of
stones or hydronephrosis, nor any solid masses. In the mid portion of the
left kidney there is a simple cyst measuring 0.8 x 1.1 x 1.1 cm. Views of the
bladder are unremarkable.
CONCLUSION: Bilateral simple renal cysts with no worrisome solid lesions nor
any signs of stones or hydronephrosis.
Radiology Report
THORACIC SPINE
CLINICAL HISTORY: T12 Chance fracture.
FINDINGS: Standing AP and lateral views of the lumbar spine with a brace in
place are provided. There has been no interval change in the alignment since
the previous radiograph and the CT on ___, with mild focal kyphosis at
T11-12 and the known Chance fracture at T12. No new fractures are identified.
Alignment is otherwise anatomic.
There is dilatation of the colon with gas, but no air-fluid levels. Gas does
extend into the rectum.
IMPRESSION: Stable alignment and appearance of T12 Chance fracture.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: T12 FX S/P PED STRUCK
Diagnosed with FX DORSAL VERTEBRA-CLOSE, MV COLL W PEDEST-PEDEST, RENAL & URETERAL DIS NOS
temperature: 98.2
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 71.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ was admitted to Neurosurgery on ___. He remained
on spinal precautions until his TLSO brace arrived on ___. He
a C/A/P CT scan on ___ which showed multiple incidental
lesions including renal hypodensities. His bun/crea bumped on
___ and a renal u/s was obtained which showed simple renal
cysts. His bun/crea trended back down with IVF resuscitation.
___ evaluated this patient and he was deemed stable for
discharge. He had a thoracic x-ray with TLSO brace which showed
mild kyphosis without canal compromise and patient remained
asymptomatic. Now DOD, he is afebrile, VSS and neurologically
intact. He has been instructed to wear TLSO brace at all times
when OOB or ambulating. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine / morphine / ACE Inhibitors /
metronidazole / Sulfa(Sulfonamide Antibiotics) / aspirin
Attending: ___.
Chief Complaint:
Bilat SDH Right > Left
Major Surgical or Invasive Procedure:
R craniotomy for evacuation of R SDH
History of Present Illness:
___ yo F hx substance abuse, Hep C, Hep B, neuropathy who
fell at least 4 times in the last 2 days. Pt is a poor
historian
and needs frequent redirection. Denies LOC. Went to the ED at
the urging of her boyfriend and PCP. C/o headache and left arm
pain. Reports baseline left sided nerve pain and left foot
weakness for which she walks with a walker at baseline.
Past Medical History:
1. Anemia.
2. Anxiety.
3. Constipation.
4. Depression.
5. GERD.
6. High cholesterol.
7. Hypertension.
8. Hep B and C, IVDA heroin in her ___.
9. Possible nerve damage left leg.
10. Possible CVA ___.
11. Chronic pain syndrome.
Social History:
___
Family History:
NC
Physical Exam:
O: T: 98.2 BP: 164/84 HR:95 R16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused. Left arm in sling
Neuro:
Mental status: Awake and alert, cooperative with exam, however
inattentive at times.
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. 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:
Unable to test left upper extremity due to humerus fx. Right UE
___ throughout.
Left ___ shows weakness ___ AT and ___ ___ other groups full.
Right ___ ___ throughout.
Bilateral clonus right > Left
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Bilateral clonus Right > Left
Coordination: normal on finger-nose-finger on right
On Discharge:
vital signs stable
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and cooperative with exam.
Orientation: Oriented to person and date (year).
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. 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:
Unable to test left upper extremity due to humerus fx. Right UE
___ throughout.
Left ___ shows weakness ___ AT and ___ ___ other groups full.
Right ___ ___ throughout.
Bilateral clonus right > Left
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Bilateral clonus Right > Left
Coordination: normal on finger-nose-finger on right
Pertinent Results:
___ CT head: The previously seen bilateral subdural
hematomas along the bilateral frontal lobes are unchanged in
size or appearance since the prior study, with the right greater
in size, measuring 15 mm, and the left measuring 3 mm. There
has been no progression of left temporal lobe intraparenchymal
hemorrhage and surrounding edema, which is unchanged in size.
The previously seen leftward shift of midline structures of 5 mm
is also
unchanged since the prior study. No new areas of hemorrhage,
edema or
infarction are seen. There is continued effacement of the
occipital horn of the right lateral ventricle and the basal
cisterns remain patent.
There is a fracture of the fracture through the right occipital
bone with
upward extension across the transverse sinus and the right
parietal bone and overlying scalp hematoma is again noted. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
___ Bilateral lower extremity dopplers: No sonographic
evidence for lower extremity deep vein thrombosis. Peroneal
veins not well seen bilaterally.
___: Xray Tib/Fib AP and lateral: There are old healed
fractures of the right distal tibia and the mid shaft of the
right fibula. No acute fracture or dislocation. Note is made
of an osseous protuberance arising from the trochlea of the
right distal femur, which appears to represent a small
osteochondroma. Limited evaluation of the right knee and ankle
joints is otherwise unremarkable.
___: Chest Xray: IMPRESSION:
1. No acute cardiopulmonary process.
2. Faint opacity in the left lung apex. Attention on followup
is recommended.
3. Chronic non-united fracture of the distal right clavicle.
___ CT head: Expected post-operative appearance following
right-sided
craniectomy, evacuation of acute-on-chronic subdural hematoma
and placement of drain. Small residual subdural hematoma
layering posteriorly, 3 mm in maximum dimension. Expected
post-operative pneumocephalus. Resolution of shift of midline
structures.
___ Continuous EEG: NO Seizures. IMPRESSION: This is an
abnormal continuous EEG recording due to the slow and
disorganized background seen with bursts of generalized delta
frequency slowing indicative a moderate encephalopathy. Further
bursts of delta frequency slowing is seen diffusely over the
left hemisphere indicative of additional left hemispheric
cerebral dysfunction. Multifocal sharp waves are
seen independently in the left central, right central, left
temporal regions suggestive of multifocal cortical irritability,
but no electrographic seizures are seen.
___ CT head: No change in the postoperative appearance
following right-sided craniectomy and evacuation of subdural
hematoma since the prior CT scan. No evidence of recurrent
hemorrhage.
___ Chest XRay: No acute cardiopulmonary process
___ CT head repeat for ? seizure: No change since the CT from 8
hr prior. Stable subdural and intraparenchymal hemorrhage
without evidence of new bleed.
___ Continuous EEG: **
___ Continuous EEG: No seizures
___ CT head: Stable, no new hemorrhage
___: L hand-
Medications on Admission:
Clonidine 0.2mg BID, Amlodipine 5mg Daily, Senna,
Oxycontin 80mg Q12, Dilaudid 8mg Q4hrs PRN, HCTZ 50mg daily,
toprol XL 200mg Daily, alprazolam ER 1mg Daily, lasix unknown
strength, neurontin unknown strength
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Closed left proximal humerus fracture
Left middle phalanx fracture
Bilateral SDH R>L
L temporal contusion
Seizures
Rib fractures
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: ___ status post fall with bilateral subdural hematomas,
right greater than left intraparenchymal hemorrhage at the left temporal lobe.
Evaluation for progression of intraparenchymal hemorrhages.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
COMPARISON: Comparison is made to CT of the head from ___.
FINDINGS:
The previously seen bilateral subdural hematomas along the bilateral frontal
lobes are unchanged in size or appearance since the prior study, with the
right greater in size, measuring 15 mm, and the left measuring 3 mm. There
has been no progression of left temporal lobe intraparenchymal hemorrhage and
surrounding edema, which is unchanged in size.
The previously seen leftward shift of midline structures of 5 mm is also
unchanged since the prior study. No new areas of hemorrhage, edema or
infarction are seen. There is continued effacement of the occipital horn of
the right lateral ventricle and the basal cisterns remain patent.
There is a fracture of the fracture through the right occipital bone with
upward extension across the transverse sinus and the right parietal bone and
overlying scalp hematoma is again noted. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No progression of bilateral subdural hematomas or left the temporal
intracranial hemorrhage. Unchanged leftward shift of midline structures of 5
mm and unchanged right occipital bone fracture.
Radiology Report
INDICATION: Swelling and tenderness to palpation over distal tibia.
COMPARISON: None.
FINDINGS: Two views of the right tibia and fibula.
There are old healed fractures of the right distal tibia and the mid shaft of
the right fibula. No acute fracture or dislocation. Note is made of an
osseous protuberance arising from the trochlea of the right distal femur,
which appears to represent a small osteochondroma. Limited evaluation of the
right knee and ankle joints is otherwise unremarkable.
IMPRESSION:
1. No acute fracture or dislocation.
2. Likely small osteochondroma arising from the right distal femur.
Radiology Report
HISTORY: ___ female with clinical concern for deep vein thrombosis in
the setting of significant opiate and benzodiazepene use, left humeral head
fracture and bilateral subdural hematomas.
TECHNIQUE: Gray scale and duplex Doppler ultrasound examinations of bilateral
lower extremity veins were performed.
COMPARISON: ___.
FINDINGS:
The right and left common femoral veins demonstrate symmetric waveforms with
respiratory variability. Bilateral common femoral, superficial femoral, and
popliteal veins demonstrate normal compressibility, flow, and augmentation.
Bilateral posterior tibial veins demonstrate compressibility and flow with
color Doppler. The peroneal veins are not well seen on either side.
IMPRESSION:
No sonographic evidence for lower extremity deep vein thrombosis. Peroneal
veins not well seen bilaterally.
Radiology Report
INDICATION: Preoperative evaluation prior to neurosurgery.
COMPARISON: Chest radiograph dated ___.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: The inspiratory lung volumes are appropriate. No focal
consolidation concerning for pneumonia, pleural effusion, or pneumothorax is
detected. There is faint increased opacity in the medial left lung apex
compared to the right. The pulmonary vasculature is not engorged and there is
no evidence of pulmonary edema. The cardiac silhouette is normal in size. The
mediastinal and hilar contours are within normal limits. Note is made of a
healed but non-united fracture of the distal end of the right clavicle, which
is unchanged from prior examinations. There is no evidence of bridging callus
across the fracture line. Mild degenerative changes are noted in the thoracic
spine.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Faint opacity in the left lung apex. Attention on followup is recommended.
3. Chronic non-united fracture of the distal right clavicle.
Radiology Report
INDICATION: Acute/subacute/chronic right subdural hematoma status post right
SDH. Left subdural hematoma. Evaluate post-operative changes.
COMPARISON: Comparison is made to head CT performed ___.
TECHNIQUE: Non-contrast axial images obtained through the brain. Coronal and
sagittal reformations are provided.
FINDINGS: The patient is status post craniectomy with partial evacuation of
known acute-on-chronic subdural hematoma and drain placement. There is a
small amount of residual acute subdural hematoma layering posteriorly
measuring 7 mm in maximal dimension with air-fluid levels evident in the
extra-axial space. A small amount of residual hematoma is also noted
anteriorly along the medial aspect of the right frontal lobe (2:20). There is
expected pneumocephalus. Stable left subdural hematoma measuring 3 mm in
maximal diameter. There is interval resolution of previously reported
rightward shift of midline structures. Cisterns are patent. The ventricles
are prominent, out of proportion to the sulci; however, this is unchanged
compared to ___ and likely represent central atrophy. There is
continued evolution of the known left temporal intraparenchymal hemorrhage
with surrounding edema. No evidence of recurrent hemorrhage. No other
intraparenchymal hemorrhage is identified. Gray-white matter differentiation
is preserved. Subcortical and periventricular white matter hypodensities are
most consistent with small vessel ischemic disease.
Redemonstration of known right occipital bone fracture with extension across
the transverse sinus and parietal bone. Resolving overlying scalp hematoma.
IMPRESSION: Expected post-operative appearance following right-sided
craniectomy, evacuation of acute-on-chronic subdural hematoma and placement of
drain. Small residual subdural hematoma layering posteriorly, 3 mm in maximum
dimension. Expected post-operative pneumocephalus. Resolution of shift of
midline structures.
Radiology Report
HISTORY: ___ female with bilateral subdural hematomas status post
surgical evacuation of left subdural hematoma. Evaluation for interval
change.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
COMPARISON: Comparison is made to multiple prior noncontrast CTs of the head
including ___.
FINDINGS:
Since that of the prior study from 11 hours prior trauma there is no evidence
of new hemorrhage.
Unchanged postoperative appearance status post right craniectomy and the ___
evacuation with small amount of residual right subdural hematoma layering
posteriorly. The previously noted left subdural hematoma is stable, again
measuring 3 mm in greatest diameter. There is no shift of midline structures
of in the basal cisterns are patent.
The ventricles and sulci are unchanged in appearance since the prior study.
The left temporal lobe intraparenchymal hemorrhage is also unchanged in
appearance with surrounding vasogenic edema. Evidence of subcortical and
periventricular white matter small vessel ischemic disease is again noted.
There is re- demonstration of previously noted right occipital bone fracture.
There is an unchanged appearance of the right scalp hematoma overlying the
craniectomy site.
IMPRESSION:
No change in the postoperative appearance following right-sided craniectomy
and evacuation of subdural hematoma since the prior CT scan. No evidence of
recurrent hemorrhage.
Radiology Report
INDICATION: ___ female patient status post crani. Study requested
for evaluation of PNA, pulmonary edema/effusion.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable AP chest radiograph.
FINDINGS: Cardiac silhouette is normal in size. The mediastinal and hilar
contours are within normal limits. The inspiratory lung volumes are
appropriate. There are no focal consolidations concerning for pneumonia. There
are no pleural effusions or pneumothorax. Previously identified faint
increased opacity in the medial left lung apex is not visualized in today's
examination. Pulmonary vasculature is not engorged and there is no evidence
of pulmonary edema. Again seen is a non-united fracture at the distal end of
the right clavicle.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Chronic non-united fracture of the distal right clavicle.
Radiology Report
HISTORY: ___ woman with questionable seizure and subdural hematoma
status post evacuation.
TECHNIQUE: Noncontrast head CT.
COMPARISON: ___ at 8:52 a.m.
FINDINGS:
There is no change from the CT 8 hours prior. Postoperative changes it from
the right craniectomy the subdural hemorrhage evacuation. A small amount of
layering right posterior subdural hemorrhage is similar in size as is the left
subdural hematoma, measuring 3 mm in greatest diameter. There is no shift of
the normal midline structures. The basal cisterns are patent.
Left temporal lobe intraparenchymal hemorrhage with surrounding vasogenic
edema is also unchanged.
IMPRESSION:
No change since the CT from 8 hr prior. Stable subdural and intraparenchymal
hemorrhage without evidence of new bleed.
Radiology Report
HISTORY: ___ female status post craniotomy.
COMPARISON: Multiple prior head nonenhanced CTs, most recently on ___.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast.
FINDINGS:
The patient is status post right frontal craniotomy with subdural hemorrhage
evacuation. Residual subdural hematoma layering along the right posterior
convexity is 8 mm, unchanged since ___. Thin subdural hematoma
along the left posterior convexity is unchanged. Subdural blood layering
along the leaflets of the tentorium cerebelli is unchanged. Left temporal
intraparenchymal hemorrhage with surrounding vasogenic edema is unchanged.
There is no shift of the normally midline structures. Slight effacement of
the occipital horn of the right lateral ventricle is unchanged. The basal
cisterns appear patent.
Nondepressed right occipital bone fracture extending to the transverse sinus
and parietal bone is unchanged. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. Status post right frontal craniotomy with residual subdural hematoma along
the right posterior convexity, thin subdural hematoma along the left posterior
convexity, and unchanged left temporal intraparenchymal hemorrhage.
2. Unchanged nondepressed right occipital bone fracture extending superiorly
to the transverse sinus.
Radiology Report
LEFT HAND
HISTORY: Right hand swelling.
IMPRESSION: Three views of a hand marked "L" show a minimally displaced
oblique fracture through the mid portion of the middle phalanx of the fourth
ray of the imaged hand. The injury may be chronic, since inferiorly there
appears to be some bony fusion of the fracture plane. There is soft tissue
swelling, more proximally at the proximal interphalangeal joint which appears
intact. No other findings noted.
Dr. ___ was paged primarily to identify the site of injury.
Radiology Report
HISTORY: ___ female with tachycardia rule out DVT.
COMPARISON: Bilateral leg ultrasound ___.
FINDINGS:
Grayscale, color and Doppler images were obtained of bilateral common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels.
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Shortness of breath, tachycardia, elevated white blood cell
count, rule out pulmonary process.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the right internal jugular
vein catheter has been removed. Otherwise, the radiograph is unchanged. No
acute or chronic lung changes. Normal size of the cardiac silhouette. Normal
hilar and mediastinal structures. Known left humeral head fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with SUBDURAL HEM W/O COMA, UNSPECIFIED FALL
temperature: 98.2
heartrate: 98.0
resprate: 16.0
o2sat: 96.0
sbp: 164.0
dbp: 73.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ was admitted to the ___ at ___ on ___ with
a SDH, L shoulder fracture and L rib fractures. She was taken
to the OR by neurosurgery on ___ for decompressive
craniotomy and drainage of SDH. She had a drain placed in the
OR that was d/ced on POD1.
Neurosurgery assumed care of the patient on the evening of ___.
On ___ her exam was improving. Dilantin level corrected to 30
and her morning Dilantin dose was held. Her INR was found to be
1.8. She was given 1 dose of Vitamin K and a head CT was
obtained which was stable. EEG demonstrated no seizure
activity. Patient reported pain in L hand which ecchymosis and
edema were seen on examination, a L hand x-ray was ordered. On
___, patient's exam remained stable. Her dilantin level
corrected was supratheraputic and was once again held. Another
level was reordered for the afternoon. She was transferred to
the floor to be evaluated with ___ and OT.
On ___ patient developed tachycardia and intermitant shortness
of breath and elevated WBC. Patient had LENIs, Cardiac enzymes
and a Cxr ordered, all of which were negative for any acute
processes.
On ___, the patient no longer had an elevated WBC and remained
afebrile. Her potassium was replenished and she was sent to
rehab with orders to repeat her potassium levels and to
administer a second dose of potassium. At the time of discharge
on ___, POD #7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
voiding without assistance, stable neuro exam and pain was well
controlled. The patient was sent to rehab given written
instructions concerning precautionary instructions and the
appropriate follow-up care. All questions were answered prior
to discharge and 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:
rib pain s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o Afib (no longer on Coumadin), ___, SSS s/p PPM,
hemochromatosis, Parkinsonism with autonomic dysfunction and
multiple falls presenting s/p fall ___ days ago. He states that
he remembers slipping and falling down some stairs after feeling
slightly lightheaded but does not recall exact circumstances.
Believes others were in the house. Unsure if he hit head, but
denies LOC, incontinence of bowel or bladder, unusual confusion
after the event, vertigo, palpitations, or h/o seizure disorder.
In the ED, initial VS were unremarkable. Labs were notable for
Trop 0.02->0.01, CK 1083, with Hct of 33 (stable). CT chest was
notable for multiple rib fractures of anterolateral left ribs 4,
5, and 7 and posterior left ribs ___. CT head and c-spine were
negative for ICH or fracture/dislocation. He was evaluated by
ACS, who felt there was no need for operative intervention for
his fractures and he was admitted to medicine.
On arrival to the floor, initial VS were: T 97 BP 200/98 HR 62
RR 20 O2 Sat 99% RA. This AM, reports significantly improved
rib pain at rest (first night of sleep since his injury) after
standing tylenol and Morphine 4mg IV x1.
Past Medical History:
Afib (s/p cardioversion in ___, no longer on Coumadin as of
___, ___, SSS s/p PPM, hemochromatosis, Parkinsonism with
autonomic dysfunction and multiple falls
Social History:
___
Family History:
No FH of early cardiac death, MI. Otherwise noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3, 157/94 (146-200/66-100), 60-86, 96-100% RA
General: lying in bed, NAD, thin elderly man, speaks
appropriately but softly and slowly
HEENT: EOMI, NCAT, MMM
Neck: supple, no JVD
CV: RRR, normal S1/S2, no m/r/g, PPM in left upper chest
Chest: CTAB, TTP on lateral and posterior lower ribs, no
increased WOB though painful taking deep breath
Abdomen: soft, NTND, NABS
Ext: WWP, no c/c/e
Neuro: A&O to person, place, and year, but not month/day. CN
II-XII intact, mild resting tremor, gait not assessed due to
pain, otherwise non focal
DISCHARGE PHYSICAL EXAM:
Vitals: 98.7, 97-149/63-81, 61-88, 97-99% RA
otherwise unchanged
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-7.3# RBC-3.41* Hgb-10.8* Hct-33.7*
MCV-99* MCH-31.8 MCHC-32.2 RDW-12.8 Plt ___
___ 01:20PM BLOOD Glucose-144* UreaN-32* Creat-0.9 Na-141
K-3.7 Cl-104 HCO3-26 AnGap-15
___ 01:20PM BLOOD CK(CPK)-1083*
___ 01:20PM BLOOD CK-MB-18* MB Indx-1.7
___ 01:20PM BLOOD cTropnT-0.02*
___ 06:50PM BLOOD cTropnT-0.01
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-6.4 RBC-3.69* Hgb-12.2* Hct-35.7*
MCV-97 MCH-33.2* MCHC-34.3 RDW-12.9 Plt ___
___ 08:00AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-139
K-4.0 Cl-100 HCO3-30 AnGap-13
___ 08:00AM BLOOD CK(CPK)-___*
___ 08:00AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
MICRO:
none
IMAGING:
CT Chest (___):
There are minimally displaced left anterolateral rib fractures
of ribs 4, 5 and 7 ___s left posterior rib fractures of
ribs 5 through 11. There is no pneumothorax. There are no
other fractures. Small nonhemorrhagic left pleural effusion.
CXR (___):
Multiple left posterior and lateral rib fractures, better seen
on
the concurrent rib films. No pneumothorax or other acute
abnormality.
Rib Films (___):
Multiple left posterior and lateral rib fractures. No
pneumothorax.
CT Head (___):
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 appear patent and 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.
CT C-Spine (___):
No acute fracture, malalignment, or prevertebral soft tissue
swelling is seen. Mild multilevel degenerative changes are again
seen, most severe at C4-5, C5-6 and C6-7 where mild to moderate
sized disc bulges result in ventral indentation of the thecal
sac. Moderate multilevel neural foraminal narrowing is most
severe at C5-C6, not significantly changed from earlier. Lucent
area in the right aspect of the C4 vertebral is unchanged,
likely a hemangioma.
EKG (___): A-paced at 60, no ST-T segment changes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Tamsulosin 0.4 mg PO HS
4. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
3. Tamsulosin 0.4 mg PO HS
4. Acetaminophen 650 mg PO Q6H
5. Docusate Sodium 100 mg PO BID
6. Lidocaine 5% Patch 2 PTCH TD DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN breakthrough pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
mechanical fall
SECONDARY:
atrial fibrillation
sick sinus syndrome with pacemaker
chronic diastolic heart failure
___ disease with autonomic dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Left chest wall pain.
COMPARISON: Chest radiograph ___, rib films ___.
FINDINGS: The cardiomediastinal and hilar contours are stable. There is no
pleural effusion or pneumothorax. There is no focal consolidation concerning
for pneumonia or contusion. Multiple left posterior and lateral rib fractures
are better seen on the concurrent rib plain films. A left pacemaker
defibrillator is seen with tips terminating in the right atrium and right
ventricle.
IMPRESSION: Multiple left posterior and lateral rib fractures, better seen on
the concurrent rib films. No pneumothorax or other acute abnormality.
Radiology Report
HISTORY: ___ male status post fall. Evaluation for traumatic injury.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast.
COMPARISON: Comparison is made to a noncontrast CT of the head from ___.
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 appear patent and 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 acute intracranial pathology.
Radiology Report
INDICATION: Left chest wall pain status post fall.
COMPARISON: Chest radiograph ___.
FINDINGS: There are minimally displaced fractures of the left posterior ribs
five through eight and the left lateral ribs six through nine. There is no
pneumothorax or left pleural effusion. Left pacemaker defibrillator is seen
with tips terminating in the right atrium and right ventricle.
IMPRESSION: Multiple left posterior and lateral rib fractures. No
pneumothorax.
Radiology Report
HISTORY: ___ man with fall. Evaluation for traumatic injury.
TECHNIQUE: Helical axial MDCT images were obtained from the skullbase through
the T3 level. Reformatted images in sagittal and coronal axes were obtained.
COMPARISON: Comparison is made to CT of the cervical spine from ___.
FINDINGS:
There is no evidence of acute fracture or malalignment. There is no
prevertebral soft tissue swelling. Mild multilevel degenerative changes are
again seen, most prominent at C4-5 and C5-6 with small disc bulges at those
levels, unchanged since the prior study.
IMPRESSION:
No acute fracture or malalignment. Persistent mild degenerative changes of
the cervical spine, as described above.
Radiology Report
INDICATION: Fall with rib fractures seen on rib films.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were taken through the chest after
the administration of Omnipaque intravenous contrast material. Coronal and
sagittal reformats were also examined.
FINDINGS: The aorta maintains a normal contour without any evidence of acute
aortic injury. There is no central filling defect in the main pulmonary
arteries. The heart size is moderately enlarged without pericardial effusion.
Pacemaker leads are seen in standard position. There is no mediastinal
hematoma. Note is made of extensive collateral vessels in the left anterior
chest, possibly as a result of stenosis of the left brachiocephalic vein.
The thyroid is unremarkable. The airways are patent to the subsegmental
level. There is no mediastinal, hilar or hilar lymphadenopathy. There is a
small nonhemorrhagic left pleural effusion. Left basilar atelectasis is
present. There is no pulmonary contusion or laceration. There are no
pulmonary nodules or masses.
There may be thickening of the left adrenal gland, which is incompletely
imaged. Calcifications are noted within the body and tail of the pancreas,
which is also incompletely imaged. The remainder of the imaged portions of
the upper abdomen are unremarkable.
There are minimally displaced left anterolateral rib fractures of ribs 4, 5
and 7 as well as left posterior rib fractures of ribs 5 through 11. There is
no pneumothorax. There are no other fractures.
IMPRESSION: Multiple left sided rib fractures as described above. No
pneumothorax. Small nonhemorrhagic left pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX MULT RIBS NOS-CLOSED, CONTUSION OF CHEST WALL, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, PARKINSON'S DISEASE
temperature: 98.8
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 75.0
level of pain: nan
level of acuity: 2.0 | ___ with h/o Afib (no longer on Coumadin), dCHF, SSS s/p PPM,
hemochromatosis, Parkinsonism with autonomic dysfunction and
multiple falls presenting s/p fall, found to have multiple rib
fractures.
# Mechanical Fall: History of multiple mechanical falls in the
setting of pt recalling slipping and falling without LOC or
prodrome makes mechanical fall most likely. Very little concern
for seizure or arrhythmia, has PPM a-paced but had one 8-beat
run of asymptomatic Vtach. Electrophysiology interrogated St.
___ pacer on ___ and found no arrhythmias, stable lead
parameters, and normal functioning pacemaker. Somewhat
orthostatic with physical therapy, though BUN/Cr ratio improved,
and so PO intake was encouraged. ___ rehabilitation was
recommended by physical therapy, and he was discharged in
medically stable on condition.
# Rib Fractures: ___ fall, comfortable when sitting and lying
down though had pain with movement and deep breaths. He was
dischargede with standing acetaminophen, Lidoderm patches, and
tramadol prn breakthrough pain.
# Altered mental status: Briefly episode of confused and
paranoid behavior, but resolved completely with hours of
receiving his carbidopa/levadopa dose (a pattern that his wife
recognizes as typical), since he had missed several of his 6
daily doses over the previous 24 hours during his ED and early
hospital stay. ___ have also been secondary to the one dose of
morphine he received.
# Afib: No longer on Coumadin as of ___ due to multiple
falls. CHADS score ___ (age and possible CHF). Previously on
dronedarone (still listed in OMR), but not listed in meds per
visiting NP through ___ most recently on ___. Currently
atrially paced at 60. His aspirin was decreased from 325mg to
81mg, and his cardiologist Dr. ___ was contacted and in
agreement with this plan.
# Elevated Troponin: chest pain free throughout hospitalization,
trop 0.02->0.01, normal MB index makes epicardial plaque rupture
unlikely. EKG with leftward axis, and he had no ST-T segment
changes or other evidence of ischemia. Likely from demand
ischemia in the setting of stress.
# Elevated CK: not high enough to merit concern for
rhabdomyolysis, and Cr was within normal limits. CK decreasing
from 1000 to 500 on admission, and this was not trended further.
# Elevated BP: 200/98 on arrival to the floor, but became
normotensive when patient became more comfortable. Pt does not
take any BP meds at home and was not started on any BP
medications in-house.
# ___: Currently euvolemic. Since he was euvolemic and had no
evidence of heart failure contributing to his chief complaint,
no TTE was ordered as an inpatient.
# Parkinsons Disease: appears well-controlled with only very
mild intermittent resting tremor. He was continued on home
Carbidopa-Levodopa 6 times per day.
# ? mild dementia: prescribed Donepezil, though refuses to take
it at home per outpatient NP though it remains on his med list.
Of note, CT head with normal ventricular size. This can be
further discussed as an outpatient.
# Anemia: Chronic, deferred to further outpatient workup if
needed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sprintec (28) / Neosporin (neo-bac-polym)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G0 with complex gynecologic hx notable for recurrent
___ of unclear etiology now ___ s/p diagnostic
laparoscopy, extensive lysis of adhesions, chromopertubation,
removal of R hydrosalpinx, occlusion of L fallopian tube,
drainage of pelvic fluid, diagnostic hysteroscopy, and dilation
and curettage, who presents as direct ED transfer from ___ to
___ for eval of abdominal pain.
She presented on ___ with periumbilical abd pain with
gradual onset beginning yesterday at 0300. Pain now comes in
waves in RLQ, ___ at worst with resolution between episodes.
Does not
radiate. Pain is sharp in quality when present. Denies
alleviating factors, believes eating makes pain worse. Has not
taken anything for pain, as she does not liken it to post-op
surgical pain. She has not had pain like this in past.
Associated watery diarrhea. Denies nausea, vomiting. Passing
flatus. Prior to diarrhea, pt was having nl bowel movements
post-op. Denies fever, chills. Denies vaginal bleeding, abnl
vaginal discharge. Denies urinary symptoms. Denies SOB, chest
pain. Of note hysteroscopy c/b blunt perforation at fundus,
visualized laparoscopically and apparently hemostatic w/o
obvious e/o bowel injury.
Past Medical History:
- diagnosed with L adnexal mass at the age ___ requiring ex lap
at ___ ___ surgeon had thought that a LSO
was performed however path report did not reveal ovarian tissue
but was associated with an inflammatory process (torsion versus
abscess; pt received high doses of IV abx for management
- pt treated medically in ___ and ___ for what was thought to
represent recurrence of abscess/PID with prolonged IV and oral
antibiotics; pt followed outpt by Dr. ___ at ___
- eval for RLQ pain documented a possible left hydrosalpinx ___
OBHx: G0
GynHx:
- recurrent episodes of ___ of unclear etiology
- monthly menses x ___ days
- denies dysmenorrhea, menorrhagia
- denies h/o abnl bleeding
- last Pap ___ and wnl
- denies h/o abnormal Paps
- currently sexually active with husband, ___
PMH:
- h/o pelvic infections as outline above
- +PPD s/p INH
- chronic hepatitis B
- anemia
- ?left hydronephrosis
PSH:
- ex lap/excision of L adnexal abscess/mass (___)
- excision of pilonidal cyst (___)
- diagnostic laparoscopy, extensive lysis of adhesions (___)
Social History:
___
Family History:
Denies family hx of cervical, uterine, ovarian, colon or breast
cancers. Denies family hx of bleeding or clotting disorders.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
LABS:
====
___ 07:30AM BLOOD WBC-9.5 RBC-3.64* Hgb-10.9* Hct-33.9*
MCV-93 MCH-29.9 MCHC-32.2 RDW-12.6 RDWSD-43.0 Plt ___
___ 07:30AM BLOOD Neuts-60.1 ___ Monos-5.1 Eos-6.8
Baso-0.3 Im ___ AbsNeut-5.69 AbsLymp-2.57 AbsMono-0.48
AbsEos-0.64* AbsBaso-0.03
___ 07:30AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-137
K-3.7 Cl-103 HCO3-25 AnGap-13
___ 07:30AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2
___ 05:22AM BLOOD WBC-12.1* RBC-3.58* Hgb-10.6* Hct-33.2*
MCV-93 MCH-29.6 MCHC-31.9* RDW-12.6 RDWSD-42.6 Plt ___
___ 05:22AM BLOOD Neuts-69.6 ___ Monos-5.5 Eos-3.9
Baso-0.3 Im ___ AbsNeut-8.42* AbsLymp-2.43 AbsMono-0.67
AbsEos-0.47 AbsBaso-0.04
___ 05:22AM BLOOD ___ PTT-32.7 ___
___ 05:22AM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-138
K-3.6 Cl-103 HCO3-23 AnGap-16
___ 05:31AM BLOOD Lactate-1.3
MICROBIOLOGY:
=============
___ - GC/CT negative
___ - BCx pending
IMAGING:
=======
___ - Second opinion CT A/P
IMPRESSION:
1. A 4.2 cm right adnexal cystic lesion is incompletely
characterized.
2. A 5 cm heterogeneous but dependently hyperdense collection
along the superior aspect of the bladder consistent with a
postoperative hematoma. Superinfection can't be excluded by
imaging.
3. Prominent loop of bowel within the lower pelvis without
definite transition point or upstream bowel dilatation most
likely represents an ileus however an early small-bowel
obstruction cannot be excluded.
4. Linear fat stranding along anterior midline abdominal wall is
most consistent with postsurgical changes from laparotomy port.
5. Mild cecal wall edema is likely secondary to underlying
inflammatory changes from recent surgery.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
2. Senna 8.6 mg PO BID:PRN constipation
only take if >2 days without a bowel movement
RX *sennosides [senna] 8.6 mg 1 tablet by mouth ___ times per
day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Second opinion CT abdomen/ pelvis.
INDICATION: ___ with abdominal pain, diarrhea, leukocytosis, fluid collection
on CT abdomen pelvis performed at ___. Described fluid collection, ?
abscess, ? hematoma, ? evidence of bowel obstruction
TECHNIQUE: Outside 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: CTDI: 8.00 mGy
DLP: 362.9 mGy-cm
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
The main portal vein, SMV, and splenic vein are patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 0.4 cm left upper pole renal hypodensity is too small to characterize
(02:23), but likely a cyst. There is no evidence of additional renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: No hiatal hernia. The stomach is unremarkable. Within the
lower mid abdomen is a slightly prominent single loop of small bowel measuring
3.1 cm without a narrow transition point. No upstream bowel wall dilatation.
Additional small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. There is mild edema within the cecal wall (2:60) with
cecal wall measuring 0.3 cm. The colon and rectum are otherwise within normal
limits. No pneumatosis. Preserved mucosal enhancement. The appendix is not
visualized. Minimal fat stranding along the right lateroconal fascia is
noted.
PELVIS: Along the superior aspect of the bladder dome is a 5 x 3.3 cm (2:71)
heterogeneous collection most consistent with a hematoma which is causing mild
mass effect along the right superior bladder dome. No internal locules of
gas. The urinary bladder and distal ureters are otherwise unremarkable.
There is small amount of nonhemorrhagic free fluid.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No left adnexal mass.
Arising from the right adnexa is a 4.2 x 4 cm thin rimmed cystic lesion
.
LYMPH NODES: Few top-normal mesenteric lymph nodes are seen within the right
lower quadrant largest measuring 0.9 cm in short axis (02:45). There is no
retroperitoneal 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: Mild fat stranding along the anterior midline abdominal soft
tissues, 3 cm above the umbilicus is most consistent with postsurgical change.
The abdominal and pelvic wall is otherwise within normal limits.
IMPRESSION:
1. A 4.2 cm right adnexal cystic lesion is incompletely characterized.
2. A 5 cm heterogeneous but dependently hyperdense collection along the
superior aspect of the bladder consistent with a postoperative hematoma.
Superinfection can't be excluded by imaging.
3. Prominent loop of bowel within the lower pelvis without definite transition
point or upstream bowel dilatation most likely represents an ileus however an
early small-bowel obstruction cannot be excluded.
4. Linear fat stranding along anterior midline abdominal wall is most
consistent with postsurgical changes from laparotomy port.
5. Mild cecal wall edema is likely secondary to underlying inflammatory
changes from recent surgery.
RECOMMENDATION(S): Recommend clinical correlation for superimposed infection
within the hematoma.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:00 ___, 15 minutes after discovery of
the findings.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Postproc hematoma of a GU sys org following other procedure
temperature: 99.0
heartrate: 103.0
resprate: 15.0
o2sat: 100.0
sbp: 113.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted to the gynecologic oncology service for RLQ
abdominal pain and complex pelvic fluid collection on POD10
status post laparoscopic lysis of adhesions, tubal occlusion and
partial salpingectomy, with low suspicion for delayed bowel
injury.
Upon admission, she was afebrile and her white count was noted
to have downtrended to 12.1 from 15 at OSH. Her lactate was also
within normal limits at 1.3. A second read of CT abdomen/pelvis
by ___ radiology revealed 5cm heterogeneous but dependently
hyperdense collection along superior aspect of bladder
consistent with postoperative hematoma, cannot exclude
superinfection. There was also prominent loop of bowel within
lower pelvis without definite transition point or upstream bowel
dilatation, most like;y ileus. Blood cultures were drawn and
pending. She was also tested for gonorrhea and chlamydia at the
outside hospital, which returned negative. She was transitioned
from NPO to clears the evening of HD#1. By HD#2, she continued
to remain afebrile, her white count normalized to 9.5. Her
abdominal pain had resolved and she tolerated a regular diet
without issues. Her loose stools also resolved spontaneously.
By HD#2, she was afebrile, tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with oral medications. She was then discharged home in stable
condition with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
lytic ___ lesions
Major Surgical or Invasive Procedure:
L2 spinous process biopsy ___
History of Present Illness:
This is a ___ who has a PMH s/f widespread mixed sclerotic/
lytic bony lesions found on CT imaging, who is being admitted
for expedited metastatic work-up. Her history is as follows (per
patient and PCP ___. She received a diagnosis of Reversible
Cerebrovascular Vasoconstriction Syndrome in ___ when she
presented to ___ with seizures. During her routine surveillance
MRIs a meningioma was found, which prompted a metastatic
work-up. A CT of the chest, abdomen and pelvis revealed multiple
mixed sclerotic/lytic bony lesions without an obvious primary
source, largest of which was in L2 and the right proximal femur.
Otherwise her metastatic work up includes an unremarkable
mammogram and a biopsy of a 7mm pigmented lesion on her back,
and a nevus on her LUE, as the leading diagnosis is metatstatic
melanoma. Her PCP and neurologist are requesting admission for
expedited work-up.
.
(+) Pressure on her right thigh with prolonged standing
(-) 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.
.
In the emergency department presenting vital signs were T=99.1,
BP=153/82, HR=108, RR=16, O2sat=100%.
Past Medical History:
#. Reversible Cerebrovascular Vasoconstriction Syndrome:
-Diagnosed this past ___ in ___ when she was admitted to
___ with seizures. A CT and MRI showed multiple areas of
intracerebral bleeding. An extensive work-up with CTA
(suggestive of vasospasm), cerebral angiogram (normal), LP
(normal).
#. Meningioma
-Confirmed on ___ MRI
#. Vitamin D insufficiency
Social History:
___
Family History:
No family history of melanoma or cancers. Both parents have
hypertension, and her mother has a aneurysm
Physical Exam:
Admission Exam:
T=98... BP=138/80... HR=62... RR=20... O2=100%RA
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
BACK: No spinous tenderness
SKIN: Multiple scattered nevi on bilateral upper thighs. Light
brown, raised, clear borders. Biopsy sites on LUE and lower back
are C/D/I
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge Exam:
unchanged from admission
Pertinent Results:
Admission Labs:
___ 10:30PM GLUCOSE-92 UREA N-9 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 10:30PM estGFR-Using this
___ 10:30PM TOT PROT-6.9 CALCIUM-9.4 PHOSPHATE-3.9
MAGNESIUM-2.1
___ 10:30PM ___ CA125-11
___:30PM PEP-NO SPECIFI
___ 10:30PM WBC-9.1 RBC-4.26 HGB-12.3 HCT-36.9 MCV-87
MCH-28.9 MCHC-33.3 RDW-14.8
___ 10:30PM NEUTS-72.1* ___ MONOS-2.4 EOS-1.0
BASOS-0.3
___ 10:30PM PLT COUNT-474*
___ 10:30PM ___ PTT-31.0 ___
Discharge Labs:
___ 06:25AM BLOOD WBC-8.8 RBC-4.30 Hgb-12.1 Hct-37.3 MCV-87
MCH-28.1 MCHC-32.4 RDW-14.7 Plt ___
___ 06:25AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
___ 06:25AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
Pertinent Labs:
CA ___ <34 U/mL
SPEP/UPEP: negative for monoclonal bands
___ 10:50AM BLOOD TSH-3.4
___ 12:36PM BLOOD PTH-69*
___ 10:30PM BLOOD ___ CA125-11
___ 08:10AM BLOOD freeCa-1.16
Imaging:
CT torso from Atrius ___- report):
1. Multiple mixed lytic and sclerotic lesions, with the largest
destructive lesion in the spinous process of L2. Large lesion in
the right proximal femur, at risk for pathologic fracture.
2. The primary neoplasm is not apparent from the available
imaging, however hemorrhagic metastasis can be caused by
melanoma, renal cell carcinoma, thyroid carcinoma or
choriocarcinoma. Thyroid gland and kidneys are without a focal
abnormality.
3. No pulmonary metastasis.
4. No evidence of abdominal or pelvic adenopathy or mass. No
hepatic
metastasis.
Skeletal survey ___:
Lytic lesions seen in the parietal bone, right proximal femur,
left patella and possibly the right iliac bone. These are of
unclear etiology. Bone scan may be helpful to establish for
additional lesions and for activity. Would recommend dedicated
radiographs of left knee for further characterization of the
patellar lesion.
Femur plain film ___:
Lytic and sclerotic lesion in the right femoral head and neck.
Right Hip, 2 views ___:
Lytic and sclerotic lesion in the right femoral head and neck.
MRI Head ___:
Multiple intra- and extra-axial enhancing masses, some with
hemorrhage, most compatible with metastatic disease. It is
possible that the dural-based lesions may be meningiomas.
MRI L-Spine ___:
Expansile heterogeneous enhancing mass centered in the posterior
elements of L2 vertebral body as described. Differential
considerations include Giant Cell Tumor, osteoblastoma, atypical
hemangioma, chordoma, eosinophylic granuloma, however metastasis
cannot be excluded. Further evaluation with CT should be
considered.
Left Knee, 3 views ___:
Lytic lesion within the proximal pole of patella. If further
evaluation is needed, recommend MRI.
Pelvic Ultrasound ___:
Three fibroids seen within the uterus. Normal appearance of the
ovaries.
MRI Hip ___:
Multiple lesions within the right ilium and proximal femora in
this patient with a known spine mass, differential diagnosis
includes metastatic disease and possibly eosinophilic granuloma
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 750 mg PO BID
Discharge Medications:
1. LeVETiracetam 750 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Osteolytic bone lesions, notably in the right hip and L2 spinous
process
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: SKELETAL SURVEY, ___.
CLINICAL HISTORY: ___ woman with meningioma and incidentally found
numerous lytic lesions on CT torso. Evaluate for sclerotic or lytic lesions.
FINDINGS: The reported CT torso study is not available for direct comparison.
LATERAL SKULL: There is an 8-mm lucency in the occipital bone, which has
ill-defined margins. No additional lesions are seen. The orbital contours
and paranasal sinuses are within normal limits.
THORACIC SPINE: There are no signs for acute fractures. The vertebral body
heights and intervertebral disc spaces appear preserved. Contrast material is
seen in the transverse colon. Heart size is normal. Visualized lung fields
are clear.
LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies.
There are no compression deformities or abnormal ___- or retrolisthesis.
There is oral contrast throughout the colon and rectum, which partially
obscures evaluation.
AP PELVIS: There is a 5.4 x 2.5 cm mixed lucent and sclerotic lesion in the
right femoral head and neck. This lesion has a non-aggressive appearance as
there is no cortical breakthrough or definite soft tissue component. There is
also a 12-mm lucency projecting over the right iliac near the SI joint which
may represent another lesion versus bowel gas.
BILATERAL HUMERI: There is some cortical thickening involving the shaft of
the right humerus. However, no discrete lytic or sclerotic lesion is seen.
The left humerus appears unremarkable.
BILATERAL FEMURS: There is a 2.1-cm lucency projecting over the left patella
superior pole and femur. This likely represents of patellar lytic lesion.
This could be further assessed with dedicated knee radiographs.
IMPRESSION:
Lytic lesions seen in the parietal bone, right proximal femur, left patella
and possibly the right iliac bone. These are of unclear etiology. Bone scan
may be helpful to establish for additional lesions and for activity. Would
recommend dedicated radiographs of left knee for further characterization of
the patellar lesion.
Radiology Report
STUDY: RIGHT HIP, ___
CLINICAL HISTORY: ___ woman with new found extensive lytic lesions.
FINDINGS: Comparison is made to skeletal survey performed on the same day. A
frog-leg view of the hip and lateral view of the distal femur have been
performed. These films demonstrate a mixed lucent and sclerotic lesion in the
right proximal femur head and neck. The lesion is better assessed on the
prior AP view of the proximal femur. There is also a lucency at the right
anterior superior iliac spine. The previously seen lesion projecting over the
right iliac bone is not well seen on these views and thus may have been
artifactual on the prior skeletal survey. The distal right femur appears
intact and there is no joint effusion or signs for acute bony injury or
significant degenerative changes. Residual contrast material is seen within
the colon and rectum.
IMPRESSION: Lytic and sclerotic lesion in the right femoral head and neck.
Radiology Report
MR HEAD WITHOUT AND WITH CONTRAST ___
HISTORY: Extensive bone lesions and history of meningioma.
Sagittal and axial short TR, short TE spin echo imaging was performed through
the brain. After administration of 9 cc of Gadovist intravenous contrast,
axial imaging was performed with gradient echo, FLAIR, long TR, long TE fast
spin echo, short TR, short TE spin echo, and diffusion technique. Sagittal
MP-RAGE imaging was performed and reformatted into axial and coronal
orientations. No prior brain imaging studies are available for comparison.
FINDINGS: There are multiple hemorrhagic lesions in the parietal lobes
bilaterally and in the right cerebellar hemisphere. There are multiple
enhancing lesions with variable surrounding edema supratentorially
bilaterally, greater on the left than right. Two extra-axial lesions, one in
the left middle cranial fossa, and the other adjacent to the right occipital
lobe near the superior sagittal sinus. These may also represent metastases,
however, correlation with prior studies would be helpful to determine whether
they may represent multiple meningiomas. There is an enhancing calvarial
lesion with interruption of the inner and outer tables in the right parietal
bone.
CONCLUSION: Multiple intra- and extra-axial enhancing masses, some with
hemorrhage, most compatible with metastatic disease. It is possible that the
dural-based lesions may be meningiomas.
Radiology Report
HISTORY: ___ woman with new onset extensive bony lesions and history
of meningioma. Evaluate for a sclerotic lesion seen on outside CT torso.
TECHNIQUE: Multiplanar multisequence MRI of the lumbar spine was obtained
before and after the administration of 11 mL of Gadavist as per department
protocol.
COMPARISON: Skeletal survey from ___.
FINDINGS:
There is an expansile heterogeneous T2 and low T1 lesion involving the
posterior elements of L2 vertebral body centered in the spinous processes with
a few foci of T1 hyperintensity and extensive enhancement. It appears to
erode the inner cortical margin of the posterior elements into the spinal
canal without definite invasion into the spinal canal or nerve roots.
A questionable area of abnormal signal is noted at the posterior elements of
S2 vertebral body, however this is incompletely imaged as no axial images were
provided.
Otherwise, the alignment is maintained. The vertebral body heights are within
normal limits. The conus medullaris terminates at L1 level and has normal
appearance and configuration. There is no evidence of abnormal enhancement
within the cord.
At L5-S1, there is a diffuse disc bulge without spinal canal narrowing. The
disc bulge may be contacting the right L5 nerve root within the foramen.
IMPRESSION:
Expansile heterogeneous enhancing mass centered in the posterior elements of
L2 vertebral body as described. Differential considerations include Giant
Cell Tumor, osteoblastoma, atypical hemangioma, chordoma, eosinophylic
granuloma, however metastasis cannot be excluded. Further evaluation with CT
should be considered.
Radiology Report
STUDY: THREE VIEWS OF THE LEFT KNEE ___.
COMPARISON: Skeletal survey ___.
INDICATION: Evaluate left patellar mass seen on skeletal survey.
FINDINGS: Unremarkable soft tissues. No joint effusion. No acute fracture
or dislocation. Again seen is the lytic lesion within the superior pole of
the patella, which appears well circumscribed. Mild patellar enthesopathy.
Mild thickening of the distal quadriceps tendon. No acute fractures or
dislocations.
IMPRESSION: Lytic lesion within the proximal pole of patella. If further
evaluation is needed, recommend MRI.
Radiology Report
HISTORY: ___ female with diffuse sclerotic/lytic bone lesions,
possible uterine fibroid seen on recent CT.
COMPARISON: No previous ultrasound for comparison.
FINDINGS:
On transabdominal imaging, the uterus measures 8.6 x 3.7 x 4.5 cm. An
endovaginal exam was performed for better visualization of the endometrium and
the adnexa. The endometrium is normal measuring 6 mm. There is a fundal
fibroid which measures 2.0 x 2.3 x 2.3 cm. A fibroid is seen in the left
portion of the lower uterine segment measuring 2.2 x 2.2 x 2.1 cm. Midline
within the lower uterine segment there is a fibroid which measures 1.5 x 1.5 x
1.5 cm.
The right ovary is normal measuring 1.6 x 2.5 x 1.8 cm. The left ovary is
normal measuring 2.3 x 2.9 x 2.1 cm. No suspicious adnexal mass is
visualized.
IMPRESSION:
Three fibroids seen within the uterus. Normal appearance of the ovaries.
Radiology Report
BIOPSY L2 SPINOUS PROCESS
HISTORY: ___ year-old-female with expansile lesion at the L2 spinous process.
OPERATORS: Dr. ___ (attending), Dr. ___ (neuroradiology
fellow), ___, NP.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl 150 mcg and Versed 3.0 mg throughout a total intraservice time of 20
minutes, during which time the patient's hemodynamic parameters were
continuously monitored.
PRE-PROCEDURE REVIEW: The MR lumbar spine was reviewed by the team carefully.
Again noted is an expansile, avidly enhancing lesion in the L2 spinous
process.
PROCEDURE AND FINDINGS: Informed consent was obtained after outlining the
risks, benefits and alternatives of the procedure. Following this, the
patient was brought to the interventional neuroradiology suite and placed
prone on the imaging table. The lumbar spine was prepped and draped in the
usual sterile fashion. A preprocedure huddle and timeout per ___ standards
was performed. A fluoroscopic scout image of the thoracolumbar spine in
correlation with the recent MR lumbar spine chest confirms the targeted L2
spinous process (counting from below).
1% lidocaine was administered to the skin and a 11-gauge ___ osteocyte
biopsy needle was advanced under continuous biplane fluoroscopic guidance into
the L2 spinous process via a posterior midline approach. Prior to the biopsy,
a 3D CT was performed at the targeted level to confirm position. An 20-guage
Franseen biopsy needle was then used to take two cores from the L2 spinous
process. Spot images were saved. The biopsy needle was removed and sterile
dressing applied.
The patient tolerated the procedure well with no immediate complications.
Dr. ___ was present and supervising the entire procedure.
IMPRESSION:
1. Successful biopsy of the L2 spinous process expansile lesion (counting
from below) via posterior midline approach.
2. Samples were sent for laboratory analysis as requested by the referring
team.
Radiology Report
MR EXAMINATION OF THE PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST
HISTORY: Newly discovered lytic and sclerotic lesion. Followup MR
evaluation.
TECHNIQUE: Multisequence, multiplanar MR examination of the pelvis was
performed both pre- and post-intravenous administration of contrast. Axial
T1, axial T2, axial STIR, coronal T1, coronal STIR, axial 3D T1 SPGR pre and
post, coronal STIR, axial 3D T1 SPGR post, axial and coronal T1 fat sat post,
and axial subtraction sequences were performed.
COMPARISON: Radiographs of the pelvis and right hip performed ___.
FINDINGS:
There is a 1.6 x 0.7 x 1.1 cm T1-hypo, T2-bright lesion in the region of the
right anterior-superior iliac spine of the ilium, which demonstrates mild
enhancement,correlating with the prior radiographs. There is a 1.4 x 1.1 x
1.4 cm ovoid T1-hypo, T2-bright lesion within the right femoral head, also
demonstrating mild internal enhancement. There is a second, larger
multilobulated lesion extending from the femoral head inferolaterally into the
right femoral neck, measuring approximately 4.0 x 1.4 x 2.7 cm (6:8, 9:42).
In addition, there is a T1-hypo, T2-bright lesion within the proximal
diaphysis of the left femur measuring approximately 1.1 x 1.1 x 1.4 cm,
demonstrating minimal internal enhancement. There is also a more distal,
smaller lesion not imaged on the axial sequences, within the left femoral
diaphysis. There is no significant surrounding marrow edema adjacent to these
lesions. The remainder of the imaged marrow is normal in signal. There are
no pathologic fractures identified.
The signal within the musculature of the pelvis is normal. There are no
pathologically enlarged inguinal or intrapelvic lymph nodes. There is a 2 cm
simple left ovarian cyst. There are multiple uterine fibroids. There is no
free fluid within the pelvis. The imaged portions of the pelvic viscera are
normal in appearance.
IMPRESSION:
Multiple lesions within the right ilium and proximal femora in this patient
with a known spine mass, differential diagnosis includes metastatic disease
and possibly eosinophilic granuloma.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABNORMAL CT SCAN
Diagnosed with BONE & CARTILAGE DIS NOS
temperature: 99.1
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 82.0
level of pain: 1
level of acuity: 3.0 | Ms. ___ is a ___ with a history of reversible
cerebrovascular vasoconstriction syndrome and meningioma who
presented for workup of diffusely scattered lytic ___ lesions
seen on outside imaging, including a potentially unstable right
hip lesion, she underwent L2 biopsy prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Nsaids / Mevacor / Codeine
Attending: ___.
Chief Complaint:
diverticulitis, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ with h/o diverticulitis ___ years ago,
breast cancer, PAF, HTN, HLD, osteoporosis, recent admission for
L1 compression fx, who presents with 2 weeks of worsening nausea
and back pain. She was discharged from ___ on ___ after
an admission for L1 compression fracture without obvious trauma.
She was treated with oxycodone for pain control. 2 weeks ago she
developing worsening nausea. She denies vomiting, F/C/NS, change
in bowel movements or bloody stool. Complains of mild LLQ
abdominal pain, hard to describe, without radiation. She reports
7 pound weight loss over the last 2 weeks because of poor
appetite. Because of worsening back pain she presented to the
ED. She has urinary incontinence at baseline, and denies fecal
incontinence. Has baseline b/l foot drop, but denies new
weakness or numbness in her lower extremities.
.
In the ED, initial VS: 98.5 66 131/62 18. Labs notable for Cr of
1.8 (near baseline). Leukocytosis of 11.1 with a left shift. CT
L spine: No acute fracture. Severe multilevel degenerative
changes throughout the lumbar spine with chronic L2, L3, and L5
wedge compression deformities and severe thecal sac narrowing,
worst at L5. Also CT pelvis performed which demonstrated
uncomplicated sigmoid diverticulitis. She was given
Cipro/Flagyl for diverticulitis, and dilaudid. VS prior to
transfer: 98.5 60 156/62 16 99%
.
Currently, she is pain free when laying still, with back pain
when moving. Abdomen is mildly TTP in LLQ, overall benign. She
is in good spirits, alert and oriented, though feels a bit
nauscious
Past Medical History:
Hypertension
Hyperlipidemia
h/o L5-S1 and L54 - 5 bilateral laminectomies for spinal
stenosis
Osteoporosis
Breast cancer s/p mastectomy
Paroxysmal atrial fibrillation
Hypothyroidism
b/l foot drop
GERD
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission
VS - Temp ___, BP 136/64 , HR 63 , R 18 , O2-sat 100% RA
GENERAL - elderly caucasian female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, mildly tender to deep palpation in LLQ, soft/ND,
no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
BACK: TTP in lumber area
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred
Discharge
VS - Temp 97.1 F, BP 118/61 , HR 68 , R 18 , O2-sat 100% RA
GENERAL - elderly caucasian female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, mildly tender to deep palpation in LLQ, soft/ND,
no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
BACK: TTP in lumber area
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
Pertinent Results:
Admission labs
___ 12:45PM BLOOD WBC-11.1* RBC-3.77* Hgb-10.8* Hct-33.4*
MCV-89 MCH-28.7 MCHC-32.4 RDW-13.3 Plt ___
___ 12:45PM BLOOD Neuts-83.7* Lymphs-10.4* Monos-4.3
Eos-1.2 Baso-0.5
___ 12:45PM BLOOD Glucose-110* UreaN-27* Creat-1.8* Na-138
K-3.9 Cl-101 HCO3-27 AnGap-14
___ 01:04PM BLOOD Glucose-104 Lactate-0.9 Na-137 K-3.9
Cl-97 calHCO3-27
Discharge labs
___ 06:30AM BLOOD WBC-6.7 RBC-3.60* Hgb-10.5* Hct-32.1*
MCV-89 MCH-29.0 MCHC-32.6 RDW-13.6 Plt ___
___ 06:30AM BLOOD Neuts-74.4* Lymphs-16.3* Monos-6.0
Eos-2.6 Baso-0.6
___ 06:30AM BLOOD Glucose-120* UreaN-22* Creat-1.8* Na-138
K-4.6 Cl-101 HCO3-30 AnGap-12
___ 06:30AM BLOOD TotProt-6.0* Albumin-3.9 Globuln-2.1
Calcium-9.4 Phos-3.1 Mg-1.6 Iron-PND
Studies
CT Pelvis/L-spine
A severe wedge deformity at L3 is again seen (401B:38). There
are
mild wedge compression deformities at L2 and L5. No acute
fracture is
detected. The bones are severely osteopenic. Grade 1
anterolisthesis of L4
on L5 is unchanged. There is severe thecal sac narrowing at L5
secondary to posterior osteophytosis in addition to the
compression deformity.
Extensive sigmoid diverticulosis is present. Fat stranding
around a
diverticulum is new since the ___ CT examination,
likely
representing acute diverticulitis, however, this process is
incompletely
imaged (3:78).
Non-contrast enhanced images of the abdomen demonstrate a
dilated main
pancreatic duct (3:15) measuring up to 7 mm in diameter, without
an obvious mass, unchanged since the prior examination. A large
left renal cyst is again seen (3:21). An infrarenal abdominal
aortic aneurysm measuring 26 mm in diameter (3:35), and
extensive atherosclerotic calcifications are unchanged
IMPRESSION:
1. Sigmoid diverticulitis, incompletely imaged.
2. Severe L3 wedge compression deformity and severe multilevel
degenerative changes throughout the lumbar spine, with no
evidence of acute superimposed fracture.
Medications on Admission:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) PRN pain
2. propafenone ___ mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime
PRN.
7. Simvastatin 20mg PO daily
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
11. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Uncomplicated diverticulitis
Secondary: pain from old L1 compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Rule out fracture.
COMPARISON: MR available from ___.
TECHNIQUE: MDCT-acquired 3.75-mm axial images of the lumbar spine were
obtained without the use of IV contrast. Coronal and sagittal reformations
were performed at 2-mm slice thickness.
FINDINGS: A severe wedge deformity at L3 is again seen (401B:38). There are
mild wedge compression deformities at L2 and L5. No acute fracture is
detected. The bones are severely osteopenic. Grade 1 anterolisthesis of L4
on L5 is unchanged. There is severe thecal sac narrowing at L5 secondary to
posterior osteophytosis in addition to the compression deformity.
Extensive sigmoid diverticulosis is present. Fat stranding around a
diverticulum is new since the ___ CT examination, likely
representing acute diverticulitis, however, this process is incompletely
imaged (3:78).
Non-contrast enhanced images of the abdomen demonstrate a dilated main
pancreatic duct (3:15) measuring up to 7 mm in diameter, without an obvious
mass, unchanged since the prior examination. A large left renal cyst is again
seen (3:21). An infrarenal abdominal aortic aneurysm measuring 26 mm in
diameter (3:35), and extensive atherosclerotic calcifications are unchanged.
IMPRESSION:
1. Sigmoid diverticulitis, incompletely imaged.
2. Severe L3 wedge compression deformity and severe multilevel degenerative
changes throughout the lumbar spine, with no evidence of acute superimposed
fracture.
Initial findings were discussed by Dr. ___ with Dr. ___ at 12:20 p.m. on
___.
NOTE ON ATTENDING REVIEW:
Numbering used is shown on se 401b, im 34.
There are a few fracture fragments noted involving the L3 body with foci of
osseous discontinuity in the anterior cortex and a fracture line
postero-inferiorly. A pathologic compression fracture cannot be completely
excluded in a particular a possible focal lesion anteriorly. Consider
post-contrast MRI if not CI or correlation with radionuclide studies or close
followup.
Radiology Report
INDICATION: Diverticulitis, incompletely imaged on lumbar spine CT.
TECHNIQUE: MDCT-acquired 5-mm axial images of the lower pelvis were obtained
without the use of IV contrast. Coronal and sagittal reformations were
performed at 5-mm slice thickness.
FINDINGS:
There is extensive colonic diverticulosis. Focal fat stranding around an
inflamed diverticulum within the sigmoid colon (2:22) is compatible with
diverticulitis. There are no fluid collection or free air.
The bladder, uterus, adnexa, and intrapelvic loops of small bowel are normal.
Severe atherosclerotic calcifications of the lower abdominal aorta and iliac
branches are present.
OSSEOUS STRUCTURES:
There is no acute fracture. No concerning blastic or lytic lesions are
identified. A mild wedge compression deformity at L5 is better visualized on
the recent CT L-spine examination performed on the same day.
IMPRESSION: Uncomplicated sigmoid diverticulitis, with no evidence of
perforation. No fluid collections detected.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with DIVERTICULITIS OF COLON, BACKACHE NOS
temperature: 98.5
heartrate: 66.0
resprate: 18.0
o2sat: nan
sbp: 131.0
dbp: 62.0
level of pain: 6
level of acuity: 3.0 | Ms ___ is a ___ with h/o diverticulitis ___ years ago,
breast cancer, PAF, HTN, HLD, osteoporosis, recent admission for
L1 compression fx, who presents with 2 weeks of worsening nausea
and back pain, found to have sigmoid diverticulitis, unable to
tolerate PO's.
.
# Diverticulitis: a mild case. She has only mild tenderness in
LLQ, and is moderately nauscious. She was treated with a 7 day
course of augmentin/flagyl, compazine PRN nausea. She was
initially NPO, then transitioned to clear liquids, which she
tolerated well. She should be on a high-fiber diet once she
recovers from this acute episode.
.
# L1 compression fracture: she has been in substantial pain
since her compression fracture occured several weeks ago. She
has been on tramadol at home without much relief. Her pain was
controlled in house with oxycodone 2.5mg PO PRN, which did help
some. She was evaluated by ___, who felt she would benefit from
___, so she was discharged with a referral for home ___. The
etiology of her compression fracture is likely osteoporosis. Her
calcium and alk phos where normal, making malignancy / lytic
lesion less likely. However, after discussion with the
Radiologist, it was decided that it would be reasonable for her
to have repeat imaging of her L-spine in ___ weeks time. Will
set her up with PCP appointment to follow up on this issue. Low
dose oxycodone was added to her home regimen for increased pain
control. She has been tolerating this very well inhouse.
.
# Paroxysmal atrial fibrillation: Not on warfarin. On metoprolol
for rate control. She is on aspirin 81mg PO daily at home.
.
#CKD: Pt with baseline creatinine of 1.5-1.8. Creatinine on
admission was 1.8. Renally dosed all medications
.
# Anemia: chronic, normocytic with normal RDW. Unlikely related
to acute presentation, though checked iron, B12, folate for
easily correctable causes.
.
# Hypertension: Well controlled. Continue amlodipine and
metoprolol
.
# Hyperlipidemia: Continue simvastatin 20mg daily
.
# Hypothyroidism: Continue synthroid ___ mg dialy.
.
# Osteoporosis: continue nasal calcitonin daily
.
# GERD: Pt claimed to no longer take omeprazole and was
therefore not continued
================================================
TRANSITIONAL ISSUES
# Consider repeat lumbar spine imaging in ___ weeks to further
work-up possible lytic lesion as underlying cause of compression
fracture
# F/u with Spine clinic on ___ for further treatment of
symptoms
# Add low dose oxycodone to home regimen
# Complete ___ugmentin/flagyl for diverticulitis
# advance diet slowly over a few days for diverticulitis
# Home physical therapy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / adhesive tape / penicillin G / Cephalosporins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
HPI: ___ reports 2 weeks of intermittent band-like tightening
across her upper abdomen and acute-onset sharp and constant
right
upper quadrant abdominal pain for the last 8.5 hours with
associated nausea but no vomiting, fevers or chills. She
reports
relief of pain only after receiving morphine in ED.
Past Medical History:
OBHx:
G1P1
Primary LTCS after failed VAVD
PMH: Denies
PSH: Breast Bx
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.8 HR: 58 BP: 128/75 Resp: 15 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, right upper quadrant
tenderness to palpation
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
___ 02:15AM BLOOD WBC-6.6 RBC-4.45 Hgb-12.8 Hct-40.3 MCV-91
MCH-28.8 MCHC-31.8 RDW-13.1 Plt ___
___ 02:15AM BLOOD Neuts-78.1* Lymphs-16.9* Monos-3.2
Eos-1.4 Baso-0.4
___ 02:15AM BLOOD Plt ___
___ 02:15AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
___ 02:15AM BLOOD ALT-19 AST-21 AlkPhos-64 TotBili-0.3
___ 02:15AM BLOOD Lipase-30
___ 02:15AM BLOOD Albumin-4.2
___: liver/gallbladder ultrasound:
IMPRESSION: Cholelithiasis with impacted 9 mm gallbladder neck
stone. There is mild focal tenderness on examination. The
gallbladder is not distended, and there is no wall thickening,
however, early acute cholecystitis is a possibility given the
history and findings.
Medications on Admission:
MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*25 Tablet(s)* Refills:*0*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Postprandial right upper quadrant pain.
TECHNIQUE: Ultrasonography of the right upper quadrant.
No comparison studies available.
FINDINGS:
The liver echotexture is normal, and there is no focal intrahepatic lesion or
intrahepatic bile duct dilation. The main portal vein is patent,
demonstrating proper hepatopetal flow. The gallbladder is filled with
numerous mobile stones. However, there is a 9-mm gallbladder neck stone that
is immobile. The gallbladder is not distended, the wall is not thickened, and
there is no pericholecystic fluid, however, mild focal tenderness is present.
The IVC is normal. Included views of the pancreatic body, head, and tail are
normal. The aorta is normal in caliber. No ascites is present.
The right kidney measures 10.6 cm, and there is no stone or hydronephrosis.
IMPRESSION: Cholelithiasis with impacted 9 mm gallbladder neck stone. There
is mild focal tenderness on examination. The gallbladder is not distended, and
there is no wall thickening, however, early acute cholecystitis is a
possibility given the history and findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.8
heartrate: 58.0
resprate: 15.0
o2sat: 100.0
sbp: 128.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the acute care service with right
upper quadrant pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging of the abdomen. On
ultrasound, she was reported to have gallstones with an immobile
9-mm gallbladder neck stone. On HD #1, she was taken to the
operating room for a laparoscopic cholecystectomy. Her
operative course was stable with minimal blood loss. She was
extubated after the procedure and monitored in the recovery
room.
She was has been started on a regular diet. Her vital signs have
been stable and she has been afebrile. She has been voiding
without difficulty.
She is preparing for discharge home with follow-up with Dr.
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
multiple facial fractures, ? tracheal injury.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M s/p assault by multiple assailants found down after the
assault with ? loss of conciousness. Per report hew as struck in
the face and neck by fists from multiple assainants. He was
found to have lefort I/II fractures, nasal fracture, mandible
ramus fracture, and possible laryngeal cartilage fracture with
significant subcutaneous emphysema on CT scan. In the ED,
primary and secondary surveys were performed and GCS was 15 in
the ___ ED. Saturations in low to mid ___ in the ED thus he
was placed on a non-rebreather facemask. He was seen by ENT in
the ED who performed a fiberoptic endoscopic exam which showed
no obvious mucosal injury or exposed cartilate but significant
blood, and mild edema in the posterior trachea, but airway was
otherwise patent. He was transferred to the ICU for close
monitoring and airway protection.
Past Medical History:
PMH: R shoulder fracture, chronic shoulder pain
PSH: R shoulder surgery
Social History:
SH: from itily, has 3 children, works as an ___. Heavy
smoker, denies alcohol or recreational drug use, but came to ED
with BAC 223.
Physical Exam:
Upon discharge:
P/E:
Vital Signs: Temp 98.3 BP 152 / 85 HR 95 RR 20 O2 95 ra
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric, abrasion on left supraorbital
skin, tenderness to palpation around left zygoma and mandibular
angle.
CV: RRR,
PULM: no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
___ 07:35AM BLOOD WBC-8.6 RBC-4.93 Hgb-16.0 Hct-45.7 MCV-93
MCH-32.5* MCHC-35.0 RDW-12.2 RDWSD-41.5 Plt ___
___ 08:00AM BLOOD WBC-8.7 RBC-4.62 Hgb-14.7 Hct-44.5 MCV-96
MCH-31.8 MCHC-33.0 RDW-12.7 RDWSD-45.4 Plt ___
___ 05:21PM BLOOD WBC-12.0* RBC-4.99 Hgb-16.2 Hct-47.6
MCV-95 MCH-32.5* MCHC-34.0 RDW-13.0 RDWSD-45.1 Plt ___
___ 05:21PM BLOOD Neuts-80.6* Lymphs-13.5* Monos-4.7*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.64* AbsLymp-1.61
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.04
___ 07:35AM BLOOD Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-25.6 ___
___ 05:21PM BLOOD Plt ___
___ 05:21PM BLOOD ___ PTT-27.8 ___
___ 07:35AM BLOOD Glucose-90 UreaN-6 Creat-0.9 Na-136 K-3.5
Cl-95* HCO3-22 AnGap-23*
___ 08:00AM BLOOD Glucose-121* UreaN-7 Creat-1.0 Na-139
K-4.0 Cl-100 HCO3-22 AnGap-21*
___ 05:21PM BLOOD Glucose-108* UreaN-7 Creat-0.9 Na-142
K-3.7 Cl-103 HCO3-24 AnGap-19
___ 04:28PM BLOOD Lipase-70*
___ 07:35AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0
___ 08:00AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.9
___ 05:21PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:28PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:32AM BLOOD HIV Ab-Negative
___ 10:32AM BLOOD HCV Ab-Negative
___ 08:00AM BLOOD HCV Ab-Negative
___ 04:40PM BLOOD pO2-43* pCO2-50* pH-7.33* calTCO2-28 Base
XS-0
___ 04:40PM BLOOD Glucose-105 Lactate-2.4* Na-144 K-4.7
Cl-108
___ 04:40PM BLOOD Hgb-17.5 calcHCT-53 O2 Sat-70 COHgb-4
MetHgb-0
___ 04:40PM BLOOD freeCa-0.94*
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate
2. Bisacodyl 10 mg PR QHS:PRN Constipation
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Rise mouth twice a day
Refills:*0
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
nebulizer every six (6) hours Disp #*10 Ampule Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL ___ mL by mouth every four (4) hours
Refills:*0
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole [Protonix] 40 mg 1 granules(s) by mouth Q24H
Disp #*30 Packet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ ___ fracture, R orbital fracture, mandibular fracture,
thyroid cartilage fracture, significant R neck subcutaneous
emphysema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with facial injury status post assault
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: CT chest ___ at 15:12
FINDINGS:
Cardiac silhouette size is top normal. Mediastinal and hilar contours are
unremarkable. Pulmonary vasculature is not engorged. Patchy atelectasis is
noted in the lung bases without focal consolidation. No pleural effusion or
pneumothorax is seen. Subcutaneous emphysema tracking along the fascial
planes of the neck is re- demonstrated. Healed fracture of the left eighth
posterior rib is re- demonstrated.
IMPRESSION:
Bibasilar atelectasis. Subcutaneous emphysema within the neck.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with multiple facial fractures status post assault.
Right knee and elbow pain.
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right elbow.
COMPARISON: Right elbow radiographs ___
FINDINGS:
No acute fracture, dislocation, or degenerative change is detected. No
suspicious lytic lesion is identified. No joint effusion is seen. No soft
tissue calcification is detected. Intravenous catheter is noted within the
antecubital fossa. Soft tissue swelling and laceration is noted overlying in
the dorsal and ulnar aspect of the elbow with small amount of subcutaneous
gas.
IMPRESSION:
No acute fracture or dislocation. Soft tissue swelling and laceration
overlying the elbow.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with multiple facial fractures status post assault.
Right knee and elbow pain.
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right knee.
COMPARISON: None.
FINDINGS:
No acute fracture, dislocation, or gross degenerative change is detected. No
suspicious lytic or sclerotic lesion is identified. A small joint effusion is
present. No soft tissue calcification or radio-opaque foreign body is
detected.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
INDICATION: History: ___ with left hand pain status post assault //fracture?
TECHNIQUE: Three views of the left hand
COMPARISON: None.
FINDINGS:
Pulse oximeter device overlying the distal aspect of the ring finger slightly
limits assessment of the middle and distal phalanges. Given this limitation,
no acute fracture or dislocation is present. No concerning lytic or sclerotic
osseous abnormality is detected. No significant degenerative changes are
seen. No embedded radiopaque foreign bodies or soft tissue calcifications are
noted.
IMPRESSION:
Slightly limited assessment of the middle and distal phalanges of the ring
finger. Otherwise, no acute fracture or dislocation.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Assault, ETOH
Diagnosed with Fracture of other parts of neck, initial encounter, Assault by other bodily force, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | The patient presented to the ED with a lefort ___ fx, R orbital
fx, mandibular fx, thyroid cartilage fx, significant R neck subq
emphysema. He was seen by ENT in the ED who performed a
fiberoptic endoscopic exam which showed no obvious mucosal
injury or exposed cartilate but significant blood, and mild
edema in the posterior trachea, but airway was otherwise patent.
He was transferred to the ICU for close monitoring and airway
protection. He maintained saturation on nonrebreather overnight.
However, he had some urinary retention of 850 ml on arrival to
ICU and so a foley was placed.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was managed with IV pain medications
including IV dilaudid and IV Tylenol and was subsequently
changed to oral medications such as liquid oxycodone, liquid
Tylenol and IV dilaudid breakthrough. Pain was very well
controlled.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. We gave him
duo nebs to help with his airway mild edema. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed in the ICU for
urinary retention of 850ml and it was removed the next day when
he was transferred to the floor. He had autonomous return of
voiding. ___ was consulted for maxillary and mandibular
fractures and so they believed surgery was warranted
non-urgently. Anesthesia was also consulted for a airway
clearance per ___'s request. Also, the patient was put on a
full diet, which he will continue to be on until his OR per
___'s request. Since the patient was clinically stable and was
awaiting for surgery, he was discharged home and was instructed
to return for his surgery.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
#OTHER: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg weakness, syncope, rapid atrial fibrillation
Major Surgical or Invasive Procedure:
none this admit
s/p ___: Aortic valve replacement with a 25 mm Epic supra
valve. Coronary artery bypass grafting x 2, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the marginal branch.
History of Present Illness:
___ year old male with known coronary
artery and aortic valve disease. He underwent CABG/AVR on
___. Surgery and post operative course were unremarkable.
He was discharged home on ___. On the morning of ___ he had
an episode ___ weakness and fell to the floor. He denies any
LOC. He was taken to a local OSH (___) and CT head was negative.
While in the ED at OSH he was found to be in rapid atrial
fibrillation. He was given IV and PO Lopressor with appropriate
response in HR. He was transferred to BID for further work up.
Upon arrival he was HD stable and his HR remained in the 110s.
He
denies any current symptoms.
Past Medical History:
Aortic Stenosis s/p tissue AVR ___
Basal Cell Carcinoma
Bicuspid Aortic Valve
BPH
Chronic Kidney Disease, baseline 1.6
Coronary Artery Disease s/p CABGx2 ___
Degenerative Disc Disease
Hyperlipidemia
Hypertension
Osteoarthritis
Rosacea
Squamous Cell Carcinoma
Surgical History:
Open Cholecystectomy
PCI/stenting LAD ___
Social History:
___
Family History:
No premature coronary artery disease and/or SCD
Physical Exam:
Admission Physical
Pulse: 110 Resp: 18 O2 sat: 94%
B/P Right: 136/72
___:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x] Right eye hematoma on sclera
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade ______ Atrial
fibrillation
Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right: + Left: +
DP Right: + Left: +
___ Right: Left:
Radial Right: + Left: +
Discharge Exam:
Vital Signs I/O
24 HR Data (last updated ___ @ 1118)
Temp: 98.3 (Tm 98.3), BP: 116/65 (109-148/64-78), HR: 80
(72-94), RR: 18 (___), O2 sat: 96% (94-98), O2 delivery: Ra,
Wt: 190.04 lb/86.2 kg
Fluid Balance (last updated ___ @ 1121)
Last 8 hours Total cumulative 200ml
IN: Total 200ml, PO Amt 200ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 780ml
IN: Total 780ml, PO Amt 780ml
OUT: Total 0ml, Urine Amt 0ml
Physical Examination:
___: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: very small R eye hematoma s/p fall [x]
Cardiovascular: RRR [] Irregular [x] Murmur [] Rub []
Respiratory: CTA w/decreased bases [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema 0
Left Upper extremity Warm [x] Edema 0
Right Lower extremity Warm [x] Edema trace
Left Lower extremity Warm [x] Edema 0
Pulses:
DP Right:1 Left:1
___ Right:1 Left:1
Radial Right:1 Left:1
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Lower extremity: Right [x] Left [] trace erythema but no
drainage/warmth/tenderness [x]
Pertinent Results:
STUDIES:
TEE ___:
LEFT ATRIUM ___ VEINS: No spontaneous echo contrast
in the ___.
Prominent appendage pectinate muscle(s). Cannot exclude ___
___ thrombus. Mildly depressed ___ ejection velocity (0.2-0.55 m/s)
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
No RA/RA appendage
spontaneous echo contrast. Small PFO.
LEFT VENTRICLE (LV): Normal cavity size.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Simple aortic arch atheroma. Simple descending aortic
atheroma.
AORTIC VALVE (AV): Bioprosthesis. Well seated prosthesis. No
mass/vegetation. No abscess. No
regurgitation.
MITRAL VALVE (MV): Normal leaflets. No systolic prolapse. No
mass/vegetation. No abscess. Mild [1+]
regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. No mass/vegetation. No
abscess. Mild [1+] regurgitation.
ADDITIONAL FINDINGS: 3D Imaging rendering with interpretation
and reporting with image post
processing under concurrent supervision; requiring an
independent workstation. Time-out completed per
___ policy: Non-operative Universal Protocol @ ___
15:01. TEE not feasible without conscious
sedation. Risks, benefits and alternatives were discussed and
Informed consent was obtained from the patient
who desired to proceed. With rhythm, blood pressure and oxygen
saturation monitors, constant nursing
observation, and direct attending supervision, the patient
received an appropriate level of sedation (see
medication list above). The attending was at the bedside
continuously for 31.0 min during sedation. The
patient was subsequently observed with serial examinations until
the return of their gag reflex and
presedation mental status. The TEE probe was placed into the
esophagus by the cardiology attending. No TEE related
complications.
CONCLUSION:
There is no spontaneous echo contrast in the body of the left
atrium or left atrial appendage. There are prominent pectinate
muscle(s) in the left atrial appendage. A left atrial appendage
thrombus cannot be
excluded. The left atrial appendage ejection velocity is mildly
depressed. No spontaneous echo contrast is seen in the body of
the right atrium or right atrial appendage. There is a small
patent foramen ovale by color
Doppler. The left ventricle has a normal cavity size. Normal
right ventricular cavity size with normal free wall motion.
There are simple atheroma in the aortic arch with simple
atheroma in the descending aorta to 36 cm from the incisors. An
aortic valve bioprosthesis is present. The prosthesis is well
seated. No masses or vegetations are seen on the aortic valve.
No abscess is seen. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
No abscess is seen. There is mild [1+] mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve. No abscess is
seen. There is mild [1+] tricuspid regurgitation.
IMPRESSION: Cannot exclude the presence of thrombus in the left
atrial appendage. Mild mitral regurgitation. Small patent
foramen ovale
TTE ___
CONCLUSION:
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg.
There is moderate symmetric left ventricular hypertrophy with a
normal cavity size. There is mild regional left ventricular
systolic dysfunction with septal and inferior wall hypokinesis
(see schematic) and preserved/normal contractility of the
remaining segments. There is beat-to-beat variability in the
left ventricular contractility due
to the irregular rhythm. The visually estimated left ventricular
ejection fraction is 40%. There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with low normal free wall
motion. Tricuspid annular plane systolic excursion (TAPSE) is
depressed. There is post-thoracotomy interventricular septal
motion. There is a mildly dilated ascending aorta. The aortic
arch diameter is normal
with a normal descending aorta diameter. There is no evidence
for an aortic arch coarctation. An aortic valve bioprosthesis is
present. The prosthesis is well seated with normal leaflet
motion and gradient. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is mild to moderate [___] mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets are mildly thickened. There is
physiologic tricuspid regurgitation. There is mild pulmonary
artery
systolic hypertension. There is a trivial pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w coronary artery disease,
with mildly reduced ejection fraction. Low normal right
ventricular free wall systolic function. Mildly dilated
ascending aorta. Well seated bioprosthetic
aortic valve with normal transvalvular gradients. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.
CXR ___
Comparison to ___. Mild decrease but no complete
resolution of the pre-existing left pleural effusion. Stable
postoperative appearance of the cardiac silhouette. No
pulmonary edema. Normal alignment of the sternal wires.
OSH Head CT ___: negative
LABS:
Admit:
___ 04:40AM BLOOD WBC-10.5* RBC-3.36* Hgb-9.6* Hct-29.2*
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.2 RDWSD-41.4 Plt ___
___ 04:40AM BLOOD ___ PTT-27.6 ___
___ 04:40AM BLOOD Glucose-145* UreaN-30* Creat-1.3* Na-136
K-4.1 Cl-101 HCO3-26 AnGap-9*
___ 04:50AM BLOOD Mg-2.4
Discharge
___ 10:18AM BLOOD WBC-15.3* RBC-3.73* Hgb-10.5* Hct-33.4*
MCV-90 MCH-28.2 MCHC-31.4* RDW-13.3 RDWSD-43.8 Plt ___
___ 04:30AM BLOOD ___ PTT-34.7 ___
___ 04:30AM BLOOD Glucose-180* UreaN-30* Creat-1.4* Na-140
K-5.3 Cl-105 HCO3-26 AnGap-9*
___ 10:18AM BLOOD UreaN-29* Creat-1.5*
___ 04:30AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.2
Micro:
___ 9:27 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ repeat Urine Culture: PENDING
Medications on Admission:
1. Atorvastatin 40 mg PO QPM
2. Furosemide 40 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
5. Lisinopril 5 mg PO DAILY
6. alfuzosin 10 mg oral DAILY
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
maximum 4000mg/day please
2. Amiodarone 400 mg PO BID postop atrial fibrillation
400mg BID x 6 days, then 200mg BID x 7 days, then 200mg daily
continuous
RX *amiodarone 400 mg 1 tablet(s) by mouth as directed Disp #*60
Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Metoprolol Succinate XL 200 mg PO BID
RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
5. Senna 17.2 mg PO DAILY
6. Warfarin ___ mg PO ASDIR atrial fibrillation
take 1 to 4 tablets daily as directed by ___ goal
INR ___
RX *warfarin [Coumadin] 1 mg ___ tablet(s) by mouth as directed
Disp #*60 Tablet Refills:*1
7. Warfarin 1 mg PO ONCE Duration: 1 Dose
will be given prior to d/c home ___
8. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
9. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
10. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
11. alfuzosin 10 mg oral DAILY
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 40 mg PO QPM
14. Omeprazole 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Rapid Atrial Fibrillation
Syncope
Secondary:
Bicuspid Aortic Valve s/p tiss AVR ___
Coronary Artery Disease s/p CABG ___
Basal Cell Carcinoma
BPH
Chronic Kidney Disease, baseline 1.6
Degenerative Disc Disease
Hyperlipidemia
Hypertension
Osteoarthritis
Rosacea
Squamous Cell Carcinoma
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
RLE EVH Incision - trace amount erythema, no warmth or drainage
Edema- trace RLE, none LLE
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p CABGx2, WBC// eval for pna, effusions,
congestion eval for pna, effusions, congestion
IMPRESSION:
Comparison to ___. Mild decrease but no complete resolution of the
pre-existing left pleural effusion. Stable postoperative appearance of the
cardiac silhouette. No pulmonary edema. Normal alignment of the sternal
wires.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Dizziness and giddiness
temperature: 99.3
heartrate: 110.0
resprate: 18.0
o2sat: 94.0
sbp: 136.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with known coronary artery and aortic valve
disease. He underwent CABG/AVR on ___ with unremarkable
OR/postop course. Following fall at home ___, he presented to
___ where head CT was normal but had new
rapid atrial fibrillation. He was transferred here and was
seen by Dr. ___ cardiology. He remained in rapid
atrial fibrillation despite increased Metoprolol dosing. His
eventual TEE on ___ could not definitively rule out thrombus,
so planned cardioversion was deferred. His INR was therapeutic
on ___ and Amiodarone was added. He remains in atrial
fibrillation with improved rate control. He completed postop
Lasix course and his lisinopril/amlodipine doses were adjusted.
He has had mild leukocytosis without fevers. His CXR is
unremarkable CXR, his first Urine culture grew mixed flora and
second one is pending. He has trace amount edema/erythema at
___ site, but otherwise incisions are healing well. He has
no obvious sequela s/p fall and has been ambulating halls
without difficulty. He will be discharged home on POD 12 with
Amiodarone ___ of Hearts monitor for 2 weeks, and will
have repeat CBC with second INR check to trend ___. Appropriate
follow up visits have been arranged. Of note, he wishes to
change his cardiologist to Dr. ___ call
himself to cancel his previously scheduled appointment with Dr.
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is pleasant ___ yo RH man with medical history of
GERD who presents to the ED for evaluation of acute LT hand
weakness and clumsiness in the setting of five days of slurred
speech, gait instability, and nausea without vomiting.
He reports was in his usual state of health (which includes
independence in all activities of daily living, with several
months of mild balance difficulties) until about five days ago
when he had some extra glasses of wine with dinner. The next
morning he reports woke up with "funny visual symptoms like the
room was changing positions". He denies HA, dizziness or
weakness associated. This resolved spontaneously over the course
of several hours. However following the initial symptoms he
developed subsequent slurred speech (knows exactly what he wants
to say but always comes out slurred), gait instability (feeling
unsteady and requiring a walker at home which he has never
needed), as well as persistent nausea w/o vomiting.
This morning he woke up around 9:00 and was trying to eat
breakfast when he noted LT hand was clumsy and weak. He was not
even able to pick up his slice of toast. At that point he
decided to come to the ED for evaluation. Of note with this
episode he denies visual, sensory symptoms, headache,
palpitations or
dizziness.
On neurologic review of systems, he notes increased salivation
and difficulty with swallowing solids which has been going on
for months. Other than the above mentioned symptoms denies
headache, lightheadedness, or confusion. Denies difficulty with
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty. Denies
numbness, parasthesia. Denies fatigability. Denies bowel or
bladder incontinence or retention.
On general review of systems, the patient notes softer stools
than his usual, abdominal cramps and nausea. He denies fevers,
rigors, night sweats, or noticeable weight loss. Denies chest
pain, palpitations, dyspnea, or cough. Denies constipation.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
PMH/PSH:
GERD
MEDICATIONS:
Omeprazole
ASA 325mg daily (pt taking spontaneously)
ALLERGIES:
NKDA
Social History:
___
Family History:
FAMILY HISTORY:
No family history of neurologic or cardiovascular disease.
Physical Exam:
Admission Exam:
PHYSICAL EXAMINATION
Vitals:
97.9
72
155/96
16
98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. Mild dysarthria, voice with nasal quality. Normal
prosody. Able to register 3 objects and recall ___ at 5 minutes.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
Cranial Nerves: PERRL 3.5->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. LT lower facial droop chronic present in driver's
license. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
Motor: Normal bulk and tone. Subtle LT drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 3 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor RT extensor LT.
Coordination: LT dysmetria with finger to nose.
Gait: unable to stand unassisted, very unsteady and leaning
fully
on his nurse to support his weight.
===================================================
Discharge exam:
T: 98.0
BP: 138-160 / 60-70s
HR: 55-64
RR: 18
O2: 92-100% on RA
General: Awake, alert, and in no distress.
Neurologic:
Mental status: alert and oriented x3, no paraphasic speech
errors, but + labial, lingual, and guttural dysarthria.
CNs: PERRL, EOM intact without nystagmus, face symmetric upon
activation. Tongue protrudes in the midline but has noticeably
slowed movements.
Motor: Right UE and ___ strength is ___. Left deltoid 4+, wrist
extensors 4+, finger extensors 4+, iliopsoas 4-, hamstring 4,
and extensor hallicus longus 4. + Left pronator drift. Reflexes
symmetric with the exception of 3+ in the left patella versus 2+
in the right. + Babinski in the left (normal in the right).
Sensory: Decreased proprioception in the right ___ (no sensation
at the toe, but normal at the ankle). Intact sensation to pin
throughout.
Coordination: + dysmetria on (left) finger-nose-finger and
heel-to-shin. Slowed finger and toe tapping on the left. +
Overshoot with saccades. + truncal ataxia
Gait: standing is unsteady; gait deferred
Pertinent Results:
___ 05:20AM BLOOD WBC-6.0 RBC-4.41* Hgb-14.3 Hct-42.9
MCV-97 MCH-32.4* MCHC-33.3 RDW-13.0 RDWSD-46.1 Plt ___
___ 05:20AM BLOOD ___ PTT-28.0 ___
___ 05:20AM BLOOD Glucose-86 UreaN-8 Creat-0.8 Na-137 K-3.7
Cl-99 HCO3-24 AnGap-18
___ 05:20AM BLOOD ALT-15 AST-18 LD(LDH)-158 CK(CPK)-36*
AlkPhos-67 TotBili-0.9
___ 05:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:09PM BLOOD Triglyc-164* HDL-45 CHOL/HD-4.7
LDLcalc-133*
___ 12:31PM BLOOD %HbA1c-4.7 eAG-88
___ 05:20AM BLOOD TSH-2.8
IMAGING:
Non-contrast head CT w/ CTA head and neck
1. No evidence of intracranial hemorrhage.
2. Focal narrowing of the mid basilar artery without critical
stenosis.
3. Slight irregularity of the left P1 segment which may be due
to tortuosity and/or atherosclerosis.
4. Mild atherosclerosis of the bilateral vertebral artery
origins. This report is provided without 3D and curved
reformats.
MRI brain:
1. Right pontine and middle cerebellar peduncle acute to
subacute infarct
without definite evidence of hemorrhagic transformation.
2. Findings suggestive of nonocclusive partial thrombosis of
basilar artery, corresponding to area of focal basilar artery
narrowing on recent head and neck CTA.
3. Paranasal sinus disease and minimal nonspecific right
mastoid fluid
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole Dose is Unknown PO DAILY
2. Aspirin 325 mg PO Frequency is Unknown
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*3
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*11
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule by mouth Daily Disp #*30 Capsule
Refills:*3
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with 2d slurred speech and difficulty ambulating //
?bleed
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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 0.8 s, 2.0 cm; CTDIvol =
56.1 mGy (Head) DLP = 112.1 mGy-cm. 2) Sequenced Acquisition 7.2 s, 18.0 cm;
CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 3) Stationary Acquisition 5.0
s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP = 27.2 mGy-cm. 4) Spiral Acquisition
4.8 s, 37.6 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,198.9 mGy-cm. Total DLP
(Head) = 2,348 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute intracranial hemorrhage or mass. The ventricles
and sulci are normal in size and configuration. There may be a faint
hypodensity of the right pons but may be attributable to artifact is
obscuring the region (04:13)
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portions of the orbits are unremarkable.
CTA HEAD:
There is a fenestrated basilar artery.There is focal narrowing of the mid
basilar artery without definite occlusion. Otherwise, the vessels of the
circle of ___ and their principal intracranial branches appear normal
without stenosis, occlusion, or aneurysm formation. The dural venous sinuses
are patent.
CTA NECK:
There is mild plaque at the origins of the bilateral vertebral arteries and
origin of the right ICA without stenosis. The carotid and vertebral arteries
and their major branches appear normal with no evidence of stenosis or
occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Focal narrowing of the mid basilar artery without definite inclusion.
2. No evidence of dissection, aneurysm >3mm, or flow limiting stenosis. No
evidence of internal carotid stenosis by NASCET criteria.
3. Possible right pontine hypodensity, however may be due artifact. MRI would
provide further evaluation.
4. No evidence of intracranial hemorrhage or mass.
Radiology Report
INDICATION: ___ year old man with ? stroke // r/o pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None available
FINDINGS:
The lungs are hyperexpanded with an emphysematous configuration of the thorax.
No focal consolidation, pleural effusion or pneumothorax identified. The size
of the cardiac silhouette is enlarged.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with slurred speech, left hand and IP weakness.
Evaluate for acute infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head and neck CTA.
FINDINGS:
Study is mildly degraded by motion. Right pons and right middle cerebellar
peduncle areas restricted diffusion, with associated T2 and FLAIR
hyperintensity, and no definite associated increase susceptibility is present.
Crescentic T2 hyperintensity within the basilar artery at region of basilar
artery narrowing noted on recent CTA is seen (see 9:9).
Right frontal encephalomalacia versus prominent Virchow ___ space is noted
(see 09:14).
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There is prominence of the ventricles and sulci suggestive
involutional changes.
Bilateral ethmoid air cell mucosal thickening is present. Minimal nonspecific
right mastoid fluid is present.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Right pontine and middle cerebellar peduncle acute to subacute infarct
without definite evidence of hemorrhagic transformation.
3. Findings suggestive of nonocclusive partial thrombosis of basilar artery,
corresponding to area of focal basilar artery narrowing on recent head and
neck CTA.
4. Paranasal sinus disease and minimal nonspecific right mastoid fluid, as
described.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Slurred speech, Numbness
Diagnosed with Cerebral infarction, unspecified
temperature: 97.9
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 155.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the neurology stroke service. He
remained hemodynamically stable throughout his admission. He had
a brain MRI which showed an acute right paramedian pontine
infarct which corresponds with his symptoms -- collectively
known as the "clumsy hand dysarthria syndrome" due to a pontine
lesion. His imaging also suggested narrowing of the basilar
artery, likely due to a thrombus, and calcifications in the
bilateral vertebral arteries, suggestive of atherosclerosis. His
LDL was elevated to 133 -- much higher than our goal LDL in
stroke patients of <70. His TSH and HbA1c were both within
normal limits.
He was started on daily aspirin (reported to only be taking
aspirin periodically at home) as well as clopidogrel (75 mg
daily x3 months) and atorvastatin (80 mg nightly).
His symptoms remained stable-to-minimally improved during his
admission. He continues to struggle with left proximal UE
weakness and distal ___ weakness. Additionally, he has noticeable
dysmetria on the left that is out of proportion to his weakness.
He also has an unsteady gait and ataxic speech.
He will be discharged to an acute rehab facility. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pre-stroke mRS ___ social history for description): 4
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not administered: outside of window,
microhemorrhages on prior MRI
Endovascular intervention:
[]Yes - Time:
[x]No - Reason EVT was not performed: outside of window, no
large
vessel occlusion on imaging, subtle new deficits
I was present during CT scanning and reviewed the images within
20 minutes of their completion.
___ Stroke Scale - Total []
1a. Level of Consciousness - 0
1b. LOC Questions - 1
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 1
5a. Motor arm, left - 1
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 1
11. Extinction and Neglect - 0
NIHSS was performed within 6 hours of patient presentation or
neurology consult at 19:10.
HPI:
Mr. ___ is a ___ right-handed man with history
notable for remote brainstem tumor s/p radiation and VPS
placement (aged ___ s/p VPS revision, meningioma s/p resection,
HLD, and recent admission (___) for a new left pontine
ischemic infarct presenting from ___ with new-onset left arm weakness.
Mr. ___ wife reports that he was making good progress at
___ over the past week, gradually becoming more ambulatory
and less dysarthric, with his wife able to understand "up to
80%"
of his speech. He was last seen at this level of function on ___
at 18:30, prior to his wife retiring home for the evening.
Today,
while checking in on him after work at approximately 16:30, she
noticed that his dysarthria had returned to his recent
post-discharge level, and that he was not using his left arm
while eating his meal. She brought this finding to the attention
___ staff, where the physiatrist also noted that he had
been using his left arm appropriately earlier that morning. Mr.
___ was accordingly transferred to ___ for further
evaluation.
Mr. ___ himself was unable to articulate his new deficits on
our assessment, but when prompted to use his left arm, he did
initially note that "it feels weak." On further questioning, he
felt that the symptoms likely started this afternoon, but was
unsure of their exact timing or rate of onset. He denies
associated headache, paresthesiae, additional areas of focal
weakness, or worsening speech disturbance. He also denies left
arm or shoulder pain or recent mechanical injury.
ROS: On review of systems, aside from the above, Mr. ___
also
reports loose stools over the past few days. He otherwise denies
vision change, dysphagia, nausea, vertigo, hearing change,
sensory disturbance, bowel or bladder incontinence, fevers,
chills, cough, chest pain, abdominal pain, or dysuria.
Past Medical History:
- Remote brainstem tumor s/p radiation and VPS placement (aged
___
- VPS revision (aged ___
- Meningioma s/p resection
- HLD
- Left pontine ischemic infarct
- Left eye strabismus s/p repair
Social History:
___
Family History:
Noncontributory family history to current illness.
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 98.1 HR: 83 BP: 126/87 RR: 16 SpO2: 96% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, ND
Extremities: warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to month and place, able
to name ___ backward without difficulty. Prominent guttural
dysarthria, though with otherwise fluent speech with intact
naming and repetition. No evidence of hemineglect. Able to
follow
both midline and appendicular commands.
- Cranial Nerves: PERRL (3 to 2 mm ___. Baseline right
exotropia.
VF full to confrontation. EOMI, no nystagmus. V1-V3 without
deficits to light touch bilaterally. L NLFF. Hearing intact to
conversation. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Pronator drift of LUE, with overall slowed finger taps
and general movement in LUE.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 4+ 4+ 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 2+
R 2+ 2+ 2+ 3+ 2+
Crossed adductors present bilaterally, no pectoralis jerk.
- Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
- Coordination: No dysmetria out of proportion to apparent
weakness with finger-to-nose testing bilaterally.
- Gait: Deferred.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
DISCHARGE PHYSICAL EXAM:
Neurologic Examination:
- Mental status: Awake, alert, person and place. Decreased
verbal output. Prominent guttural dysarthria (improving) and
hypophonia, though with otherwise fluent speech with intact
naming and repetition. No evidence of hemineglect. Able to
follow both midline and appendicular commands.
- Cranial Nerves: PERRL (5 to 3 mm ___. Baseline right
exotropia.
VF full to confrontation. EOMI does not fully ___ left eye on
abduction, no nystagmus. V1-V3 without deficits to light touch
bilaterally. L NLFF. Hearing intact to conversation. Palate
elevation symmetric. Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Pronator drift of LUE, with overall slowed finger taps
and general movement in LUE.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 3 3 5 5 5 3 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 4- 3 3 3+ 2+
R 3 3 3 3+ 2+
Crossed adductors present bilaterally, +suprapatellar, no
pectoralis jerk. Upgoing toes bilaterally
- Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
- Coordination: No dysmetria out of proportion to apparent
weakness with finger-to-nose testing bilaterally.
- Gait: Deferred
Pertinent Results:
Labs:
___ 04:15AM BLOOD WBC-7.1 RBC-4.60 Hgb-13.6* Hct-40.2
MCV-87 MCH-29.6 MCHC-33.8 RDW-12.5 RDWSD-39.8 Plt ___
___ 04:15AM BLOOD ___ PTT-41.4* ___
___ 04:15AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-147
K-4.2 Cl-106 HCO3-25 AnGap-16
___ 07:08PM BLOOD ALT-58* AST-20 CK(CPK)-47 AlkPhos-122
TotBili-0.4
___ 04:15AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9
___ 07:08PM BLOOD %HbA1c-5.3 eAG-105
___ 07:08PM BLOOD TSH-1.0
___ 07:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING:
___ 7:08 ___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC &
RECONS (PRELIMINARY)
CT HEAD WITHOUT CONTRAST: There is no evidence of acute large
territorial infarct or hemorrhage. A linear hyperdensity seen in
the left temporal lobe is unchanged compared to prior exams.
There are chronic bilateral basal ganglia, and brainstem
infarcts. A right parietal approach VP shunt is seen
the terminating in the region of the septum pellucidum.
Ventriculomegaly is stable from prior exam. Subcortical and
periventricular white matter hypodensities are nonspecific, but
are likely the sequela of chronic small vessel ischemic disease.
CTA HEAD AND NECK: THE left vertebral artery is hypoplastic.
Bilateral carotid arteries AND the right vertebral arteries are
patent without evidence of stenosis or occlusion. There is a
stable 3 mm broad-based outpouching of the left cavernous ICA
(3;
258). There is narrowing of bilateral P2 segments, similar to
prior. Otherwise, the vessels of the circle of ___ and their
primary intracranial branches are patent without evidence of
stenosis or occlusion.
MRI BRAIN:
1. Within this limitation, there is a punctate focus of slow
diffusion in the pons at the level of the middle cerebellar
peduncle consistent with an acute infarct (4:8). No additional
foci of slow diffusion to suggest additional sites of acute
infarcts are seen.
2. No acute hemorrhage is identified, however on GRE images,
there are
multifocal areas of blooming artifact that suggest likely
chronic
microhemorrhage. This finding is similar to ___.
3. Right posterior ventriculostomy catheter is in unchanged
position near the foramina of ___. Ventricular size is stable.
4. Flow-void in the ophthalmic portion of the left internal
carotid artery
appears enlarged in comparison with the study of 2 days prior.
This could be related to artifact versus increasing aneurysm
size.
5. Re-demonstrated multifocal T2/FLAIR hyperintensities, likely
related to
remote infarcts and chronic small vessel ischemic disease.
Final dictation to follow.
MRI C-SPINE:
IMPRESSION:
1. Degenerative changes in the lower cervical spine at C5-6 and
C6-7, cause moderate to severe left C5-6 neural foraminal
narrowing.
2. Degenerative changes also cause milder neural foraminal
narrowing on the right at C5-6 (mild) and bilaterally at C6-7
(mild-to-moderate), as well as mild C5-6 and C6-7 spinal canal
narrowing without spinal cord encroachment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM hyperlipidemia
2. QUEtiapine Fumarate 12.5 mg PO QHS:PRN sleep
3. Gemfibrozil 600 mg PO BID
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FLUoxetine 20 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Atorvastatin 20 mg PO QPM hyperlipidemia
5. Clopidogrel 75 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Gemfibrozil 600 mg PO BID
8. QUEtiapine Fumarate 12.5 mg PO QHS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Pontine Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with new llef sided weakness// eval for LVO
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.7 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,330.9 mGy-cm.
Total DLP (Head) = 2,166 mGy-cm.
COMPARISON:
1. MRI MRA brain and neck ___.
2. CTA head and neck ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST: Hypodensity in the midline pons is unchanged, likely
reflecting chronic infarct (2:9). Additionally, hypodensities in the
bilateral basal ganglia and right corona radiata (for example 02:17) are
stable and likely reflect chronic infarcts.
There is a right posterior approach ventriculostomy catheter with tip in the
region of the foramen of ___, unchanged. The ventricles are stable caliber
and configuration compared with prior exam of ___. There is a cavum
septum pellucidum, a normal anatomic variant. Linear hyperdensity in the left
frontal lobe in the region of the sylvian fissure is stable from ___
(02:16). There is no evidence of hemorrhage, infarction, mass effect, or
edema. Global involutional changes are noted, unchanged from prior studies.
Subcortical and periventricular white matter hypodensities are nonspecific,
but are likely the sequela of chronic small vessel ischemic disease.
No fractures are identified. The visualized paranasal sinuses, mastoid air
cells, middle ear cavities are well pneumatized and clear. Globes are
unremarkable.
CTA HEAD:
There is a right dominant vertebral artery, unchanged. There is likely severe
left and moderate right P 2 segment of the PCA luminal narrowing, stable from
prior (3:272 and 3: 266). There is an unchanged 3-4 mm medial outpouching
arising from the cavernous/clinoid left ICA (3:258). Otherwise, the remainder
of the vessels of the circle of ___ and their principal intracranial
branches appear normal without stenosis, occlusion, or aneurysm formation.
The dural venous sinuses are not well evaluated on this exam.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is a diminutive left vertebral
artery, unchanged, likely congenital. There is no evidence of internal
carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Stable CTA head and neck examination demonstrating an unchanged 3-4 mm
medial outpouching from the cavernous/clinoid left ICA, and bilateral moderate
right and severe left P2 segment PCA luminal narrowing, as above. No ICA
stenosis by NASCET criteria.
2. No acute intracranial process identified by CT.
3. Stable ventriculomegaly and configuration of right posterior approach
ventriculostomy catheter.
4. Unchanged brainstem and bilateral basal ganglia/white matter chronic
infarcts.
Radiology Report
INDICATION: ___ year old man with VP shunt, AMS// ? VP shunt function and
position
TECHNIQUE: Shunt series consisting of AP and lateral views of the skull and
neck, AP view of the chest, and AP view of the abdomen
COMPARISON: Shunt series ___
FINDINGS:
Re-demonstrated is a right posterior parietal approach shunt catheter with
tubing coursing along the right neck, right anterior chest, into the right
upper abdomen with the tubing abruptly crossing midline at about the L1
vertebral body, with distal aspect terminating in the left lower quadrant. As
noted previously, a kink at the level where the catheter courses to the left
abdomen cannot be excluded on this single view. Shunt catheter tubing is
intact throughout with the course appearing similar to the previous
radiograph. Abandoned shunt catheter segment is also seen within the right
anterior chest wall.
Skull appears intact. Paranasal sinuses are grossly clear.
Cardiac, mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is not engorged. Minimal atelectasis is seen in the lung bases.
No pleural effusion or pneumothorax.
Bowel gas pattern is nonobstructive. Radiopaque density in the right upper
quadrant may reflect contrast retained within a diverticulum. No acute
osseous abnormalities detected.
IMPRESSION:
1. Right-sided VP shunt catheter appears intact, with a similar course as
before, with possible kinking of the catheter at the level of the L1 vertebral
body as it courses across the midline.
2. Abandoned shunt catheter segment again noted in the right anterior chest
wall.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with cough, AMS// ? pna
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Apart from minimal atelectasis in the lung
bases, lungs are clear. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities. Right-sided VP shunt catheter courses
along the right anterior chest wall. An abandoned shunt catheter segment is
also seen within the right anterior chest wall.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old man with AMS// ? stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck ___. Prior MRI of the brain dated ___.
FINDINGS:
Study is motion degraded on several sequences, somewhat limiting assessment.
New from MRI of ___, there is a small focus of restricted diffusion
(4 and 3:8) in the right pons consistent with acute infarct. Again seen are
numerous bilateral foci of susceptibility artifact, both supra- and
infratentorial and within the brainstem, consistent with foci of
microhemorrhage. This appearance is unchanged. Again seen is a right
posterior approach ventriculostomy catheter with tip seen in the region of the
foramen ___. Artifact in the right proximal regions on limits assessment of
this area. There is stable ventriculomegaly. Stable prominence of the sulci
is consistent with global involutional changes. Scattered bilateral
periventricular and deep white matter foci of T2/FLAIR signal hyperintensity
are nonspecific but compatible with moderate changes of chronic white matter
microangiopathy. Previously described tectal lesion is not well seen on this
study, although extensive blooming artifact is seen in the region of the right
tectum (11:11), as on prior study, possibly representing the previously
treated lesion.
The globes are intact. Major intracranial vascular flow voids are preserved.
17 mm signal void described in the preliminary interpretation of this report
in the region of the ophthalmic segment of the left ICA likely represents
signal void due to air in the sphenoid sinus rather than a flow void. Known
mild outpouching of the left intracranial ICA is not well evaluated on this
study. There is a cavum septum pellucidum, a normal anatomic variant.
IMPRESSION:
1. New small acute right pontine infarct.
2. Otherwise, no significant change since MRI of ___.
Redemonstration of numerous foci of brainstem, cerebellar, and cerebral
microhemorrhage, ventriculomegaly, stable right posterior approach
ventriculostomy catheter, moderate white matter microangiopathic changes, and
global involutional changes.
3. Note, 17 mm signal void in the region of the left ophthalmic segment of the
ICA described in the preliminary report likely represents air-related signal
void from the sphenoid sinus rather than flow void.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:55 am, 75 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with recent pontine infarct p/w new LUE
weakness// Evaluate for C5-C6 radiculopathy Evaluate for C5-C6
radiculopathy
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON:
1. CT head and neck ___.
2. CTA head and neck ___.
FINDINGS:
The imaged cervical vertebral bodies demonstrate normal alignment and
preserved height. There is no concerning focal marrow signal abnormality.
Slight height and signal loss of the cervical intervertebral discs, most
conspicuous at C5-6 and C6-7, is consistent with degenerative changes. There
is no epidural collection. The imaged cervical and upper thoracic spinal cord
is normal in caliber and signal intensity. There are T2/STIR signal
abnormalities within the brainstem centered in the pons, better evaluated on
same-day head MRI. There are mild multilevel, multifactorial cervical
degenerative changes, most pronounced at C5-6 and C6-7. Specifically:
At C5-6, there is a posterior disc bulge which, in conjunction with bilateral
osteophytes, uncovertebral hypertrophy, projecting posteriorly, cause mild
spinal canal narrowing without contact with the spinal cord or cord signal
abnormality. Uncovertebral osteophytes and facet arthropathy cause moderate
to severe left and mild right neural foraminal narrowing (06:22).
At C6-7, a similar posterior disc bulge and posterior intervertebral
osteophytes cause mild canal narrowing without contact of the spinal cord.
Uncovertebral osteophytes and facet arthropathy cause mild-to-moderate
bilateral neural foraminal narrowing (06:26).
At C7-T1 level, there is no evidence of neural foraminal narrowing or spinal
canal stenosis.
The visualized paravertebral structures are grossly unremarkable.
IMPRESSION:
1. Degenerative changes in the lower cervical spine at C5-6 and C6-7, cause
moderate to severe left C5-6 neural foraminal narrowing.
2. Degenerative changes also cause milder neural foraminal narrowing on the
right at C5-6 (mild) and bilaterally at C6-7 (mild-to-moderate), as well as
mild C5-6 and C6-7 spinal canal narrowing without spinal cord encroachment.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, L Weakness
Diagnosed with Weakness, Dysarthria and anarthria
temperature: 98.1
heartrate: 83.0
resprate: 16.0
o2sat: 96.0
sbp: 126.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ right-handed man with history
notable for remote brainstem tumor s/p radiation and VPS
placement (aged ___ s/p VPS revision, meningioma s/p resection,
HLD, and recent admission (___) for a new left pontine
ischemic infarct who presented from ___ on ___ with new-onset left arm weakness and worsening
dysarthria. He was found to have a new right pontine stroke.
# Right Pontine Infarct
On presentation, examination notable for apparent left deltoid
and biceps weakness and recent setback in recovery from his
dysarthria. MRI showing new right pontine infarct. Given
localization of recent strokes and otherwise well controlled
risk factors, it is most likely that this could be sequelae to
previous radiation therapy patient received for brainstem tumor.
- ___: 5.3, TSH: 1.0, LDL: 31
- Continue home clopidogrel and add ASA 81 daily, continue
statin
- Start fluoxetine 20mg daily per ___ trial and for depressive
affect. This medication can be discontinued at the discretion of
PCP
# Cardiopulmonary:
CXR w/ no acute changes. Telemetry did not reveal arrhythmia.
Did not repeat ECHO at this time as etiology of stroke most
likely sequelae from previous radiation.
- Continue home statin and fibrate
_
_
_
________________________________________________________________
1. Patient started on Aspirin and Plavix for stroke prevention
as he failed both agents individually.
2. Follow up with stroke neurology ___
3. Patient was started on fluoxetine 20 mg daily for depressive
affect ad per ___ trial. Continuation of this medication at
discretion of PCP.
4. Patient to see PCP ___ ___ weeks post discharge
5. Patient to continue all other home medications
_
_
_
_
_
_
________________________________________________________________
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? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 31) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. 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: (x)
Antiplatelet - () 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: MEDICINE
Allergies:
___ / ___
Attending: ___.
Chief Complaint:
Anxiety, found to have hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with hx. ESRD on HD, epilepsy, right MCA
stroke (___), HTN/HLD, anxiety presenting with c/o
hypoglycemia.
Patient reports that she has been feeling lightheaded and
subjectively unwell for the past week. She also has had
decreased PO intake because she did not have food around that
was compliant with her renal diet. She woke this morning to her
husband trying to wake her up, and being taken to the hospital
in an ambulance, told her blood sugar was low. Reports she has
felt similarly in the past when anemic or shaky at HD, but has
always been told her sugar is fine. Per husband, patient may
have accidentally taken glipizide instead of ASA last night, but
patient insists this is not the case. No seizure was witnessed
per report. She does endorse 20 lb weight loss since ___ in
setting of poor PO, denies fevers/night sweats.
Of note, patient was recently admitted ___ with c/o
increased seizures. Patient was noted to have increased
difficulty taking medications at home. Her phenytoin level was
found to be low so this was increased, oxcarbazapine was
discontinued for hyponatremia and she was started on zonisamide.
Home BP meds were increased for episodes of hypertensive
emergency. Since admission she reports seizure frequency of
2x/week.
In the ED, initial vitals: 96.6 75 135/90 20 100% RA. Labs
were notable for CBC with H/H ___, chem-panel with normal
electrolytes, Bun/Cr 39/6.4, trop 0.04, lactate 2.1, ASA level
4.1, patient had CT head that was negative for acute process.
CXR notable for mild pulmonary edema. Patient had intermittent
episodes of hypoglycemia to the ___ that responded to D50 and
orange juice. Given concern for sulfonylurea toxicity,
toxicology was consulted. Given SBPs to >200 they recommended
holding octreotide at this time. Patient was given nifedipine
60mg PO, losartan 100mg PO, as well as D50.
On arrival to the FICU, patient appears alert, oriented, eating
and feeling well. She received 10 mg hydralazine. Hourly
fingersticks were as low as 61.
REVIEW OF SYSTEMS:
(+) Per HPI, 10 point ROS otherwise negative.
Past Medical History:
# ESRD: on HD MWF, initially developed kidney disease after
pneumococcal sepsis in ___
# h/o Pneumococcal sepsis: pulmonary source in ___, complicated
by ten toe and one finger amputations secondary to necrosis and
CKD
# Right PCA/MCA stroke with left heminaopsia: occurred after
episode of pneumococcal sepsis, unknown etiology, thought
related to hypercoagulable state (neg TEE, MRA carotids, verts;
neg LP)
# Seizure disorder: first event in ___ auras in a month
and ___ seizurs in a month. Often left arm/leg shaking with
generalization.
# Hypertension
# Hyperlipidemia
# Anemia: hct in the high ___
# Anxiety and Depression
Social History:
___
Family History:
# stroke (father-___, paternal grand-father - ___)
# migraine (daughter) # No family history of seizure
# T2DM: Mother, Mother's family members # HTN: Mother's family
members # Kidney failure: Brother with solitary kidney
Physical Exam:
ADMISSION EXAM
Vitals: T: 98.6 BP: 152/62 P: 71 R: 16 O2: 100%
GENERAL: AOx3 although slightly confused, no acute distress
HEENT: Sclerae anicteric, PERRL, MMM
NECK: Supple
LUNGS: CTAB, no wheezes/rales/rhonchi
CV: RRR with I/VI systolic murmur loudest at RUSB
ABD: Soft, nontender, nondistended, normoactive bowel sounds
EXT: WWP, no c/c/e. Fistula in R antecubital fossa with palpable
thrill.
SKIN: No rashes
NEURO: AOx3, moving all extrems equally. L hemianopsia.
DISCHARGE EXAM:
Vitals: T: 99 BP: 177/68 P: 68 R: 18 O2: 100% BG in last 12 h:
162>>169>>234
GENERAL: AOx3, no acute distress, aware of reason for
hospitalization
HEENT: Sclerae anicteric, PERRL, MMM
NECK: Supple
LUNGS: CTAB, no wheezes/rales/rhonchi
CV: RRR with I/VI systolic murmur loudest at RUSB
ABD: Normoactive bowel sounds, Soft, nontender, nondistended,
EXT: No rashes, Fistula in R antecubital fossa with palpable
thrill.
SKIN: No rashes
NEURO: AOx3, moving all extremities equally, no drift,
symmetric face . L hemianopsia.
Pertinent Results:
ADMISSION LABS
___ 07:00AM BLOOD WBC-7.4 RBC-2.90* Hgb-9.5* Hct-29.9*
MCV-103* MCH-32.8* MCHC-31.8* RDW-16.1* RDWSD-61.1* Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-39* Creat-6.4* Na-140
K-4.5 Cl-98 HCO3-26 AnGap-21*
___ 07:00AM BLOOD Albumin-4.1 Calcium-9.6 Phos-4.4 Mg-2.0
___ 07:07AM BLOOD Glucose-81 Lactate-2.1*
___ 03:15AM BLOOD Phenyto-1.1*
DISCHARGE LABS
___ 06:15AM BLOOD WBC-6.1 RBC-2.54* Hgb-8.4* Hct-25.8*
MCV-102* MCH-33.1* MCHC-32.6 RDW-15.8* RDWSD-58.7* Plt ___
___ 06:15AM BLOOD Glucose-134* UreaN-29* Creat-5.2*# Na-137
K-4.0 Cl-95* HCO3-30 AnGap-16
___ 06:15AM BLOOD Calcium-9.8 Phos-4.3 Mg-1.9
___ 07:00AM BLOOD ASA-4.1 Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
REPORTS
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial hemorrhage or infarction.
2. Unchanged right occipital cystic encephalomalacia with ex
vacuo dilatation of the right lateral ventricle occipital horn.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Mild to moderate cardiomegaly with findings suggestive of
worsened pulmonary edema, when compared to the prior radiograph
___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 2 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Labetalol 800 mg PO TID
4. LACOSamide 150 mg PO BID
5. LACOSamide 100 mg PO 3X/WEEK (MO,TH,SA)
6. NIFEdipine CR 60 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Cinacalcet 90 mg PO 2X/WEEK (___)
9. ClonazePAM 0.5 mg PO 3X/WEEK (___)
10. Epoetin Alfa 4000 UNIT SC QMOWEFR
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Rosuvastatin Calcium 5 mg PO QPM
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Citalopram 10 mg PO DAILY
15. Zonisamide 200 mg PO QHS
16. Acetaminophen 650 mg PO Q6H:PRN pain
17. Senna 8.6 mg PO BID:PRN constipation
18. Fleet Enema ___AILY:PRN constipation
19. B complex with C#20-folic acid 1 mg oral DAILY
20. Losartan Potassium 100 mg PO DAILY
21. Phenytoin Sodium Extended 430 mg PO QHS
Discharge Medications:
1. Cinacalcet 90 mg PO 2X/WEEK (___)
2. Citalopram 10 mg PO DAILY
3. ClonazePAM 0.5 mg PO 3X/WEEK (___)
4. FoLIC Acid 2 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Labetalol 800 mg PO TID
7. LACOSamide 100 mg PO 3X/WEEK (MO,TH,SA)
8. Losartan Potassium 100 mg PO DAILY
9. NIFEdipine CR 60 mg PO BID
10. Phenytoin Sodium Extended 430 mg PO QHS
11. Rosuvastatin Calcium 5 mg PO QPM
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Zonisamide 200 mg PO QHS
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Aspirin 81 mg PO DAILY
16. B complex with C#20-folic acid 1 mg oral DAILY
17. Epoetin Alfa 4000 UNIT SC QMOWEFR
18. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoglycemia secondary to Glipizide
ESRD
Hypertension
Epilepsy
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with AMS, hypoglycemia, cough. Evaluate for acute
process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___, and ___.
FINDINGS:
Mild to moderate cardiomegaly is unchanged. Compared with the prior
radiograph, there are increased pulmonary interstitial markings, as well as
cephalization of the vessels and small bilateral pleural effusions. Findings
are compatible with pulmonary edema. No pneumothorax identified.
IMPRESSION:
Mild to moderate cardiomegaly with findings suggestive of worsened pulmonary
edema, when compared to the prior radiograph ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with ams, prior cva. Eval for acute intracranial
hemorrhage or infarction.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.4 cm; CTDIvol = 51.1 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: CT head from ___ and ___.
FINDINGS:
There is no evidence of intracranial infarction, hemorrhage, edema, or mass
effect. Cystic encephalomalacia the right occipital lobe, with ex vacuo
dilatation of the occipital horn of the right lateral ventricle, is unchanged.
The ventricles and sulci are stable in size and configuration. Basal cisterns
are patent.
Diffusely mottled appearance of the calvaria is unchanged and likely related
to renal osteodystrophy as mentioned previously. No fracture identified. The
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial hemorrhage or infarction.
2. Unchanged right occipital cystic encephalomalacia with ex vacuo dilatation
of the right lateral ventricle occipital horn.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with HYPOGLYCEMIA NOS, END STAGE RENAL DISEASE
temperature: 96.6
heartrate: 75.0
resprate: 20.0
o2sat: 100.0
sbp: 135.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | PRIMARY PRESENTATION:
___ year old female with hxistory of ESRD on HD, epilepsy, right
MCA stroke (___), HTN/HLD, anxiety presenting confusion, found
hypoglycemic, likely due to accidental intake of husband's
glipizide, with symptomatic improvement after dextrose and
glucose administration, monitored in ICU overnight, with stable
FSS and no further symptoms. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ female ___ with no
significant PMH or medical care, transferred from OSH
after sustaining a mechanical fall down a flight of stairs
earlier today. Per the patient's son, she missed one stair, lost
her balance and fell backwards, landing on her butt first before
striking the back of her head. The patient is unable to recall
details of the fall, but states that she did not lose
consciousness. She had immediate onset of back pain. The patient
was taken to an OSH where CT scans revealed a small (6mm) R SDH,
T1 body fracture and a minimally displaced left sacral fracture.
She was transferred to ___ for further management and the
orthopaedic surgery service was consulted with regards to the
sacral fracture. On arrival, she endorses back pain, headache,
dizziness and mild nausea. She denies numbness, paresthesias or
weakness of her lower extremities. No incontinence of bowel or
bladder. Of note, the patient has never seen a traditional
doctor
due to her beliefs, but reports general good health. At
baseline,
she lives with her daughter and is able to perform ADLs/IDLs
without difficulties.
Past Medical History:
PMH:
1. Short-term memory loss
2. Kidney stone (passed) ___
3. Decreased vision R eye
PSH:
None
Social History:
___
Family History:
NC
Physical Exam:
Admission:
Vitals: 98.1 71 121/67 18 99% 2L
GEN: NAD, alert, oriented to person and place only
CV: RRR, no M/R/G
PULM: CTAB
ABD: Soft, NTND
Pelvis stable but painful to AP and lateral compression
Diffuse tenderness to palpation over bilateral sacrum
distributions ___ pulses,
Discharge:
Vitals: 98.1 71 121/67 18 99% 2L
GEN: NAD, A&Ox3
CV: RRR, no M/R/G
PULM: CTAB, nonlabored
ABD: Soft, NTND
Ext: moving all extremities bilaterally, intact sensation
Pertinent Results:
___ 06:01AM BLOOD WBC-9.0 RBC-3.84* Hgb-11.5* Hct-36.3
MCV-95 MCH-29.8 MCHC-31.6 RDW-13.3 Plt ___
___ 05:20AM BLOOD Hct-32.4*
___ 06:01AM BLOOD Glucose-178* UreaN-21* Creat-0.5 Na-137
K-3.5 Cl-103 HCO3-24 AnGap-14
___ 05:20AM BLOOD Glucose-137* UreaN-10 Creat-0.5 Na-139
K-3.9 Cl-107 HCO3-25 AnGap-11
___ 05:20AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
CT T-spine:
IMPRESSION:
1. Known fracture of the anterior-inferior corner of T1 again
noted.
2. No other acute fracture or vertebral alignment.
CT L-spine:
IMPRESSION:
No acute fracture or vertebral alignment.
Osteopenia and degenerative changes
CT head ___ 10:41 AM)
IMPRESSION:
1. Limited study due to patient motion. Grossly stable, small
right frontal subdural hematoma, although not well seen due to
patient motion. No increase in hemorrhage identified. Trace
left intraventricular hemorrhage. No evidence of mass effect or
midline shift.
2. Mild thickening of the posterior mid falx, unclear whether
just thickening of the falx or related to a small amount of
subdural hemorrhage
CT head (___)
IMPRESSION:
Previously seen right frontal subdural hematoma not well
visualized on this exam. Hemorrhage in the occipital horn of
left lateral ventricle and along the posterior falx is similar
prior exam.
Medications on Admission:
None
Discharge Medications:
1. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall
Small 6, Right sided frontal subdural hematoma
Minimally displaced Sacral fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Known T1 and sacral fractures.
COMPARISON: Comparison is made with OSH CT C-spine from earlier the same day,
___.
TECHNIQUE: Helical axial MDCT sections were obtained through the thoracic
spine. Reformatted images in sagittal and coronal axes were obtained.
DLP: 1574.82 mGy-cm
CTDIvol: 48.31 mGy
FINDINGS:
The known fracture of the anterior-inferior corner of T1 is again seen. No
other acute fracture or vertebral malalignment is seen. The vertebral body
and disc heights are maintained. Multilevel degenerative changes with
endplate sclerosis and vacuum disc phenomenon are noted throughout the
thoracic spine. CT is not able to provide intrathecal detail comparable to
MRI, but the visualized outline of the thecal sac appears unremarkable. The
visualized lungs are clear. Atherosclerotic calcification is noted in the
aorta. Hypodense nodules are seen in the thyroid bilaterally.
IMPRESSION:
1. Known fracture of the anterior-inferior corner of T1 again noted.
2. No other acute fracture or vertebral alignment.
Radiology Report
HISTORY: Known T1 and sacral fractures.
COMPARISON: Comparison is made with OSH CT C-spine from earlier the same day,
___.
TECHNIQUE: Helical axial MDCT sections were obtained through the lumbar spine.
Reformatted images in sagittal and coronal axes were obtained.
DLP: 790.60 mGy-cm
CTDIvol: 31.82 mGy
FINDINGS:
No acute fracture or vertebral malalignment is seen. The vertebral body and
disc heights are maintained. Multilevel degenerative changes with endplate
sclerosis and vacuum disc phenomenon are noted throughout the lumbar spine.
CT is not able to provide intrathecal detail comparable to MRI, but the
visualized outline of the thecal sac appears unremarkable. The visualized
lungs are clear. Atherosclerotic calcification is noted in the aorta.
IMPRESSION:
No acute fracture or vertebral alignment.
Osteopenia and degenerative changes
Radiology Report
HISTORY: Followup known right frontal subdural hematoma.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
DLP: ___
COMPARISON: Comparison is made to reference CT head dated ___ at
00:26.
FINDINGS:
The examination is severely limited due to patient motion. There is a possible
small right frontal subdural hematoma without increase from the prior study.
It is difficult to well evaluate the subdural due to adjacent artifact and
patient motion. A trace degree of left intraventricular hemorrhage is again
noted in the dependent portion of the left posterior horn. The posterior mid
falx apepars to be mildly thickened which may be due just to thickening, but a
minimal degree of subdural hemorrhage is not excluded. There is no evidence of
mass effect, midline shift, or large territorial infarction.
Prominent ventricles and sulci suggest age-related involutional changes or
atrophy. Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease.The basal cisterns appear patent and
there is preservation of gray-white matter differentiation.
No fracture is identified. Mildly mucosal thickening is seen within the left
maxillary sinus. The remainder of the visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. Atherosclerotic mural
calcification of the vertebral and internal carotid arteries is noted. The
globes are intact.
IMPRESSION:
1. Limited study due to patient motion. Grossly stable, small right frontal
subdural hematoma, although not well seen due to patient motion. No increase
in hemorrhage identified. Trace left intraventricular hemorrhage. No evidence
of mass effect or midline shift.
2. Mild thickening of the posterior mid falx, unclear whether just thickening
of the falx or related to a small amount of subdural hemorrhage.
Radiology Report
HISTORY: Status post fall with documented right subdural now with continued
confusion, anisocoria.
COMPARISON: Comparison is made with CT head from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
DLP: 1114.91 mGy-cm
CTDIvol: 53.02 mGy
FINDINGS:
This exam is somewhat limited due to patient motion. The previously seen
right frontal subdural hematoma not well visualized on this exam. Hemorrhage
is again seen in the occipital horn left lateral ventricle and layering along
the posterior falx, similar to prior exam. No new areas of hemorrhage are
seen. No area of infarction is detected. Prominent ventricles and sulci
suggest age related involutional changes or atrophy. Periventricular white
matter hypodensities are consistent with chronic small vessel ischemic
disease. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. Mucosal thickening is seen in the maxillary sinus.
Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The globes are unremarkable.
IMPRESSION:
Previously seen right frontal subdural hematoma not well visualized on this
exam. Hemorrhage in the occipital horn of left lateral ventricle and along
the posterior falx is similar prior exam.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX SACRUM/COCCYX-CLOSED, OTHER FALL
temperature: 97.7
heartrate: 96.0
resprate: 22.0
o2sat: 98.0
sbp: 153.0
dbp: 82.0
level of pain: 13
level of acuity: 2.0 | Patient was admitted to the Acute Care Surgery service from the
Emergency department. Please refer to the HPI for details of the
initial presentation. Patient's injuries included small a small
(6mm) Right sided frontal subdural hematoma, T1 body fracture
vs a lytic lesion and a minimally displaced left sacral
fracture. Patient had CT scans at the outside hosptial however
given time gap and the presence of known injuries, a CT scans of
the L,T spine and head was repeated at ___. A repeat head CT
showed grossly stable, small right frontal
subdural hematoma with no evidence of change. Neurosurgery was
consulted and given the small size, normal neurologic exam and
patient's stability, she was recommended to take Keppra 500mg PO
BID for 7 days and follow up in ___ clinic only if she
experiences any neurologic symtpoms for over 30 days.
Orthopaedic surgery was consulted for the sacral fracture which
was minimally displaced. She was recommended pain control weight
bearing as tolerated and follow up in orthopaedic trauma clinic
in 2 weeks.
On the night of admission, there were concerns of mild
anisocoria on her serial neurologic exams (R pupil > L pupil).
She underwent a repeat CT scan without any changes and intact
serial neuroexams thereafter. She was re-evaluated by
neurosurgery with the same recommendations. A tertiary survey on
HD2 was nonrevealing. Patient was seen by physical therapy and
occupational therapy and was cleared to be discharged home with
adequate teaching. Patient was discharged home on HD2 with
follow ups for ___ clinic, Orthopaedic trauma clinic regarding
her sacral fracture and with her primary care physician to
workup ___ likely chronic/lytic lesion in her T1 spine. This was
communicated to the patient's daughter and her son as well.
Patient agreed and verbalized adequate understanding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Penicillins
Attending: ___.
Chief Complaint:
Weight gain and hypoxia concerning for right heart failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with PMHx notable for CKD, DM, and PAH who
presents with weight gain, hypoxia, concerning for decompensated
right heart failure. Patient with baseline modestly controlled
PH/RV failure (on sildenafil, macitentan, torsemide), followed
by Dr. ___ for his pulm hypertension. Seen by PCP ___
___, pt noted to have weight gain of >20lbs over past month,
and hypoxic to ___ during visit. Patient weight in high 250s
despite continued compliance of diuretics. Patient reports that
there has been no escalation in his torsemide dose over this
time period (140 mg daily), although per OMR note, there has
been. Patient denies any increased ___ edema, but dose note some
increased abdominal fullness. He denies cp, palpitations,
increased dyspnea, orthopnea or change in urinary frequency. He
uses 2L O2 at home at night, denies any increased O2
requirement. He does report that he has been eating a lot more
over the past few months. Patient was advised to come to ED
after PCP spoke with Dr. ___.
Past Medical History:
- Pulmonary arterial hypertension, presumed idiopathic (IPAH).
Diagnosed during admission ___ (mPAP 63, PVR 11.6, RA 15, CI
1.8). Mild ground glass nodular abnormality on CT raising
question of group 1' disease (PCH>PVOD).
- Chronic renal insufficiency. Notable improvement in creatinine
during admission with treatment of PH/RV failure
- COPD by history
- Strep pneumo pneumonia and bacteremia, admission ___
- Positive ___, 1:320 titer ___, other autoAbs negative
- Hypertension
- DM type II
- Hyperlipidemia
- Gout
- Homelessness at time of initial PAH admission, now
intermittent
- Smoking history: current off/on, ___ PPD, 20 pack years total
Social History:
___
Family History:
Both mother and father died of natural causes. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: 98.3 113/67 81 18 93%2L
Weight not recorded on floor.
249.6 lbs in ED. (weight 242 ___.
I/O 360/450
GENERAL: WDWN, obese man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 11cm.
CARDIAC: RRR. ___ systolic murmur loudest at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles, no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pedal edema. Extremities are warm, well
perfused.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Discharge Physical Exam:
VS: 98.2 102/55 72 18 94%3L
I/O: 8hr: ___ 24 hr: nothing recorded.
Wt: 111.9 <- 112.3
GENERAL: WDWN, obese man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 11cm.
CARDIAC: RRR. ___ systolic murmur loudest at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles, no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pedal edema. Extremities are warm, well
perfused.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Pertinent Results:
___ 07:05PM BLOOD WBC-8.8 RBC-5.30 Hgb-12.0* Hct-40.6
MCV-77* MCH-22.6* MCHC-29.6* RDW-18.9* RDWSD-49.7* Plt ___
___ 03:10PM BLOOD WBC-9.2 RBC-5.04 Hgb-11.4* Hct-39.1*
MCV-78* MCH-22.6* MCHC-29.2* RDW-18.7* RDWSD-49.8* Plt ___
___ 04:43AM BLOOD ___ PTT-27.0 ___
___ 03:10PM BLOOD Glucose-199* UreaN-112* Creat-3.2* Na-135
K-3.9 Cl-91* HCO3-31 AnGap-17
___ 07:05PM BLOOD Glucose-157* UreaN-108* Creat-3.0* Na-135
K-4.6 Cl-93* HCO3-28 AnGap-19
___ 07:05PM BLOOD ALT-13 AST-35 AlkPhos-120 TotBili-0.3
___ 03:10PM BLOOD Calcium-9.3 Phos-5.0* Mg-2.1
___ 04:43AM BLOOD calTIBC-445 Ferritn-9.9* TRF-342
Imaging:
CT Chest ___
FINDINGS:
The imaged thyroid gland appears homogeneous in attenuation
without a focal
lesion identified. Scattered small axillary nodes appear to
been present on
prior examination and are unchanged, not pathologically
enlarged. A small
right supraclavicular node measures 3 mm (2:2), present
previously and
unchanged. Numerous central nodes are again identified which
are either
stable or marginally decreased in size relative to prior
examination. The
largest conglomerate of nodes within the right lower
paratracheal station
measures approximately 2.8 x 1.8 cm, unchanged. A previously 9
mm prevascular
station node currently measures 6 mm in short axis (02:23). A
subcarinal node
previously 10 mm in short axis currently measures 7 mm in short
axis (02:31).
Numerous additional nodes are not significantly changed in size.
Number of
nodes appears unchanged.
Severe enlargement of the right atrium is unchanged. The right
ventricle
appears enlarged relative to the left ventricle, stable. The
ascending aorta
is non aneurysmal. The descending aorta measures up to 34mm,
previously 35mm,
mildly dilated. The main pulmonary artery is dilated measuring
up to 3.8 cm,
unchanged, suggestive of though not diagnostic for pulmonary
hypertension.
Trace pericardial fluid is physiologic. Coronary artery
calcifications are
moderate to severe and most pronounced within the left anterior
true
descending coronary artery. No esophageal abnormality is
identified.
Airways are patent to the subsegmental level. Paraseptal and
centrilobular
emphysema is mild and upper lobe predominant. Bibasilar
atelectasis is
moderate and symmetric. Broad based and dependent nodule along
the posterior
pleural surface within the right lower lobe (4:139) is likely
atelectatic in
etiology. Numerous calcified granulomas bilaterally are
unchanged (4:78, 79,
106, 107, 123, 124, 133, 141, 154, 171, 193). There is no
pleural effusion or
pleural abnormality.
Although study is not tailored for subdiaphragmatic evaluation,
imaged portion
of the upper abdomen is unremarkable.
No lytic or blastic osseous lesion worrisome for malignancy or
infection is
identified.
IMPRESSION:
1. Prominent mediastinal lymph nodes are either stable in size
or marginally
decreased in size relative to prior examination dated ___ and remain
indeterminate.
2. Paraseptal and centrilobular emphysema is mild and upper
lobe predominant.
3. Enlarged main pulmonary artery is consistent with though not
diagnostic
for pulmonary hypertension.
4. Unchanged right atrial enlargement and right ventricular
dilation.
5. Coronary artery calcifications are moderate in extent and
most extensive
within the left anterior descending coronary artery.
6. Numerous and scattered calcified pulmonary nodules most
consistent with
granulomas.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Cyanocobalamin 50 mcg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. macitentan 10 mg oral daily
7. Sildenafil 20 mg PO TID
8. Torsemide 140 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. albuterol sulfate 90 mcg/actuation inhalation Q6H: PRN
wheezing
11. Allopurinol ___ mg PO DAILY
12. Carvedilol 12.5 mg PO BID
13. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
14. Metolazone 5 mg PO 2X/WEEK (___)
15. NexIUM (esomeprazole magnesium) 20 mg oral DAILY
16. GlipiZIDE XL 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 12.5 mg PO BID
6. Cyanocobalamin 50 mcg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. macitentan 10 mg oral daily
9. Sildenafil 20 mg PO TID
10. albuterol sulfate 90 mcg/actuation INHALATION Q6H: PRN
wheezing
11. GlipiZIDE XL 10 mg PO DAILY
12. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
13. Metolazone 5 mg PO 2X/WEEK (___)
14. NexIUM (esomeprazole magnesium) 20 mg oral DAILY
15. Torsemide 140 mg PO DAILY
RX *torsemide [Demadex] 20 mg 7 tablet(s) by mouth daily Disp
#*210 Tablet Refills:*0
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Acute on chronic diastolic heart failure exacerbation
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dyspnea // dyspnea
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Multiple prior chest x-rays dating back to ___ with
most recent from ___.
FINDINGS:
___ severe cardiomegaly is again seen. Hila are enlarged bilaterally
compatible with pulmonary hypertension. Right lung base opacity is likely
atelectasis and when compared to multiple priors is unchanged. There is no
new consolidation or pulmonary edema. No acute osseous abnormalities.
IMPRESSION:
Cardiomegaly and enlarged pulmonary arteries compatible with pulmonary
hypertension without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with PAH, RH failure, with mediastinal lymph
nodes // eval mediastinal lymph nodes
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) = 913 mGy-cm.
COMPARISON: CT chest performed ___.
FINDINGS:
The imaged thyroid gland appears homogeneous in attenuation without a focal
lesion identified. Scattered small axillary nodes appear to been present on
prior examination and are unchanged, not pathologically enlarged. A small
right supraclavicular node measures 3 mm (2:2), present previously and
unchanged. Numerous central nodes are again identified which are either
stable or marginally decreased in size relative to prior examination. The
largest conglomerate of nodes within the right lower paratracheal station
measures approximately 2.8 x 1.8 cm, unchanged. A previously 9 mm prevascular
station node currently measures 6 mm in short axis (02:23). A subcarinal node
previously 10 mm in short axis currently measures 7 mm in short axis (02:31).
Numerous additional nodes are not significantly changed in size. Number of
nodes appears unchanged.
Severe enlargement of the right atrium is unchanged. The right ventricle
appears enlarged relative to the left ventricle, stable. The ascending aorta
is non aneurysmal. The descending aorta measures up to 34mm, previously 35mm,
mildly dilated. The main pulmonary artery is dilated measuring up to 3.8 cm,
unchanged, suggestive of though not diagnostic for pulmonary hypertension.
Trace pericardial fluid is physiologic. Coronary artery calcifications are
moderate to severe and most pronounced within the left anterior true
descending coronary artery. No esophageal abnormality is identified.
Airways are patent to the subsegmental level. Paraseptal and centrilobular
emphysema is mild and upper lobe predominant. Bibasilar atelectasis is
moderate and symmetric. Broad based and dependent nodule along the posterior
pleural surface within the right lower lobe (4:139) is likely atelectatic in
etiology. Numerous calcified granulomas bilaterally are unchanged (4:78, 79,
106, 107, 123, 124, 133, 141, 154, 171, 193). There is no pleural effusion or
pleural abnormality.
Although study is not tailored for subdiaphragmatic evaluation, imaged portion
of the upper abdomen is unremarkable.
No lytic or blastic osseous lesion worrisome for malignancy or infection is
identified.
IMPRESSION:
1. Prominent mediastinal lymph nodes are either stable in size or marginally
decreased in size relative to prior examination dated ___ and remain
indeterminate.
2. Paraseptal and centrilobular emphysema is mild and upper lobe predominant.
3. Enlarged main pulmonary artery is consistent with though not diagnostic
for pulmonary hypertension.
4. Unchanged right atrial enlargement and right ventricular dilation.
5. Coronary artery calcifications are moderate in extent and most extensive
within the left anterior descending coronary artery.
6. Numerous and scattered calcified pulmonary nodules most consistent with
granulomas.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Shortness of breath
temperature: 97.6
heartrate: 88.0
resprate: 24.0
o2sat: 95.0
sbp: 121.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of idiopathic PAH (mPAP to 61), CKD, HTN, and
DMII presents with weight gain c/f decompensated heart failure.
# Acute on chronic diastolic heart failure:
On last ECHO patient had LVEF 75% on ___ and was noted to
have RV dilation with depressed free wall contractility likely
secondary to PAH. Patient on 140mg daily torsemide at home in
addition to twice weekly 5mg metolazone. Though patient reported
20 lb weight gain over past ___ weeks, weight gain documented in
record over past month was only 7 lbs. Gain in past 8 months was
more significant (around 25 lbs) Weighed 228 in ___.
In fact patient seemed only mildly volume overloaded on physical
exam, with no ___ edema on physical exam; no overt pulmonary
edema on xray, no increased O2 requirement from baseline
(patient uses 3L O2 at night at home); BNP elevated (1700s)
however less than prior admissions for heart failur.. Patient
does report increased abdominal fullness, which may represent
fluid retention, but he believes he has gained body fat, not
water. He endorses increased appetite for past few months. We
attempted to diurese him using a lasix drip. Some diuresis
occurred, but was also immediately accompanied by an increase in
Creatine. Since patient was eager to leave we then discharged
him on his home medications, with the plan for him to schedule a
right heart cath with his pulmonologist in 3 days. We continued
him on his CHF regimen, including Carvedilol and losartan.
# Type 1 Pulmonary Arterial Hypertension: Patient with mPAP 61
on RHC on ___, presumed to be idiopathic. Is on sildenafil
and macitentan (endothelin receptor antagonist) at home. Patient
has been on 2L NC at home at night. Denies any increase in home
O2 requirement or worsening shortness of breath. Continued home
macitentan, sildenafil. Follow up with pulmonologist.
# Acute on chronic kidney disease: Cr 3.0 on admission;
baseline unclear - ___, 2.8 ___ be
pre-renal in setting of decreased pre-load from PAH and RV
failure / 3+ TR. Renal function improved during previous
admission with diuresis. However on this admission renal
function decreased with diuresis; we concluded he was not
significantly volume overloaded.
# hypertension:
- continue home carvedilol 12.5 mg BID
- cont losartan
# Type 2 DM: on glipizide at home. HISS while in house
- adjust as needed
# GERD: on nexium at home, non-formulary
- omeprazole while in house
# Gout: Continued on allopurinol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: cyclist hit
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male unhelmeted bicyclist who was struck by a car at
unknown speeds. He had positive loss of consciousness and was
perseverating and confused in the ED. He was complaining of low
back and left knee pain. On initial CT scan he found to have
tiny left pneumothorax with pneumomediastinum, T12 fracture, L1
vertebral body fracture and left fibular fracture. He was
admitted to the trauma ICU for monitoring.
Past Medical History:
hx of IVDU
PSH: None
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admisssion: ___
HR: 75 BP: 150 over palp O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: No obvious head injury/contusion, Pupils equal, round and
reactive to light, Extraocular muscles intact Left-sided neck
crepitus
Chest: Diminished breath sounds on the left side, no
palpable rib fractures
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Nontender, Soft
Extr/Back: No midline back tenderness; minimal movement of left
leg, distally has normal movement of the toes, normal perfusion
Skin: Abrasions over left lower extremity
Neuro: GCS 15, cranial nerves intact, motor and sensation normal
aside from limited by left lower extremity injury
Psych: Normal mentation
Pertinent Results:
___ 12:55AM BLOOD WBC-8.5 RBC-3.78* Hgb-11.7* Hct-36.0*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.1 Plt ___
___ 02:45AM BLOOD WBC-11.7* RBC-3.83* Hgb-11.8* Hct-36.5*
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.2 Plt ___
___ 08:50PM BLOOD WBC-12.2* RBC-4.12* Hgb-12.7* Hct-39.0*
MCV-95 MCH-30.9 MCHC-32.6 RDW-13.0 Plt ___
___ 12:55AM BLOOD Plt ___
___ 12:55AM BLOOD ___ PTT-36.7* ___
___ 12:55AM BLOOD Glucose-104* UreaN-15 Creat-0.9 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
___ 12:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
___ 08:59PM BLOOD Glucose-108* Lactate-1.5 Na-141 K-3.6
Cl-103 calHCO3-25
___ 08:59PM BLOOD freeCa-1.10*
___: Chest x-ray:
Pneumomediastinum as seen on CT. Known small pneumothoraces not
well seen.
___: Cat scan of the head:
No intracranial hemorrhage and no fracture.
___: Cat scan of abdomen and pelvis:
IMPRESSION:
1. Vertebral fractures involving T12 and L1 with compromise of
anterior,
middle, and posterior columns, representing an unstable fracture
for which MRI is recommended to further assess.
2. Extensive pneumomediastinum likely reflect small airways
injury.
3. Small bilateral pneumothoraces which could reflect bleb
rupture given the presence of underlying emphysema. Small
hematocele along the left anterior lung without significant
contusion.
4. Left posterior twelfth rib fracture.
___: Cat scan of the c-spine:
No fracture or malalignment within the cervical spine.
Extensive
subcutaneous emphysema and gas within the deep fascial planes of
the neck, tracking up from the mediastinum. Please refer to CT
torso report for further details.
___: X-ray of the left femur:
Left distal fibular shaft fracture.
___: X-ray of the left shoulder:
Three views of the left shoulder demonstrate no fracture or
dislocation. The glenohumeral alignment appears maintained on
the axillary view. The imaged left upper ribs are intact.
___: Chest x-ray:
As compared to the CT torso and chest radiograph obtained at
9:00 p.m. on
___, current study is redemonstrated subcutaneous
air in the
neck, pneumomediastinum and small amount of left pneumothorax.
Overall, the findings appear to be minimally increased as
compared to the most recent examination
___: Cat scan of the chest:
IMPRESSION:
1. Increased left pneumothorax with minimal rightward
mediastinal shift.
2. Possible perforation of the anterior wall of the proximal
left mainstem bronchus. Linear air density emanating from this
area of irregularity, which has persisted since the prior study,
raises the possibility of active air leak at this site.
3. Pneumopercardium and extrapleural air with new mild mass
effect on the
right ventricle.
4. T12 and L1 vertebral fractures, as seen previously.
___: Left tibula/fibula X-ray:
Fracture of the distal fibular shaft.
___: MRI of lumbar spine:
Known T12 lamina fractures and L1 compression fracture with
minimal loss of vertebral body height and no retropulsion. No
evidence of epidural hematoma or other cause of spinal canal
compromise.
___: Chest x-ray:
Unchanged moderate left pneumothorax, pneumomediastinum, and
extensive
subcutaneous emphysema
___: X-ray of the Lumbar spine:
Fractured T12 facet without significant fracture displacement.
___: X-ray of the T spine:
T12 and L1 vertebral fracture are grossly stable.
Medications on Admission:
None
Discharge Medications:
1. CloniDINE 0.1 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
5. Senna 1 TAB PO BID
6. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: Cyclist hit by car
Left fibular fracture
T12/L1 unstable fracture
pneumomediastinum, bilat pneumothorax
Left ___ posterior rib 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
TRAUMA CHEST AND PELVIS RADIOGRAPH PERFORMED ON ___
COMPARISON: Same day CT of the torso.
CLINICAL HISTORY: Bicycle struck by car, assess traumatic injury.
FINDINGS: Supine portable chest and pelvis radiograph provided. Linear
lucencies along the mediastinum are compatible with known pneumomediastinum
better assessed on the same day CT of the torso. The lungs remain well
aerated. The cardiomediastinal silhouette is maintained. The left 12th rib
fracture cannot be visualized on this chest radiograph. The small bilateral
pneumothoraces are better assessed on the same day CT. The bony pelvic ring
appears intact with acetabular spurring noted bilaterally.
IMPRESSION: Pneumomediastinum as seen on CT. Known small pneumothoraces not
well seen.
Radiology Report
NON-CONTRAST HEAD CT PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Bicycle struck by car, assess for hemorrhage.
TECHNIQUE: Multidetector CT through the head without contrast with
multiplanar reformations provided.
FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of
normally midline structures, or evidence of acute major vascular territorial
infarction. Minimal mucosal thickening within the paranasal sinuses noted.
There is normal aeration of the mastoid air cells and middle ear cavities.
There is no skull fracture. Mild scalp hematoma along the left posterior
scalp region.
IMPRESSION: No intracranial hemorrhage and no fracture.
Radiology Report
CT OF THE CERVICAL SPINE PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Bicyclist struck by car, assess fracture, malalignment of
C-spine.
TECHNIQUE: Multidetector CT to the cervical spine was performed without
contrast with multiplanar reformations provided.
FINDINGS: There is extensive subcutaneous emphysema involving the superficial
and deep fascial planes of the neck bilaterally, tracking up from the
mediastinum. Please refer to the concurrently performed CT of the torso for
additional details. No sinus upper airway injury. There is no acute fracture
or malalignment within the cervical spine. There is a small disc osteophyte
complex at C5-6 and C6-7 minimally indenting the anterior thecal sac.
Otherwise, the outline of the thecal sac is unremarkable in this non-contrast
exam. Air in the retropharyngeal space tracks upward to the skull base.
There is no prevertebral soft tissue hematoma. The thyroid gland is normal.
Paraseptal blebs at the lung apices are noted.
IMPRESSION: No fracture or malalignment within the cervical spine. Extensive
subcutaneous emphysema and gas within the deep fascial planes of the neck,
tracking up from the mediastinum. Please refer to CT torso report for further
details.
Radiology Report
CT OF THE CHEST, ABDOMEN, AND PELVIS PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Bicyclist struck by car, assess traumatic injury.
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was
performed following IV contrast administration with multiplanar reformations
provided.
CHEST: There is extensive pneumomediastinum which tracks superiorly into the
neck. Findings suggest an airway injury likely at the level of smaller
branches, though the site of injury cannot be clearly defined. There is no
mediastinal hematoma. The aorta is intact. Central pulmonary arteries appear
intact. The heart is normal in size and shape. No pleural or pericardial
effusion is seen. There are small bilateral pneumothoraces with signs of
tension. A tiny bleb in the left anterior lung on series 2, image 44,
contains a small fluid level, likely a small hematocele. No hemothorax or
large contusion. There is minimal ground-glass opacity in the left lower lobe
which could represent a small amount of contusion, best seen on series 2,
image 43.
ABDOMEN: The liver enhances normally without focal lesion or signs of injury.
The gallbladder and spleen are intact. Adrenal glands and pancreas appear
normal. The kidneys enhance symmetrically without signs of injury. The aorta
is normal in course and caliber with minimal atherosclerosis noted.
The stomach and duodenum appear normal.
PELVIS: Loops of small and large bowel demonstrate no signs of injury. No
free fluid is seen. No free air is seen. Urinary bladder is only partially
distended appearing unremarkable. There is moderate fecal load within the
large bowel.
BONES: Fractures involving the T12 and L1 vertebral body are seen. At T12,
the transverse fracture lucency traverses the right and left lamina and the
spinous process with only minimal distraction of the fracture fragments. The
T12 vertebral body appears intact. At L1 level, there is a compression
deformity of the vertebral body with minimal loss of vertebral body height.
Posterior extension of this fracture is likely reflected within the T12
vertebral body. These findings represent an unstable injury given the
compromise of anterior, middle, and posterior columns reversing T12 and L1,
likely with a hyperflexion distraction. No definite paraspinal hematoma is
seen. Left twelfth posterior rib fracture.
IMPRESSION:
1. Vertebral fractures involving T12 and L1 with compromise of anterior,
middle, and posterior columns, representing an unstable fracture for which MRI
is recommended to further assess.
2. Extensive pneumomediastinum likely reflect small airways injury.
3. Small bilateral pneumothoraces which could reflect bleb rupture given the
presence of underlying emphysema. Small hematocele along the left anterior
lung without significant contusion.
4. Left posterior twelfth rib fracture.
The findings were discussed with Dr. ___ at the time of initial
review.
Radiology Report
PELVIS, LEFT FEMUR, LEFT TIBIA AND FIBULAR RADIOGRAPH
CLINICAL HISTORY: Traumatic injury with bicyclist struck by car with left leg
pain.
FINDINGS: A total of nine images of the left leg and pelvis were provided.
There is an acute fracture through the distal shaft of the left fibula with
minimal posterior and medial displacement of the distal fracture fragment.
The left ankle appears intact. There is mild osteoarthritis at the left knee.
No joint effusion at the left knee. The bony pelvic ring and bilateral hips
align normally with degenerative spurring noted at the acetabulae. Excreted
contrast is noted within the urinary bladder.
IMPRESSION: Left distal fibular shaft fracture.
Radiology Report
LEFT SHOULDER RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Bicyclist struck by car, assess fracture with left shoulder
pain.
FINDINGS: Three views of the left shoulder demonstrate no fracture or
dislocation. The glenohumeral alignment appears maintained on the axillary
view. The imaged left upper ribs are intact.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pneumothorax and
pneumomediastinum after trauma.
AP chest radiograph
As compared to the CT torso and chest radiograph obtained at 9:00 p.m. on
___, current study is redemonstrated subcutaneous air in the
neck, pneumomediastinum and small amount of left pneumothorax. Overall, the
findings appear to be minimally increased as compared to the most recent
examination.
Radiology Report
REASON FOR EXAMINATION: Followup of the patient with pneumothorax.
Portable AP radiograph of the chest was reviewed in comparison to ___ obtained at 0018.
Since the prior study, there is interval increase in mediastinal air
consistent with pneumomediastinum and subcutaneous air. There is also a small
amount of pneumothorax projecting laterally and inferiorly over the left
hemithorax. Of note, is the vast majority of air seen on the CT torso is
extrapleural thus consistent with extrapleural air collection and not
pneumothorax per se .
Radiology Report
HISTORY: ___ male with posttraumatic pneumothorax, pneumomediastinum,
and pneumopericardium.
TECHNIQUE: Axial CT images through the chest were acquired without
intravenous contrast. Coronal, sagittal, thin slice, and axial maximum
intensity projection reformatted images were created and reviewed.
COMPARISON: ___ at approximately 9 cm.
FINDINGS:
Irregularity of the anterior wall of the proximal left mainstem bronchus is
seen. Linear air density emanating from this area of irregularity has
persisted since the prior study.
Extensive pneumomediastinum, pneumopericardium, right pneumothorax,
extrapleural air, and subcutaneous emphysema appear similar in severity and
distribution compared to 14 hours prior. Extrapleural air dissects anteriorly
below the diaphragm. Left pneumothorax has increased in size compared to
prior. Mild anterior indentation on the right ventricle suggests an element
of tension; the superior vena cava appears normal in caliber. There is minimal
rightward mediastinal shift. Bilateral apical predominant paraseptal
emphysema is seen. Bilateral minimal dependent atelectasis is seen.
The thyroid is homogeneous in attenuation. No lymphadenopathy is detected in
the chest. No pleural or pericardial effusion is seen.
The study is not optimized for evaluation of subdiaphragmatic structures, but
within this limitation, no acute abnormalities are detected. Residual
contrast within the renal collecting systems bilaterally and vicarious
excretion of contrast into the gallbladder are seen. A 1 cm hypodense lesion
at the dome of the liver with coarse calcifications is incompletely evaluated
on this study but likely benign.
Compression fracture of the L1 vertebral body without retropulsion and
fracture through the posterior elements of T12 appear similar compared to
prior. A fracture through the posterior left 12th rib is again seen.
IMPRESSION:
1. Increased left pneumothorax with minimal rightward mediastinal shift.
2. Possible perforation of the anterior wall of the proximal left mainstem
bronchus. Linear air density emanating from this area of irregularity, which
has persisted since the prior study, raises the possibility of active air leak
at this site.
3. Pneumopercardium and extrapleural air with new mild mass effect on the
right ventricle.
4. T12 and L1 vertebral fractures, as seen previously.
Findings were discussed with Dr. ___ by ___ by telephone at 2:34
p.m. on ___ at time of attending radiologist review.
Per Dr. ___ dose chest CT is being used to follow the left
pneumothorax, since the patient is unable to position for chest radiographs
due to vertebral fractures. Prior to protocoling, it may be helpful to
discuss further CT examinations directly with the thoracic radiologist to
ensure low dose technique. This recommendation was discussed with ___
___ by ___ by phone at 2:54 p.m. on ___.
Radiology Report
STUDY: Left tib-fib and ankle, ___.
CLINICAL HISTORY: ___ male with left tib-fib fracture.
FINDINGS: There is a cast which limits fine bony detail. There is a fracture
involving the distal shaft of the left fibula. There are degenerative changes
of the left knee with narrowing medially and laterally and prominent
subchondral cystic changes and spurring, medial greater than lateral.
Well-corticated density at the proximal fibular head is also seen and may be
degenerative or sequela of prior old trauma.
IMPRESSION:
Fracture of the distal fibular shaft.
Radiology Report
HISTORY: ___ male with pneumothorax.
COMPARISON: Multiple prior chest radiographs, most recently of ___.
FINDINGS:
Single frontal view of the chest was obtained. Moderate-sized left
pneumothorax is unchanged. Pneumomediastinum and emphysema involving nearly
all the extrapleural planes are stable. No focal consolidation or pleural
effusion. Heart size is normal and cardiomediastinal contours are unchanged.
No radiopaque foreign body.
IMPRESSION:
Unchanged moderate left pneumothorax, pneumomediastinum, and extensive
subcutaneous emphysema.
Radiology Report
HISTORY: ___ man status post bicycle accident with spinal fractures,
fibular fracture, and pneumothorax. Please evaluate T12 and L1 vertebral
fractures.
COMPARISON: CT thorax, ___.
TECHNIQUE: Sagittal T1, T2, and STIR images as well as axial T2 weighted
images were acquired through the lumbar spine without intravenous contrast.
FINDINGS:
A cleft of STIR hyperintensity is seen traversing the bilateral T12 pedicles
and lamina, corresponding to the known posterior element fracture. There is a
compression fracture of the anterior and posterior L1 vertebral body with bone
marrow STIR-hyperintensity, with the hyperintense signal extending into the
pedicles, bilaterally. There is minimal vertebral body height loss and no
retropulsion. There is no epidural hematoma. Spinal alignment is preserved.
No other fracture is identified.
The intervertebral discs are normal in height and signal intensity. The
visualized distal spinal cord and the conus medullaris are normal in
appearance, with the conus terminating at the level of the L1-2 disc.
At L3-L4, there is a diffuse disc bulge, ligamentum flavum thickening, facet
degenerative change without significant spinal canal or neural foraminal
narrowing.
At L4-L5, there is a mild diffuse disc bulge, ligamentum flavum thickening,
and facet degenerative change, slightly narrowing of the subarticular zones
and neural foramina, with no significant spinal canal narrowing.
At L5-S1, there are facet degenerative changes without significant spinal
canal or neural foraminal narrowing.
IMPRESSION:
Known T12 lamina fractures and L1 compression fracture with minimal loss of
vertebral body height and no retropulsion. No evidence of epidural hematoma
or other cause of spinal canal compromise.
Radiology Report
HISTORY: Trauma to torso with multiple bony fractures, including T12 facet
fracture, and L1 compression fractures. Evaluation of the T12 facet fracture,
status post external brace placement.
COMPARISON: CT from ___.
FINDINGS:
AP and lateral views of the thoracic and lumbar spine shows nondisplaced
fracture lucency involving T12 lamina. No further decrease in height of L1
compression fracture. Degenerative changes involving the thoracic and lumbar
spine are noted (mild to moderate). Moderate degenerative disease involving
the weightbearing aspects of both hips are also noted. Pneumomediastinum,
subcutaneous emphysema and small left pneumothorax are still visualized.
IMPRESSION:
T12 and L1 vertebral fracture are grossly stable.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: BIKE VS CAR
Diagnosed with FX SHAFT FIBULA-CLOSED, FX DORSAL VERTEBRA-CLOSE, FX LUMBAR VERTEBRA-CLOSE, FRACTURE ONE RIB-CLOSED, TRAUM SUBCUTAN EMPHYSEMA, TRAUM PNEUMOTHORAX-CLOSE, MV-OTH VEH COLL-PED CYCL, PED CYCL ACC-PED CYCLIST
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to the hospital after being struck by a
car while he was riding his cycle. As a result of the accident,
he sustained loss of consciousness. Upon admission to the
hospital, he was made NPO, given intravenous fluids and
underwent imaging of his head, neck, spine. He was reported to
have a left posterior rib fracture, T12-L1 fracture, and a left
fibular fracture. In addition to this, he was reported to have a
pneumo-mediastinum reflective of small airway injury. His
respiratory status was closely monitored and he did not require
a chest tube. Because of the extent of his injuries, the patient
was admitted to the trauma intensive care unit for monitoring.
The Neurosurgery service was consulted for his spine injury
which was reported to be neurologically intact with an unstable
T12-L1 fracture. An MRI was ordered which showed known T12
lamina fractures and L1 compression fracture with minimal loss
of vertebral body height and no retropulsion. There was no
evidence of epidural hematoma or other cause of spinal canal
compromise. The patient was placed on log-roll precautions and a
TLSO brace was ordered. During the initial assessment, he was
reported to have a left distal fibular fracture which was
splinted. The orthopedic service was consulted and recommended
an air cast boot after the patient progressed to ambulation.
Serial chest xrays were obtained due to his pneumomediastinum
and these remained stable. A repeat chest CT on HD #2 was
stable. The patient was transferred to the surgical floor on HD
#3.
Upon admission to the surgical floor, the patient was reporting
lower back pain despite the medical regimen. The Chronic Pain
service was consulted and revised his analgesics including
medication for break-through pain. This provided minimal
relief. The patient was tolerating a regular diet and voiding
without difficulty. Physical therapy evaluated the patient after
the TLSO brace arrived and upon examination determined that the
patient was a candidate for discharge home with family support.
The social worker also met with the patient about his substance
abuse and he declined information on Narcotics Anonymous.
The patient was discharged home on HD # 7 with stable vital
signs. Follow-up appointments were made with the acute care
service, neurosurgery, orthopedics, and with his primary care
provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Slurred speech, left facial weakness, left sided hemiparesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Stroke Scale Score: 19
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: out of window
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: no LVO
NIHSS performed within 6 hours of presentation at: 0920
time/date
___
___ Total: 19
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 2
10. Dysarthria: X
11. Extinction and Neglect: 2
REASON FOR CONSULTATION: code stroke
HPI:
___ F w/ PMH HFrEF, afib on eliquis, remote breast ca,
hypothyroidism.
Real name: ___
She was admitted to cardiology ___ after presenting with
shortness of breath, found to have a new dx of HFrEF. TTE showed
EF of 30%. Cath was done on ___, there was 60% stenosis in the
LAD, 70% in the diagonal. No intervention was performed. Most
likely etiology of her new HFrEF was felt to be due hypertensive
heart disease, patient was to undergo outpatient cardiac MR
___ for ___ for further workup.
EKG on outpatient visit ___ showed afib, she was started on
Eliquis after this, she has been on this for a few days. She
last
took this at 9pm last night, as seen by her niece who was
staying
with her.
Last known well around 1230am when she went to sleep. Around
0600
this morning she was found on the floor next to her bed, with L
facial droop, L weakness. There was report of possible vomiting
of bright red blood. she was brought to ___ for
evaluation. There NCHCT was done which on the read was
concerning
for R hyperdense MCA sign and she was transferred here for
further care. CXR done at OSH unremarkable.
Past Medical History:
HTN
Papillary thyroid Ca s/p thyroidectomy, RAI with resultant
surgical hypothyroidism
___: Stage 3 IDC ER+ s/p L mastectomy, s/p chemoradiation with
anthracyclines and taxanes, also adjuvant tamoxifen for ___ years.
Recurrence free since then. last mammogram ___ at ___
(undergoing annually). No BRCA ___ mutations present.
Hysterectomy for fibroids
Afib (diagnosed last week)
HFrEF (diagnosed last month)
Social History:
___
Family History:
Non-contributory to presenting complaint
Physical Exam:
ADMISSION EXAM:
===============
T 98.1 HR 67 BP 109/72 RR 18
NSR on monitor while in room
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Speech is quite dysarthric. I am unable
to
make out the majority of what she is saying. She is able to
write
"thank you" appropriately with the R hand. She follows complex 2
step commands fine. She does not clearly tell me how old she is
or where she is at, although the severe dysarthria makes it hard
to judge as she does attempt to say something. Some sentences
are
with understandable with appropriate responses. Names chair on
stroke card. Unable to tell if she is reading words correctly.
neglecting L side clearly. R gaze preference. States L arm is
not
her own when asked.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI. Does not cross
midline on own.
V: Facial sensation intact to light touch.
VII: L facial droop apparent at rest, with minimal movement.
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI:
XII: Tongue protrudes in midline
-Motor: Normal bulk and tone throughout
plegic on L side. TF on L leg. L arm withdraws slightly.
R arm and leg, able to keep in air for >10 seconds without
drift.
-Sensory: Decreased sensation on L. Does not recognize left arm
as own.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor on R, unable to test on L
DISCHARGE EXAM:
===============
VS: Temp: 97.8 (Tm 98.2), BP: 126/78 (109-126/68-79), HR: 55
(55-66), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: Ra
Exam
General: Awake, cooperative, upright in bed, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Pulmonary: Normal work of breathing.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert. Eyes open. Interactive. Speech is
dysarthric though improving. Able to intelligibly repeat "Today
is a rainy day in ___ and ___ Able to follow
multi-step cross-body commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 3 mm and brisk. EOMI though she has
a
right gaze preference. Able to cross midline easily.
V: Facial sensation intact to light touch.
VII: Left facial droop apparent at rest, with minimal
activation.
VIII: Hearing intact to conversation
XI: Decreased strength on left
XII: Tongue protrudes in midline
-Motor: Normal bulk and tone throughout. Left deltoid ___. There
is some internal rotation of the left leg in the plane of the
bed.
-Sensory: Decreased sensation on left arm/leg, 40% compared to
the right. Able to recognize her left arm as her own.
-Reflexes: Deferred.
-Coordination: No dysmetria with FNF on the right.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:38AM URINE HOURS-RANDOM
___ 09:38AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:38AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 09:38AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:38AM URINE MUCOUS-RARE*
___ 09:22AM ___ PO2-66* PCO2-36 PH-7.44 TOTAL CO2-25
BASE XS-0 COMMENTS-GREEN TOP
___ 09:22AM GLUCOSE-157* CREAT-0.6 NA+-139 K+-3.4*
CL--103
___ 09:22AM estGFR-Using this
___ 09:22AM HGB-11.9* calcHCT-36
___ 09:15AM GLUCOSE-161* UREA N-21* CREAT-0.7 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
___ 09:15AM estGFR-Using this
___ 09:15AM ALT(SGPT)-56* AST(SGOT)-58* ALK PHOS-71 TOT
BILI-0.8
___ 09:15AM cTropnT-<0.01
___ 09:15AM ALBUMIN-3.7 CALCIUM-8.2* PHOSPHATE-2.7
MAGNESIUM-1.7
___ 09:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 09:15AM WBC-12.1* RBC-3.92 HGB-11.2 HCT-34.3 MCV-88
MCH-28.6 MCHC-32.7 RDW-15.0 RDWSD-47.1*
___ 09:15AM NEUTS-89.2* LYMPHS-5.6* MONOS-4.2* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-10.75* AbsLymp-0.67* AbsMono-0.51
AbsEos-0.01* AbsBaso-0.04
___ 09:15AM ___ PTT-23.4* ___
___ 09:15AM PLT COUNT-135*
IMAGING:
========
CTA HEAD/NECK ___:
1. Acute infarction involving the posterior right frontal, right
insula, right parietal lobes, corresponding to right MCA
distribution. ASPECTS ___.
2. Segmental occlusion of the proximal right M2 posterosuperior
branch with diminished opacification of the distal right MCA
branches.
3. Chronic infarcts in the left thalamus and right corona
radiata.
4. No evidence of acute intracranial hemorrhage.
5. Patent neck vasculature with no evidence of focal stenosis or
occlusion.
6. Age indeterminate moderate anterior wedge-shaped compression
deformity of the T5 vertebral body, likely chronic.
MRI HEAD WITHOUT CONTRAST ___:
1. Study is degraded by motion.
2. Right MCA territory acute infarct involving both the
precentral and
postcentral gyrus, posterior aspect of the right insular cortex,
smaller
adjacent right frontal and parietal cortical, subcortical, and
deep white
matter acute infarcts.
3. Small acute cortical infarct, right occipital lobe, location
possibly
representing external MCA-PCA watershed.
4. Small chronic left thalamic infarct and small right corona
radiata chronic lacunar infarcts.
5. Punctate right cerebellum chronic blood products versus
mineralization,
nonspecific.
6. No extra-axial collection or mass effect. No definite
evidence of
hemorrhagic transformation.
7. Mild changes of chronic white matter microangiopathy.
8. Mild global parenchymal volume loss.
CXR ___:
Interval development of bibasilar opacities concerning for
aspiration/pneumonia.
On the second and final image, the tip of the nasogastric tube
projects over the stomach.
TTE ___:
The left atrial volume index is SEVERELY increased. No
thrombus/mass is seen in the body of the left atrium (best
excluded by TEE). The right atrium is mildly enlarged. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function and mild global hypokinesis of the remaining
segments. The visually estimated left ventricular ejection
fraction is 40-45%. Left ventricular cardiac index is normal
(>2.5 L/min/m2). There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. Intrinsic right ventricular systolic function
is likely lower due to the severity of tricuspid regurgitation.
The aortic sinus diameter is normal for gender with normal
ascending aorta diameter for gender. The aortic arch is mildly
dilated with a normal descending aorta diameter. There is no
evidence for an aortic arch coarctation. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is moderate [2+] mitral regurgitation. The
pulmonic valve leaflets are normal. There is significant
pulmonic regurgitation. The tricuspid valve leaflets appear
structurally normal. There is moderate to severe [3+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. There is a very small circumferential
pericardial
effusion. There are no 2D or Doppler echocardiographic evidence
of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mild regional/mild global systolic
function. Moderate to severe tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension. Moderate mitral
regurgitation. Mildly dilated aortic arch. Small circumferential
pericardial effusion without echo evidence for hemodynamic
compromise. No definite structural cardiac source of embolism
identified (rhythm is atrial fibrillation).
CT HEAD ___:
1. Evolving right MCA territory infarct.
2. Small focal hyperdensity in posterior frontal lobe gyri,
suggests
microhemorrhage or small area of hemorrhagic conversion.
3. Trace linear hyperdensity within right temporal lobe sulci
may suggest
trace subarachnoid hemorrhage versus artifact.
4. No midline shift. Patent basal cisterns.
5. Mild asymmetric prominence of the temporal horn of the right
lateral
ventricle may suggest mild trapping warrants attention on
subsequent exams.
CXR ___:
No previous images. Cardiac silhouette is mildly enlarged and
there is
indistinctness of engorged pulmonary vessels consistent with
elevated
pulmonary venous pressure. No evidence of acute pneumonia or
pleural
effusion. Specifically, the nasogastric tube extends to the
stomach, with the side port several cm distal to the
esophagogastric junction. Of incidental note are multiple old
healed rib fractures on the left.
CT HEAD ___:
Stable subacute right MCA distribution infarct, with small areas
of cortical based linear microhemorrhage. No parenchymal
hematoma.
CXR ___:
In comparison with the study of ___, there is suggestion of
increased
opacification in the retrocardiac region with less well
visualization of the hemidiaphragm in the area. In the
appropriate clinical setting, this would be concerning for
possible aspiration/pneumonia. If the patient condition would
permit, a PA and lateral view would be helpful.
VIDEO OROPHARYNGEAL SWALLOW ___:
1. Aspiration with nectar thick liquids.
2. Penetration with honey thick liquids.
3. Delayed swallow initiation and slow oral manipulation.
DISCHARGE LABS:
===============
___ 06:51AM BLOOD WBC-8.8 RBC-4.82 Hgb-13.3 Hct-42.0 MCV-87
MCH-27.6 MCHC-31.7* RDW-14.3 RDWSD-45.6 Plt ___
___ 05:47AM BLOOD Glucose-130* UreaN-22* Creat-0.6 Na-143
K-3.6 Cl-105 HCO3-20* AnGap-18
___ 05:47AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
___ 06:10AM BLOOD %HbA1c-5.8 eAG-120
___ 06:10AM BLOOD Triglyc-67 HDL-31* CHOL/HD-2.4 LDLcalc-31
___ 06:10AM BLOOD TSH-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Apixaban 5 mg PO BID
8. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Apixaban 5 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
8. Sertraline 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic stroke
Atrial fibrillation
Heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: Suspected stroke with acute neurological deficit. Please exclude
ICH, signs of early ischemic stroke, large vessel occlusion, or other vascular
abnormality.
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 8.5 s, 0.5 cm; CTDIvol = 92.6 mGy (Head) DLP =
46.3 mGy-cm.
4) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,207.5 mGy-cm.
Total DLP (Head) = 4,671 mGy-cm.
COMPARISON: MRI head dated ___.
CT head without contrast dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is loss of the gray-white matter differentiation involving the posterior
right frontal, right insular, and right parietal lobes compatible with acute
infarction. ASPECTS ___.
There is small chronic infarcts involving the right corona radiata and left
thalamus. No evidence of acute intracranial hemorrhage. Mild prominence of
the ventricles and sulci is suggestive of involutional changes. There is no
mass effect or midline shift.
CT PERFUSION:
The CBF <30% volume is 87 mL.
The T-max >6.0 seconds volume is 308 mL.
As such, the mismatch volume is 221 mL.
The RAPID perfusion maps are limited due to placement of the arterial inflow.
There are patchy to confluent areas elevated mean transit time and T-max
without correspondence to specific vascular territories. Findings likely
reflect combination of ischemic penumbra and artifact.
CTA HEAD:
There is a filling defect involving the proximal right M2 posterosuperior
branch (image ___ of series 5) compatible with occlusion. There is
minimal/markedly diminished opacification of the more distal right MCA
branches. The intracranial internal carotid arteries and anterior circulation
demonstrate opacification without evidence of occlusion. There is normal
opacification of the left middle cerebral artery and branching vessels. The
vertebrobasilar system and both posterior cerebral arteries demonstrate normal
opacification.
CTA NECK:
Standard 3 vessel aortic arch anatomy. Mild atherosclerotic calcifications of
the aortic arch. The carotid and vertebral arteries and their major branches
demonstrate opacification without evidence of stenosis or occlusion. There is
no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
Mosaic attenuation of the visualized lungs likely relates to a combination of
air trapping and changes and perfusion. The visualized esophagus is patulous.
No lymphadenopathy by size criteria.
Enlargement of the central pulmonary arteries. Correlate for pulmonary
arterial hypertension.
Multilevel degenerative changes of the spine. Age-indeterminate
mild-to-moderate anterior wedge-shaped compression deformity of the T5
vertebral body, probably chronic. Correlate with prior imaging and point
tenderness.
IMPRESSION:
1. Acute infarction involving the posterior right frontal, right insula, right
parietal lobes, corresponding to right MCA distribution. ASPECTS ___.
2. Segmental occlusion of the proximal right M2 posterosuperior branch with
diminished opacification of the distal right MCA branches.
3. Chronic infarcts in the left thalamus and right corona radiata.
4. No evidence of acute intracranial hemorrhage.
5. Patent neck vasculature with no evidence of focal stenosis or occlusion.
6. Age indeterminate moderate anterior wedge-shaped compression deformity of
the T5 vertebral body, likely chronic.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ w/ PMH HFrEF, hypothyroidism, stage 3 breast Ca ___ years ago
presents with L facial droop, hemiplegia concerning for stroke.// eval stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Earlier same-day CTA head and neck and CT perfusion ___
performed at 09:01.
FINDINGS:
Study is degraded by motion.
There is a moderate-sized acute infarct involving the right MCA territory
primarily involving the right frontal and parietal lobe, involving both right
precentral and postcentral gyri. There are adjacent smaller foci of superior
right frontal gyrus cortical, right frontal centrum semiovale and subcortical
white matter acute infarction, as well as posteriorly adjacent right parietal
cortical and subcortical infarction. Infarct also involves the posterior half
of the right insular cortex. There is additionally a small acute cortical
infarct in the right occipital lobe, location suggestion of external watershed
distribution (series 3 and 4 images ___.
Punctate focus of increased susceptibility, right cerebellum.
Small chronic left thalamic infarct. Small chronic lacunar infarcts, right
corona radiata.
No evidence of extra-axial collection, parenchymal edema, mass, or mass
effect.
The ventricles and sulci are mildly prominent, compatible with global
parenchymal volume loss.
Bilateral periventricular and scattered small deep white matter foci of
T2/FLAIR signal hyperintensity are nonspecific but compatible with mild
changes of chronic white matter microangiopathy.
The globes and orbits are preserved. Visualized portion of the major
intracranial vascular flow voids are preserved. Bilateral ethmoid air cell
mucosal thickening is present.
IMPRESSION:
1. Study is degraded by motion.
2. Right MCA territory acute infarct involving both the precentral and
postcentral gyrus, posterior aspect of the right insular cortex, smaller
adjacent right frontal and parietal cortical, subcortical, and deep white
matter acute infarcts.
3. Small acute cortical infarct, right occipital lobe, location possibly
representing external MCA-PCA watershed.
4. Small chronic left thalamic infarct and small right corona radiata chronic
lacunar infarcts.
5. Punctate right cerebellum chronic blood products versus mineralization,
nonspecific.
6. No extra-axial collection or mass effect. No definite evidence of
hemorrhagic transformation.
7. Mild changes of chronic white matter microangiopathy.
8. Mild global parenchymal volume loss.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with stroke.// NGt placement
TECHNIQUE: AP portable chest radiographs were obtained
COMPARISON: ___ from earlier in the day
FINDINGS:
Did 2 images demonstrate placement of a nasogastric tube which ultimately
extends well into the stomach.
There is mild pulmonary edema. Since earlier today, there are new airspace
opacities in the right lower lung. Retrocardiac opacities are re-visualized
and also increased since prior. There is no pneumothorax or large pleural
effusion. The size of the cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Interval development of bibasilar opacities concerning for
aspiration/pneumonia.
On the second and final image, the tip of the nasogastric tube projects over
the stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with RMCA infarct// Headache on apixaban, r/o
bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None available in PACs at the time of interpretation.
FINDINGS:
Hypodensity involving the right posterior frontal, parietal, and temporal
lobes is compatible with reported evolving subacute right MCA territory
infarct. Area of relative ___ involving a posterior frontal lobe
gyri (02:23), may suggest area of microhemorrhage. Trace linear ___
within right temporal lobe sulci may suggest trace subarachnoid hemorrhage
(02:15) versus artifact. No midline shift. Patent basal cisterns. Mild
asymmetric prominence of the temporal horn of the right lateral ventricle may
suggest mild trapping. No definite acute infarct. No acute osseous
abnormality. Left maxillary sinus mucosal thickening is mild. Clear mastoid
air cells and middle ears bilaterally.
IMPRESSION:
1. Evolving right MCA territory infarct.
2. Small focal ___ in posterior frontal lobe gyri, suggests
microhemorrhage or small area of hemorrhagic conversion.
3. Trace linear ___ within right temporal lobe sulci may suggest
trace subarachnoid hemorrhage versus artifact.
4. No midline shift. Patent basal cisterns.
5. Mild asymmetric prominence of the temporal horn of the right lateral
ventricle may suggest mild trapping warrants attention on subsequent exams.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new NGTplacement// tube placement
IMPRESSION:
No previous images. Cardiac silhouette is mildly enlarged and there is
indistinctness of engorged pulmonary vessels consistent with elevated
pulmonary venous pressure. No evidence of acute pneumonia or pleural
effusion.
Specifically, the nasogastric tube extends to the stomach, with the side port
several cm distal to the esophagogastric junction. Of incidental note are
multiple old healed rib fractures on the left.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with right MCA stroke// Assess for interval
change in hemorrhagic transformation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
Again seen is right MCA distribution subacute infarct. Linear areas of
cortical microhemorrhage are similar. No parenchymal hematoma. Probable
chronic lacunar infarct left thalamus, stable.. Mild brain parenchymal
atrophy. Chronic small vessel ischemic changes. No midline shift, no
hydrocephalus.. Mild mucosal thickening paranasal sinuses. Nasal tube in
place. Clear mastoids.
IMPRESSION:
Stable subacute right MCA distribution infarct, with small areas of cortical
based linear microhemorrhage. No parenchymal hematoma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with rising WBC count// Assess for aspiration
pneumonia/pneumonitis
IMPRESSION:
In comparison with the study of ___, there is suggestion of increased
opacification in the retrocardiac region with less well visualization of the
hemidiaphragm in the area. In the appropriate clinical setting, this would be
concerning for possible aspiration/pneumonia.
If the patient condition would permit, a PA and lateral view would be helpful.
Radiology Report
EXAMINATION: Oropharyngeal swallowing video fluoroscopy
INDICATION: ___ year old woman with dysphagia// assess swallow
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: 4 minutes 15 seconds. SKIN: 39 mGy. DAP: 609.1 uGym2
COMPARISON: None.
FINDINGS:
There was delayed swallow initiation and slow oral manipulation. Penetration
was seen with honey thick liquids. Aspiration was seen with nectar thick
liquids.
IMPRESSION:
1. Aspiration with nectar thick liquids.
2. Penetration with honey thick liquids.
3. Delayed swallow initiation and slow oral manipulation.
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 AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | PATIENT SUMMARY:
================
___ is a ___ year old woman with PMH HFrEF, newly
diagnosed atrial fibrillation recently started on Eliquis,
remote history of breast cancer, and hypothyroidism who was
admitted with a right MCA syndrome subsequently found to have
distal R M2/proximal M3 occlusion on CTA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
right knee pain/swelling, supratherapeutic INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ PMHx dementia, diabetes, HTN, ESRD on HD,
systolic and diastolic heart failure with LVEF ___ and LV
thrombus requiring anticoagulation with warfarin, osteoarthritis
and chronic diarrhea who presents from from ___ clinic with
diarrhea and worsening R knee pain/swelling.
Per the dialysis center, patient has required increasing care.
She has known severe OA of the right knee which is already
followed by outpatient orthopedics. Her right knee pain has
worsened in the last several days with swelling. While at
dialysis today, patient needed to have multiple diarrheal BMs,
but was unable to ambulate. According to the patient's daughter,
Ms. ___ is normally able to ambulate, but has been unable to
do so over the past several days. Because of these issues, the
HD nurse reported that the ___ clinic could not handle the acuity
of care required by the patient and she did not receive dialysis
treatment that day. Based on conversation with an NP at ___
___, the patient will not be able to return to the dialysis
center in this state since she requires more care than can be
provided at ___ or at the ___ clinic.
In the ED, VS ___ 98.5 90 113/61 18 100% RA. Pt was AOx1
(baseline). Right knee was noted to be warm, swollen, tender,
with limited ___. Abdomen was soft NTND. Labs notable for a K
4.6, HCO3 26, BUN 49, AG 16, Cre 6.5, and lactate 1.9. WBC 7.5,
Hct 32.5, and INR was supratherapeutic at 5.1. Blood cultures
were drawn in the ED.
On the floor, VS 98, 135/64, 89, 18, 100% on RA. Pt is a poor
historian, but according to her daughter, pt was last able to
ambulate with her walker this past ___. On ___, she was
noted to have significant painful swelling of her R knee such
that any weight-bearing activity or knee flexion has not been
possible. She has not had any fevers or chills, and there is no
known history of any recent trauma to her joint. She has never
had any instrumentation of her R knee. She has been on
oxycodone at rehab for longstanding osteoarthritic pain, but has
had some n/v at HD during which she is unable to keep down her
medications. According to her nurse at ___, the pt was
previously on 4 mg Coumadin daily up until ___ when her INR was
3.2. At that time her Coumadin was decreased to 2.5 mg daily.
Her INR on ___ returned at 5.0 so since then, her Coumadin has
been held.
With regards to her diarrhea, this was initially reported as a
chronic issue. However, according to a nurse at ___
___, the patient only diarrhea for the first time the day of
admission. The patient has not had any recent antibiotics. She
has not had any nocturnal diarrhea, no blood in her stools, and
has not had any abdominal pain. Pt denies any orthostatic
symptoms.
Past Medical History:
Past Medical History:
- dementia (likely ___ type)
- hypertension
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in ___
- congestive heart failure EF 20%
- hyperlipidemia
- osteoarthritis
- depression
- anemia,
- secondary versus tertiary hyperparathyroidism
- hypothyroidism
- back pain
- Upper GI bleed
Past Surgical History:
-TAH BSO
-appendectomy
-AV fistula ___
-multiple fistula angioplasties (most recent ___
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: VS 98, 135/64, 89, 18, 100% on RA
GENERAL: NAD, lying in bed in moderate discomfort
HEENT: NCAT, EOMI
NECK: nontender and supple, no appreciable JVD
CARDIAC: RRR, nl S1 S2, systolic murmur best heard at ___
LUNG: CTAB, no w/r/r, no tachypnea, no accessory muscle use
ABDOMEN: soft, NTND, normoactive bowel sounds, no palpable
hepatosplenomegaly
EXT: warm and well-perfused, distal pulses of BLE intact, no
peripheral edema of BLE. L knee with well-healed vertical scar,
R knee with warmth, erythema, and significant soft tissue
swelling. ROM of R knee limited by pain. Sensation of BLE
grossly intact. AVfistula with no tenderness and good palpable
thrill of LUE.
NEURO: AOx1 (to self). Unable to assess asterixis.
Skin: no rash or lesions
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4, 98, 118/65 (116/65-118/68), 80 (80-92), 18, 99%
on RA
GENERAL: asleep but easily arousable, lying in bed comfortably,
NAD
HEENT: NCAT, EOMI
NECK: supple
CARDIAC: RRR, nml S1 and S2, systolic murmur best heard at ___
LUNG: Clear to auscultation b/l, no w/r/r, no tachypnea, no
accessory muscle use
ABDOMEN: soft, NTND, bowel sounds present
EXT: WWP,L knee with well-healed vertical scar, R knee with
warmth, wrapped in ace bandage, improved joint swelling. ROM of
R knee still limited by pain, but improved. Pain w/ passive hip
flexion and knee extension
NEURO: AOx1, moving all extremities spontaneously
Skin: no rash or lesions
Pertinent Results:
Admission Labs:
___ 01:20PM GLUCOSE-123* UREA N-49* CREAT-6.5*#
SODIUM-135 POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-26 ANION GAP-21*
___ 01:20PM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-2.7*
___ 01:30PM LACTATE-1.9
___ 01:20PM WBC-7.5 RBC-3.57*# HGB-10.5*# HCT-32.5*
MCV-91 MCH-29.3 MCHC-32.2 RDW-16.7*
___ 01:20PM NEUTS-84.5* LYMPHS-10.3* MONOS-3.9 EOS-0.9
BASOS-0.4
___ 01:20PM PLT COUNT-234
___ 03:18PM ___ PTT-82.6* ___
Interim Labs:
___ 02:58PM BLOOD ___
___ 06:35AM BLOOD ___ PTT-60.8* ___
___ 06:25AM BLOOD ___ PTT-60.0* ___
Discharge Labs:
___ 07:10AM BLOOD WBC-5.0 RBC-3.42* Hgb-10.2* Hct-30.0*
MCV-88 MCH-30.0 MCHC-34.2 RDW-15.9* Plt ___
___ 07:10AM BLOOD ___ PTT-61.5* ___
___ 07:10AM BLOOD Glucose-78 UreaN-29* Creat-5.7*# Na-132*
K-4.2 Cl-92* HCO3-29 AnGap-15
___ 07:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2
___ KNEE (2 VIEWS) RIGHT
FINDINGS: Blunting of the fat planes is suggestive of joint
effusion, in
particular at the level of the suprapatellar recess. Moderate
narrowing of the medial aspect of the joint space with slight
subcortical sclerosis and osteophyte formation. The findings
are strongly suggestive of moderate medial knee arthrosis.
Moderate-to-severe degenerative changes in the femoropatellar
joint. The cortical structures are intact. There is no
evidence of fracture.
___ TTE
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is 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) 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. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. No pathologic valvular regurgitation. Mild
biatrial dilatation.
Compared with the prior study (images reviewed) of ___,
left ventricular function has normalized. The severity of mitral
and tricuspid regurgitation is markedly reduced. No left
ventricular thrombus is appreciated. Estimated pulmonary artery
systolic pressure is normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine-Prilocaine 1 Appl TP ASDIR
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Omeprazole 40 mg PO DAILY
6. QUEtiapine Fumarate 25 mg PO 3X/WEEK (___)
7. Sertraline 100 mg PO DAILY
8. Warfarin 5 mg PO DAILY16
9. Lorazepam 0.5 mg PO DAILY:PRN anxiety
10. OxycoDONE (Immediate Release) 10 mg PO QHS
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Polyethylene Glycol 17 g PO BID
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Lorazepam 0.5 mg PO DAILY:PRN anxiety
3. Nephrocaps 1 CAP PO DAILY
4. Omeprazole 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 10 mg PO QHS
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. QUEtiapine Fumarate 25 mg PO 3X/WEEK (___)
8. Sertraline 100 mg PO DAILY
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Lidocaine-Prilocaine 1 Appl TP ASDIR
11. Polyethylene Glycol 17 g PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Supratherapeutic INR
Right knee hemarthrosis
Secondary:
Systolic and diastolic congestive heart failure (resolved)
Left ventricular thrombus (resolved)
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
RIGHT KNEE
INDICATION: Pain, swollen knee, no evidence of trauma.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: Blunting of the fat planes is suggestive of joint effusion, in
particular at the level of the suprapatellar recess. Moderate narrowing of
the medial aspect of the joint space with slight subcortical sclerosis and
osteophyte formation. The findings are strongly suggestive of moderate medial
knee arthrosis. Moderate-to-severe degenerative changes in the femoropatellar
joint. The cortical structures are intact. There is no evidence of fracture.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with JOINT PAIN-L/LEG, DIARRHEA, END STAGE RENAL DISEASE, SENILE DEMENTIA UNCOMP
temperature: 98.5
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ PMHx diabetes, HTN, ESRD on HD, CHF with
LV thrombus requiring warfarin, osteoarthritis and chronic
diarrhea who presents from from ___ clinic with diarrhea,
worsening R knee pain, and admission for placement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
left intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
___ Left TFN
History of Present Illness:
___ man with no significant PMH presenting with left
intertrochanteric fracture s/p mechanical fall. Pt states today
he was trying to get into a car when he lost his balance, fell
backwards and landed on left hip. He had immediate pain in the
left hip and was unable to ambulate. Denies
numbness/paresthesias. Denies other injuries. At baseline he
ambulates without assistive devices. Lives in a retirement
community, independent.
Past Medical History:
- Back surgery in ___ for spinal stenosis with
pseudoclaudication and sciatica
- Remote prostate cancer in remission s/p radical prostatectomy
and bilateral pelvic lymph node dissection in ___.
- Appendectomy
- Left TKA
- Psoriasis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Temp: 97.7 PO BP: 103/53 L Lying HR: 88 RR: 18 O2 sat: 90% O2
delivery: RA
General: Well-appearing, breathing comfortably
MSK:
Right lower extremity:
- Dressing c/d/i
- Does not cooperate with strength or sensation exam
- 1+ ___ pulses, WWP
DISCHARGE EXAM:
VS: ___ 1042 Temp: 97.8 PO BP: 117/67 R Lying HR: 83 RR: 18
O2 sat: 95% O2 delivery: 2L
GENERAL: Well appearing, lying in bed comfortably
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, no murmurs. JVP mildly elevated.
PULM: CTAB.
GI: Soft, NDNT.
NEURO: Alert, oriented, attentive.
MSK:
Left lower extremity:
- Dressing c/d/i
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
ADMISSION LABS:
___ 02:42PM BLOOD WBC-12.2* RBC-4.63 Hgb-13.3* Hct-39.9*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.4 RDWSD-44.7 Plt ___
___ 02:42PM BLOOD ___ PTT-28.7 ___
___ 02:42PM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-141
K-4.1 Cl-102 HCO3-26 AnGap-13
___ 02:42PM BLOOD ALT-15 AST-23 AlkPhos-111 TotBili-0.4
___ 02:42PM BLOOD Albumin-4.0 Calcium-8.6 Phos-2.9 Mg-2.0
DISCHARGE LABS:
___ 06:59AM BLOOD WBC-7.8 RBC-2.95* Hgb-8.8* Hct-26.1*
MCV-89 MCH-29.8 MCHC-33.7 RDW-15.6* RDWSD-48.5* Plt ___
___ 06:59AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-137
K-3.6 Cl-98 HCO3-27 AnGap-12
IMAGING & STUDIES:
CT A/P without contrast
1. No hematoma seen in the retroperitoneal space or elsewhere in
the imaged abdomen, pelvis and bilateral thighs.
2. Status post rod and screw fixation for a left femoral
intertrochanteric fracture. Marked subcutaneous and
intramuscular edema involving the left hip and thigh is likely
postsurgical. No organized fluid collections.
3. Cholelithiasis.
CTA Chest
1. Large saddle pulmonary embolus extending into the distal
pulmonary arterial branches to all lung lobes with findings
suggesting right heart strain, for which echocardiography is
recommended.
2. 9 mm right upper lobe part solid and part ground-glass
nodule. Recommend follow-up chest CT in ___ months.
___ Duplex
Acute deep venous thrombosis of 1 of the paired left posterior
tibial veins and acute thrombosis of the left soleus vein.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Apixaban 10 mg PO BID Duration: 7 Days
Last day ___
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice daily
Disp #*13 Tablet Refills:*0
3. Apixaban 5 mg PO BID
4. Bisacodyl 10 mg PO/PR DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*15 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
8. Senna 8.6 mg PO BID
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Left intertrochanteric femur fracture
#Acute pulmonary embolism with right ventricular strain
#Acute deep venous thrombosis of left lower extremity
#Paroxysmal atrial fibrillation
#Acute hypoxemic respiratory failure
#Acute blood loss anemia
#Reactive leukocytosis
#Consumptive thrombocytopenia
SECONDARY DIAGNOSES:
#Pulmonary nodule
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: Intraoperative radiographs for surgical guidance
INDICATION: Left femoral neck fracture, ORIF.
TECHNIQUE: A total of 99.6 seconds continuous fluoroscopic time was employed.
COMPARISON: Left hip radiographs ___
FINDINGS:
3 intraoperative images were acquired without a radiologist present.
Images show intramedullary gamma nail in place with anatomic alignment of the
proximal femoral comminuted fracture.
IMPRESSION:
Intraoperative images were obtained during left femoral fracture fixation.
Please refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: ___ year old man with SOB// sob
COMPARISON: ___.
FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Lung volumes are low. Streaky left lower lung
opacities unchanged suggesting minor scarring. There is a nodular focus
projecting over the left lateral upper lung and the course of the left
anterior third rib, although this does not necessarily appear to be a rib
lesion. Although it may be a summation shadow, pulmonary nodule should be
excluded.
IMPRESSION:
No significant abnormality identified. Possible pulmonary nodule in the left
lung. When clinically appropriate follow-up low-dose noncontrast chest CT is
suggested to reassess. Finding and recommendation discussed with Dr. ___
___ at 12:25 am by telephone on ___.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: ___ w new onset afib w RVR// ? volume status
COMPARISON: Prior day.
FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. There is no definite
pleural effusion although possibilities not excluded noting slight blunting of
each costophrenic sulcus. Lungs appear clear. Nodular opacity mention
previously is not well demonstrated on the study. There is no pneumothorax.
IMPRESSION:
No evidence of acute disease.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITHOUT CONTRAST
INDICATION: ___ s/p L TNF for hip fx with multiple transfusions and afib w
RVR// ? RP/pelvic bleed. Please scan abdomen/pelvis through the knee
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 6.8 s, 90.2 cm; CTDIvol = 14.4 mGy (Body) DLP =
1,295.4 mGy-cm.
Total DLP (Body) = 1,295 mGy-cm.
COMPARISON: CTA chest from ___.
FINDINGS:
LOWER CHEST: Please refer to the separate report of CT chest performed on the
same day for description of the thoracic findings.
ABDOMEN:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
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. 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: There is a small hiatus hernia. Small bowel loops
demonstrate normal caliber and wall thickness throughout. The colon and
rectum are within normal limits.
RETROPERITONEUM: No retroperitoneal hematoma. Trace hyperdense fluid within
the pelvis (series 2, image 64) may represent a small amount of blood
products.
PELVIS: The urinary bladder is unremarkable. Multiple surgical clips are
noted in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are not definitely
seen.
LYMPH NODES: No large lymph nodes in the abdomen or pelvis, within limitations
of a noncontrast enhanced exam.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. Decreased blood pool density suggests anemia.
BONES: The patient is post rod and screw fixation of a left intertrochanteric
fracture, without evidence of hardware failure. Multiple fracture fragments
the left femoral neck and proximal femur are noted, without significant callus
formation. A left knee prosthesis is in situ. Thoracolumbar scoliosis is
present. No worrisome osseous lesions are identified.
SOFT TISSUES: There is extensive subcutaneous and intramuscular edema
involving the left hip and thigh. The left thigh muscles appear
asymmetrically enlarged compared to the right side, and also appear mildly
hyperdense likely due to postsurgical changes including intramuscular
hemorrhage. There are no organized fluid collections. Small foci of
subcutaneous gas around the left hip are likely related to recent surgery. A
small to moderate right knee joint effusion is noted.
IMPRESSION:
1. No discrete hematoma seen in the retroperitoneal space. Hyperdense free
fluid in the pelvis may represent a small amount of blood products.
Asymmetric thickening of the left thigh musculature compared to the right side
associated with intramuscular hyperdensity is likely related to intramuscular
blood products, as part of postsurgical changes.
2. Status post rod and screw fixation for a left femoral intertrochanteric
fracture. Marked subcutaneous and intramuscular edema involving the left hip
and thigh is likely postsurgical. No organized fluid collections.
3. Cholelithiasis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:13 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ w new onset afib w RVR and O2 req// ? PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 32.9 cm; CTDIvol = 11.6 mGy (Body) DLP = 382.1
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
Total DLP (Body) = 397 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
HEART AND VASCULATURE: There is a large saddle pulmonary embolus straddling
the bilateral main pulmonary arteries, which extends into distal pulmonary
arterial branches of all lung lobes. There is asymmetric enlargement of the
right ventricle relative to the left, suggesting right heart strain. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma.
The heart is normal in size. Coronary artery, aortic and mitral annular
calcifications are severe. There is no pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There are small bilateral dependent pleural effusions. No
pneumothorax.
LUNGS/AIRWAYS: There is mild biapical scarring and bilateral dependent
atelectasis. A 9 mm part solid, part ground-glass nodule is seen near the
right lung apex (___). A tiny calcified granuloma is seen in the right
middle lobe (301:43). 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: Please refer to separate report for CT abdomen pelvis performed on
the same day for discussion of abdominal findings.
BONES: No suspicious osseous abnormality is seen. Multilevel degenerative
changes of the thoracic spine are noted. A mild anterior wedge deformity of
the T7 vertebral body is of indeterminate chronicity but likely degenerative
in etiology.
IMPRESSION:
1. Large saddle pulmonary embolus extending from the main pulmonary artery
into the bilateral lobar, segmental and subsegmental pulmonary arterial
branches to all lung lobes with findings suggesting right heart strain.
2. 9 mm right upper lobe part solid and part ground-glass nodule. Recommend
follow-up chest CT in ___ months.
3. Bilateral small pleural effusions and bibasilar atelectasis.
RECOMMENDATION(S):
1. Echocardiography.
2. For an incidentally detected single part-solid nodule bigger than 6mm, CT
follow-up in 6 to 12 months is recommended to confirm persistence. If the
nodule is unchanged and the solid component remains smaller than 6 mm, annual
CT follow-up is recommended for ___ years.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:13 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ w large pulmonary embolus s/p hip surgery// ? DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Occlusive thrombus is noted within the left soleus vein and 1 of the paired
left posterior tibial veins.
There is normal compressibility and flow within the right common femoral,
femoral, and bilateral popliteal veins. Of note, the left common femoral vein
cannot be entirely compressed due to patient discomfort but wall the wall flow
was demonstrated. Normal color flow and compressibility are demonstrated in
the right posterior tibial and bilateral peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Incidental note is made of a right suprapatellar knee effusion.
IMPRESSION:
Acute deep venous thrombosis of 1 of the paired left posterior tibial veins
and acute thrombosis of the left soleus vein.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:23 pm, 1 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hip pain, s/p Fall
Diagnosed with Pain in left hip
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 96.0
sbp: 163.0
dbp: 84.0
level of pain: 8
level of acuity: 3.0 | BRIEF SUMMARY
===================
Mr. ___ is an ___ y/o healthy independent man with no
significant PMH, admitted with L hip fracture after mechanical
fall. He underwent successful TFN without immediate
complications. However, on POD#3 he developed new onset atrial
fibrillation with RVR and was found to have a saddle pulmonary
embolus with RV strain. Fortunately he remained hemodynamically
stable and was transitioned from IV heparin to apixiban. He was
discharged to acute rehab with close Cardiology and Orthopedics
follow-up.
ACUTE ISSUES
==================
# Left intertrochanteric femur fracture
The patient presented with hip pain after a mechanical fall and
was found to have an intertrochanteric fracture. He was
initially admitted to the Orthopedic Surgery service and was
taken to the operating room on ___ for left TFN, which he
tolerated well. 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 worked
with ___ who determined that discharge to rehab was appropriate.
# Submassive pulmonary embolism and deep venous thrombosis -
acute, provoked
# Right ventricular strain
On POD#3, the patient developed new onset a-fib with RVR with
right bundle branch block and was found to have a large saddle
pulmonary embolus on CTA chest. Troponins and BNP were
moderately elevated, consistent with RV strain. TTE showed RV
dilation but preserved RV function. Left ___ doppler found a
small distal DVT. MASCOT team was consulted and felt that no
advanced therapies were needed given patient's hemodynamic
stability. He was treated with IV heparin for >48 hours and then
transitioned to apixiban.
# New onset paroxysmal atrial fibrillation
Patient had two episodes of rapid a-fib to 130s-140s which
abated with low-dose beta-blockade. Likely provoked by PE/RV
strain. He was discharged in sinus rhythm on metoprolol
succinate 25mg daily and anticoagulation as above. He would
likely benefit from indefinite anticoagulation (CHADS2Vasc = 2).
# Acute hypoxemic respiratory failure
Patient developed mild hypoxemia post-operatively ___ NC),
attributed to PE and atelectasis. No evidence of pulmonary edema
or pneumonia. He was treated with anticoagulation, incentive
spirometry, and mobilization and weaned to 2L O2 on discharge.
# Acute blood loss anemia
Patient required 4u pRBCs post-operatively. CT A/P showed no
evidence of intra- or retro-peritoneal bleeding. Hgb and BP
remained stable after starting anticoagulation.
# Reactive leukocytosis
WBC was mildly elevated immediately post-op with no localizing
symptoms of infection. Cultures and CXR were negative, and this
was felt to represent leukemoid reaction to surgery and DVT/PE.
Normalized by discharge.
# Mild thrombocytopenia
Platelets dipped to low 100s post-operatively and then
normalized prior to discharge. Likely due to consumption from
surgical blood loss and DVT/PE. Time course was not consistent
with HITT, and platelets normalized prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with PMH CAD (s/p
PCI
to RCA in ___, HFpEF (LVEF 55%), HTN, T2DM, morbid obesity,
COPD (not on home O2), and depression who was referred to ED for
weight gain and progressive dyspnea for the past 2 weeks, worse
in the past 1 week.
Pt states that she last felt "normal" with regards to her
breathing and activity 2 months ago. She first began feeling
short of breath 2 weeks ago; this was fairly mild dyspnea and
provoked by her usual activity level (able to walk approximately
a half a block before being limited by knee pain and dyspnea).
Starting ___ days ago, however, the patient's SOB began getting
worse. She has had markedly limited activity, to the point
where
she is barely able to get from her hospital bed to the bathroom
today without getting dyspneic.
Pt states her dyspnea is constant, and worse with any activity
or
"when I get agitated/when my nerves get up." She has stable
orthopnea at baseline, and this is unchanged. She has not tried
any medications for her SOB, though reports taking all of her
doses on time and without skipped meds. She feels that her SOB
improves when she calms herself down with deep breathing and
relaxation techniques.
Pt presented to her PCP's office today because her dyspnea had
become progressive. Given her degree of subjective dyspnea, Pt
was referred to the ___ ED for further evaluation.
- In the ED, initial vitals were: 97.9 87 147/99 16 100% 2L NC
- Labs were notable for: proBNP 3026, WBC 10.2, BUN/Cr ___,
Trop-T 0.02
- Studies were notable for:
___ CXR PA/LATERAL: Patchy opacities in the lung bases
likely
reflect areas of atelectasis. Early infection is difficult to
exclude in the correct clinical setting.
___ EKG:
Compared to most recent prior dated ___. Normal sinus
rhythm at a rate of 83bpm with intermittent PVC's. Left axis
deviation. LVH, likely ___. Likely J-point elevation in V1 and
V2. QTc borderline at 486, otherwise intervals WNL.
Compared to most recent prior, PVC's are present. There are no
new ischemic changes.
-The patient was given: CTX 1 g IV, Azithromycin 500 mg IV,
Ipratropium-Albuterol Neb 1 NEB, furosemide 100 mg IV
On arrival to the floor, patient endorses the above history.
Her
dyspnea she said really improved with the duoneb in the ED.
She further notes an 11 lb weight gain over the past week
(usually weighs between 320-325 lbs, and currently is 333lbs),
progressive lower extremity swelling and pain from the knees
down, dry cough, subjective chills, palpitations, intermittent
left-sided chest pain that lasts for minutes (relieved by deep
breathing as above), and intermittent dizziness. She denies
fevers, sputum production, abdominal pain, N/V/D, headaches,
blurry/double vision.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Congestive Heart Failure, diastolic (EF 55%)
Depression
Diabetes Mellitus Type II, not on insulin
Hyperlipidemia
Hypertension
Severe Obesity
Obstructive sleep apnea; not compliant with her CPAP at home as
it is a difficult device to set up
Social History:
___
Family History:
Mother had "heart conditions" and also a history of renal
cancer.
Mother's side of the family has heart disease and heart attacks,
all > ___ y/o per Pt report. Father's side has similarly
advanced
___ y/o onset of heart disease. There is a maternal uncle who
had "back cancer" before he was ___ years old, which Pt is not
able to elucidate further.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.3 BP 194/112 HR 97 RR 26 O2 95% on RA
GENERAL: Morbidly obese Caucasian woman, sitting up at edge of
bed. Pleasant and cooperative, mildly dyspneic at rest.
HEENT: Sclerae anicteric, MMM.
NECK: JVP difficult to assess owing to habitus; at least 10cm
H2O
while lying at 30 degrees in bed. Difficult to appreciate
hepatojugular reflux. Exam is cut short owing to orthopnea.
CHEST: Pt points to one spot on the left anterior chest wall
that was the source of her earlier chest pain. This pain is
reproducible with palpation.
CARDIAC: Distant heart sounds. RRR, normal S1/S2, no M/R/G.
LUNGS: Faint bibasilar crackles, upper airway sounds auscultated
___ in upper fields. No frank wheezing.
ABDOMEN: Hypoactive BS. Abdomen is soft, non distended,
non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: There is lower extremity edema to just above the
ankles bilaterally. Brawny venous stasis changes on the
anterior
shins.
NEUROLOGIC: Moves all four extremities with purpose. Negative
pronator drift, normal finger-nose-finger bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
Temp: 97.6 (Tm 99.2), BP: 126/66 (105-149/57-70), HR: 62
(61-69),
RR: 18, O2 sat: 95% (91-95), O2 delivery: Ra, Wt: 318.6
lb/144.52
kg
GENERAL: Morbidly obese Caucasian woman, sitting in chair.
Pleasant and cooperative, comfortable.
HEENT: Sclerae anicteric, MMM.
CARDIAC: RRR, normal S1/S2, no M/R/G.
LUNGS: Faint bibasilar crackles.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants. No organomegaly.
EXTREMITIES: No visible edema, brown venous stasis changes on
the
anterior shins.
NEUROLOGIC: AOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 02:44PM BLOOD WBC-10.2* RBC-4.73 Hgb-13.3 Hct-43.1
MCV-91 MCH-28.1 MCHC-30.9* RDW-13.7 RDWSD-46.5* Plt ___
___ 07:50PM BLOOD Neuts-63.8 ___ Monos-5.4 Eos-3.6
Baso-0.6 Im ___ AbsNeut-6.51* AbsLymp-2.69 AbsMono-0.55
AbsEos-0.37 AbsBaso-0.06
___ 02:44PM BLOOD UreaN-13 Creat-1.0 Na-144 K-4.3 Cl-101
HCO3-26 AnGap-17
___ 02:44PM BLOOD ALT-12 AST-11
___ 02:44PM BLOOD proBNP-3026*
___ 07:50PM BLOOD CK-MB-2 proBNP-2892*
___ 02:44PM BLOOD Cholest-193
___ 07:50PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
___ 02:44PM BLOOD %HbA1c-6.3* eAG-134*
___ 02:44PM BLOOD Triglyc-219* HDL-43 CHOL/HD-4.5
LDLcalc-106
___ 02:44PM BLOOD TSH-1.9
DISCHARGE LABS:
___ 07:34AM BLOOD WBC-9.7 RBC-4.90 Hgb-13.8 Hct-44.2 MCV-90
MCH-28.2 MCHC-31.2* RDW-14.3 RDWSD-47.8* Plt ___
___ 07:34AM BLOOD Plt ___
___ 01:24PM BLOOD Glucose-169* UreaN-48* Creat-1.2* Na-140
K-4.4 Cl-96 HCO3-29 AnGap-15
___ 07:34AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1
MICRO:
n/a
IMAGING:
TTE: ___
The left atrial volume index is normal. There is moderate
symmetric left ventricular hypertrophy with a normal
cavity size. There is normal regional left ventricular systolic
function. Overall left ventricular systolic function is
normal. The visually estimated left ventricular ejection
fraction is 55-60%. There is no resting left
ventricular outflow tract gradient. Diastolic function could not
be assessed. Mildly dilated right ventricular
cavity with normal free wall motion. The aortic sinus diameter
is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is
moderate mitral annular calcification. There is mild
[1+] 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 physiologic tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension.
There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with
normal cavity size and regional/global left ventricular systolic
function. Unable to assess diastolic
function. Mild right ventricular dilation, unable to asess
function. At least moderate pulmonary
hypertension.
Compared with the prior TTE ___ , the estimated pulmonary
artery systolic pressure is now
increased.
CXR:
Patchy opacities in the lung bases likely reflect areas of
atelectasis. Early
infection is difficult to exclude in the correct clinical
setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. DULoxetine 60 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
9. GlyBURIDE 1.25 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Torsemide 80 mg PO DAILY
14. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
15. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
affected areas
16. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 25 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. GlyBURIDE 1.25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
13. Torsemide 80 mg PO DAILY
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
affected areas
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Heart failure with preserved ejection fraction
Secondary Diagnoses:
Depression
Diabetes Mellitus Type II, not on insulin
Hyperlipidemia
Hypertension
Severe Obesity
Obstructive sleep apnea; not compliant with her CPAP at home
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with 2 weeks of dyspnea// r/o pulmonary edema,
pneumonia or other acute CP abnormalities
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is mild-to-moderately enlarged. The mediastinal and hilar contours
are normal. The pulmonary vasculature is normal. Patchy opacities are seen in
the lung bases without focal consolidation. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
Patchy opacities in the lung bases likely reflect areas of atelectasis. Early
infection is difficult to exclude in the correct clinical setting.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.9
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 147.0
dbp: 99.0
level of pain: 3
level of acuity: 2.0 | SUMMARY ASSESSMENT
====================
Ms. ___ is a ___ woman with a history of
heart failure with preserved ejection fraction (LVEF 55%), CAD
s/p PCI
to RCA (___), hypertension, type 2 diabetes, morbid obesity,
chronic obstructive pulmonary disease, and depression who was
referred to ED for weight gain and progressive dyspnea
concerning for HFpEF exacerbation. Patient underwent diuresis in
hospital with 100 mg IV Lasix twice per day. Patient was
discharged at weight of 318.61 pounds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, intermittent chills and fevers x3 weeks
Major Surgical or Invasive Procedure:
ERCP with stent placement, EUS with core needle biopsy
History of Present Illness:
___ with hx of melanoma (removed in ?___, htn, HLD,
nephrolithiasis, pancreatic mass with biopsies negative for
malignancy followed by Dr. ___ presenting with recurrent
abdominal pain.
Pt initially presented in ___ with postprandial epigastric
pain with nausea without emesis. He presented to ___, and was
found to have a pancreatic head mass involving SMV and SMA and
duodenal invasion. A CT angiogram at ___ on ___ confirmed a
3.5 cm pancreatic head mass with obliteration of portal SMV
confluence. EUS on ___ was again concerning for a pancreatic
mass, with mucus covering the ampulla, and evidence of
ulceration and a frond-like tissue. EUS also revealed complex
masses highly concerning for main duct IPMN with malignant
degeneration. Biopsies at that time demonstrated nondiagnostic
mucinous cells with high grade dysplasia. Repeat EUS on ___
again was nondiagnostic. Pt proceeded to laparoscopic biopsy
with Dr. ___ on ___ pathology again failed to identify
malignancy. He has been discussed at multidisciplinary
conference; given radiographic findings, despite inconclusive
biopsies, marginally elevated CEA at 5.7 and ___ WNL, remain
for pancreatic malignancy remains high. Based on most recent
notes, plan has been to monitor q6 months with repeat imaging.
He now returns with reports of 3 weeks of intermittent nausea,
Rikers, and fever. He reports onset of nausea with nonbloody
emesis on ___. ___ ___, 3 weeks prior to presentation. He
recalls that he ate corned beef and cabbage, and subsequently
developed nausea and vomiting. Symptoms at that time were
associated with ___, and intermittent fevers as high as
102. He notes that the symptoms were intermittent, lasted to 3
days, then resolved. ___ days later, similar symptoms recurred
although less intense, with nausea and dry heaves but no frank
emesis. Symptoms again lasted ___ days, then resolved. In the
week prior to this presentation, he presented to his PCP for
further evaluation, and was advised to present to the nearest ED
if symptoms again recurred. On the evening of ___, he had
dinner, and subsequently developed nausea and dry heaves. He
notes that nausea, fevers, chills have never been associated
with abdominal pain. He notes occasional bright red blood on
toilet paper after wiping, which occurs every ___ days, and for
which he is scheduled for a hemorrhoidectomy in the coming week.
He also endorses drenching night sweats and some degree of
weight loss over the past year which he has not quantified. He
does note that he has had to tighten his ___ over the past
year. He denies significant change in his bowel movements,
although subsequently states that they had been soft and watery,
and are now more formed with the addition of fiber
supplementation. He denies change in the color of his stool or
urine. He endorses intermittent polyarticular joint pains
involving his ankles and wrists, last occurred ___ weeks prior
to presentation, consistently resolves with ibuprofen.
He initially presented to ___, where VS included
temp 102.3, HR 91, SBP 131/79. Labs were ordered but results not
sent in transfer; per ED dash, Tbili was modestly elevated to
?1.3, WBC was ?18. RUQ u/s raised concern for biliary
obstruction, and pt was transferred to ___ for further care.
Past Medical History:
Past Medical History:
-Melanoma: excised ___ years ago, continues to follow with
dermatologist, never required chemo or further tx
-HTN (no longer on medications)
-HLD (no longer on medications)
-nephrolithiasis ___ years ago)
-Lyme disease: per patient was quite significant, involving
severe joint pains, fatigue, 25 pound weight loss
-Possible anemia, patient unsure
Past Surgical History: Excision of melanoma from back ___ years
ago
Social History:
___
Family History:
Family History: Denies any family history of cancer, liver or
biliary disease, or gastrointestinal diseases
Mother - diabetes, CAD
Father - possible CAD
Physical Exam:
GEN: alert and interactive, lying in bed
HEENT: anicteric sclera, MMM
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic
murmur, no rubs or gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, normal active bowel sounds
EXTREMITIES: no edema
SKIN: no jaundice
NEURO: Alert and interactive, speech fluent
PSYCH: normal mood and affect
Pertinent Results:
___ 06:45PM BLOOD WBC-15.5* RBC-3.09* Hgb-9.5* Hct-29.7*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.9 RDWSD-48.7* Plt ___
___ 07:08AM BLOOD WBC-6.7 RBC-2.91* Hgb-9.0* Hct-27.5*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.4 RDWSD-46.5* Plt ___
___ 07:00AM BLOOD ___
___ 06:45PM BLOOD Glucose-102* UreaN-11 Creat-1.1 Na-134*
K-4.5 Cl-100 HCO3-21* AnGap-13
___ 07:08AM BLOOD Glucose-84 UreaN-14 Creat-1.0 Na-140
K-4.6 Cl-104 HCO3-24 AnGap-12
___ 06:45PM BLOOD ALT-93* AST-133* LD(LDH)-147 AlkPhos-675*
TotBili-1.1
___ 07:08AM BLOOD ALT-46* AST-47* AlkPhos-440* TotBili-0.4
___ 06:16AM BLOOD GGT-687*
___ 06:45PM BLOOD Albumin-3.1* Iron-21*
___ 06:45PM BLOOD calTIBC-235* Hapto-284* Ferritn-355
TRF-181*
___ 06:55PM BLOOD Lactate-1.4
MRCP:
1. Pancreatic masses slightly larger compared to ___
with slightly
enlarged enhancing component and suspicious for malignant
degeneration of
IPMN, versus mucinous adenocarcinoma at the pancreatic head.
The inferior
aspect of the mass demonstrates more solid enhancement than the
bulk of the
lesion.
2. Upstream common bile duct and intrahepatic bile ducts are
diffusely
dilated. There is abrupt caliber change of the common bile duct
at the level
of the pancreatic mass but the duct patency remains maintained
at this level.
There is ampullary thickening which is continuous with the
pancreatic mass
which is suspicious for mass involvement of the ampulla or
duodenum, more
likely to be the cause of the biliary obstruction.
3. SMV is obliterated by the pancreatic mass.
4. Stable enlarged precaval lymph node.
ERCP
In the duodenal bulb friable appearing mucosa with large amounts
of thick ucus was noted. This appeared to be from erosion into
the duodenum from the known pancreatic lesion causing a mass
like lesion. The mucus was thick and was not able to be
aspiratied. Double pig tail biliary stent placed. Brushings
taken
EUS:
Mass measuring approximately 6.2 cm in max dimension was noted
in the head of the pancreas. The mass was hypoechoic and
heterogeneous in echotexture. ___ performed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Common bile duct obstruction
Pancreatic mass
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 elevated bili, wbc count// CBD stone
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital ultrasound from ___ performed 6 hours
previous. CTA pancreas performed ___.
FINDINGS:
PANCREAS: There remains a large partially cystic/necrotic pancreatic mass
within the head/periampullary region, measuring 5.3 x 4.3 x 4.7 cm, overall
similar to recent CT allowing for difference in modality, indenting common
bile duct and portal vein, without definite tumor invasion. Although the body
and tail are largely obscured by overlying bowel gas, we note there was
pre-existing pancreatic atrophy.
BILE DUCTS: There is progressed moderate upstream intrahepatic and
extrahepatic biliary dilation, with the common hepatic duct/common bile duct
measuring up to 16 mm.
LIVER: There remain multiple periportal lymph nodes/soft tissue, with a small
amount of periportal ascites. No suspicious liver lesions.
GALLBLADDER: There is gallbladder sludge without Findings of acute
cholecystitis
SPLEEN: Not enlarged, 11.5 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.1 cm
Left kidney: 11.8 cm
RETROPERITONEUM: Not visualized due overlying bowel gas.
IMPRESSION:
1. There remains of large 5.3 x 4.3 x 4.7 cm pancreatic head/periampullary
mass, previously characterized as possible mucinous neoplasm. There is
progressed upstream moderate dilation of the intra and extrahepatic bile
ducts.
2. Gallbladder sludge without evidence of acute cholecystitis or
choledocholithiasis.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with pancreatic head mass of unknown etiology now
with fevers and intra and extra hepatic ductal dilatation// Assess level of
duct obstruction to see if ERCP could help relieve obstruction
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CTA pancreas ___
FINDINGS:
Lower Thorax: No pulmonary mass or pleural effusion is identified.
Liver: No significant hepatic steatosis is identified. Periportal edema is
demonstrated.
Biliary: Proximal common bile duct is now dilated up to 2.3 cm in diameter.
Abrupt caliber change identified at mid to distal common bile duct at the
level of pancreatic head mass (03:20), but nonetheless the common bile duct
appears patent to the level of the ampulla (23:1) and measures 0.6 cm in
diameter distally. Intrahepatic bile ducts are mildly diffusely dilated.
Gallbladder is unremarkable.
Pancreas: Large T2 hyperintense mass in the pancreatic head measuring 6.7 x
6.3 x 5.3 cm appears increased compared to prior CT from ___,
within the limits of comparing between different imaging modalities
(previously 6.8 x 5.1 x 4.8 cm). The mass demonstrates band of internal mild
enhancement (1301: 99). Inferior aspect of the mass demonstrates more solid
enhancement, enlarged slightly since the prior examination measuring 4.7 x 3.2
cm on axial images (1301: 111), previously 4.1 x 2.4 cm. There is thickening
of the ampullary region which is continuous with mass (1303:121).
The right-sided wall of the T2 hyperintense masslike component of this mass is
indistinct, and might be imperceptible, versus fistulizing to the second
portion the duodenum (series 1301: 98).
The pancreas is severely atrophic at the body and tail without ductal
dilation.
The duodenal wall is thinned compressed by the mass but appears intact.
Spleen: Spleen is normal size.
Adrenal Glands: Bilateral adrenal glands are unremarkable.
Kidneys: Bilateral nephrograms are symmetric. Multiple renal cysts measuring
up to of 1.2 cm. There is no hydronephrosis.
Gastrointestinal Tract: Duodenum as described above. Possible fistulization
to the pancreatic mass. Stomach is unremarkable. Small and large bowel loops
are normal caliber.
Lymph Nodes: 1.8 cm enlarged precaval lymph node is grossly unchanged
(1301:87)
Vasculature: There is no abdominal aortic aneurysm. SMV is obliterated by the
pancreatic head mass. There is development of early SMV collaterals.
Osseous and Soft Tissue Structures: Degenerative changes of the lumbar spine
is noted. 3.3 cm T2 hyperintense lesion in L5 vertebral body demonstrated
thickened trabecula on prior CT, suggestive of hemangioma.
IMPRESSION:
1. Pancreatic masses slightly larger compared to ___ with slightly
enlarged enhancing component and suspicious for malignant degeneration of
IPMN, versus mucinous adenocarcinoma at the pancreatic head. The inferior
aspect of the mass demonstrates more solid enhancement than the bulk of the
lesion.
2. Upstream common bile duct and intrahepatic bile ducts are diffusely
dilated. There is abrupt caliber change of the common bile duct at the level
of the pancreatic mass but the duct patency remains maintained at this level.
There is ampullary thickening which is continuous with the pancreatic mass
which is suspicious for mass involvement of the ampulla or duodenum, more
likely to be the cause of the biliary obstruction.
3. SMV is obliterated by the pancreatic mass.
4. Stable enlarged precaval lymph node.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, N/V, Transfer
Diagnosed with Unspecified jaundice, Other cholangitis
temperature: 96.8
heartrate: 81.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | ___ with hx of melanoma (removed in ?___, htn, HLD,
nephrolithiasis, pancreatic mass (original biopsy suggesting
mucinous neoplasm with high-grade dysplasia) presenting with
nausea, fevers, and elevated liver enzymes.
# Pancreatic mass:
# CBD obstruction: Pt with known pancreatic mass who presented
with fevers, vomiting, and US plus MRCP showing intra and
extrahepatic bile duct dilatation. Alk phos and transaminases
were elevated though Tbili was WNL. ERCP was performed which
demonstrated the obstruction as well as thick mucus in the duct.
A double pigtail stent was placed, brushings taken. EUS was also
performed with core needle biopsy. The patient did well after to
procedure. His diet was advanced to solids without development
of pain or nausea. He was initially treated with ceftriaxone and
metronidazole due to concern for cholangitis. He will complete a
course of ciprofloxacin on ___. He will follow up with the
multidisciplinary pancreas team in clinic to discuss the biopsy
results.
# Anemia of chronic disease: Normocytic, with normal RDW, likely
anemia of chronic inflammation from his pancreatic mass. Iron
studies support this diagnosis, given low serum iron, ferritin
at high end of normal range, and low TIBC and transferrin. He
has also been experiencing hemorrhoidal blood loss, but only
intermittently, and has been scheduled for a hemorrhoidectomy.
His hgb remained stable, and he has not been experiencing
fatigue.
# EtOH use disorder: No reported history of EtOH withdrawal
symptoms, although unclear if patient has days on which he does
not drink. He did not develop signs of withdrawal.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee Pollen
Attending: ___.
Chief Complaint:
chest pain and history of positive staph aureus blood culture x
1
Major Surgical or Invasive Procedure:
1. TEE ___
2. PICC line placement ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Pt is a ___ y/o female with history of IVDU and HepC presenting
with chest pain transferred from OSH where she was admitted for
positive BCx and to r/o endocarditis. She presented to OSH
(___) on ___ for 4-day history of chest pain, fever
(101), and night sweats. She was found to have a S. aureus
positive BCx. TTE was negative for endocarditis; she left AMA
yesterday and refused TEE. She went home and smoked cocaine last
night and mom states that she found a needle in her bed. Her
chest pain started again and brought her to the hospital again
this morning.
Chest pain is located on the left side, she points to her left
lower ribs, rates it ___ in severity, sharp in quality, and
radiating to her back. Pain worsens with deep breathing but no
relieving factor. She says it is not positional. At times, she
has pain-induced SOB.
In the ED, initial vs were: 88 105/63 18 99% RA. Labs were
remarkable for leukocytosis to 20.4; remainder of CBC and
chemistry WNL, UA normal, troponin x1 negative, UCG negative,
BCx x2 sent, CXR with focal opacity and blunting of costophrenic
angles. She also had a urine tox which was positive for cocaine
but otherwise negative. Patient was given tylenol. Vitals on
Transfer: 98.4 70 108/57 18 100%
Past Medical History:
IVDU cocaine and heroin
Hepatitis C
Social History:
___
Family History:
No signifcant family history of coronary disease or hx of
infections.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.3 BP: 109/73 on Rt arm 104/59 on Lt P: 58
R: 18 O2: 99% at RA
General: young female laying comfortably in bed, flat affect,
c/o chest pain with deep breathing
HEENT: NCAT, ___, EOMI, no pharyngeal erythema or exudate, MMM.
Limited fundoscopic exam without emboli
Neck: subtle, no JVP
Lungs: CTAB, no wheezing, crackles, or rhonchi. No
constochondritic pain.
CV: tachycardic, regualr rhythm, +S1/S2, no m/r/g,
Abdomen: soft, NT, ND, no HSMG, no gaurding
Ext: no E/C/C
Skin: no rashes
Neuro: CN II-XII intact, sensation intact globally, strength
intact globally. NTTP along spine or ribs.
DISCHARGE PHYSICAL ___:
Vitals: 98.5 113/59 76 16 99% on RA
General: A&Ox3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVP
Lungs: CTAB, no wheezes/rales/crackles
CV: +S1/S2, RRR, no m/r/g, no friction rub
Abdomen: soft, NT, ND, no HSMG
Ext: no clubbing, cyanosis or edema
Skin: no petechiae, splinter hemorrhages, or other sings of
dermatologic septic emboli
Pertinent Results:
ADMISSION LABS:
___ 08:33AM BLOOD WBC-20.4*# RBC-4.17* Hgb-12.5 Hct-37.1
MCV-89 MCH-30.0 MCHC-33.6 RDW-13.5 Plt ___
___ 08:33AM BLOOD Neuts-69.9 ___ Monos-6.3 Eos-0.5
Baso-0.8
___ 08:33AM BLOOD Plt ___
___ 08:33AM BLOOD Plt ___
___ 08:33AM BLOOD ESR-21*
___ 08:33AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-141
K-3.7 Cl-108 HCO3-22 AnGap-15
___ 08:33AM BLOOD ALT-68* AST-21 AlkPhos-98 TotBili-0.2
___ 03:15PM BLOOD CK(CPK)-18*
___ 08:33AM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:45AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
___ 08:39AM BLOOD Lactate-1.4
RELEVANT LABS:
___ 05:45AM BLOOD D-Dimer-1592*
___ 03:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 03:15PM BLOOD HIV Ab-NEGATIVE
PERTINENT MICRO:
_______________________________________________________
___ 7:00 am BLOOD CULTURE SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:33 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:33 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
PERTINENT IMAGING:
Cardiac MRI ___
Normal left and right atrial sizes. Normal left ventricular
cavity size and wall thickness and mass. Normal regional and
global left ventricular systolic function. Normal right
ventricular size and function. No evidence of any left or right
ventricular masses. Ascending aorta and descending aorta were
normal. The main pulmonary artery was normal. No aortic
stenosis. No aortic regurgitation. Mild mitral regurgitation.
No evidence of perivalvular fluid collection. Very small
pericardial effusion. Small left pleural effusion.
TEE ___:
Prominence of the AV groove surrounding the tricuspid valve
likely representing a normal variant (prominent pericardial
fat), although (in the appropriate clinical scenario) early
annular abscess cannot be excluded. Repeat TEE in one week's
time is suggested to follow this area. No 2D echocardiographic
evidence of endocarditis involving the cardiac valves. Normal
biventricular systolic function.
Ultrasound spleen ___:
Normal appearance of the spleen without enlargement, fluid
collection, or
thrombosis.
CT chest ___:
A dozen of bilateral lung nodules, some of them are cavitary,
are consistent
with septic emboli.
CXR ___:
Focal opacity in the right mid and lower lung could represent
infection.
Possible small effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Nafcillin 2 g IV Q4H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. tricuspid endocarditis
2. MSSA bactremia
3. chest pain
SECONDARY DIAGNOSES:
1. IV drug abuse
2. Chronic Hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: None available.
FINDINGS:
Frontal upright and lateral chest radiographs demonstrate well-expanded lungs.
Cardiomediastinal contour is within normal limits. Focal opacities in the
right mid and lower lung could represent infection. Blunting of posterior
costophrenic angles suggest small effusions. No pneumothorax. Tube-like
opacity projecting over the right costophrenic sulcus is thought to be
external.
IMPRESSION:
Focal opacity in the right mid and lower lung could represent infection.
Possible small effusions.
Radiology Report
HISTORY: Evaluate for splenic abscess or thrombosis in a patient with a
history of IV drug abuse and hepatitis C presenting with chest pain and
bacteremia.
COMPARISON: Head CT from ___.
FINDINGS:
Grayscale and spectral color Doppler examination of the spleen was conducted.
The spleen is without fluid collection or focal lesion and measures 10.7 cm in
length. There is normal vascular flow within the parenchyma. The hilar
splenic arterial and venous waveforms are normal.
IMPRESSION:
Normal appearance of the spleen without enlargement, fluid collection, or
thrombosis.
Radiology Report
CHEST CT WITH CONTRAST
INDICATION: Patient with hepatitis C and IV drug abuse, presenting with chest
pain and positive Staph aureus bacteremia, rule out pulmonary infarct,
infectious process.
COMPARISON: CT of the upper extremity of ___.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with administration of IV contrast. Multiplanar reformatted
images in coronal and sagittal axis were generated.
LUNGS AND AIRWAYS:
A dozen of round lesions are scattered throughout the lungs, some of them are
cavitary, for example in right upper lobe, series 4, image 81, measuring 1 cm.
The largest lesion in right lower lobe, series 4, image 158, measures 15 mm.
The airways are patent till the subsegmental level.
MEDIASTINUM:
Thyroid is unremarkable. Borderline central lymph nodes are reactive, for
example 7 mm lymph node is in right lower paratracheal station. The thymus is
normal for patient's age. There is no pleural or pericardial effusion. Heart
and great vessels are not dilated. Non-hemorrhagic pleural effusions are
small, left more than right. There is no pericardial effusion.
UPPER ABDOMEN: This study is not tailored for assessment for intra-abdominal
organs. The upper abdomen appears unremarkable. The spleen is not enlarged.
OSSEOUS STRUCTURES: There is no bone lesion concerning for malignancy or
infection.
CONCLUSION:
A dozen of bilateral lung nodules, some of them are cavitary, are consistent
with septic emboli.
The results have been discussed over the phone by Dr. ___ to Dr. ___ at 8:40 p.m.
Radiology Report
STUDY INFORMATION:
Patient Name: ___ Date of Study: ___
MRN: ___
Date of Birth: ___ Requesting Physician: ___, MD
___: ___ Cardiology Staff: ___, MD
Gender: Female Radiology Staff: ___, MD
Technologist: ___, RT
Status: Inpatient Nursing Support: ___, RN
Height (in): 63
Weight (lbs): 125
Body Surface Area (m2): 1.59
Blood Pressure (mmHg): 107/60
Heart Rate(bpm): 69
Rhythm: Sinus rhythm
Complications: None.
Image Quality: Good
Indication: Rule out perivalvular abscess/fluid collection.
CMR MEASUREMENTS:
Measurement ___ Normal Range
Left Ventricle
LV End-Diastolic Dimension (mm) 45 <55
LV End-Diastolic Dimension Index (mm/m2) 28 <33
LV End-Systolic Dimension (mm) 33
LV End-Diastolic Volume (ml) 133 <143
LV End-Diastolic Volume Index (ml/m2) *84 <78
LV End-Systolic Volume (ml) 54
LV Stroke Volume (ml) 79
LV Stroke Volume Index (ml/m2) 50
LV Ejection Fraction (%) 59 >=56
LV Mass (g) 87
LV Mass Index (g/m2) 55 <60
Basal ___ wall thickness (mm) 4 <10
Basal infero-lateral wall thickness (mm) 4 <9
Q-Flow Aortic Net Forward Stroke Volume (ml) 67
Q-Flow Aortic Total Stroke Volume (ml) 68
Q-Flow Aortic Cardiac Output (l/min) 4.6
Q-Flow Aortic Cardiac Index (l/min/m2) 2.9
LV Effective Forward Ejection Fraction (%) *50 >=56
Right Ventricle
RV End-Diastolic Volume (ml) 121
RV End-Diastolic Volume Index (ml/m2) 76 47-103
RV End-Systolic Volume (ml) 48
RV Stroke Volume (ml) 73
RV Stroke Volume Index (ml/m2) 46
RV Ejection Fraction (%) 60 >=49
Q-Flow Pulmonary Net Forward Stroke Volume (ml) 70
Q-Flow Pulmonary Total Stroke Volume (ml) 71
Qp/Qs 1.04 0.8-1.2
Atria
Left Atrial Dimension (Axial) (mm) 18 <40
Left Atrial Length (4-Chamber) (mm) 50 <52
Left Atrial Length (2-Chamber) (mm) 47
Right Atrial Dimension (4-Chamber) (mm) 44 <50
Great Vessels
Ascending Aorta Diameter (mm) 27 <35
Ascending Aorta Diameter Index (mm/m2) 17 <21
Transverse Aorta Diameter (mm) 17
Transverse Aorta Diameter Index (mm/m2) 11
Descending Aorta Diameter (mm) 16 <25
Descending Aorta Index (mm/m2) 10 <15
Abdominal Aorta Diameter (mm) 13
Abdominal Aorta Diameter Index (mm/m2) 8
Main Pulmonary Artery Diameter (mm) 18 <27
Main Pulmonary Artery Diameter Index (mm/m2) 11 <15
Valves
Aortic Valve Morphology Trileaflet
Aortic Valve Excursion Normal
Aortic Valve Regurgitant Volume (ml) 1
Aortic Valve Regurgitant Fraction (%) 1 <5
Mitral Valve Regurgitant Volume (ml) 11
Mitral Valve Regurgitant Fraction (%) *14 <5
Pulmonary Valve Regurgitant Volume (ml) 1
Pulmonary Valve Regurgitant Fraction (%) 1 <5
Tricuspid Valve Regurgitant Volume (ml) 2
Tricuspid Valve Regurgitant Fraction (%) 3 <5
* Mildly abnormal | ** Moderately abnormal | *** Severely abnormal
CMR TECHNICAL INFORMATION:
Structure
" T1-Weighted (Black Blood): Dual-inversion T1-weighted fast spin echo images
were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular
anatomy.
" Fat Saturated T1-Weighted (Fat ___: Fat saturated dual-inversion T1-
weighted fast spin echo images were acquired in 5-mm contiguous axial slices
to evaluate fat-containing structures.
" T2* (T2 Star): Multiecho ultrafast gradient echo images were acquired with
increasing TE in one mid-ventricular short axis slice. The T2* time was
measured in a region of interest in the interventricular septum to evaluate
myocardial iron content.
Function
" Cine SSFP: Breath-hold SSFP cine images were acquired in 8-mm slices in the
4-chamber, 3-chamber, 2-chamber, and short axis orientations.
" Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired
at the level of the aortic valve.
" Cine SSFP (Additional Right Heart Views): Additional breath-hold SSFP cine
images were acquired to further evaluate the right heart, pulmonary valve, and
pulmonary arteries.
Flow
" Aortic Valve Flow: Phase-contrast cine images were acquired transverse to
the proximal ascending aorta to quantify through-plane flow.
" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse
to the main pulmonary artery to quantify through-plane flow.
CMR FINDINGS:
Left Ventricle
" LV cavity size: Mildly increased
" LV ejection fraction: Normal
" LV mass: Normal
Right Ventricle
" RV cavity size: Normal
" RV ejection fraction: Normal
" Intra-cardiac shunt: None present
Atria
" LA size: Normal
" RA size: Normal
Great Vessels
" Ascending aortic diameter: Normal
" Main pulmonary artery diameter: Normal
Valves
" Aortic valve morphology: Trileaflet
" Mitral regurgitation: Mild
ADDITIONAL INFORMATION/FINDINGS:
None.
NON-CARDIAC FINDINGS:
Scattered bilateral pulmonary septic emboli, small layering left pleural
effusion and small pericardial effusion as on recent CT examination.
IMPRESSION:
Normal left and right atrial sizes. Normal left ventricular cavity size
and wall thickness and mass. Normal regional and global left ventricular
systolic function. Normal right ventricular size and function. No evidence
of any left or right ventricular masses. Ascending aorta and descending aorta
were normal. The main pulmonary artery was normal. No aortic stenosis. No
aortic regurgitation. Mild mitral regurgitation. No evidence of perivalvular
fluid collection. Very small pericardial effusion. Small left pleural
effusion.
Interpreted by Drs.: ___, Murilo ___
___, and ___.
Radiology Report
INDICATION: ___ woman with new right PICC line.
COMPARISON: Prior chest radiograph from ___.
FINDINGS: A right PICC line terminates 7.8 cm below the carina. There is no
pneumothorax. Cardiomediastinal and hilar contours are within normal limits.
Areas of possible opacification are still present in the right mid and lower
lung. Blunting of the left costophrenic angle likely represents a small
effusion. There is increased abdominal distension.
IMPRESSION: Right PICC line terminates 7.8 cm below the carina, withdrawal of
3 cm is recommended for adequate positioning.
These findings were discussed with ___, IV team nurse by ___
via telephone on ___ at 1:50 p.m., at time of discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: +VE BLC
Diagnosed with FEVER, UNSPECIFIED, CHEST PAIN NOS
temperature: nan
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 105.0
dbp: 63.0
level of pain: 5
level of acuity: 2.0 | Pt is a ___ y/o F with history of HepC and IV drug abuse
presenting with chest pain and history of S. aureus positive BCx
from OSH. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
colchicine
Attending: ___
Chief Complaint:
bilateral hand numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with gout who presents
with progressive ascending numbness/tingling that started in his
arms and have now started in his legs.
On ___, he woke up with a gout attack that he gets from time to
time. Was in ___ and drank quite a bit of
wine the week before. Was also in ___ recently doing yard
work.
No known tick bites, no rash. Started taking colchicine because
of the gout attack.
On ___, he noticed some numbness/tingling/burning sensation in
his bilateral fingertips. When he was washing his hands with
cold
water, his hands felt "weird," unable to say if he was unable to
feel the temperature of the water. Also felt a weird sensation
in
the shower, also unclear if it was ___ temperature. Woke up on
___, and the sensation was still there, sometimes extending
into his palms. Went to ___ where they drew some labs and
recommended follow-up with PCP due to ?hemolytic anemia. PCP
drew
more labs and checked in over the phone in the following days.
On ___, he had tingling to his elbows bilaterally. This came and
went, but his hands remained persistently numb. This morning, he
woke up and both his arms and legs felt numb and tingly. He
thought he slept on them wrong, but the sensation did not
resolve. When he got up out of bed, his legs felt like "jello."
The numbness and tingling in his arms and legs have resolved
upon
arrival to the ED, but it remains in his hands. He had no recent
infections, no recent vaccines, did have diarrhea this morning
in
the setting of colchicine. His wife and ___ old daughter have
been ill with diarrhea and URI symptoms recently but are
recovering.
Of note, over the last ___ years, he would have soreness in
between his shoulder blades from time to time. Feels like "he
threw out his shoulder," resolves on its own. Last episode was a
few weeks ago. No family history of autoimmune diseases.
He has also had headaches over the last month, does not usually
have headaches at baseline. Pain is between his eyes and is
worsened if he turns his head from side to side. Throbbing pain,
no radiation, better with tylenol/advil. Thought it was in the
setting of sleep deprivation. This has since resolved.
Past Medical History:
gout
Social History:
___
Family History:
grandfather with stroke, no family history of autoimmune disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: ___ HR: 75 BP: 133/84 RR: 18 SaO2: 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, no
meningismus
___: RRR
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, petichiae present on bilateral
shins
and dorsum of feet
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: anisocoria R pupil 4->2, L pupil 3->2, no
ptosis. VF full to number counting. EOMI, no nystagmus. No
diplopia. V1-V3 without deficits to light touch, pin, or
temperature 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. RUE pronator drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 4+ 5- 5 5 5 5
R 5 5 5 5 5- 5- 5 5 5 5
- Reflexes: (FYI pt must be distracted to obtain reflexes)
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 0 1+ 2 1
R 1+ 0 1+ 2 1
Plantar response flexor bilaterally
- Sensory: decreased sensation to light touch and temperature in
bilateral hands and feet, no temperature sensation in soles of
feet. Intact to pin and proprioception throughout, including the
back. No spinal level apparent.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Walks on the side of his
right foot ___ pain from gout. Favors his right foot. Able to
tandem 7 steps. Negative Romberg.
DISCHARGE PHYSICAL EXAM:
Tm 98.3, HR ___, BP 129-130/78-81, RR 18, >98% RA
General: sitting up in bed, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, no
meningismus
___: RRR
Pulmonary: normal WOB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema, moderate swelling of R great toe
with extreme TTP, few petechiae scattered on legs
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. No paraphasias. No dysarthria. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: Subtle anisocoria R pupil 4->2, L pupil 3->2,
no ptosis. VF full to number counting. EOMI, no nystagmus. No
diplopia. V1-V3 without deficits to light touch, pin, or
temperature 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. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 1 1 2 1
R 2 1 1 2 1
Plantar response flexor bilaterally
- Sensory: decreased sensation to light touch in bilateral palms
and fingertips, normal temperature sensation. Intact to pin and
proprioception throughout. No spinal level apparent.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Normal initiation. Narrow base.
Pertinent Results:
___ 10:45AM BLOOD Neuts-30* Bands-0 ___ Monos-13
Eos-2 Baso-2* ___ Myelos-0 Im ___ AbsNeut-1.98
AbsLymp-3.50 AbsMono-0.86* AbsEos-0.13 AbsBaso-0.13*
___ 05:15AM BLOOD WBC-6.2 RBC-4.58* Hgb-13.4* Hct-39.2*
MCV-86 MCH-29.3 MCHC-34.2 RDW-12.5 RDWSD-38.6 Plt ___
___ 08:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
___ 05:15AM BLOOD ___ PTT-36.4 ___
___ 08:40PM BLOOD Parst S-NEGATIVE
___ 08:40PM BLOOD Ret Aut-2.0 Abs Ret-0.09
___ 05:15AM BLOOD Glucose-90 UreaN-11 Creat-0.8 Na-140
K-3.7 Cl-105 HCO3-23 AnGap-16
___ 05:15AM BLOOD ALT-819* AST-530* LD(___)-558* AlkPhos-61
TotBili-0.6 DirBili-<0.2 IndBili-0.6
___ 08:40PM BLOOD ALT-864* AST-605* LD(___)-649* AlkPhos-63
TotBili-0.6 DirBili-<0.2 IndBili-0.6
___ 10:45AM BLOOD ALT-863* AST-649* LD(___)-706* AlkPhos-65
TotBili-0.6
___ 05:15AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 08:40PM BLOOD Hapto-<10*
___ 10:45AM BLOOD TSH-0.89
___ 10:45AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative
___ 05:15AM BLOOD CRP-3.0
___ 10:45AM BLOOD HCV Ab-Negative
___ 05:15AM BLOOD SED RATE-Test
___ 10:45AM BLOOD BABESIA ANTIBODIES, IGG AND IGM-PND
___ 10:45AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 10:06PM URINE Color-Straw Appear-Clear Sp ___
___ 10:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:04PM CEREBROSPINAL FLUID (CSF) TNC-17* RBC-907*
Polys-4 ___ ___ 02:04PM CEREBROSPINAL FLUID (CSF) TNC-43* ___
Polys-14 ___ ___ 02:04PM CEREBROSPINAL FLUID (CSF) TotProt-86*
Glucose-50
___ 02:04PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
IMAGING:
MRI C-SPINE ___:
FINDINGS:
The visualized elements of the posterior fossa and
craniocervical junction are
unremarkable, the vertebral bodies are normal in height and
alignment. The
signal intensity throughout the cervical spinal cord is normal
with no
evidence of focal or diffuse lesions. There is no evidence of
abnormal
enhancement after contrast administration. There is mild
diffuse loss of
height and normal T2 signal of the cervical intervertebral
discs. Thin linear
water IDEAL hyperintensity in the prevertebral space from the
craniocervical
junction to approximately T4 along the midline with postcontrast
enhancement,
especially given the appearance on the axial sequences, is
likely vascular in
etiology (series 4, image 9). There is no epidural or paraspinal
fluid
collection or soft tissue abnormality otherwise.
At C2-C3, there is no spinal canal or neural foraminal
narrowing.
At C3-C4, there is no spinal canal or neural foraminal
narrowing.
At C4-C5, there is mild disc bulge, causing anterior thecal sac
deformity,
slightly asymmetric towards the left with no evidence of neural
foraminal
narrowing or spinal canal stenosis (image 24, series 5).
At C5-C6, there is a posterior central and left central disc
protrusion, that
mildly indents the left anterior cord. Spinal canal narrowing
is mild. There
is no neural foraminal narrowing.
At C6-C7, small posterior disc protrusion does not result in
significant
narrowing of the spinal canal or neural foramina.
From C7-T1 through T2-T3, there is no disc herniation, spinal
canal narrowing,
or neural foraminal stenosis.
IMPRESSION:
1. Disc degenerative changes at C5-C6 level, and right
paracentral disc
protrusion C6-C7, resulting in mild anterior indentation of the
spinal cord,
but minimal narrowing of the spinal canal.
2. Normal caliber and signal intensity of the visualized spinal
cord without
abnormal enhancement.
RUQ Ultrasound ___:
INDICATION: ___ year old man with elevated LFT in the
600s-800s// eval for
cholecystitis, ductal dilation, hepatic lesion
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.3 cm.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
Splenomegaly, measuring up to 16.3 cm. Otherwise normal scan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Indomethacin 50 mg PO DAILY:PRN gout flare
2. Colchicine 0.6 mg PO DAILY:PRN gout flare
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
2. Indomethacin 50 mg PO DAILY:PRN gout flare
Discharge Disposition:
Home
Discharge Diagnosis:
viral illness, colchicine toxicity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST; MR ___ SCAN WITH CONTRAST
T___; T___ MR ___ SPINE.
INDICATION: ___ man with numbness and tingling of arms and legs,
evaluate for cord impingement.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 and gradient echo imaging were next performed. 8 cc of Gadavist
intravenous contrast was administered.
COMPARISON: No prior examinations of the cervical spine are available.
FINDINGS:
The visualized elements of the posterior fossa and craniocervical junction are
unremarkable, the vertebral bodies are normal in height and alignment. The
signal intensity throughout the cervical spinal cord is normal with no
evidence of focal or diffuse lesions. There is no evidence of abnormal
enhancement after contrast administration. There is mild diffuse loss of
height and normal T2 signal of the cervical intervertebral discs. Thin linear
water IDEAL hyperintensity in the prevertebral space from the craniocervical
junction to approximately T4 along the midline with postcontrast enhancement,
especially given the appearance on the axial sequences, is likely vascular in
etiology (series 4, image 9). There is no epidural or paraspinal fluid
collection or soft tissue abnormality otherwise.
At C2-C3, there is no spinal canal or neural foraminal narrowing.
At C3-C4, there is no spinal canal or neural foraminal narrowing.
At C4-C5, there is mild disc bulge, causing anterior thecal sac deformity,
slightly asymmetric towards the left with no evidence of neural foraminal
narrowing or spinal canal stenosis (image 24, series 5).
At C5-C6, there is a posterior central and left central disc protrusion, that
mildly indents the left anterior cord. Spinal canal narrowing is mild. There
is no neural foraminal narrowing.
At C6-C7, small posterior disc protrusion does not result in significant
narrowing of the spinal canal or neural foramina.
From C7-T1 through T2-T3, there is no disc herniation, spinal canal narrowing,
or neural foraminal stenosis.
IMPRESSION:
1. Disc degenerative changes at C5-C6 level, and right paracentral disc
protrusion C6-C7, resulting in mild anterior indentation of the spinal cord,
but minimal narrowing of the spinal canal.
2. Normal caliber and signal intensity of the visualized spinal cord without
abnormal enhancement.
Radiology Report
INDICATION: ___ undergoing infectious workup.// ? pneumonia
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
Relatively linear opacity noted in the ___ region on the left
within the lingula on the lateral view. The lungs are otherwise clear without
consolidation, effusion, or edema. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
Linear opacity in the lingula likely atelectasis. Infection is not entirely
excluded, to be correlated clinically.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST; MR ___ SCAN WITH CONTRAST
T___; T___ MR ___ SPINE.
INDICATION: ___ man with numbness and tingling of arms and legs,
evaluate for cord impingement.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 and gradient echo imaging were next performed. 8 cc of Gadavist
intravenous contrast was administered.
COMPARISON: No prior examinations of the cervical spine are available.
FINDINGS:
The visualized elements of the posterior fossa and craniocervical junction are
unremarkable, the vertebral bodies are normal in height and alignment. The
signal intensity throughout the cervical spinal cord is normal with no
evidence of focal or diffuse lesions. There is no evidence of abnormal
enhancement after contrast administration. There is mild diffuse loss of
height and normal T2 signal of the cervical intervertebral discs. Thin linear
water IDEAL hyperintensity in the prevertebral space from the craniocervical
junction to approximately T4 along the midline with postcontrast enhancement,
especially given the appearance on the axial sequences, is likely vascular in
etiology (series 4, image 9). There is no epidural or paraspinal fluid
collection or soft tissue abnormality otherwise.
At C2-C3, there is no spinal canal or neural foraminal narrowing.
At C3-C4, there is no spinal canal or neural foraminal narrowing.
At C4-C5, there is mild disc bulge, causing anterior thecal sac deformity,
slightly asymmetric towards the left with no evidence of neural foraminal
narrowing or spinal canal stenosis (image 24, series 5).
At C5-C6, there is a posterior central and left central disc protrusion, that
mildly indents the left anterior cord. Spinal canal narrowing is mild. There
is no neural foraminal narrowing.
At C6-C7, small posterior disc protrusion does not result in significant
narrowing of the spinal canal or neural foramina.
From C7-T1 through T2-T3, there is no disc herniation, spinal canal narrowing,
or neural foraminal stenosis.
IMPRESSION:
1. Disc degenerative changes at C5-C6 level, and right paracentral disc
protrusion C6-C7, resulting in mild anterior indentation of the spinal cord,
but minimal narrowing of the spinal canal.
2. Normal caliber and signal intensity of the visualized spinal cord without
abnormal enhancement.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with elevated LFT in the 600s-800s// eval for
cholecystitis, ductal dilation, hepatic lesion
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.3 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Splenomegaly, measuring up to 16.3 cm. Otherwise normal scan.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Numbness
Diagnosed with Other idiopathic peripheral autonomic neuropathy, Acquired hemolytic anemia, unspecified
temperature: 98.0
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with history of gout who presented
with an acute gout flare treated with colchicine and
indomethacin, who developed bilateral hand numbness and tingling
for 4 days. His exam was notable for intact strength and
reflexes, and mild decreased sensation to light touch and
temperature over bilateral hands and feet but intact to pain and
proprioception. His labs were significant for mild normocytic
anemia (Hgb 13.4, Hct 39.2, MCV 86), thrombocytopenia (PLT 146)
with occasional poiklocytes, ovalocytes and burr cells, with
reticulocyte count 2.0%. Elevated liver enzymes (AST 863, ALT
649) with normal alk phos (65) and normal total and direct
bilirubin (0.6 and <0.2, respectively). Coags were normal. LDH
was elevated (863) and haptoglobin low (<10). TSH was normal.
Hepatitis viral testing was unremarkable. Monospot was negative.
CRP was 3.0. Blood parasite smear was negative. He had an LP
that was traumatic, with >35,000 RBCs and 43 RBCs (decreased to
907 RBCs and 17 WBCs with lymphocytic predominance in tube 4).
Pending tests include direct coombs antibody testing, tick-borne
illness testing (Lyme, Babesia, Anaplasma/Ehrlicia).
The Medicine team was consulted, and together we thought his
presentation was likely secondary to a viral process in addition
to colchicine toxicity. A RUQ ultrasound showed splenomegaly
with unremarkable liver. The day of discharge his LFTs had
slightly improved to AST 819 and ALT 530. There was no evidence
of myelopathy and his C-spine MRI showed mild disc generative
changes at C5-C6 level and right paracentral disc protrusion at
C6-7.
He should avoid colchicine, acetaminophen, alcohol, and other
hepatotoxic agents until labs are improved. He should also
avoid contact sports at this time given splenomegaly.
He will have follow-up with his PCP on ___ (in 3 days) and
Neurology in 1 month. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Morphine / Femara / Amoxicillin
Attending: ___.
Chief Complaint:
dyspnea, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of HTN, DM, breast cancer,,CKD stage III, asthma and
significant kyphoscoliosis (followed by ___ Dr. ___ who
originally presented with rib fractures s/p fall and now being
transferred from ACS to medicine due to hypoxemia in the setting
of acute ___ and ___ right rib fractures.
On ___, she was at the movie theater, and when getting up from
a very low seat she lost her balance and fell backward onto the
arm rest. She had no associated lightheadedness, chest pain,
dizziness, or LOC with this episode. No head strike. She
initially presented to an OSH ED, where she was discharged home.
She was unable to tolerate the pain and became progressively
dyspneic at home, so she presented to ___ yesterday at the
urging of her PCP. Here, she was admitted to the ___ service
with aggressive pulmonary toilet. Her O2 saturation has
improved, and she is now at mid-90s on room air. CT chest
showed known rib fractures, mildly displaced, as well as a small
hemorrhagic effusion and small apical PNX. Repeat CXR today
demonstrated low lung volumes with persistence of the
pneumothorax. There appears to be worsening of the effusion on
the right side (she does have a chronic right sided pleural
effusion) as well as some associated atelectasis vs
consolidation. She denies productive cough or fevers. Her
torsemide has been held and she was given ~1L of IVF on
admission.
Currently, she denies any dyspnea, breathing comfortably on room
air, sitting up in the chair. She states that she does feel
tired and sleepy and finds it hard to stay awake. She is not
sure if this is a result of the pain medication. She continues
to have ___ right rib pain and pain with inspiration. This is
better than yesterday, when she had ___ rib pain. Denies
N/V/abdominal pain, diarrhea, dysuria, chest pain, cough, URI
symptoms. Prior to her rib fractures she states that she does
tend to be dyspneic with exertion but that her dyspnea became
notably worse after her fall.
Past Medical History:
CHRONIC KIDNEY DISEASE STAGE III
ADRENAL ADENOMA
ALLERGIC RHINITIS
ANEMIA
ASTHMA
B12 DEFICIENCY ANEMIA
BACK PAIN
BREAST CANCER
CYST/PSEUDOCYST, PANCREAS
DIABETES MELLITUS
HEARING LOSS
HYPONATREMIA
INTERNAL KNEE DERANGEMENT
BOWEL ADHESIONS
OSTEOARTHRITIS
OSTEOPENIA
SARCOMA
SCOLIOSIS
SMALL BOWEL OBSTRUCTION
SUPRAVENTRICULAR TACHYCARDIA
URINARY INCONTINENCE
PSHx:
Appendectomy
Cholecystectomy
Hysterectomy
Multiple abdominal surgeries for SBOs
Social History:
___
Family History:
- Two sisters died of breast cancer.
- Mother had stroke in her ___
- Father had DM, multiple MIs
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7/98.4 111/54 71 18 99% 2L -> 94% on RA during my
exam
General: Alert, oriented, no acute distress, did seem sleepy but
easily arousable
HEENT: Pupils equal/round, EOMI, Sclera anicteric, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: No accessory muscle use, Very kyphotic. Decreased breath
sounds and crackles right base. Apices clear. No
wheezes/rhonchi.
Back: Has lidocaine patch over right upper back. Tender to
palpation at location of rib fractures. No crepitus.
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
Left shoulder: Chronically unable to abduct without help
Neuro: Alert, oriented, no facial asymmetry, Moving all
extremities well.
DISCHARGE PHYSICAL EXAM:
Vitals: 99.3/99.3 SBP 120s-150s, this AM 160/83, 77 18 96% RA
24h: 920 in / ___ out, BMx1
General: Alert, oriented, no acute distress, sitting up and
eating breakfast
HEENT: Pupils equal/round, EOMI, Sclera anicteric, MMM,
oropharynx clear
Neck: Supple, JVP not elevated
Lungs: No accessory muscle use, Very kyphotic. Decreased breath
sounds and crackles right base. Apices clear. No
wheezes/rhonchi.
Back: Tender to palpation at location of rib fractures. No
crepitus.
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
Neuro: Alert, oriented, no facial asymmetry, Moving all
extremities well.
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-7.6 RBC-3.41* Hgb-10.3* Hct-33.0*
MCV-97 MCH-30.3 MCHC-31.3 RDW-14.1 Plt ___
___ 02:00PM BLOOD Neuts-70.3* ___ Monos-7.2 Eos-1.6
Baso-0.5
___ 02:00PM BLOOD ___ PTT-27.4 ___
___ 02:00PM BLOOD Glucose-150* UreaN-29* Creat-1.3* Na-132*
K-6.1* Cl-98 HCO3-25 AnGap-15
___ 05:15AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.3* Hct-30.2*
MCV-97 MCH-29.7 MCHC-30.7* RDW-14.3 Plt ___
___ 05:40AM BLOOD Glucose-136* UreaN-23* Creat-1.2* Na-138
K-5.0 Cl-100 HCO3-31 AnGap-12
___ 05:40AM BLOOD Phos-2.7 Mg-2.0
MICRO:
___ URINE CULTURE-negative, grew mixed flora c/w skin
contamination, not speciated
IMAGING/STUDIES:
***** ___ EKG ****
Sinus rhythm. Prominent precordial QRS voltage suggestive of
left ventricular hypertrophy. No major change from previous
tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 162 92 448/462 72 56 78
***** ___ CT CHEST, ABDOMEN, PELVIS w/o contrast****
FINDINGS:
CT CHEST: There is no axillary, hilar or mediastinal
lymphadenopathy.
Extensive coronary calcifications are seen. The pericardium is
intact without
evidence of a pericardial effusion. The intrathoracic aorta is
tortuous due
to significant scoliosis; however, no aneurysmal dilatation is
identified.
The main pulmonary artery is normal in size and configuration.
The airways are patent. There is a small right hemorrhagic
pleural effusion
as well as a small anterior right pneumothorax. 4 mm
ground-glass nodule is
seen in the right middle lobe, series 2, image 28. The left
lung overall
appears to be clear. There may be a small 4 mm lung nodule at
the left lung
base, series 2, image 28.
CT ABDOMEN: Liver is unremarkable. The patient is status post
cholecystectomy. No focal hepatic lesions concerning for
malignancy are
identified. Spleen is normal. There appears to be a rounded
soft tissue
focus at the pancreatic tail as well as additional hypodensities
in the
pancreatic head and uncinate process. There is no evidence of
pancreatic duct
dilatation. There is a large left adrenal nodule measuring
approximately 2.3
cm x 2.2 cm, series 2, image 14. Additional hypodensities
within the kidneys
bilaterally are too small to characterize by CT.
The stomach, duodenum and small bowel are normal without
evidence of wall
thickening or obstruction. There is no retroperitoneal or
mesenteric
lymphadenopathy.
CT PELVIS: Urinary bladder is unremarkable. There is no pelvic
free fluid.
No pelvic wall or inguinal lymphadenopathy is identified.
OSSEOUS STRUCTURES: Patient is status post left-sided hip
replacement. Acute
rib fractures are seen involving the ninth and tenth right
posterior ribs
which are minimally displaced. Old left-sided rib fractures are
seen. No
definite lytic or sclerotic lesions concerning for malignancy
are identified.
There is severe scoliosis at the mid thoracic spine.
IMPRESSION:
1. Acute right ninth and tenth minimally displaced rib
fractures. There is a small right-sided hemorrhagic effusion as
well as small anterior right pneumothorax.
2. Soft tissue densities along the pancreatic head, uncinate
and tail is
incompletely evaluated by this exam. Although these may be
representative of IPMNs, an MRI is recommended for further
evaluation.
3. Large left adrenal nodule measures up to 2.3 cm, which can
be further
evaluated by MRI.
4. Unchanged bilateral pulmonary nodules.
***** ___ CXR ****
PORTABLE CHEST
Compared to previous radiograph of ___ and CT torso of
___.
FINDINGS: Lung volumes are low, accentuating the cardiac
silhouette and
bronchovascular structures. Moderate right pleural effusion has
increased in
size and is accompanied by adjacent atelectasis or consolidation
in the right
lung base. Known right rib fractures are more fully
characterized on recent
CT ___. Tiny right apical pneumothorax is present,
and is
probably unchanged since the recent CT.
***** ___ LEFT SHOULDER XRAY ****
THREE VIEWS OF THE LEFT SHOULDER: Demonstrate no evidence of
acute fracture
or dislocation. There are severe degenerative changes of the
glenohumeral and
acromioclavicular joint, with joint space narrowing, subchondral
sclerosis and
subchondral cyst formation. These findings have progressed
since ___.
There is soft tissue ossification adjacent to the proximal
diaphysis of the
left humerus, which has increased in degree since ___ exam and
may represent
myositis ossificans. Multiple surgical clips project over the
proximal
humerus. The humeral head is high riding, suggestive of rotator
cuff injury.
Partially visualized right lung demonstrates no pneumothorax.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Severe osteoarthritis of the glenohumeral and
acromioclavicular joints,
progressed since ___ exam.
3. High-riding left humeral head, suggestive of underlying
rotator cuff
injury.
The study and the report were reviewed by the staff radiologist.
***** ___ CXR PA and LAT ****
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old woman with right pleural effusion
(hemorrhagic per
CT) and right sided rib fractures presented with dyspnea. Please
evaluate for
change in size of effusion. // Evaluate for progression of
right pleural
effusion
COMPARISON: Chest radiographs ___ through ___
IMPRESSION:
Previous asymmetric pulmonary edema has cleared although
pulmonary vascular
engorgement and moderate cardiomegaly persist. There is probably
a substantial
hiatus hernia, projecting to the left of the midline just above
left
hemidiaphragm. . Small right pleural effusion is the residual.
Right basal
consolidation could be either atelectasis hila or concurrent
pneumonia.
Followup advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 10 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze
6. Montelukast 10 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Torsemide 5 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QPM
11. Tamoxifen Citrate 20 mg PO QAM
12. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral TID
13. Carvedilol 25 mg PO BID
14. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
15. Clarinex (desloratadine) 5 mg oral QAM
16. Enablex (darifenacin) 15 mg oral QPM
17. Alendronate Sodium 70 mg PO DAILY
18. Januvia (sitaGLIPtin) 50 mg oral QAM
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze
3. Carvedilol 25 mg PO BID
4. Clarinex (desloratadine) 5 mg oral QAM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Enablex (darifenacin) 15 mg oral QPM
7. Escitalopram Oxalate 10 mg PO DAILY
8. Januvia (sitaGLIPtin) 50 mg oral QAM
9. Montelukast 10 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Tamoxifen Citrate 20 mg PO QAM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Torsemide 5 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Hold for sedation or respiratory rate < 12 per minute.
RX *oxycodone 5 mg half to 1 tablet(s) by mouth Up to every 4
hours Disp #*14 Tablet Refills:*0
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO HS
20. Simethicone 40-80 mg PO QID:PRN bloating, stomach upset
21. Alendronate Sodium 70 mg PO DAILY
22. Caltrate 600+D Plus Minerals (Ca-D3-mag
___ 600
mg-400 unit tablet oral BID
23. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
24. MetFORMIN (Glucophage) 850 mg PO BID
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS IH BID
26. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Right ___ and 10th rib fractures
- Dyspnea secondary to splinting
- Right pleural effusion
- Small right apical pneumothorax
- s/p fall
SECONDARY DIAGNOSES:
- Kyphoscoliosis
- Reactive airways
- Left rotator cuff injury, likely chronic
- Incidental pancreatic head lesion on CT
- Incidental left adrenal mass on CT
- Pyuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History of right-sided pain, rib fractures. Please evaluate.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: ___ MDCT images were obtained through the chest, abdomen and pelvis
without the administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axis were generated and reviewed.
FINDINGS:
CT CHEST: There is no axillary, hilar or mediastinal lymphadenopathy.
Extensive coronary calcifications are seen. The pericardium is intact without
evidence of a pericardial effusion. The intrathoracic aorta is tortuous due
to significant scoliosis; however, no aneurysmal dilatation is identified.
The main pulmonary artery is normal in size and configuration.
The airways are patent. There is a small right hemorrhagic pleural effusion
as well as a small anterior right pneumothorax. 4 mm ground-glass nodule is
seen in the right middle lobe, series 2, image 28. The left lung overall
appears to be clear. There may be a small 4 mm lung nodule at the left lung
base, series 2, image 28.
CT ABDOMEN: Liver is unremarkable. The patient is status post
cholecystectomy. No focal hepatic lesions concerning for malignancy are
identified. Spleen is normal. There appears to be a rounded soft tissue
focus at the pancreatic tail as well as additional hypodensities in the
pancreatic head and uncinate process. There is no evidence of pancreatic duct
dilatation. There is a large left adrenal nodule measuring approximately 2.3
cm x 2.2 cm, series 2, image 14. Additional hypodensities within the kidneys
bilaterally are too small to characterize by CT.
The stomach, duodenum and small bowel are normal without evidence of wall
thickening or obstruction. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT PELVIS: Urinary bladder is unremarkable. There is no pelvic free fluid.
No pelvic wall or inguinal lymphadenopathy is identified.
OSSEOUS STRUCTURES: Patient is status post left-sided hip replacement. Acute
rib fractures are seen involving the ninth and tenth right posterior ribs
which are minimally displaced. Old left-sided rib fractures are seen. No
definite lytic or sclerotic lesions concerning for malignancy are identified.
There is severe scoliosis at the mid thoracic spine.
IMPRESSION:
1. Acute right ninth and tenth minimally displaced rib fractures. There is a
small right-sided hemorrhagic effusion as well as small anterior right
pneumothorax.
2. Soft tissue densities along the pancreatic head, uncinate and tail is
incompletely evaluated by this exam. Although these may be representative of
IPMNs, an MRI is recommended for further evaluation.
3. Large left adrenal nodule measures up to 2.3 cm, which can be further
evaluated by MRI.
4. Unchanged bilateral pulmonary nodules.
Radiology Report
PORTABLE CHEST
Compared to previous radiograph of ___ and CT torso ___.
FINDINGS: Lung volumes are low, accentuating the cardiac silhouette and
bronchovascular structures. Moderate right pleural effusion has increased in
size and is accompanied by adjacent atelectasis or consolidation in the right
lung base. Known right rib fractures are more fully characterized on recent
CT ___. Tiny right apical pneumothorax is present, and is
probably unchanged since the recent CT.
Radiology Report
INDICATION: Patient status post fall with rib fractures and shoulder pain.
Assess for fracture.
COMPARISONS: ___.
FINDINGS:
THREE VIEWS OF THE LEFT SHOULDER: Demonstrate no evidence of acute fracture
or dislocation. There are severe degenerative changes of the glenohumeral and
acromioclavicular joint, with joint space narrowing, subchondral sclerosis and
subchondral cyst formation. These findings have progressed since ___.
There is soft tissue ossification adjacent to the proximal diaphysis of the
left humerus, which has increased in degree since ___ exam and may represent
myositis ossificans. Multiple surgical clips project over the proximal
humerus. The humeral head is high riding, suggestive of rotator cuff injury.
Partially visualized right lung demonstrates no pneumothorax.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Severe osteoarthritis of the glenohumeral and acromioclavicular joints,
progressed since ___ exam.
3. High-riding left humeral head, suggestive of underlying rotator cuff
injury.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old woman with right pleural effusion (hemorrhagic per
CT) and right sided rib fractures presented with dyspnea. Please evaluate for
change in size of effusion. // Evaluate for progression of right pleural
effusion
COMPARISON: Chest radiographs ___ through ___
IMPRESSION:
Previous asymmetric pulmonary edema has cleared although pulmonary vascular
engorgement and moderate cardiomegaly persist. There is probably a substantial
hiatus hernia, projecting to the left of the midline just above left
hemidiaphragm. . Small right pleural effusion is the residual. Right basal
consolidation could be either atelectasis hila or concurrent pneumonia.
Followup advised.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p fall with rib fractures, presented with
dyspnea and now improving. Want to ensure that effusion is not enlarging prior
to discharge. // Evaluate for progression of effusion and right apical
pneumothorax
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Compared to the prior radiograph, the trace right pleural effusion is not
enlarging. The left pleural effusion is not perceived. The configuration of
the cardiomediastinal contours is unchanged. The lungs are similarly clear
aside from bibasilar atelectasis. Severe degenerative changes in the
shoulders.
IMPRESSION:
No interval change in trace right pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, Back pain
Diagnosed with FRACTURE TWO RIBS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.4
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 114.0
dbp: 68.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is an ___ year-old woman with hypertension, diabetes
mellitus type II, breast cancer, CKD stage III, asthma and
significant kyphoscoliosis who originally presented with rib
fractures s/p fall and was then transferred from ACS to medicine
due to hypoxemia in the setting of acute ___ and ___ right rib
fractures. Her respiratory status improved, as detailed below,
and she was discharged to rehab after evaluation by Physical
Therapy.
# HYPOXEMIA, DYSPNEA: The patient's dyspnea and hypoxemia (desat
to ___ on room air with ambulation) was likely secondary to pain
on inspiration due to rib fractures, in the setting of low lung
volumes and significant scoliosis. There may also be a small
contribution from enlarging right sided effusion, which looked
hemorrhagic on CT and may be secondary to trauma and rib
fractures. She was treated with incentive spirometry, pain
control with acetaminophen and oxycodone, and continued on home
inhalers. On repeat chest xrays, her right-sided effusion
appeared to improve. Her respiratory status improved and she had
O2 sat of mid-90s on room air. Her small right apical
pneumothorax did not progress on repeat chest xrays.
Additionally, her hct remained stable around 30, so there was no
concern for extension of her small possibly hemorrhagic right
pleural effusion. We discussed her case with Dr. ___
patient's outpatient pulmonologist, who will continue to follow
up with the patient after discharge.
# s/p FALL: Clinical history is most suggestive of mechanical
fall. UA showed pyuria suggesting possible contribution of a
UTI. She was empirically started on IV ceftriaxone on ___ and
narrowed to cefpodoxime 200mg Q12H on discharge. Last dose
should be on ___ for a 3 day course. Urine culture grew mixed
flora that was not speciated. She was seen by physical therapy,
who suggested discharge to rehab. She was placed on Fall
Precautions while in the hospital.
# LEFT SHOULDER PAIN: On presentation, the patient had
complained about left shoulder pain. Xray of the left shoulder
showed no acute fracture and possible rotator cuff injury. The
patient states that she has baseline trouble abducting her left
shoulder, and this has not changed since her fall; therefore,
rotator cuff injury most likely chronic. This issue should be
followed up by the patient's PCP as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Labs:
___ 10:00PM BLOOD WBC-8.9 RBC-4.19 Hgb-12.0 Hct-37.7 MCV-90
MCH-28.6 MCHC-31.8* RDW-15.4 RDWSD-50.6* Plt ___
___ 10:00PM BLOOD Glucose-132* UreaN-21* Creat-0.5 Na-144
K-4.4 Cl-105 HCO3-27 AnGap-12
___ 10:00PM BLOOD ALT-18 AST-21 AlkPhos-51 TotBili-0.3
___ 10:00PM BLOOD Albumin-4.0 Calcium-10.8* Phos-3.5 Mg-1.9
___ 10:00PM BLOOD VitB12-532 Folate-6
___ 10:00PM BLOOD TSH-4.0
___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
UA:
___ 01:50AM URINE Color-Straw Appear-Clear Sp ___
___ 01:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
MICRO:
___ 1:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION. PREDOMINATING ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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
IMAGING; CT Head ___
IMPRESSION:
1. Ventricular dilatation which appears slightly
disproportionate to the degree of parenchymal volume loss
largely appears similar to the prior study from ___.
Question minimal interval increase in size of lateral ventricles
versus volume averaging artifact. While finding is nonspecific,
similar appearance may be seen in the setting of normal pressure
hydrocephalus.
2. Otherwise, no definite evidence of acute large territorial
infarction or acute intracranial hemorrhage. Please note MRI of
the brain is more sensitive for the detection of acute infarct.
3. Paranasal sinus disease with findings concerning for chronic
and/or fungal sinusitis, as described.
MRI BRAIN: ___
1. Severe hippocampal atrophy with moderate-to-severe changes of
small vessel disease are consistent with clinical diagnosis of
mixed Alzheimer's and vascular dementia.
2. No acute infarcts or mass effect.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. PredniSONE 3 mg PO DAILY
2. Gabapentin 100 mg PO QHS
3. LOPERamide 2 mg PO 1X/WEEK (WE)
4. Colchicine 0.6 mg PO ASDIR
5. CARVedilol 12.5 mg PO BID
6. MetFORMIN XR (Glucophage XR) 750 mg PO BID
7. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
9. amLODIPine 10 mg PO DAILY
10. Pravastatin 20 mg PO QPM
11. Naproxen 220 mg PO DAILY
12. oxaprozin 600 mg oral DAILY
13. Donepezil 10 mg PO QHS
14. Nystatin Cream 1 Appl TP BID
15. Cetirizine 10 mg PO DAILY
16. Sertraline 100 mg PO DAILY
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Vitamin E 400 UNIT PO QID
20. LORazepam 0.5 mg PO QHS:PRN agitation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl ___AILY:PRN Constipation - Second Line
3. Chlorthalidone 12.5 mg PO DAILY
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. amLODIPine 10 mg PO DAILY
8. CARVedilol 12.5 mg PO BID
9. Donepezil 10 mg PO QHS
10. Levothyroxine Sodium 50 mcg PO DAILY
11. MetFORMIN XR (Glucophage XR) 750 mg PO BID
12. Pravastatin 20 mg PO QPM
13. PredniSONE 3 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 400 UNIT PO QID
17.Equipment
Rx: ___ Lift
Dx: Immobility M62.3, Dementia F03.90
Duration: 12 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Moderate to severe dementia
Type 2 diabetes mellitus
HTN
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: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS, left sided weakness // ? stroke, other
intracranial pathology
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head MRI ___.
___ noncontrast head CT.
FINDINGS:
There is no evidence of acute, large territorial infarction,
fracture,hemorrhage,edema,or mass. Chronic lacunar infarcts of the left basal
ganglia and thalamus are again seen. There is prominence of the ventricles
and sulci suggestive of involutional changes. The degree of ventricular
dilatation appears slightly disproportionate to the degree of parenchymal
volume loss, which predominately appears similar to the prior study from ___, with question slight increased dilatation of the temporal horns versus
volume averaging artifact.
There are periventricular and subcortical lucencies, which may represent small
vessel ischemic changes. Atherosclerotic vascular calcifications are noted.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are preserved. Left sphenoid
sinus air-fluid level with area of high density and adjacent bony sclerosis is
noted. Right frontal sinus probable osteoma is again noted (see 3:16 on
current study and 3:4 on ___ prior exam).
IMPRESSION:
1. Ventricular dilatation which appears slightly disproportionate to the
degree of parenchymal volume loss largely appears similar to the prior study
from ___. Question minimal interval increase in size of lateral
ventricles versus volume averaging artifact. While finding is nonspecific,
similar appearance may be seen in the setting of normal pressure
hydrocephalus.
2. Otherwise, no definite evidence of acute large territorial infarction or
acute intracranial hemorrhage. Please note MRI of the brain is more sensitive
for the detection of acute infarct.
3. Paranasal sinus disease with findings concerning for chronic and/or fungal
sinusitis, as described.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with history of dementia, worsening confusion
and subtle left sided weakness. // stroke
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: No prior similar examinations for comparison.
FINDINGS:
There is severe dilatation of the temporal horns indicating hippocampal
atrophy. Extensive periventricular and subcortical hyperintensities indicate
moderate-to-severe changes of small vessel disease. Mild brain atrophy with
moderate dilatation of the ventricles is also seen.
No acute infarcts are identified. No mass effect is seen. No midline shift
identified. There are no micro hemorrhages. Artifact are seen projected over
the left frontal region minimally obscuring the details of the adjacent brain.
The nature of the artifacts is unknown. Mild mucosal thickening is seen in
the sinuses. Vascular flow voids are maintained.
IMPRESSION:
1. Severe hippocampal atrophy with moderate-to-severe changes of small vessel
disease are consistent with clinical diagnosis of mixed Alzheimer's and
vascular dementia.
2. No acute infarcts or mass effect.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 97.8
heartrate: 71.0
resprate: 20.0
o2sat: 96.0
sbp: 171.0
dbp: 100.0
level of pain: 0
level of acuity: 3.0 | ___ y/o F with PMHx of HTN, DM2, GERD, polymyositis on chronic
steroids, as well as dementia, who presented to the ED with
progressive weakness and confusion.
# Acute Encephalopathy
# Dementia
The patient presented with worsening weakness, confusion for the
past 6 weeks. However, this is superimposed on a slower
years-long decline in the setting of a dementia diagnosis. Most
likely, this represents progression of the patient's known
dementia. The patient was evaluated by neurology who did not
think that the patient's presentation was consistent with NPH.
MRI brain without acute findings and was consistent with
diagnosis of mixed Alzheimers and vascular dementia. The patient
was started on ASA for secondary prevention. Her mental status
may also have been worsened by medications recently introduced-
Gabapentin, Oxaprozin which have been held. The patient
returned to baseline mental status prior to discharge.
# POLYMYOSITIS: On chronic prednisone for many years which was
continued. CPK is lower than prior indicating polymyositis is
likely not contributing to acute presentation. Colchicine and
NSAID held for now
#Type 2 diabetes without complications:
Metformin was held while hospitalized and resumed on discharge.
# HTN: BP was quite elevated throughout much of ED stay but has
since downtrended. Of note, review of most recent ___ clinic
visit note also mentions a BP of 203/75 on arrival with
improvement to 140/70 during exam. Per daughter no longer on
Lisinopril at home. BP frequently elevated in AM and then
improves throughout the day. The patient was continued on her
home regimen of amlodipine, carvedilol. Did not aggressively
control blood pressure in setting of advanced dementia.
Chlorthalidone was initiated at a low dose of 12.5mg daily for
BP
- titrate BP meds as needed
# DEMENTIA: Mixed components of Alzheimer's disease and vascular
disease per neuro notes. She was most recently seen by her
neurologist (Dr. ___ in ___, as which time it was noted,
"Overall she continues to have a slow decline is now somewhere
between moderate and severe in terms of her stage of dementia."
Addition of memantine was discussed at that time; however, the
patient declined additional medications. Continued home
donepezil, sertraline
# HLD:
- continued home statin
# HYPOTHYROIDISM
- continued home levothyroxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / lisinopril / amlodipine
Attending: ___.
Chief Complaint:
Bright red blood per rectum, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmhx Alzheimer's, recent decline with plan for home hospice
but not set who presents with BRBPR, AMS.
Per report she has had ongoing decline but more acutely (2d)
became obtunded with melena and BRBPR, found to have BRBPR
witnessed by EMS. EMS notes she was hypotensive with systolic in
___, hypothermic, finger stick BS 35.
She was treated with dextrose and brought to the hospital.
In ED
Initial VS: 30.8, 127/94, HR 61, 15, 100% RA
Labs significant for: Hgb 8.6 (b/l 10.5), WBC 5.2, Mild
transaminitis, Alb 2.7, BUN 63, Cr 1.0
Patient was given: Broad abx (vanc/cef), stress dose steroids,
1L IVF
Imaging notable for: clean CXR
Consults:
-- GI: IV PPI, Will follow
GOC was briefly discussed with family in ED, DNR but OK to
intubate.
On arrival to the MICU, she is alert but not interactive with
team. She does not answer any questions, does not follow any
directions.
Past Medical History:
- Alzheimer's disease
- HTN
- HLD
- CKD (b/l Cr 1.0)
- Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
VITALS: Reviewed in metavision, admission weight 31kg
GEN: Cachectic, non-interactive
HEENT: MM tacky, EOMI
CV: RRR nl s1/s2, no mrg
PULM: CTA b/l, no wrc
GI: S/ND/NT
EXT: WWP, thin, non-edematous
Discharge physical exam:
___ 10 98 Ra
GENERAL: Cachectic elderly woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink.
NECK: Supple with no LAD or JVD.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA
bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric.
Extremely thin.
SKIN: Warm, dry, no rashes or obvious lesions.
Pertinent Results:
ADMISSION LABS:
___ 11:51AM WBC-5.2 RBC-3.12* HGB-8.6* HCT-26.5* MCV-85
MCH-27.6 MCHC-32.5 RDW-16.8* RDWSD-50.9*
___ 11:51AM PLT SMR-LOW* PLT COUNT-104*
___ 11:51AM ___ PTT-31.2 ___
___ 01:23AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:51AM CORTISOL-91.1*
___ 11:51AM TSH-6.7*
___ 11:51AM ALBUMIN-2.7*
___ 11:51AM LIPASE-11
___ 11:51AM ALT(SGPT)-116* AST(SGOT)-81* ALK PHOS-147*
TOT BILI-0.3
___ 11:51AM GLUCOSE-291* UREA N-63* CREAT-1.0 SODIUM-136
POTASSIUM-5.4 CHLORIDE-99 TOTAL CO2-22 ANION GAP-15
___ 12:03PM LACTATE-2.8*
___:03PM ___ PO2-36* PCO2-57* PH-7.28* TOTAL
CO2-28 BASE XS--1
___ 03:27PM TYPE-ART PO2-118* PCO2-33* PH-7.41 TOTAL
CO2-22 BASE XS--2
___ 03:43PM CALCIUM-7.7* PHOSPHATE-5.5* MAGNESIUM-2.0
___ 01:36AM BLOOD ___ pO2-58* pCO2-34* pH-7.45
calTCO2-24 Base XS-0
___ 01:36AM BLOOD Lactate-1.6
___ 10:08PM BLOOD WBC-5.9 RBC-3.34* Hgb-9.4* Hct-26.9*
MCV-81* MCH-28.1 MCHC-34.9 RDW-15.0 RDWSD-43.8 Plt ___
___ 01:30AM BLOOD WBC-5.7 RBC-2.84* Hgb-8.1* Hct-23.7*
MCV-84 MCH-28.5 MCHC-34.2 RDW-15.5 RDWSD-46.4* Plt Ct-93*
___ 09:10AM BLOOD WBC-6.5 RBC-2.63* Hgb-7.5* Hct-21.6*
MCV-82 MCH-28.5 MCHC-34.7 RDW-15.8* RDWSD-46.2 Plt Ct-86*
___ 02:31PM BLOOD WBC-6.4 RBC-2.70* Hgb-7.6* Hct-22.1*
MCV-82 MCH-28.1 MCHC-34.4 RDW-15.9* RDWSD-46.5* Plt Ct-91*
IMAGING:
CXR ___
FINDINGS:
AP portable upright view of the chest. Multiple overlying EKG
leads are
present. The lungs appear lucent and hyperinflated. No signs
of pneumonia or
edema. No large effusion or pneumothorax is seen. Heart is
mildly enlarged
though unchanged. Aortic calcifications again noted. The
mediastinal contour
is normal. No acute osseous abnormality.
IMPRESSION:
No acute findings in the chest.
MICROBIOLOGY:
___ 1:23 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood cultures pending at ___.
DISCHARGE LABS:
Labs not checked on day of DC.
Medications on Admission:
None
Discharge Medications:
None.
Hospice will manage home symptom management meds.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hematochezia
Anemia
Advanced dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with altered mental status// r/o acute process
COMPARISON: Prior from ___
FINDINGS:
AP portable upright view of the chest. Multiple overlying EKG leads are
present. The lungs appear lucent and hyperinflated. No signs of pneumonia or
edema. No large effusion or pneumothorax is seen. Heart is mildly enlarged
though unchanged. Aortic calcifications again noted. The mediastinal contour
is normal. No acute osseous abnormality.
IMPRESSION:
No acute findings in the chest.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified, Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is an ___ woman with a history of advanced
dementia secondary to Alzheimer's disease who presents with
altered mental status and hematochezia.
# GOC
Presently patient is DNR, DNI. Patient has had a marked
cognitive decline over the past several months and the family
had been considering transitioning to ___, but had not
yet pursued this. Multiple goals of care conversations in the
ICU with family, and decision was made to not pursue
interventions including imaging, EGD, colonoscopy, chest
compression, shocks or intubation. Transfusions, finger sticks
and IV fluids are all within goals. Family has decided to pursue
hospice and preference is home hospice. Case management was
involved in hospice coordination and Ms. ___ is being
discharged with home hospice. For symptom management, we
continued IV Tylenol for pain (ulcers).
# BRBPR
# Anemia
Hemodynamically stable, BUN elevated. Given BRBRP + stable
hemodynamics, likely lower GIB. Presently HDS with fluids &
blood, ongoing maroon stool. Diverticular vs angiodysplasia
(unlikely) vs malignant. EGD or colonoscopy is not within goals
of care. However, supportive blood transfusion and IV fluids are
both within her goals WHILE inpatient. Fluids were bolused as
needed. She was treated with an IV PPI for her inpatient stay. 2
large-bore IVs were maintained an active type and screen was
maintained. She only required 1 blood transfusion throughout
this admission which was on ___. Hemoglobin and hematocrit
remained stable thereafter and labs were not checked towards the
end of her admission as she was clinically stable.
# Hypothermia
By history, lab, imaging no clear evidence for infectious
source. TSH elevated. Nutritional status in setting of
significant Alzheimer's could be driving it as well. Alb 2.6.
Antibiotics were discontinued as we did not feel that she had an
infection.
# Alzheimer's dementia
Baseline nonverbal. End stage.
# Hypoglycemia Likely iso poor PO intake, low liver stores.
Fingersticks were checked 4 times daily, IV dextrose was given
as needed for hypoglycemia, and maintenance fluids with D5 NS
were given as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Poultry
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
appendectomy
History of Present Illness:
___ year old male otherwise healthy who last night began to
feel unwell after dinner. States he had vague nausea and crampy
lower abdominal pain. Had a bowel movement that was regular that
gave him some relief. This morning, he began to have recurrent
abdominal pain. By this afternoon the pain was constant and more
right sided in the lower abdomen. He last ate at 4pm. He denies
emesis or fevers.
He states he was out this evening and had an episode where his
abdominal pain acutely worsened and he experienced profuse
sweating. He felt the chills come on. He became acutely
lightheaded and had to be helped to the ground. He states when
his legs were held above the level of his heart he felt better.
He was taken by ambulance to ___ for further evaluation.
Here, he states his abdominal pain is improved after a dose of
morphine. He denies nausea at this point. He is passing flatus.
Past Medical History:
denies
Social History:
___
Family History:
CAD, bladder cancer
Physical Exam:
98.4 60 127/65 18 98% RA
GEN: NAD, alert and oriented x3
HEENT: oropharynx clear
CV: RRR, nml s1+s2
PULM: nonlabored and regular respirations, clear
ABD: soft, no distention, minimally tender. Wound d/c/i.
Bilateral inguinal hernia.
EXT: warm, well perfused. 2+ dp pulses. no lower extremity edema
Pertinent Results:
___ 12:15AM WBC-12.7* RBC-5.13 HGB-15.8 HCT-46.3 MCV-90
MCH-30.8 MCHC-34.2 RDW-13.1
___ 12:15AM GLUCOSE-118* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 (One) capsule(s) by mouth
twice a day Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink alcohol, drive, or operate heavy machinery while
taking this medication
RX *oxycodone 5 mg 1 (One) capsule(s) by mouth every four (4)
hours Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with lower abdominal pain, nausea, peritoneal signs on
examination.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of 130cc intravenous contrast. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 316 mGy-cm
CTDIvol: 6 mGy
COMPARISON: None
FINDINGS:
CHEST: The visualized lung bases are clear. There is no pleural or
pericardial effusion.
ABDOMEN:
The liver is normal in attenuation with subcentimeter hypodensities in segment
8 and 7, too small to characterize. There is no intrahepatic biliary
dilatation. The gallbladder is normal with no radio-opaque gallstones. The
pancreas is normal with no peripancreatic fat stranding or fluid collections.
The spleen is normal in size and homogeneous in attenuation. The adrenal
glands are normal in size and morphology. The kidneys enhance symmetrically
and display prompt contrast excretion with no focal lesions or hydronephrosis.
The distal esophagus and stomach are normal. The small and large bowel are
normal in caliber with no wall thickening. The appendix is fluid-filled and
dilated, measuring up to 9 mm at the tip. There is a paucity of surrounding
inflammatory changes, but the morphology of the appendix indicates early
appendicitis. There is no retroperitoneal or mesenteric lymphadenopathy by CT
size criteria. There is no intraabdominal free air or free fluid.
PELVIS: The distal ureters and urinary bladder are normal. The reproductive
organs are unremarkable. There is no pelvic side-wall or inguinal
lymphadenopathy by CT size criteria. No free pelvic fluid is identified.
VESSELS: The aorta is normal in caliber and its major branches are patent.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
Fluid dilated appendix measuring up to 9 mm, with a paucity of surrounding
inflammatory changes, likely represents early appendicitis.
NOTIFICATION: Findings were relayed to Dr. ___ by Dr. ___
telephone at 02:32 on ___, upon discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.1
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 133.0
dbp: 89.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed appendicitis. WBC was
elevated at 12.7. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor on
IV fluids, and dilaudid for pain control. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Arthralgia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH HTN, Afib on Coumadin, MVR and TVR from rheumatic
heart disease in ___, HFrEF EF 25% on ___, noncrystal
proven gout on allopurinol with recent admission in early
___ with presumed gout flare who presents for evaluation of
supratherapeutic INR noted yesterday, downtrending HCT x 8
weeks, and polyarthralgias.
Pt c/o continued left ankle, left wrist, left elbow pain,
acutely worse x4 days, with pain never fully resolved from last
inpt admission. Notes possible concentrated urine with redness,
as well as darkened stool. No fevers, no dyspnea, no chest pain,
no cough.
INR noted to be ___ yesterday at ___, Hgb 6.6 there, given
2.5mg Vit K.
In the ED, initial vitals were:
97.6 85 127/62 18 100% RA
Exam notable for
Left ankle warm, mildly erythematous, TTP, left wrist and left
elbow likewise TTP
POCUS - Pericardial effusion without apparent tamponade
Labs showed
WBC 15.8, Hgb 7.1, plt 265
Chem 7 wnl with creatinine 1.0
ALT 48, AST 62, AP 105, Tbili 1.4, Alb 3.3
UA 14 wbc, few bacteria, negative nitrites, <1 epi
INR 2.4
Received 1g ceftriaxone
Cardiac surgery was consulted and recommended deferral of
management to medicine/cardiology, a formal TTE, and
consideration of rheumatology consult for recurrent gout.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports pain in his left ankle,
left knee, left elbow, and left third finger pain. He says these
symptoms have been present for the past 19 days. He also reports
lower abdominal pain but denies any dysuria, hematuria, or
increased frequency. No cough, SOB, CP, nausea, vomiting,
diarrhea, weakness, numbness. He does endorse constipation.
Past Medical History:
HFrEF EF 25% in ___
Atrial fibrillation
Hypertension
History of CAD with Prior MI
Tricuspid Regurgitation s/p TV repair
Mitral regurgitation s/p MV repair
Gout
GERD
Right eye peripheral blindness
Social History:
___
Family History:
No premature coronary artery disease
Physical Exam:
=============
ADMISSION EXAM
=============
Vital Signs: 98.7 152/91 96 18 97% RA.
Weight: 86.3 kg
Pulsus: 8 mmHg
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Mildly tachycardic, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, trace pedal edema, left ankle, left
wrist, and left elbow are TTP, swollen, and warm to the touch.
Neuro: CNII-XII intact, alert and oriented, moving all
extremities spontaneously and with purpose
=============
DISCHARGE EXAM
=============
Vitals: T: 97.9 P: 79 BP: 140/74 R: 18 O2: 97% on RA.
Weight: 84.8 kg
General: ___ speaking patient. Comfortable, no acute
distress.
HEENT: Sclera anicteric, PERRLA, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, no cyanosis, left ankle 1+ edema and
warm to palpation.
Skin: no observable discoloration or wounds
Neuro: A&Ox3, purposeful movement in all extremities
Pertinent Results:
=============
ADMISSION LABS
=============
___ 07:50PM URINE HOURS-RANDOM
___ 07:50PM URINE UHOLD-HOLD
___ 07:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
___ 07:50PM URINE RBC-3* WBC-14* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:50PM URINE AMORPH-RARE
___ 07:50PM URINE MUCOUS-RARE
___ 05:16PM GLUCOSE-171* UREA N-20 CREAT-1.0 SODIUM-136
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
___ 05:16PM estGFR-Using this
___ 05:16PM ALT(SGPT)-48* AST(SGOT)-62* LD(LDH)-1068* ALK
PHOS-105 TOT BILI-1.4
___ 05:16PM ALBUMIN-3.3* IRON-31*
___ 05:16PM calTIBC-261 FERRITIN-372 TRF-201
___ 05:16PM CRP-33.7*
___ 05:16PM WBC-15.8* RBC-UNABLE TO HGB-7.1* HCT-25.0*
MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO
RDWSD-UNABLE TO
___ 05:16PM NEUTS-71 BANDS-0 LYMPHS-18* MONOS-8 EOS-1
BASOS-0 ___ METAS-2* MYELOS-0 AbsNeut-11.22* AbsLymp-2.84
AbsMono-1.26* AbsEos-0.16 AbsBaso-0.00*
___ 05:16PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ TARGET-OCCASIONAL
SCHISTOCY-1+ BURR-OCCASIONAL FRAGMENT-OCCASIONAL
___ 05:16PM PLT SMR-NORMAL PLT COUNT-265
___ 05:16PM ___ PTT-32.8 ___
================
PERTINENT IMAGING
================
TRANSTHORACIC ECHOCARDIOGRAM (___):
The estimated right atrial pressure is ___ mmHg. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. A mitral valve
annuloplasty ring is present. Mild (1+) mitral regurgitation is
seen. A tricuspid valve annuloplasty ring is present. The
tricuspid prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. There is a moderate to large
sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION:
1) Moderate to severe regional left ventricular systolic
dysfunction c/w prior myocardial infarction in the RCA
territory.
2) Moderate likely circumferential pericardial effusion without
specific echocardiographic signs of tamponade and normal RA
pressure.
Compared with the prior study (images reviewed) of ___,
compared to prior images the inferolateral wall has been better
visualized now ischemic cardiomyopathy in distribution of a
dominant RCA is visualized. Findings are similar in particular
the size of the pericardial effusion.
CXR (___):
FINDINGS:
Sternotomy. Bibasilar consolidations have nearly resolved.
Increased heart
size, improved since prior. Pulmonary vascularity has improved.
No edema. No effusion. No pneumothorax.
IMPRESSION:
Improve may since prior.
==============
PERTINENT MICRO
==============
___ 7:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 8 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ 3:28 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
=============
DISCHARGE LABS
=============
___ 06:30AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
___ 06:30AM BLOOD Glucose-79 UreaN-11 Creat-0.9 Na-137
K-4.5 Cl-101 HCO3-24 AnGap-17
___ 06:30AM BLOOD ___ PTT-30.3 ___
___ 06:30AM BLOOD WBC-11.8* RBC-2.95* Hgb-7.7* Hct-24.9*
MCV-84 MCH-26.1 MCHC-30.9* RDW-21.4* RDWSD-62.4* Plt ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Digoxin 0.0625 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
8. Carvedilol 12.5 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Lisinopril 2.5 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Omeprazole 20 mg PO DAILY BEFORE BREAKFAST
13. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY
This medication should be taken for six months.
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Warfarin 1 mg PO DAILY16
Goal INR ___.
6. Lisinopril 5 mg PO DAILY
7. Senna 17.2 mg PO HS
8. Allopurinol ___ mg PO DAILY
9. Amiodarone 100 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Carvedilol 12.5 mg PO BID
13. Digoxin 0.0625 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Omeprazole 20 mg PO DAILY BEFORE BREAKFAST
16. Polyethylene Glycol 17 g PO DAILY
17. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
Hemolytic anemia, mechanical
Acute gout flare
Pericardial effusion
SECONDARY:
History of heart failure with reduced ejection fraction
History of atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleuritic chest pain // please evaluate for
acute cardiopulmonary process
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Sternotomy. Bibasilar consolidations have nearly resolved. Increased heart
size, improved since prior. Pulmonary vascularity has improved. No edema.
No effusion. No pneumothorax.
IMPRESSION:
Improve may since prior.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Anemia, unspecified
temperature: 97.6
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with a PMH significant for HTN,
atrial fibrillation, mitral and tricuspid valve regurgitation
and repair of both ~2 months prior, CHF, and gout evaluated due
to a supertherapeutic INR of 4.8, 8 weeks of downtrending Hct,
and joint pain. He was admitted due to his above issues as well
as pericardial effusion and anemia found on initial evaluation.
Workup notable for a hemolytic anemia (likely mechanical due to
recent valve repair), moderate-sized pericardial effusion
without tamponade physiology, and no evidence of UTI. No
hemodynamic instability or lab work consistent with DIC.
Hemoglobin stabilized prior to discharge, and supra therapeutic
INR resolved after correction with Vitamin K and holding
warfarin for several days (restarted prior to discharge).
Folate/iron/B complex vitamins provided for his anemia. Given
patient continued to complain of moderate left ankle joint on
day of discharge, he was discharged on an extra 5 days of
colchicine 0.6 mg PO BID.
=================
TRANSITIONAL ISSUES
=================
# CODE: presumed full
# CONTACT: cousin ___ # ___
# Patient will need repeat echocardiogram in 7 days and then
frequency to be determined thereafter. THIS NEEDS TO BE
SCHEDULED PLEASE.
# MEDICATION CHANGES:
- Added colchicine (0.6mg daily), to be continued for a total of
6 months.
- Added ferrous sulfate 325mg daily.
- Discontinued furosemide. Can be restarted if clinically
volume overloaded.
- To continue taking warfarin indefinitely given prior Afib and
anticoagulation risk. Start with 1mg daily, titrate to goal INR
___.
# FOLLOW-UP LABS:
- Please monitor CBC once weekly to ensure stability and
evaluate for worsening hemolysis.
- Please check INR, goal ___.
# WARFARIN DOSING: Came in supratherapeutic on warfarin 2mg
daily. Please titrate to goal ___ as above.
Discharge weight: 84.8 kg
Discharge Hg: 7.7
Discharge Cr: 0.9
Discharge INR: 1.4 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C2 odontoid fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old healthy young man who presents after a
fall
from a top bunk bed. His roomate heard a thud and found him face
down on the floor. He immediate regained consciousness without
any confusion. He denies ETOH or illicits. He currently reports
neck and back pain but no weakness, numbness or bowel or bladder
changes.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on Admission
96.7 49 122/77 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact
Neck: C-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact propioception, pinprick and
bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
Toes downgoing bilaterally
Rectal exam normal sphincter control
Exam on Discharge
A&Ox3, PERRL, EOMI, MAE ___
Pertinent Results:
___ NCHCT
1. Normal brain CT.
2. Dens fracture is partially imaged. Please refer to
concurrent CT C-spine report.
___ CT C-spine
1. Comminuted fracture of base of the dens with vertical and
horizontal
components.
2. The dens is angulated posteriorly and displaced slightly to
the left.
3. Oblique fracture through the upper portion of the odontoid.
___ Cervical MRI
Odontoid fracture is not well visualized as on CT and there is
no surrounding edema. No spinal canal narrowing or spinal cord
compression seen. No evidence of ligamentous disruption.
___ Cervical CTA
Hypoplastic right vertebral artery ending in the distal neck.
No evidence of dissection.
Cervical Spine-Non Trauma: ___
IMPRESSION:
Displaced odontoid fracture as detailed above.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN neck pain
Do not exceed more than 4 grams of tylenol in 24hrs.
2. Cyclobenzaprine 10 mg PO TID spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. TraZODone 25 mg PO QHS:PRN insomnia
Follow up with your PCP for further prescriptions.
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth Q HS Disp
#*4 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
pain/headcahe
Please do not drive or operate mechanical machinery while taking
pain meds.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4 hrs Disp #*90
Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 3 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth Q 8hrs Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
C2 odontoid fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Q25
INDICATION: ___ year old man with C2 and dens fracture // ? vert dissection
TECHNIQUE: Following contrast administration and departmental protocol CT
angiography of the neck was obtained.
DOSE: Total DLP (Head) = 1,185 mGy-cm.
COMPARISON: None
FINDINGS:
CT angiography of the neck shows normal appearance of the carotid and
vertebral arteries without stenosis or occlusion or dissection. The right
vertebral artery is very small in size and terminates in the distal neck.
This appears to be congenital hypoplasia given the small size of the right
vertebral foramen. There is odontoid fracture seen as demonstrated on the
previous cervical spine CT.
IMPRESSION:
Hypoplastic right vertebral artery ending in the distal neck. No evidence of
dissection.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man with a C2 odontoid fracture now in a collar/vest.
// evaluation of cervical alignment with while in brace. evaluation of
cervical alignment with while in brace.
TECHNIQUE: Two views
COMPARISON: No prior radiographs. Comparison made with ___ CT.
FINDINGS:
There is a fracture through the odontoid process, with about 5 mm of posterior
displacement of the cranial component. Of note, the caudal component is
positioned slightly anterior to the posterior cortex of the anterior arch of
C1. No other bony injury. There is some associated prevertebral soft tissue
swelling in the upper cervical spine.
Note that no open mouth view is provided.
IMPRESSION:
Displaced odontoid fracture as detailed above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ s/p fall with head trauma // r/o injury
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or large mass. The
ventricles and sulci are normal in size and configuration.
Dens fracture is partially imaged. The paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Normal brain CT.
2. Dens fracture is partially imaged. Please refer to concurrent CT C-spine
report.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with s/p fall with head trauma // r/o injury
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.4 s, 24.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 921.7
mGy-cm.
Total DLP (Body) = 922 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is a comminuted fracture of C2 with a transverse fracture line through
the base of the odontoid. The dens is angulated posteriorly and displaced
slightly to the left. There is also a vertically oriented oblique fracture
extending through the upper portion of the odontoid. There is no evidence of
spinal canal stenosis. There is mild prevertebral soft tissue swelling
anterior to C2.
IMPRESSION:
1. Comminuted fracture of base of the dens with vertical and horizontal
components.
2. The dens is angulated posteriorly and displaced slightly to the left.
3. Oblique fracture through the upper portion of the odontoid.
NOTIFICATION: The findings were discussed by ___ with ___
on the telephone on ___ at 5:58 AM.
Radiology Report
EXAMINATION:
MRI OF THE CERVICAL SPINE
INDICATION: ___ year old man with C2 and dens fracture // ligamentous injury
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient sequence T2
axial images of cervical spine obtained.
COMPARISON: Cervical spine CT ___.
FINDINGS:
The fracture of odontoid process visualized on the CT is not clearly apparent
on the MRI. No significant surrounding edema seen within the C2 vertebra.
Small area of increased signal between the spinous processes of C1 and C2
indicate mild soft tissue trauma and supports a an acute fracture despite the
absence of edema at the fracture site. There is no evidence of ligamentous
disruption identified. There is no significant vertebral malalignment seen.
There is no intraspinal hematoma or spinal cord compression. No abnormal
signal is seen within the spinal cord.
IMPRESSION:
Odontoid fracture is not well visualized as on CT and there is no surrounding
edema. No spinal canal narrowing or spinal cord compression seen. No evidence
of ligamentous disruption.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: s/p Fall, Neck pain
Diagnosed with FX C2 VERTEBRA-CLOSED, FALL-1 LEVEL TO OTH NEC
temperature: 96.7
heartrate: 49.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ was admitted to the floor from the emergency room
after a CT of his cervical spine showed a C2 odontoid fracture.
A CTA of the neck was obtained to rule out vertebral dissection
which showed no acute findings and no evidence of dissection. A
MRI of the cervical spine was also obtained to rule out
ligamentous damage.
On ___, the patients exam remains stable. He continues to wear
his cervical collar. His MRI was negative for any ligamentous
injury. He will be fit for a long term cervical collar today.
If he can tolerate the cervical collar he can continue to wear
that until cleared, otherwise he will have to wear a halo. Dr.
___ to discuss with the patient today.
On ___, the patient remained neurologically and hemodynamically
stable. An Xray of the cervical spine was obtained to evaluate
his fracture in the new collar. He is to wear the collar on at
all times. Case management is working on transportation to rehab
in ___.
On ___, the patient and family expressed readiness to be
discharge home. However, the patient was uncomfortable with his
brace. Rep from the brace shop was called to re-evaluate fitting
of the neck brace. Physical therapy evaluated the patient for
home safetyness and recommended dispo to home. The patient was
discharged home in stable conditions. All discharge instructions
and follow up was given prior to leaving. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Pertussis Vaccine,Fluid
Attending: ___.
Chief Complaint:
possible wound infection
Major Surgical or Invasive Procedure:
___ revision
___ placement.
History of Present Illness:
___ y/o F with s/p L1-5 laminectomies and resection of T3-4
meningioma presents to ___ today from rehab for evaluation.
While
at her appointment, it was noted that her incision was
erythematous and painful to touch with sutures in place. She was
told to present to the ED for further evaluation by
neurosurgery.
Patient reports pain to palpation of incision, but denies any
drainage, fevers, chills, numbness, tingling, weakness, or bowel
or bladder dysfunction. The risks and benefits of surgical
intervention were discussed and the patient consented to the
procedure.
Past Medical History:
1. T-spine meningioma as above
2. Diabetes
3. Hypertension
4. Dyslipidemia
Social History:
___
Family History:
She has two healthy daughters. She has one healthy
sister. Her mother is alive. Her father died at ___.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T:97.9 BP:147/77 HR:90 R: 20 O2Sats: 96%
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch
Incision: erythematous with sutures in place burrowed into skin,
no active drainage, dehiscence of wound, or hematoma.
PHYSICAL EXAMINATION ON DISCHARGE:
A&OX3,
MAE ___
Senstion intact to light touch
Incision cd&i with staples and sutures
Pertinent Results:
MRI Thoracic Spine: ___
The extradural collection extending from C7-T1 through the T3-4
level has
increased in size and causes more mass effect on the thecal sac.
There is no abnormal cord signal. Mild myelomalacia at the T3-T4
level is unchanged. The subcutaneous soft tissue fluid
collection overlying the laminectomy site has also increased in
size now measuring 6.2 x 4.9 x 9.1 cm. otherwise unchanged from
prior thoracic spine MRI dated ___.
Chest Xray: ___
FINDINGS:
As compared to the previous radiograph, the PICC line has been
slightly pulled back and is now in the mid-to-low SVC. No
evidence of
complications, notably no pneumothorax. The remaining
monitoring and support devices are unchanged.
Medications on Admission:
colace, dilaudid, keflex, lantus, lexapro, novolog pen, tricor,
vitamin D2, zocor, amitriptyline, flexeril, heparin, metformin,
metorprolol, morphine, tizanidine
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Bisacodyl 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. Heparin 5000 UNIT SC TID
6. Glargine 10 Units Breakfast
Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. MetFORMIN (Glucophage) 1500 mg PO BID
8. Morphine SR (MS ___ 15 mg PO Q12H
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
this medication/ narcotics.
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4hrs
Disp #*60 Tablet Refills:*0
10. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
11. Nystatin Ointment 1 Appl TP QID:PRN the fungus
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Nafcillin 2 g IV Q4H
Antibiotic Stop date: ___
14. Senna 8.6 mg PO BID
15. Simvastatin 40 mg PO DAILY
16. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
17. Tizanidine 6 mg PO TID
18. Tricor (fenofibrate nanocrystallized) 48 mg ORAL HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Staphlococcus aureus coagulase positive wound infection
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: Thoracic spine MRI without and with contrast.
INDICATION: History: ___ with thoracic meningioma resection, now with wound
erythema,discharge // presence of fluid collection, abscess formation
TECHNIQUE: Thoracic spine MRI and obtained pre and post intravenous
administration of 10 cc of Gadavist. The following sequences were utilized:
Sagittal T2, sagittal T1, sagittal STIR, axial T2, sagittal T1 post and axial
T1 post.
COMPARISON: Thoracic spine MRI dated ___.
FINDINGS:
The patient is status post T1 through T5 laminectomy and resection of
intradural extramedullary enhancing lesion at the T3-T4 level. There is
unchanged focal thinning and myelomalacia at this level.
Dorsal to the cord the extra dural fluid collection extending from C7-T1 to
the T3-T4 level has increased in size and now measures 1.8cm x 1.1cm x 6.5cm
(TV x AP x SI) versus 1.7cm x 1.2cm x 7.8 cm (TB x AP x SI). There is also
increased mass effect on the thecal sac at these levels with no visualized CSF
space surrounding the cord. There is no abnormal cord signal. The curvilinear
low level enhancing tissue posterior to the thecal sac at the T4 level is
unchanged.
The subcutaneous soft tissue fluid collection overlying the laminectomy site
has also increased in size now measuring 6.2cm x 4.9cm x 9.1cm (TV x AP x SI).
There is unchanged left paracentral disc protrusion at T6-T7, which abuts and
remodels the thoracic cord. There are no other significant degenerative
changes identified.
The vertebral body heights and alignment are maintained. The bone marrow
signal is mildly heterogeneous without a focal suspicious lesion. The conus
medullaris is normal in appearance and terminates at the L1-L2 level.
IMPRESSION:
The extradural collection extending from C7-T1 through the T3-4 level has
increased in size and causes more mass effect on the thecal sac. There is no
abnormal cord signal. Mild myelomalacia at the T3-T4 level is unchanged.
The subcutaneous soft tissue fluid collection overlying the laminectomy site
has also increased in size now measuring 6.2 x 4.9 x 9.1 cm.
Otherwise unchanged from prior thoracic spine MRI dated ___.
Case discussed with the physician assistant ___ via telephone by Dr.
___ at 10:45am on ___, immediately after the findings were made.
Radiology Report
HISTORY: Erythematous incision, question infection. Preop evaluation.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. Lungs are
well expanded and clear. There is no focal consolidation, pleural effusion or
pneumothorax.
IMPRESSION:
Normal chest radiographs.
Radiology Report
AP CHEST, 10:38 P.M., ___
HISTORY: ___ woman with a new left IJ line.
IMPRESSION: AP chest compared to ___:
Tip of the new left internal jugular line projects over the origin of the SVC.
No pneumothorax, pleural effusion, or mediastinal widening. Lungs clear.
Heart size normal.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Right PICC line placement.
FINDINGS: The right PICC line shows a normal course. However, the tip is in
the inferior vena cava. The line must be pulled back by approximately 9 cm.
The left internal jugular vein catheter is in unchanged position. No
pneumothorax or other complications.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement.
COMPARISON: ___, 5:29 p.m.
FINDINGS: As compared to the previous radiograph, the PICC line has been
slightly pulled back and is now in the mid-to-low SVC. No evidence of
complications, notably no pneumothorax. The remaining monitoring and support
devices are unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-PROCEDURE NOS
temperature: 97.9
heartrate: 90.0
resprate: 20.0
o2sat: 96.0
sbp: 147.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | ___ y/o F s/p L1-5 laminectomies and resection of meningioma
presents with erythematous incision concerning for infection.
Patient was admitted to the neurosurgery service. An MRI of the
T spine shows fluid collection at C7-T1 through, T3-4 level with
increased mass effect. Patient was made NPO and pre opped for
the OR tomorrow morning
On ___ Patient remained neurologically intact. She was taken to
the OR for a wound revision. Intraoperatively, patient had an
inflitrated L arm. She was extubated and transferred to the PACU
for recovery. She remained stable post operatively and was
transferred to the floor in stable condtion. ID was consulted.
On ___, patient remained stable, incision was clean and intact.
She was started on vancomycin and cefepime while awaiting ID
recommendations. A PICC line was ordered and she was consented
for the PICC. An MRI was ordered to check for an residual
postoperative fluid collection, however, the patient was too
anxious and unable to lay still for exam.
On ___, the patient remained stable. Her Vanco level was 7.2,
her vancon was redosed. A PICC line was placed for antibiotic
administration, with good placement. The TLC catherter was
removed.
On ___, the patient remained stable. Her hemovac was removed
without difficulty, the wound is slowly improving. Based on
Infectious Disease recommendations, the patient's vancomycin and
cefepime were discontinued. She was then started on Nafcillin 2
grams every four hours. The course of therapy is expected to be
approximately four weeks. The ID service will contact the
___ rehabilitation facility to schedule a follow-up visit.
As noted on the discharge summary, the patient will need to
have weekly CBC with differential, BUN, Cr and LFTs ordered.
On ___, the patient remained neurologically stable and was
awaiting acceptance to a rehabilitation facility.
On ___ she continued to mobilize and was neurologically stable
while awaiting rehab bed.
On ___, the patient remained neurologically and hemodynamically
intact. She was discharge to the rehab facility in stable
conditions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fluphenazine / Penicillins / Phenothiazines / Prolixin
Attending: ___
Chief Complaint:
hypotension and respiratory failure
Major Surgical or Invasive Procedure:
intubation, arterial line placement, temporary central line
placement, PICC line placement
History of Present Illness:
___ yo female history of schizoaffective disorder and dementia
from nursing home found unresponsive by staff with copious
secretions in mouth. She was satting at ___'s. Placed on NC and
sats improved to ___. Vitals 97.5, 104/51, 110, 22, 69-71% 2L
NC. EMS called and BP in the ___ and sats in the ___. Gave 1L
IVF and NRB with sats in the ___.
Patient was evaluated at ___ and initial vitals: 102.2, 100,
40, 130/80, 88% on 15L NRB. CXR showed no acute process. CT head
noted no acute process, but with diffuse atrophy and
microvascular leukoencephalopathy. Neuro exam showed deviated
left eye and had aginal congestive breathing and hypoxia.
Intubated without difficulty with etomadate and succ. ET tube
became plugged with purulent, yellow secretions. Received 3L of
fluids. UA with large blood, 4+ bacteria and mucus, with ___
WBC. She was given metronidazole and levofloxacin; started on
neo-synephrine for hypotension, and transferred to ___ for
evaluation. Right IJ was placed.
In the ED, initial VS were: 98.4 95 135/58 18 94% on Assist
control 400/16/30%/5.
On arrival to the MICU, patient's VS are 98.2, 103, 133/65, 20,
96%. She is sedated and moans to pain.
Past Medical History:
1. Frequent UTI's and hx of urosepsis
2. Schizoaffective
3. Dementia
4. CKI
5. COPD
6. CAD
7. HTN
8. GERD
9. Anemia
Social History:
___
Family History:
unable to obtain
Physical Exam:
Admission physical:
Vitals: 98.2, 103, 133/65, 20, 96%
General: sedated, NAD
HEENT: Sclera anicteric, dried mucoous membranes, oropharynx
clear, EOMI, PERRL, unable to track with eyes, +corneal reflex
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2
Lungs: diffuse rhonchi throughout, and decreased breath sounds
at left base
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
peripheral edema up to thigh
Neuro: + clonus, but downgoing babinski
Discharge physical:
Vitals: 98.4 134/45 HR 76 sat 94% RA
Gen: NAD, A&Ox2 (to person and date)
Pulm: expiratory rhonchi with occasional wheezes
CV: ___ systolic murmur best heard at R upper sternal border,
RRR, no rubs/gallops
Abd: +BS, nondistended, soft, tender to palpation at lower
mid-abdomen
Ext: trace edema up to knees
Pertinent Results:
Admission labs:
___ 01:05PM BLOOD WBC-11.7* RBC-3.20* Hgb-10.1* Hct-30.4*
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.5 Plt ___
___ 01:05PM BLOOD Neuts-68 Bands-18* Lymphs-4* Monos-6
Eos-0 Baso-0 ___ Metas-4* Myelos-0
___ 01:05PM BLOOD ___ PTT-33.1 ___
___ 01:05PM BLOOD Glucose-138* UreaN-33* Creat-1.9* Na-143
K-3.7 Cl-113* HCO3-21* AnGap-13
___ 01:05PM BLOOD CK(CPK)-482*
___ 01:05PM BLOOD cTropnT-0.12*
___ 01:05PM BLOOD CK-MB-4
___ 12:08AM BLOOD CK-MB-4 cTropnT-0.11*
___ 02:48AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7
___ 11:25AM BLOOD Type-ART Rates-20/ Tidal V-450 PEEP-5
FiO2-100 pO2-219* pCO2-43 pH-7.29* calTCO2-22 Base XS--5
AADO2-452 REQ O2-77 -ASSIST/CON Intubat-INTUBATED
___ 01:27PM BLOOD Lactate-1.0
Discharge labs:
Micro:
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)} - Source:
Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ BLOOD CULTURE: PENDING - no growth
___ URINE URINE CULTURE: FINAL - no growth
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ MRSA SCREEN MRSA SCREEN: FINAL - no MRSA
isolated
___ URINE Legionella Urinary Antigen: FINAL -
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ BLOOD CULTURE: PENDING - no growth
___ URINE CULTURE: FINAL - no growth
IMAGING:
___ CXR: PICC placed well in atriocaval junction
___ CHEST (PORTABLE AP):
Mild pulmonary edema accompanied by greater pulmonary vascular
congestion has developed since ___, accompanied by new
small pleural effusions. Heart size is mildly enlarged but
unchanged. The left lower lobe remains consolidated due either
to pneumonia or collapse. At some point, investigation with CT
scanning would be helpful to assess possible central adenopathy
and bronchial compromise. Right internal jugular line ends in
the low SVC.
___ CHEST (PORTABLE AP):
New mediastinal and pulmonary vascular congestion and increased
small left pleural effusion probably reflect increased
intravascular volume. The left lower lobe has been uniformly
consolidated since ___, whether this represents
atelectasis or pneumonia is radiographically indeterminate, but
given the large size of the left hilus, it warrants CT
evaluation to look for hilar adenopathy as well as bronchial
occlusion. ET tube and nasogastric tube are in standard
placements. Right internal jugular line ends at least 6 cm
below the level of the carina, probably in the right atrium and
would require withdrawal of 2 to 2.5 cm to place it in the low
SVC.
___ RENAL U.S. PORT:
The right kidney measures 11.2 cm. The left kidney measures 9.1
cm. Visualization of the left kidney is extremely limited due to
technical factors. 5-mm cortical crystal is noted in the lower
pole. No definite hydronephrosis is seen. The right kidney is
normal without hydronephrosis, stone, or mass. The bladder is
not distended and contains a Foley catheter and cannot be
completely evaluated.
IMPRESSION: Technically limited study. Normal right renal
ultrasound. Limited views of the left kidney, including a 5-mm
cortical crystal.
___ CHEST (PORTABLE AP):
As compared to the previous radiograph, the signs indicative of
mild pulmonary edema have nearly completely resolved. However,
there is an ongoing small left pleural effusion with
retrocardiac atelectasis. Borderline size of the cardiac
silhouette. No parenchymal opacities suggesting pneumonia. The
monitoring and support devices are in constant position.
___ ECHO: The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
hyperdynamic left ventricular function. Calcified and mildly
stenotic aortic valve. No evidence of endocarditis although if
clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations
___ ECG: Sinus rhythm. Possible anteroseptal wall
myocardial infarction, age indeterminate. Compared to tracing #1
there is an upright R wave in lead V5 which is likely secondary
to proper lead positioning.
___ CHEST (PORTABLE AP):
Single portable chest radiograph was provided. ET tube is above
the clavicles, approximately 5.5 cm above the carina. NG tube
courses below the diaphragm into the stomach. New right IJ
sheath is seen with the tip at the cavoatrial junction. Mild
prominence of pulmonary vasculature is compatible with mild
pulmonary edema. There is obscuration of the left hemidiaphragm
and blunting of the costophrenic angle which may be due to small
pleural effusion with atelectasis or infection. Osseous
structures are intact.
IMPRESSION: Right IJ sheath at the cavoatrial junction. Mild
pulmonary edema with atelectasis or infection at the left base
and possible small left pleural effusion.
___ CHEST (PORTABLE AP):
IMPRESSION:
1. ET tube 5 cm above the carina. NG tube below the diaphragm.
2. Mild pulmonary edema.
3. Patchy bibasilar opacities, possibly atelectasis, but
infection or aspiration cannot be excluded. Probable small left
pleural effusion.
4. Possible right humeral head subluxation. Clinical
correlation recommended and consider dedicated radiographs of
the right shoulder for further evaluation.
___ ECG:
Sinus rhythm. Possible anteroseptal wall myocardial infarction,
age indeterminate with likely incorrect lead positioning in
leads V4-V6. Repeat tracing is suggested with precordial leads
replaced.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Lorazepam 1 mg PO TID
9am, 1pm, 5pm
2. Docusate Sodium 100 mg PO BID
3. cranberry extract *NF* 425 mg Oral BID
4. Divalproex (DELayed Release) 875 mg PO QHS
5. Divalproex (DELayed Release) 500 mg PO QAM
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Amlodipine 5 mg PO DAILY
10. Risperidone 0.5 mg PO BID
11. zinc oxide *NF* 20 % Topical BID
apply to buttocks every shift
12. Hydrocortisone Cream 1% 1 Appl TP BID
apply to buttocks
13. Ketoconazole 2% 1 Appl TP BID
to face
14. Vagifem *NF* (estradiol) 10 mcg Vaginal 2 times weekly at
bedtime
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Divalproex (DELayed Release) 875 mg PO QHS
3. Divalproex (DELayed Release) 500 mg PO QAM
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety, agitation
Hold for oversedation, confusion or RR < 12
7. Risperidone 0.5 mg PO BID
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
9. Docusate Sodium 100 mg PO BID
10. cranberry extract *NF* 425 mg Oral BID
11. Hydrocortisone Cream 1% 1 Appl TP BID
apply to buttocks
12. Ketoconazole 2% 1 Appl TP BID
to face
13. Vagifem *NF* (estradiol) 10 mcg Vaginal 2 times weekly at
bedtime
14. zinc oxide *NF* 20 % Topical BID
apply to buttocks every shift
15. Vancomycin 1250 mg IV Q 24H
day 1: ___. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. Simvastatin 20 mg PO DAILY
18. Senna 2 TAB PO DAILY
19. Meropenem 500 mg IV Q6H
20. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
22. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
23. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Healthcare Associated Pneumonia, Urinary Tract Infection
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
INDICATION: ___ female with question sepsis, intubated, question tube
placement.
COMPARISON: None.
TECHNIQUE: Single AP portable radiograph was provided.
FINDINGS: ET tube is present with tip approximately 5 cm from the carina. NG
tube courses below the diaphragm into the stomach. Mild pulmonary edema is
noted. There are bilateral patchy opacities, more prominent at the lung bases
which may reflect atelectasis, however, infectious process cannot be excluded.
Small left pleural effusion may be present. No pneumothorax. Cardiomediastinal
silhouette is unremarkable. Right humeral head appears slightly inferiorly
subluxed.
IMPRESSION:
1. ET tube 5 cm above the carina. NG tube below the diaphragm.
2. Mild pulmonary edema.
3. Patchy bibasilar opacities, possibly atelectasis, but infection or
aspiration cannot be excluded. Probable small left pleural effusion.
4. Possible right humeral head subluxation. Clinical correlation recommended
and consider dedicated radiographs of the right shoulder for further
evaluation.
Radiology Report
INDICATION: ___ female with right IJ line placement.
COMPARISONS: Portable AP radiograph from ___.
FINDINGS: Single portable chest radiograph was provided. ET tube is above
the clavicles, approximately 5.5 cm above the carina. NG tube courses below
the diaphragm into the stomach. New right IJ sheath is seen with the tip at
the cavoatrial junction. Mild prominence of pulmonary vasculature is
compatible with mild pulmonary edema. There is obscuration of the left
hemidiaphragm and blunting of the costophrenic angle which may be due to small
pleural effusion with atelectasis or infection. Osseous structures are
intact.
IMPRESSION: Right IJ sheath at the cavoatrial junction. Mild pulmonary edema
with atelectasis or infection at the left base and possible small left pleural
effusion.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Urosepsis and pneumonia, endotracheal tube placement.
COMPARISON: ___
FINDINGS: As compared to the previous radiograph, the signs indicative of
mild pulmonary edema have nearly completely resolved. However, there is an
ongoing small left pleural effusion with retrocardiac atelectasis. Borderline
size of the cardiac silhouette. No parenchymal opacities suggesting
pneumonia. The monitoring and support devices are in constant position.
Radiology Report
INDICATION: Recurrent UTIs and urosepsis. Evaluation for obstruction.
TECHNIQUE: Renal ultrasound.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.2 cm.
The left kidney measures 9.1 cm.
Visualization of the left kidney is extremely limited due to technical
factors. 5-mm cortical crystal is noted in the lower pole. No definite
hydronephrosis is seen. The right kidney is normal without hydronephrosis,
stone, or mass.
The bladder is not distended and contains a Foley catheter and cannot be
completely evaluated.
IMPRESSION: Technically limited study. Normal right renal ultrasound.
Limited views of the left kidney, including a 5-mm cortical crystal.
Radiology Report
AP CHEST, 5:40 A.M ___
HISTORY: ___ woman with hypoxic respiratory failure and septic shock.
IMPRESSION: AP chest compared to ___ and ___:
New mediastinal and pulmonary vascular congestion and increased small left
pleural effusion probably reflect increased intravascular volume. The left
lower lobe has been uniformly consolidated since ___, whether this
represents atelectasis or pneumonia is radiographically indeterminate, but
given the large size of the left hilus, it warrants CT evaluation to look for
hilar adenopathy as well as bronchial occlusion.
ET tube and nasogastric tube are in standard placements. Right internal
jugular line ends at least 6 cm below the level of the carina, probably in the
right atrium and would require withdrawal of 2 to 2.5 cm to place it in the
low SVC.
Findings were discussed by telephone with ___ at 9:40 a.m.
Radiology Report
AP CHEST, 5:21 A.M., ___
HISTORY: ___ woman with pneumonia, on mechanical ventilator.
IMPRESSION: AP chest compared to ___ through ___:
Mild pulmonary edema accompanied by greater pulmonary vascular congestion has
developed since ___, accompanied by new small pleural effusions. Heart
size is mildly enlarged but unchanged. The left lower lobe remains
consolidated due either to pneumonia or collapse. At some point,
investigation with CT scanning would be helpful to assess possible central
adenopathy and bronchial compromise.
Right internal jugular line ends in the low SVC. Dr. ___, covered by Dr.
___, was paged at 10:40, at the time of the findings were recognized.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pulmonary edema,
followup.
AP radiograph of the chest.
As compared to ___, the current radiograph demonstrates interval
improvement of pulmonary edema, substantial with minimal vascular engorgement
noted on the current study. Left retrocardiac opacity is still seen and might
reflect residual edema versus infectious process. Bilateral pleural effusions
are noted, mild. The left internal jugular line tip is slightly low and might
be pulled back for approximately 1.5 cm to secure its position at the
cavoatrial junction or above.
Radiology Report
HISTORY: ___ female with new right PICC.
COMPARISON: Chest radiograph from ___
PORTABLE SUPINE CHEST RADIOGRAPH: There has been interval placement of a
right PICC terminating at the cavoatrial junction. A right internal jugular
approach central venous catheter terminates in the right atrium, unchanged
from prior. There is unchanged mild pulmonary edema. A moderate left pleural
effusion with associated atelectasis is also unchanged. Mild blunting of the
right costophrenic angle is suggestive of a small effusion, unchanged from
prior. There is no pneumothorax Mild enlargement of cardiac silhouette is
stable.
IMPRESSION: Interval placement of new right PICC terminating at the
cavoatrial junction. No other significant change compared to recent prior.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UROSEPSIS
Diagnosed with URIN TRACT INFECTION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Brief Hospital course:
Ms. ___ is a ___ female with COPD, HTN, CAD, CKD, hx of
recurrent UTI's admitted for hypoxic respiratory failure
secondary to LLL pneumonia and urosepsis leading to septic shock
and care from the ICU.
# Health-care associated pneumonia: Pt with infiltrate suggested
on CXR, fevers. Pt resides at a nursing home, so concern for
HCAP. Pt was intubated on arrival from ___ given
respiratory distress. CXR showed increasing consolidation on the
left. Given that, she had a bronchoscopy on ___ that showed
copious secretions but no endobronchial lesions. She was
initially started on vancomycin and cefepime (d1 = ___ and
this was eventually transitioned vancomycin and meropenem
___ past cultures with E. coli resistant to cefepime.
She was extubated on ___ without difficulty.
# Hypoxia Respiratory distress: Likely ___ pneumonia and
possible contribution from volume overload. She was intubated at
___ prior to transfer to ___. She was treated for
pneumonia as above. Bronchoscopy on ___ showed LLL PNA but no
evidence of endobronchial obstruction. She was extubated
post-bronchoscopy and was weaned to 2L NC. Given some vascular
congestion on imaging, pulmonary edema thought to be
contributing and she was given a two doses of lasix 10 mg IV in
the ICU and responded well with > 1.5L diuresis over 24 hours.
# Septic shock: As above, likely secondary to HCAP. She has also
had resistant UTI's in the past. She was initially on
Vanc/Cefepime for PNA and UTI; however, pt spiked on HD #2 to
103. She was started on Meropenem. Outside cultures showed E.
coli ESBL. She defervesced and remained hemodynamically stable.
Her pressors were weaned on evening of ___. Planned for 8 day
course with Vanc/Meropenem.
# COPD: No home oxygen requirement. She is only on Flovent at
home with no inhalers. In the ICU she was started on albuterol
and ipratropium nebs with Advair given BID.
# Tremor, mouth: Could be tardive diskenesia. But per nursing
home, did not have this mouth tremor before. Unclear if this is
related to holding her home antipsychotics while intubated and
sedated. This improved prior to discharge and could be worked up
further if she has more episodes.
# Mental status: Her mental status is improving and she is able
to follow commands. Per SNF, is alert and oriented to self only
at baseline. After recovering from sedation, she returned to
baseline with intermittent agitation/delerium, which resolved on
restarting home risperidone and ativan. She may have been less
alert/oriented after receiving lorazepam, so dose was decreased
to 0.5mg BID.
# CAD: Troponins at 0.12 and 0.11 in setting of CKD. Likely does
not represent ischemia given that EKG in sinus rhythm, with no
acute ST-T changes. Echo this admission was also unconcerning.
# Schizoaffective: Continued on home Depakote and risperidone.
Ativan was initially held given that she was on Midazolam during
intubation. Following extubation, Ativan was restarted at lower
dose of 0.5mg BID.
# CKD: Cr was 1.7 on admission (unclear baseline) in the setting
of likely volume depletion. Creatinine improved to 1.1 with
fluids.
# HTN: Initially hypotensive in the setting of sepsis (above) so
amlodipine was held on admission. On resolution of hemodynamic
stability, her amlodipine was restarted on ___ and SBPs
remained in the 130s-160s range on discharge.
# Anemia: Patient presented normocytic anemia with hematocrit of
30.4. Unclear baseline. She had no evidence of bleeding and
hematocrit remained stable throughout admission.
# Code: Full
# Contact: ___ (son) ___. ___
(___, lawyer) ___
### Transitional issues:
- Patient with anemia of unclear etiology, should be worked up
as an outpatient
- considering tapering ativan to improve mental status
- please check electrolytes ___ in morning and replete as
needed
- please check vancomycin trough 1 hour before vanc dose in
morning of ___ and adjust dose as needed
- last dose of vancomycin to be given ___ for 8 day course
- last dose of meropenem to be given ___ for 8 day course
- please perform chest physical therapy to mobilize thick
purulent secretions
- please follow up on sputum speciation and pending blood
cultures |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Elevated LFTs/Fever
Major Surgical or Invasive Procedure:
___ ERCP
History of Present Illness:
___ with a history of cryptogenic cirrhosis complicated by
portal
HTN, ascites and esophageal varices, status post DDLT
(___), complicated by acute T-cell mediated rejection
(___) and mild T-cell mediated rejection (___), and
biliary strictures status post stent placement (___) and
replacement (___), recurrent cholangitis, GERD, and restless
leg syndrome, who presents with elevated LFTs and fever.
Patient was in his usual state of health until ___, when he
developed fever/chills, headache and lower extremity pains.
Described lower extremity pain as "achy" in nature, limited not
only to his muscles, but also to his joints. Does experience
muscle cramping on a daily basis, however these pains were
different and more severe. Headache was diffuse, throbbing in
nature, but not associated with any other symptoms including
vision changes, photophobia, phonophobia, facial weakness, focal
motor deficits, or sensory changes. Checked his temperature
around 5PM, and found it to be elevated to 102.5F. Denied recent
infectious symptoms, inclusive of cough, sputum production,
shortness of breath, chest pain, abdominal pain,
nausea/vomiting,
constipation/diarrhea, skin rashes, and lower urinary tract
symptoms. However, he did report poor PO intake over the past
day, due to nausea, only taking in sips of water with his
medications.
Of note, patient had lab tests drawn with his PCP ___ ___ and
was told prior to presentation to the ED that his LFTs were
mildly elevated. His prednisone dose was increased to 7.5mg
daily, having been reduced three weeks ago to 5mg daily.
In the ED, initial vital signs were notable for;
Temp 100.1 HR 129 BP 100/49 RR 16 SaO2 100% RA
Examination notable for;
Uncomfortable appearing, no scleral icterus, MMM, clear lungs,
tachycardic, no murmurs, no lower extremity edema,
soft/non-tender abdomen.
Labs were notable for;
WBC 3.2 Hgb 12.9 Plt 130
___ 12.8 PTT 29.8 INR 1.2
Na 136 K 4.3 Cl 98 HCO3 23 BUN 14 Cr 1.2 Gluc 107
ALT 82 AST 63 ALP 134 Lipase 21 Tbili 1.4 Alb 4.6
Lactate 1.5
CXR demonstrated no acute cardiopulmonary abnormality. RUQUS
with
no evidence of biliary obstruction, CBD stent partially
visualized, patent hepatic vasculature, no suspicious focal
liver
lesions, splenomegaly, no ascites, and small right pleural
effusion.
Hepatology were consulted; recommended admission to
___.
Patient was given;
- 1000ml LR
- Tacrolimus 2.5mg
- MMF 1500mg
- IV Zosyn 4.5g
- IV vancomycin 1500mg
Transfer vital signs notable for;
Temp 98.8 HR 105 BP 120/87 RR 24 SaO2 99% RA
Upon arrival to the floor, the patient repeats the above story.
Currently pain in lower extremities has significantly improved,
however has not resolved. Headache is also still present. Feels
dehydrated, but his appetite is returning.
Past Medical History:
- Cryptogenic cirrhosis complicated by portal HTN, ascites and
esophageal varices, status post DDLT (___), complicated
by
acute T-cell mediated rejection (___) and mild T-cell
mediated rejection (___), and biliary strictures status post
stent placement (___) and replacement (___)
- Recurrent cholangitis
- Anisocoria
- Asthma
- GERD
- Restless leg syndrome
- Headaches
- Vitamin D deficiency
Social History:
___
Family History:
History of stroke in father. No known family hx of liver disease
or autoimmune diseases.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: Temp 99.5 BP 110/66 HR 121 RR 18 SaO2 97% RA
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival, anicteric sclera, dry MM
NECK: supple, non-tender, no JVP elevation
CV: tachycardic, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema, no
pain with palpation of lower extremities
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact, no neck stiffness
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: ___ 1232 Temp: 97.5 PO BP: 127/82 L Lying HR: 76
RR:
16 O2 sat: 99% O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably, well-groomed
HEENT: Sclera anicteric and without injection, MMM, oropharynx
clear, no meningismus
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: No respiratory distress, CTAB, no crackles, wheezes, or
rhonchi
ABD: Normoactive bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly, negative ___ sign
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: Alert and oriented to person, time, and place. Motor and
sensory function grossly intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
=============
___ 09:50PM BLOOD WBC-3.2* RBC-4.38* Hgb-12.9* Hct-37.9*
MCV-87 MCH-29.5 MCHC-34.0 RDW-13.3 RDWSD-41.1 Plt ___
___ 09:50PM BLOOD Neuts-87* Bands-1 Lymphs-5* Monos-7
Eos-0* Baso-0 AbsNeut-2.82 AbsLymp-0.16* AbsMono-0.22
AbsEos-0.00* AbsBaso-0.00*
___ 09:50PM BLOOD RBC Mor-WITHIN NOR
___ 10:12PM BLOOD ___ PTT-29.8 ___
___ 09:50PM BLOOD Plt Smr-LOW* Plt ___
___ 09:50PM BLOOD Glucose-107* UreaN-14 Creat-1.2 Na-136
K-4.3 Cl-98 HCO3-23 AnGap-15
___ 09:50PM BLOOD ALT-82* AST-63* AlkPhos-134* TotBili-1.4
___ 09:50PM BLOOD Lipase-21
___ 09:50PM BLOOD Albumin-4.6
___ 10:03PM BLOOD Lactate-1.5
PERTINENT LABS:
=============
___ 06:10AM BLOOD CMV IgG-POS* CMV IgM-Equivocal* CMVI-CMV
infect EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI
___ 05:05AM BLOOD CMV VL-3.5*
___ 09:07AM BLOOD Vanco-11.2
___ 06:10AM BLOOD tacroFK-9.5
___ 05:59AM BLOOD tacroFK-10.4
___ 06:46AM BLOOD tacroFK-10.2
___ 07:08AM BLOOD tacroFK-9.9
PENDING LABS:
=============
___ 07:08AM BLOOD CYTOMEGALOVIRUS RESISTANCE GENOTYPE-PND
DISCHARGE LABS:
==============
___ 05:34AM BLOOD WBC-3.1* RBC-4.43* Hgb-12.9* Hct-38.5*
MCV-87 MCH-29.1 MCHC-33.5 RDW-13.4 RDWSD-41.6 Plt ___
___ 05:34AM BLOOD Plt ___
___ 05:34AM BLOOD ___ PTT-27.2 ___
___ 05:34AM BLOOD Glucose-102* UreaN-14 Creat-0.9 Na-140
K-4.5 Cl-102 HCO3-24 AnGap-14
___ 05:34AM BLOOD ALT-73* AST-47* LD(LDH)-298* AlkPhos-120
TotBili-0.6
___ 05:34AM BLOOD Albumin-4.0 Calcium-8.2* Phos-4.0 Mg-2.1
___ 05:34AM BLOOD tacroFK-13.0
MICROBIOLOGY:
============
___ 10:01 pm STOOL
CYCLOSPORA STAIN (Pending):
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 5:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:13 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (___)
2. Mycophenolate Mofetil 1500 mg PO BID
3. Omeprazole 20 mg PO BID
4. Pramipexole 0.125 mg PO QHS
5. PredniSONE 7.5 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Tacrolimus 2.5 mg PO Q12H
8. ValGANCIclovir 900 mg PO Q24H
9. Cetirizine 10 mg PO BID:PRN Allergies
10. DiphenhydrAMINE 50 mg PO QHS:PRN Insomnia
11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
12. Magnesium Oxide 400 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - Second Line
Discharge Medications:
1. Cetirizine 10 mg PO BID:PRN Allergies
2. DiphenhydrAMINE 50 mg PO QHS:PRN Insomnia
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Magnesium Oxide 400 mg PO BID
5. Mycophenolate Mofetil 1500 mg PO BID
6. Omeprazole 20 mg PO BID
7. Pramipexole 0.125 mg PO QHS
8. PredniSONE 7.5 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - Second Line
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 2.5 mg PO Q12H
12. ValGANCIclovir 900 mg PO Q24H
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14.Outpatient Lab Work
CMV viral load
CHEM10, CBC, AST, ALT, tBili, AlkPhos
B25.9
Please fax to ___ ___, MD
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Diarrhea
CMV viremia
Cholangitis secondary to biliary sludge
Cryptogenic cirrhosis status post DDLT (___)
Pancytopenia
Transaminitis
Acute kidney injury
Restless leg syndrome
Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided non targeted liver biopsy
INDICATION: rising LFTs, has hx of rejection// ?rejection of DDLT
COMPARISON: Multiple prior comparisons, most recent from ___
PROCEDURE: Ultrasound-guided non targeted liver biopsy.
OPERATORS: Dr. ___, radiology resident 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 US scan table. Limited
preprocedure ultrasound of the liver was performed. Based on the ultrasound
findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 10 cc of 1%
lidocaine were administered to the subcutaneous and deep tissues for local
anesthetic effect. Under continuous ultrasound guidance, an 18 gauge core
biopsy device with a 22 mm throw was used to obtain 1 core biopsy specimen,
which were sent for pathology.
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 13
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Unchanged appearance of the hepatic parenchyma. Right lobe of the liver was
targeted for biopsy.
IMPRESSION:
Clinically successful ultrasound-guided non targeted liver biopsy. One 18
gauge core biopsy specimen was sent to pathology for assessment.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Fever
Diagnosed with Fever, unspecified, Liver transplant status, Myalgia, other site
temperature: 100.1
heartrate: 129.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 49.0
level of pain: 7
level of acuity: 2.0 | BRIEF HOSPITAL COURSE:
======================
___ with a history of cryptogenic cirrhosis complicated by
portal HTN, ascites and esophageal varices, status post DDLT
(___), complicated by acute T-cell mediated
___ and mild T-cell mediated rejection (___),
and biliary strictures status post stent placement (___) and
replacement (___), recurrent cholangitis, GERD, and restless
leg syndrome, who presents with elevated LFTs and fever. Initial
concern was for cholangitis versus transplant rejection. He was
started on Vanco/cefepime/Flagyl empirically. ERCP was performed
and biliary sludge was removed, with visualization of patent
stent and no evidence of obstruction. These findings,
downtrending LFTs, and resolution of his fevers with only
antibiotic treatment suggested that likelihood of transplant
rejection was low and liver biopsy was deferred. He also
developed watery diarrhea after being started on antibiotics,
and our infectious work-up revealed a newly detectable CMV
viremia with 3000 copies per milliliter. His stool CMV PCR was
pending at discharge. He had a biopsy of his liver for LFT
elevation which did NOT show acute rejection. CMV pathology was
pending at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
Right hip ORIF (DHS) by Dr. ___ on ___
History of Present Illness:
___ s/p fall at home, presenting with R hip pain. She was
walking to her bed when she fell. Denies HS/LOC. She was unable
to ambulate after. Home health aid called ___ she was brought
to
ED. This is her isolated complaint.
Past Medical History:
Osteoporosis, h/o seizures
Social History:
___
Family History:
NC
Physical Exam:
AFVSS
NAD
Breathing comfortably
Abdomen soft, non tender
RLE:
Wound well approximated with adjacent ecchymosis. No signs of
infection
Pertinent Results:
___ 06:25PM URINE HOURS-RANDOM
___ 06:25PM URINE GR HOLD-HOLD
___ 06:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:25PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:25PM URINE MUCOUS-RARE
___ 04:53PM ___ PTT-28.2 ___
___ 03:12PM LACTATE-0.9
___ 02:55PM GLUCOSE-89 UREA N-46* CREAT-0.8 SODIUM-141
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13
___ 02:55PM estGFR-Using this
___ 02:55PM CK(CPK)-310*
___ 02:55PM WBC-7.1 RBC-3.59* HGB-11.7* HCT-34.2* MCV-95
MCH-32.6* MCHC-34.3 RDW-13.1
___ 02:55PM NEUTS-72.1* ___ MONOS-3.2 EOS-0.9
BASOS-0.2
___ 02:55PM PLT COUNT-298
Medications on Admission:
gabapentin 3600 QD, clonazepam 0.5mg BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. ClonazePAM 0.5 mg PO QAM
3. ClonazePAM 1 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC Q24H Duration: 14 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Gabapentin 1200 mg PO TID
7. LeVETiracetam 1000 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
10. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip intertrochanteric fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with unwitnessed fall and right hip pain.
COMPARISON: None available.
FINDINGS:
Single AP view of the pelvis and two additional views of the right hip were
obtained. These demonstrate a minimally displaced fracture through the right
femur, intertrochanteric in location. The distal femoral shaft appears
displaced laterally 5 mm. The right femoral head appears seated in the
acetabulum. A single view of the left hip is unremarkable. Degenerative
changes are noted within the lower lumbar spine. A nonobstructive bowel gas
pattern is noted.
IMPRESSION:
Minimally displaced intertrochanteric fracture through the proximal right
femur.
NOTIFICATION: Findings were communicated to the ordering physician via the ___
dashboard by Dr. ___ at 16:30 on ___ immediately upon discovery
of the finding.
Radiology Report
INDICATION: ___ female status post fall.
TECHNIQUE: Single AP supine.
COMPARISON: None available.
FINDINGS:
Single AP supine radiograph demonstrates hyperinflated lungs. Patient is
significantly rotated to her right. Allowing for this, mediastinal structures
appear within normal limits. There is no pleural effusion or pneumothorax.
Irregularity is noted along what appears to be the left ninth rib laterally,
reflective of a fracture, age indeterminate. Remaining osseous structures are
unremarkable.
IMPRESSION:
Irregularity noted along what appears to be the left ninth rib laterally.
Clinical correlation with pain at this site is recommended to exclude acute
fracture. Single AP supine radiograph suboptimal for the detection of rib
fractures. If clinical concern persists, dedicated rib films can be obtained.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female with unwitnessed fall.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1115 mGy-cm
CTDI: 53 mGy
COMPARISON: None
FINDINGS:
There is no acute intracranial hemorrhage, acute infarction, edema or mass
effect. A slightly dysmorphic appearance of the left lateral ventricle is
noted. A chronic lacune is noted within the left lentiform nucleus. The basal
cisterns are clear. The gray white matter differentiation appears preserved.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ female status post unwitnessed fall.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 590 mGy
DLP: 32 mGy-cm
COMPARISON: None available.
FINDINGS:
Exaggerated cervical lordosis noted. No acute fracture is detected. Lateral
masses are symmetric about the dens. Degenerative changes are most pronounced
at the C7-T1 level. There is no prevertebral soft tissue swelling. Biapical
lungs demonstrate mild centrilobular emphysema. The thyroid gland appears
heterogeneous with a 5 x 5 mm nodule within the right thyroid lobe. A coarse
calcification is noted in the left thyroid lobe.
IMPRESSION:
1. Exaggerated cervical lordosis without acute fracture or subluxation.
2. Centrilobular emphysema at lung apices.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: History: ___ with r hip fx // r hip fx, preop r hip fx,
preop
TECHNIQUE: AP and lateral views of the right femur
COMPARISON: Pelvis and right hip radiographs from earlier today, ___ at 15:42
FINDINGS:
Known right intertrochanteric fracture is mildly displaced. Anatomic alignment
is maintained. There is no evidence of dislocation. No fracture of the more
distal femur is seen. There is no suprapatellar joint effusion.
IMPRESSION:
Known right intratrochanteric fracture, mildly displaced, but in gross
anatomic alignment. No acute fracture seen of the more distal right femur.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R.
INDICATION: RT HIP FX.ORIF
IMPRESSION:
Images from the operating suite show fixation of a fracture of the proximal
femur. Further information can be gathered from the operative report.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman s/p hip ORIF now with distended abdomen //
ileus vs obstruction
TECHNIQUE: PORTABLE ABDOMEN
COMPARISON: None
IMPRESSION:
Severe degenerative changes of the spine and potentially DH a present. There
is diffuse mild dilatation of the bowel loops but no overt abnormality
demonstrated. Internal fixation of the right hip is noted, partially imaged
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL
temperature: 97.6
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 65.0
level of pain: 7
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 rgiht intertrochanteric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip ORIF/DHS 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. While here, it was noted that she is very
deconditioned/emaciated, and nutrition was consulted who
recommended high calorie foods with extra protein shakes such as
ensure. 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
WBAT RLE, and will be discharged on lovenox injections x 2 weeks
for DVT prophylaxis. The patient will follow up in two weeks
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:
phenobarbital / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
AMS, falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with PMH of DMII, hypothyroidism,
adrenal insufficiency, tachycardia of unclear cause, dementia,
who had been healthy prior to resection of pituitary
craniopharyngioma 6 months ago. Since then he has had
significantly decreased functional status and was reportedly
diagnosed with dementia (A&Ox3 before the surgery). He has had a
gradual decline in his mental status over the last 10 days since
flying in from ___ where he lives. His daughter describes
poor PO intake, unable to take meds. This became acutely worse
over the last two days after he was found down after an unknown
period of time. Since then he has had more falls, worsening gait
and increased fatigue. The daughter also reports that he has
been complaining of diffuse arthralgias for the past two months.
He is unable to answer questions now but endorsed chest pressure
earlier in the day per the daughter.
In the ED, initial vitals were:
97.5 110 114/70 20 96% RA
Labs showed
CBC wnl
INR 1.1
Chem7 notable for bicarb of 21, creatinine 1.1
Lactate 2.2 -> 1.5
Trop 0.01 x 2
D-Dimer 1081
CK 194
UA moderate blood, 3 RBC, few bacteria
Imaging showed
CTA chest:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small airways disease with mild bronchial wall thickening and
moderate air-trapping.
3. Three pulmonary nodules, largest measuring 0.7 cm in right
middle lobe. As per ___ pulmonary nodule
recommendations for
low risk patients, initial follow-up CT at ___ months and then
at ___ months if no change. For high risk patients - initial
follow-up CT at ___ months and then at ___ and 24 months if no
change.
4. Small hiatal hernia.
CT C-spine
-No acute fracture.
-Mild anterolisthesis of C3 on C4 and C4 on C5, likely
degenerative.
-Mild degenerative changes of cervical spine with mild spinal
canal narrowing
at C5-C6 and C6-C7.
CT head
2.3 cm partially calcified cystic lesion at level of foramen of
___. Although atypical differential includes colloid cyst,
hemangioblastoma, and less likely craniopharyngioma. No
hydrocephalus.
Gleno-humeral shoulder, left
No acute findings
EKG sinus tachycardia, rate 108, QTc ~510, TWI in III, V1-V5,
STD in V3-V4
Received NS, aspirin 300 mg
Transfer VS were
97.5 110 114/70 20 96% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, the patient mumbles incoherently. Per
the daughter, he has been dizzy with very poor balance and has
been somewhat agitated. He has recently been sleeping 18 hours
per day. He occasionally complains of palpitations.
Review of systems:
Unable to obtain further ROS
Past Medical History:
# DMII
# Panhypopituitarism (adrenal insufficiency, hypothyroidism)
# Paroxysmal tachycardia
# dementia s/p R frontal craniotomy w/ resx of craniopharyngioma
___
# GERD
# Glaucoma (primary open angle)
# osteoarthritis knees bl
Social History:
___
Family History:
Without family history of neurological malignancy or malignancy
of other kinds.
Physical Exam:
ADMISSION EXAM:
Vital Signs:96.9 Axillary ___ 18 93 ra
General: A&Ox0, lying in bed with eyes closed
HEENT: Sclerae anicteric, MM dry, no LAD, unable to assess JVP,
EOMI, or oropharynx due to lack of cooperation
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No cellulitis or rash
Neuro: Unable to assess fully due to lack of cooperation with
commands but is moving all extremities spontaneously and equally
bilaterally, no facial droop, no obvious gaze abnormalities
DISCHARGE EXAM:
VS: 98.5 133/71 76 17 94RA
GEN: lying in veil bed, NAD
HEENT: Sclerae anicteric, MMM
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
PULM: CTAB, no wheezes, rales, rhonchi
ABD: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No cellulitis or rash
NEURO: Motor grossly intact, no facial droop, normal tone, toes
down b/l; alert and oriented to self only
Pertinent Results:
ADMISSION
============
___ 08:52PM LACTATE-1.5
___ 08:45PM cTropnT-<0.01
___ 04:16PM D-DIMER-1081*
___ 04:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:15PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:15PM URINE HYALINE-3*
___ 04:15PM URINE MUCOUS-RARE
___ 03:13PM LACTATE-2.2*
___ 03:00PM GLUCOSE-204* UREA N-14 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
___ 03:00PM estGFR-Using this
___ 03:00PM CK(CPK)-194
___ 03:00PM cTropnT-<0.01
___ 03:00PM VIT B12-654
___ 03:00PM TSH-0.60
___ 03:00PM FREE T4-0.3*
___ 03:00PM CORTISOL-0.6*
___ 03:00PM WBC-7.4 RBC-4.90 HGB-14.2 HCT-42.4 MCV-87
MCH-29.0 MCHC-33.5 RDW-13.9 RDWSD-43.2
___ 03:00PM NEUTS-44.7 ___ MONOS-12.5 EOS-7.1*
BASOS-0.4 IM ___ AbsNeut-3.28 AbsLymp-2.59 AbsMono-0.92*
AbsEos-0.52 AbsBaso-0.03
___ 03:00PM PLT COUNT-174
___ 03:00PM ___ PTT-35.3 ___
DISCHARGE LABS:
___ 11:30AM BLOOD WBC-6.9 RBC-4.70 Hgb-13.3* Hct-41.8
MCV-89 MCH-28.3 MCHC-31.8* RDW-14.7 RDWSD-47.6* Plt ___
___ 06:51AM BLOOD ___ PTT-36.6* ___
___ 06:51AM BLOOD Glucose-116* UreaN-19 Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-24 AnGap-16
___ 06:51AM BLOOD ALT-54* AST-58* LD(LDH)-202 AlkPhos-78
TotBili-0.7
___ 06:51AM BLOOD Albumin-3.9 Calcium-9.0 Phos-4.3 Mg-2.5
___ 06:45AM BLOOD Free T4-0.7*
IMAGING:
___ CT Head w/o contrast
IMPRESSION:
Cystic partially calcified rounded mass in the suprasellar
region measuring
2.2 x 2.3 cm. Although atypical differential includes
craniopharyngioma,
colloid cyst, and less likely hemangioblastoma.
*Please note, given the position of this mass, patient is at
risk for
development of hydrocephalus given concern for potential
mass-effect on the
third ventricle.
___ CT C-spine w/o contrast
IMPRESSION:
1. No acute fracture.
2. Mild anterolisthesis of C3 on C4 and C4 on C5, likely
degenerative.
3. Mild degenerative changes of cervical spine with mild spinal
canal
narrowing at C5-C6 and C6-C7.
___ MRI Brain and pituitary
IMPRESSION:
1. Study is severely degraded by motion and limited due to the
lack of
intravenous contrast administration.
2. 2.3 cm cystic structure with rim calcification posteriorly in
the third
ventricle, concerning for residual or recurrent
craniopharyngioma. If
clinically indicated, consider repeat contrast examination when
patient can
tolerate exam.
___ Pre-surg Planning MRI WAND
FINDINGS:
Mixed cystic and solid enhancing lesion in the floor of the
third ventricle is again identified. There is no significant
change in size or imaging appearances. The findings are
suggestive of residual craniopharyngioma as suggested
previously.
IMPRESSION:
Examination performed for surgical planning demonstrates
partially cystic and solid lesion in the floor of the third
ventricle.
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small airways disease with mild bronchial wall thickening
and moderate
air-trapping.
3. Three pulmonary nodules, largest measuring 0.7 cm in right
middle lobe.
4. Small hiatal hernia.
MICRO:
___ UCx: NG (final)
___ BCx: NG (final)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H
2. Divalproex (DELayed Release) 125 mg PO BID
3. GlipiZIDE 5 mg PO DAILY
4. Hydrocortisone 5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Mirtazapine 7.5 mg PO QHS
7. Omeprazole 20 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Famotidine 20 mg PO DAILY
2. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. PredniSONE 5 mg PO DAILY
4. QUEtiapine Fumarate 12.5 mg PO QHS
5. QUEtiapine Fumarate 12.5 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. HELD- GlipiZIDE 5 mg PO DAILY This medication was held. Do
not restart GlipiZIDE until discharged with outpatient follow-up
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- craniopharyngioma
- panhypopituitarism s/p craniopharyngioma resection
- adrenal insufficiency
- hypothyroidism
- delirium/agitation/ dementia
- emesis/transaminitis
SECONDARY DIAGNOSIS:
- diabetes mellitus type II
- hypernatremia
- GERD
- BPH
- insomnia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with found down // assess for trauma infection
COMPARISON: Same-day chest CTA
FINDINGS:
AP portable upright view of the chest. Lung volumes are somewhat low. There
is streaky perihilar opacities which may reflect a combination of
bronchovascular crowding as well as central airways inflammation. No lobar
consolidation, large effusion or pneumothorax. No signs of congestion or
edema. The mediastinal contour is prominent though better assessed on
same-day CTA chest. The heart size is normal. Bony structures are intact.
No free air below the right hemidiaphragm.
IMPRESSION:
As above. Please refer to same-day CTA chest for further details.
Radiology Report
INDICATION: ___ with found down // assess for trauma infection
COMPARISON: None
FINDINGS:
Three views of the left shoulder demonstrate no fracture or dislocation. No
significant osteoarthritis. No worrisome calcifications. The imaged left
ribs appear intact.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with found down. Assess for trauma infection
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformats as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Rim contrast
FINDINGS:
There is a well-circumscribed 2.2 x 2.3 cm suprasellar mass, which appears
cystic with areas of calcification. This lesion is located adjacent to the
third ventricle at the level of the foramen of ___. The sella turcica is
unremarkable without hyperostosis or enlargement. There is no evidence of
acute major infarction, hemorrhage,or edema. There is prominence of
ventricles and sulci suggestive of involutional changes. No evidence of
transependymal flow or blunting of the temporal horns to suggest
hydrocephalus. Patent basal cisterns.
Patient is status post right frontal craniotomy with associated postsurgical
changes. There is no evidence of fracture. Mild mucosal thickening of
bilateral maxillary sinuses. The additional visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. Calcification of the
cavernous portion of the internal carotid arteries.
IMPRESSION:
Cystic partially calcified rounded mass in the suprasellar region measuring
2.2 x 2.3 cm. Although atypical differential includes craniopharyngioma,
colloid cyst, and less likely hemangioblastoma.
*Please note, given the position of this mass, patient is at risk for
development of hydrocephalus given concern for potential mass-effect on the
third ventricle.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with found down. Assess for trauma or infection.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 828 mGy-cm.
COMPARISON: None.
FINDINGS:
Mild anterolisthesis of C3 on C4 and C4 on C5. No fractures are
identified.Mild multilevel degenerative changes of the cervical spine with
anterior/posterior osteophytes, disc space narrowing, and subchondral
sclerosis. Calcification of the nuchal ligament noted. Mild spinal canal
narrowing at C5-C6 and C6-C7 from small posterior osteophytes. There is no
prevertebral soft tissue swelling. There is no evidence of infection or
neoplasm. 0.2 cm punctate left thyroid calcification noted.
IMPRESSION:
1. No acute fracture.
2. Mild anterolisthesis of C3 on C4 and C4 on C5, likely degenerative.
3. Mild degenerative changes of cervical spine with mild spinal canal
narrowing at C5-C6 and C6-C7.
Radiology Report
EXAMINATION: CTA chest.
INDICATION: ___ with chest pain, positive dimer. Assess for pulmonary
embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE:
Total DLP (Body) = 494 mGy-cm.
COMPARISON: Chest radiograph ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
Subcentimeter calcified mediastinal lymph nodes are consistent with prior
granulomatous exposure. There is no supraclavicular, axillary, mediastinal,
or hilar lymphadenopathy. The thyroid gland appears unremarkable.
The heart is top normal in size. There is no evidence of pericardial
effusion. There is no pleural effusion.
Moderate air trapping on this expiratory phase scan. Bibasilar atelectasis is
mild. Pulmonary nodules are as follows: 0.3 cm left upper lobe (03:104), 0.7
x 0.7 cm right middle lobe (3:122) and 0.6 x 0.4 cm right lower lobe (3:134).
There is no additional evidence of pulmonary parenchymal abnormality. Mild
bronchial wall thickening. No bronchiectasis. The airways are otherwise
patent to the subsegmental level.
Limited images of the upper abdomen are notable for small hiatal hernia.
Additional visualized solid organs are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small airways disease with mild bronchial wall thickening and moderate
air-trapping.
3. Three pulmonary nodules, largest measuring 0.7 cm in right middle lobe.
4. Small hiatal hernia.
Radiology Report
EXAMINATION: MRI BRAIN AND PITUITARY PT78 MR ___
INDICATION: ___ year old man with panhypopituitarism, dementia status post
right frontal craniotomy and craniopharyngioma resection in ___. Evaluate
for recurrent or residual tumor.
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
axial and coronal T2 imaging. Due to confusion and claustrophobia, the
patient was unable to complete the entire study, and therefore contrast was
not administered.
COMPARISON: ___ CT head without contrast.
FINDINGS:
Study is severely degraded by motion.
Re- demonstrated is a 1.9 x 2.3 cm in T2 hyperintense, FLAIR intermediate
lesion with areas of rim calcification posteriorly within the third ventricle.
Prominence of the ventricles and sulci suggest age-related involutional
change. No evidence of acute hydrocephalus. No large acute intracranial
hemorrhage, large territorial infarct, or abnormal extra-axial collection.
Gray-white differentiation is preserved.
The visualized portion the orbits, paranasal sinuses, and mastoid air cells
are normal.
IMPRESSION:
1. Study is severely degraded by motion and limited due to the lack of
intravenous contrast administration.
2. 2.3 cm cystic structure with rim calcification posteriorly in the third
ventricle, concerning for residual or recurrent craniopharyngioma. If
clinically indicated, consider repeat contrast examination when patient can
tolerate exam.
Radiology Report
EXAMINATION: PRE-SURGICAL PLANNING WAND STUDY
INDICATION: ___ year old man s/p craniopharyngioma resection // BLADE STUDY.
eval for size of residual craniopharyngioma; please trace fiducial markers
TECHNIQUE: Axial T1 and MPRAGE post gadolinium images were obtained with
surface markers for surgical planning.
COMPARISON: MRI of ___.
FINDINGS:
Mixed cystic and solid enhancing lesion in the floor of the third ventricle is
again identified. There is no significant change in size or imaging
appearances. The findings are suggestive of residual craniopharyngioma as
suggested previously.
IMPRESSION:
Examination performed for surgical planning demonstrates partially cystic and
solid lesion in the floor of the third ventricle.
Radiology Report
INDICATION: Mr. ___ is a ___ yo male with PMH of DMII, hypothyroidism,
adrenal insufficiency, tachycardia of unclear cause, dementia, who had been
healthy prior to resection of pituitary craniopharyngioma 6 months ago who
presents with AMS, falls, soon to NSGY OR for Ommaya (cyst drainage +/- chemo)
// pre-NSGY Ommaya placement Surg: ___ (Ommaya)
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest and radiographs dated ___
FINDINGS:
Interval decrease in the streaky predominantly perihilar opacities. Patchy
opacities at both lung bases likely reflect atelectasis. No pleural effusion
or pneumothorax is identified.
The size of the cardiac silhouette is mildly enlarged. Tortuous thoracic
aorta.
IMPRESSION:
Bibasilar atelectasis. Interval decrease in the previously described streaky
perihilar opacities.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Confusion, Weakness, Dizziness, Found down
Diagnosed with Unspecified injury of head, initial encounter, Altered mental status, unspecified, Abnormal electrocardiogram [ECG] [EKG], Fall on same level, unspecified, initial encounter
temperature: 97.5
heartrate: 110.0
resprate: 20.0
o2sat: 96.0
sbp: 114.0
dbp: 70.0
level of pain: unable
level of acuity: 2.0 | ___ yo ___ speaking male with PMH of DMII, tachycardia of
unclear cause, dementia, and craniopharyngioma s/p resection 6
months ago now presenting with several days of weakness,
confusion, and falls. Treated for adrenal
insufficiency/hypothyroidism due to hypopituitarism with
improvement of acute issues. However, underlying behavioral
issues remained from previous surgery 6 months ago. Neurosurgery
recommended draining the cystic lesion at the sight of the
crandiopharyngioma, but patient's daughter requested a second
opinion from another center and therefore was transferred to
___.
The patient was persistently very agitated while inpatient and
after multiple medication trials was responsive to Seroquel. He
was seen by both medical and surgical consulting services while
inpatient: endocrinology assisted with treatment of
panhypopituitarism; neurology aided with diagnostic workup of
his imbalance, delirium, and behavior issues; and neurosurgery
ultimately wished to place an Ommaya for an imaging visualized
cystic lesion at the site of previous surgery. Ultimately the
patient's daughter deferred having surgery at ___ and wished
to seek a second surgical opinion at ___ regarding his
behavioral problems including outbursts, agitation, and
aggression. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / lisinopril / colchicine
Attending: ___.
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
Cardiac Catheterization ___
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of SVT,
hypertension, dyslipidemia, and recent admission for NSTEMI
complicated by LAD perforation and tamponade (___) who
presented to the ___ ED for evaluation of chest pain.
Symptoms began approximately ___. Patient had an episode of
chest pressure, left side, non radiating that lasted
approximately 10 minutes. The pain occurred while at an exercise
class and resolved spontaneously, without nitroglycerin use.
Patient reported additional episodes ___ and ___ prior
to
presentation which were again described as chest pressure and
associated with dyspnea. Patient unsure of number of episodes or
duration of subsequent episodes.
Prior to hospitalization patient and son report that one month
ago patient was feeling increasingly fatigued and dyspneic with
usual activities. This prompted a visit with Dr. ___ stress
testing which demonstrated diastolic heart failure. Patient's
symptoms were felt to be in the setting of Metoprolol dosing
which was subsequently decreased to 12.5mg daily. On day of
presentation, patient with worsened dyspnea prompting ED visit.
Of note, patient hospitalized for an NSTEMI in ___.
Patient
underwent cardiac catheterization that was complicated by LAD
perforation. A balloon occlusion was performed followed by a
pericardiocentesis with removal of ~75cc of blood. A covered
___ was placed. Patient had short stay in CCU with no post
hospitalization complications.
ED Course: While in the ED EKG notable for Normal sinus rhythm,
normal axis, normal intervals, non specific t wave changes,
troponin elevated to 0.12 concerning for Type I NSTEMI. CXR
without acute abnormalities. Patient received aspirin load and
started on heparin gtt, received home Ticagrelor, Metoprolol.
Atorvastatin increased to 80mg. Admitted to ___
service following Cardiology consultation.
In the ED initial vitals were: afebrile, HR 62, 135/65 RR 100%
EKG: Normal sinus rhythm, normal axis, normal intervals, peak T
waves and V4 5 and 6 as compared to prior
Labs/studies notable for: Troponin elevation to 0.12
Patient was given: Aspirin 243 (for total of 325mg) started on
heparin gtt with half bolus.
Vitals on transfer: HR63 BP101/61 RR19 96% RA
On the floor patient denies any ongoing chest pain or dyspnea.
She had no new acute concerns. Thinks her current chest pressure
is different than her presentation in ___, unable to
quantify.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, dyspnea, orthopnea, lower extremity edema.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes
+ Hypertension
+ Dyslipidemia
2. CARDIAC HISTORY
- NSTEMI (___)
3. OTHER PAST MEDICAL HISTORY
Osteoporosis, hyperparathyroidism
"mini stroke"
Iron deficiency anemia
SVT
osteopenia
carpal tunnel syndrome
osteoarthritis
anemia
Meniere's disease
Social History:
___
Family History:
Father deceased ___ MI, Mother died of CVD
Physical Exam:
ADMISSION PHYSICAL:
VS: 98.7 BP133/71 HR71
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: supple, no JVD appreciated.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, well perfused. 2+ pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL:
VS: 97.9F, 76, 130/76, 16, 98% on RA.
GENERAL: Well appearing, pleasant female in NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: CTAB
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Neuro: AOx3, CN ___ intact, ___ strength in upper and lower
extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:44AM BLOOD WBC-5.7 RBC-4.71 Hgb-13.0 Hct-40.8 MCV-87
MCH-27.6 MCHC-31.9* RDW-15.0 RDWSD-47.3* Plt ___
___ 06:29AM BLOOD WBC-5.4 RBC-4.50 Hgb-12.9 Hct-39.6 MCV-88
MCH-28.7 MCHC-32.6 RDW-15.4 RDWSD-48.7* Plt ___
___ 10:44AM BLOOD ___ PTT-27.4 ___
___ 10:44AM BLOOD Glucose-100 UreaN-16 Creat-0.8 Na-142
K-4.0 Cl-101 HCO3-25 AnGap-16
___ 10:44AM BLOOD cTropnT-0.12*
___ 07:18PM BLOOD CK-MB-3 cTropnT-0.12*
___ 06:29AM BLOOD CK-MB-3 cTropnT-0.11*
IMAGING/PROCEDURES:
===================
CATH ___:
Dominance: Right
* Left Main Coronary Artery
The LMCA is without flow limiting stenosis.
* Left Anterior Descending
The LAD has a proximal 30% followed by a 95% mid at the proximal
edge of the stents (3 layers)
involving the origina of a large D1 which has 90% stenosis.
* Circumflex
The Circumflex is without flow limiting stenosis.
The ___ Marginal is.
* Right Coronary Artery
The RCA is small and non-dominant.
CATH ___
XB LAD guide provided good support. angio showed 99% proximal
LAD, 70% mid, in ___, 90% diag,
stented LAD proximal and mid with 0% residual. rescued Diag with
2.0 mm balloon with <50%
RESIDUAL AND NORMAL FLOW
PATIENT HAD VAGAL REACTION FOLLOWED BY SEVERE htn AND
TACHYCARDIAC AFTER
ATROPINE (SIMILAR TO EPI),
THIS RESOLVED. LVEDP WAS 8 MMhG
Impressions:
XB LAD guide provided good support. angio showed 99% proximal
LAD, 70% mid, in ___, 90% diag,
stented LAD proximal and mid with 0% residual. rescued Diag with
2.0 mm balloon with <50%
RESIDUAL AND NORMAL FLOW
PATIENT HAD VAGAL REACTION FOLLOWED BY SEVERE htn AND
TACHYCARDIAC AFTER
ATROPINE (SIMILAR TO EPI),
THIS RESOLVED. LVEDP WAS 8 MMhG
ECHO ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the distal
septum. The remaining segments contract normally (LVEF >= 60 %).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD (LAD territory). Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___
mild pulmonary hypertension is seen. Other findings are not
significanlty different (distal septal hypokinesis also present
on prior).
CT HEAD ___:
No acute intracranial abnormality.
Periapical lucencies about posterior left maxillary molar, only
partially seen on this scan, surrounding mild stranding,
consider infection.
DISCHARGE LABS:
==============
___ 07:10AM BLOOD WBC-5.3 RBC-4.14 Hgb-11.8 Hct-36.5 MCV-88
MCH-28.5 MCHC-32.3 RDW-15.5 RDWSD-49.6* Plt ___
___ 07:10AM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-141
K-4.3 Cl-102 HCO3-22 AnGap-17
___ 07:10AM BLOOD CK-MB-2 cTropnT-0.12*
___ 07:10AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Calcipotriene 0.005% Cream 1 Appl TP BID
3. Halobetasol Propionate 0.05 % topical BID
4. Hydrochlorothiazide 12.5 mg PO 3X/WEEK (MO,WE,SA)
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. TiCAGRELOR 90 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D ___ UNIT PO 4X/WEEK (___)
9. Vitamin D 4000 UNIT PO 3X/WEEK (___)
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth Daily Disp #*10
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet
Refills:*0
3. coenzyme Q10 200 mg oral DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Anginal pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5 minutes PRN
Disp #*100 Tablet Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea
RX *ondansetron [Zofran ODT] 4 mg 3 tablet(s) by mouth Q8H: PRN
Disp #*3 Tablet Refills:*0
6. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*10
Tablet Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Calcipotriene 0.005% Cream 1 Appl TP BID
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
10. Halobetasol Propionate 0.05 % topical BID
11. Multivitamins 1 TAB PO DAILY
12. TiCAGRELOR 90 mg PO BID
13. Vitamin D ___ UNIT PO 4X/WEEK (___)
14. Vitamin D 4000 UNIT PO 3X/WEEK (___)
15. HELD- Hydrochlorothiazide 12.5 mg PO 3X/WEEK (MO,WE,SA)
This medication was held. Do not restart Hydrochlorothiazide
until evaluated by your PCP and cardiologist
___ Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
====================
Type I NSTEMI
Secondary Diagnosis:
====================
Coronary artery disease
Hypertension
Hyperparathyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with cp work up// cp work up
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs of ___
FINDINGS:
The lungs are hyperinflated and clear. Top-normal heart size is unchanged.
No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality. Unchanged top-normal heart size.
Radiology Report
EXAMINATION: CAROTID SERIES COMPLETE
CLINICAL HISTORY ___ year old woman with hx of CVA, pre-op for in-stent
thrombosis// please evaluate for carotid stenosis please evaluate for
carotid stenosis
FINDINGS:
Duplex was performed of bilateral carotid arteries.
Right: Mild heterogeneous plaque is seen in the proximal ICA. Peak velocities
are 82, 80 and 63 cm/sec in the ICA, CCA and ECA respectively. This is
consistent with less than 40% stenosis.
Left: Bulky heterogeneous plaque is seen in the proximal ICA. Peak velocities
are 184, 82 and 152 cm/sec in the ICA, CCA and ECA respectively. The ICA
end-diastolic velocity is 43. The ICA CCA ratio is 2.3. This is consistent
with 60-69% left ICA stenosis.
Vertebral flow is antegrade bilaterally.
IMPRESSION:
Right ICA less than 40% stenosis. Left ICA 60-69% stenosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ female with history of hyperlipidemia,
hypertensionand, SVT previously on verapamil, CAD with NSTEMI in ___, s/p
2 drug-eluting stents in the LAD who presents with chest pain and troponin
elevation with type I NSTEMI found to have in stent rethrombosis s/p high risk
PCI on ___ with intra-procedure course c/b bradycardia/hypotension s/p
atropine with severe hypertensive response, admitted to CCU for further
monitoring.// Assess for pulmonary edema
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-rays from ___ and ___
FINDINGS:
Inspiratory volumes are slightly low. There is mild cardiomegaly. The
cardiomediastinal silhouette appearsvery slightly smaller compared with ___. There is upper zone redistribution, without overt CHF. No
focal infiltrate or gross effusion is identified. Possible minimal blunting
at the right costophrenic angle. Coronary artery density again noted,
compatible with stent.
IMPRESSION:
Upper zone redistribution, without overt CHF, grossly unchanged compared with
___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with with history of hyperlipidemia,
hypertension and, SVT previously on verapamil, had SBPs 250s-300s during cath,
no focal neurologic defects// Please evaluate for bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular and subcortical white matter
hypodensities are nonspecific but likely reflect sequelae of mild chronic
small vessel ischemic disease. Atherosclerotic vascular calcifications of the
cavernous internal carotid arteries are noted.
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. Periodontal disease.
Periapical lucency posterior left maxillary molar, sometimes ending mild
inflammatory changes, consider infection.
IMPRESSION:
No acute intracranial abnormality.
Periapical lucencies about posterior left maxillary molar, only partially seen
on this scan, surrounding mild stranding, consider infection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NSTEMI, new dyspnea// dyspnea
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-ray from ___ at ___
11:22
FINDINGS:
Compared with ___ at 08:18, I doubt significant interval change.
Cardiomediastinal silhouette is unchanged. Apparent coronary stent noted. As
before, there is upper zone redistribution, without overt CHF. Minimal
retrocardiac atelectasis and minimal subsegmental atelectasis the right base.
Otherwise, no focal opacity. Minimal blunting the right costophrenic angle is
probably unchanged. No definite left effusion.
Compared with ___ the appearance is also quite similar. There may
have been subtle increase in the degree of retrocardiac opacity compared to
___.
No pneumothorax. No gross effusion.
IMPRESSION:
Upper zone redistribution without overt CHF, unchanged.
Bibasilar atelectasis. No definite infectious infiltrate. If there is
ongoing concern for subtle lower lobe pneumonic infiltrate, the lateral view
could help for further assessment.
No gross effusion. No pneumothorax.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.5
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Patient Summary for Admission:
===============================
Mrs. ___ is a ___ year old woman with a history of SVT,
hypertension, dyslipidemia, and recent admission for ___
complicated by LAD perforation and tamponade (___) who
presented to the ___ ED for evaluation of chest pain. EKG on
admission without obvious ischemic changes, troponins elevated
to 0.12. Patient admitted for NSTEMI management. While in the
ED, patient received an aspirin load, Brillinta and started on a
heparin gtt. She was transferred to ___ service for
further management. Patient underwent cardiac catheterization
___ which demonstrated ___ restenosis of the previous DES
placed in the LAD. Intervention was initially deferred, however
patient underwent cardiac catheterization with stenting to the
LAD on ___ with Dr. ___. Post catheterization course
complicated by hypotension and subsequently hypertension
requiring brief CCU stay. Patient transferred back to ___
service ___ where she remained hemodynamically stable and
follow evaluation by ___ was felt safe to discharge home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / duloxetine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Chest tube placement
J tube exchange ___
History of Present Illness:
Mr. ___ is a chronically ill ___ gentleman with a
history of CAD c/b MI in ___ (s/p stent), L pontine stroke,
recurrent aspiration pna (w/ two recent hospitalizations in
___ at ___, who was sent to the ED from rehab
with altered mental status and is admitted to the MICU with
concern for pneumonia and sepsis.
Over the past two months the patient has been admitted multiple
times for aspiration pneumonia to ___ ___ - ___ and more
recently at ___ (___). At ___ he was found to
have MRSA and acinetobacter in his sputum and discharged to
complete a course of vanc/zosyn via PICC (completed ___. Since
he completed his course of antibiotics, he reports that he has
continued to feel generally unwell, which is his recent
baseline. On the day of presentation to the hospital, the
patient was noted to have a fever at rehab to 101. He was given
Tylenol and his fever persisted. Per report he was also noted to
be lethargic so he was transferred to the ___ ED.
In ED initial VS: ___ 16 96%
Exam:
- Chronically ill appearing
- Coarse b/l breath sounds
- Abd tenderness at PEG site (chronic)
- ___ bruising without open wounds
- report of rash on bottom, not visualized
- PICC in RUE looks c/d/I
- Foley is draining clear urine
Labs significant for:
- WBC 12.5, Hb 7.6 (similar to recent baseline)
- K 5.3, BUN/Cr 60/1.2 ___ in ___
- Lactate 0.8
- FluA/B negative
- U/A inflammatory, no bacteria
- Sputum, blood, urine cultures pending
Patient was given:
- 1L NS
- Meropenem
- Vancomycin
Imaging notable for:
- CXR: Moderate L pleural effusion with atelectasis, LUL
opacity, pleural effusion, underlying pna or aspiration cannot
be ruled out.
The patient was admitted to the MICU with concern for sepsis and
pneumonia.
VS prior to transfer: 103.5, 98/65, 19, 93% 3LNC
On arrival to the MICU, the patient is tired and falls asleep
during the interview but awakes quickly when I say his name. He
denies any shortness of breath or chest pain. Other than the
fever yesterday morning, he feels no different than he has felt
in a long time. He does not know if he has had any diarrhea. He
denies abdominal pain. He also reports general weakness and
fatigue. When asked what bothers him the most he says, "my
entire body".
REVIEW OF SYSTEMS: Per HPI above
Past Medical History:
- CAD s/p stent S/p PTCA and bare metal stent to ___
- Chronic systolic CHF: EF 40-50% ___
- ___
- Fibromyalgia
- Depression
- HCV dx ___ s/p harmony
- Ventral hernia s/p mesh repair
- ___ diagnosed with severe disabling moderate-severe
oropharyngeal dysphagia resulting in significant weight loss and
post pyloric dobhoff placement for nutrition; extensive work up
unrevealing. Dysphagia secondary to isolated pathology of
glossopharyngeal and vagal innervated muscles. Outpatient
swallow reevaluation as performed after swallow therapy and
___ his dobhoff was pulled and he initiated a modified diet
of nectar-thick liquids and soft solids.
- HTN
- Bilaterally lower extremity weakness since ___ for which he
had seen PCP who was ___ primary neurologic process, including
ALS, MS however pt unable to follow up with Neurology until post
CVA ___
- Left pontine ischemic CVA ___ w/ resultant right
hemiplegia but no dysphagia at time of VVA diagnosis
- Chronic nausea on prolonged years of raglan, since
discontinued
- Chronic indwelling foley after neurogenic bladder since ___
- Presumed osteomyelitis or deep soft tissue infection of the
right lower extremity, now completed seven weeks of
antimicrobials in setting of mixed arterial/venous insufficiency
___
- Recurrent aspiration PNAs admissions since ___ s/p dobhoff
placement for TFs ___
Social History:
___
Family History:
Mother, deceased: ___, CAD
Father: deceased, ___ artery disease, pancreatic cancer
Brother: alive, ___
Physical Exam:
ADMISSION EXAM
==============
VITALS: Reviewed in OMR
GENERAL: Lethargic, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Rhonchorous breath sounds over R lung fields, reduced
breath sounds and dullness to percussion over L middle to lower
lung
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, mildly tender to palpation of R hemiabdomen, Jtube
site bandaged c/d/I, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Per
NEURO: Pupils pinpoint but reactive, R hemiparesis, LUE ___
strength, RLE ___ strength w/ poor effort.
DISCHARGE EXAM
==============
24 HR Data (last updated ___ @ 1210)
Temp: 98.4 (Tm 98.5), BP: 148/75 (109-150/63-75), HR: 77
(74-85), RR: 18, O2 sat: 95% (91-95), O2 delivery: Ra
Gen: Chronically ill-appearing, otherwise in NAD, lying in bed
resting comfortably.
HEENT: NCAT.
Neck: Supple.
Lungs: Transmitted upper-airway sounds, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
GI: Soft, moderately distended, mildly tender to deep palpation
in all quadrants. No guarding. G-J tube in place, with erythema
and small amount of discharge stable from yesterday.
Ext: No c/c/e. Lateral arm scab, no edema or tenderness to
palpation in the lower extremities bilaterally.
Neuro: alert, conversing appropriately.
Pertinent Results:
ADMISSION LABS
==============
___ 07:40PM WBC-12.5* RBC-2.29* HGB-7.6* HCT-22.2* MCV-97
MCH-33.2* MCHC-34.2 RDW-16.2* RDWSD-55.9*
___ 07:40PM NEUTS-86.1* LYMPHS-8.6* MONOS-4.9* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-10.77* AbsLymp-1.07* AbsMono-0.61
AbsEos-0.00* AbsBaso-0.03
___ 07:40PM PLT COUNT-332
___ 07:40PM ___ PTT-35.8 ___
___ 07:40PM LACTATE-0.8 K+-5.3*
___ 07:40PM GLUCOSE-154* UREA N-60* CREAT-1.2 SODIUM-144
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-32 ANION GAP-10
MICRO
=====
___ 2:21 pm PLEURAL FLUID LEFT PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
STUDIES
=======
CXR ___
IMPRESSION: Patient rotated to the left. Moderate left pleural
effusion with overlying atelectasis. Left upper to mid lung
opacity, likely combination of chronic interstitial abnormality,
lung with pleural effusion and atelectasis, but underlying
consolidation due to pneumonia or aspiration may be present.
Right-sided PICC terminates in the region of the mid SVC.
PLEURAL FLUID, LEFT:
NEGATIVE FOR MALIGNANT CELLS.
Reactive appearing mesothelial cells, many lymphocytes,
scattered histiocytes, and a few neutrophils. See also
concurrent microbiological culture results ___ # ___ and
___
and flow cytometry report (___).
Immunohistochemical stains on cell block preparation show that
the vast majority of the lymphocytes are CD3-positve
T-lymphocytes with scattered occasional CD20-positive
B-lymphocytes, consistent with a reactive process.
Chest Port Line Placement ___
IMPRESSION:
Interval placement of left pigtail pleural drainage catheter
with marked
interval decrease in left pleural effusion and increased
ventilation of the left lung. Opacification within the right
midlung appears new and may
represent superimposition of structures, although consolidation
due to
aspiration/pneumonia cannot be excluded.
Abdominal US ___
Mild overlying soft tissue swelling without suggestion of
underlying
collection.
KUB ___
1. Extensive colonic stool burden.
2. No evidence of bowel obstruction.
CXR ___
There are no clear findings of pneumonia. Pulmonary fibrosis is
chronic and extensive. Heart size is normal. No appreciable
pleural effusion.
J-Tube Exchange ___
Successful replacement of a jejunostomy tube. The indwelling,
clogged tube was replaced with a new, 16 ___ MIC gastrostomy
tube functioning as a jejunostomy tube. The tube is ready to
use.
KUB ___
Significant colonic dilatation and air-fluid levels suggest
large-bowel
obstruction or colonic ileus. Recommend CT abdomen pelvis for
further
evaluation.
CT A/P WC ___
1. Large rectal fecal load with diffuse gaseous distension of
the entire colon is likely secondary to constipation, with some
associated rectal wall thickening suggesting stercoral
proctitis. No evidence of obstructing mass or abrupt transition
point.
2. No specific evidence of bowel wall ischemia although not
totally excluded by this exam.
3. Small bilateral pleural effusions with compressive
atelectasis.
4. Although likely atelectasis, superimposed infection cannot be
excluded
within the left lower lobe consolidation in the appropriate
clinical setting.
CTA CHEST/ABD/PELVIS ___
IMPRESSION:
1. New moderate to large amount of hemoperitoneum. The site of
hemorrhage is not elucidated.
2. Persistent colonic dilatation with new wall thickening.
Findings may be
infectious/inflammatory or related to colonic ileus. However,
ischemia may be considered given the persistent dilatation and
wall thickening
disproportionate to distension.
3. No acute pulmonary embolism. Patchy consolidation within the
lingula and left lower lobe and mild to moderate pulmonary edema
in a background of upper lobe predominant fibrotic interstitial
lung disease.
CT ABD/PELVIS with contrast PO and IV ___
IMPRESSION:
1. No evidence of bowel obstruction or extraluminal contrast to
suggest leak from the J-tube.
2. Worsened dilation of the sigmoid colon with persistent
colonic wall
thickening again concerning for mild colitis. Caliber change
between the
rectum and the anal canal as also noted on multiple prior scans
this is
concern for a stricture, correlation with clinical exam findings
to look for the same to be considered.
3. Interval decrease in small to moderate volume hemoperitoneum.
4. Worsened left lower lobe consolidation with air bronchograms
concerning for pneumonia.
5. Worsened small left greater than right-sided pleural
effusions
DISCHARGE LABS
==============
___ 04:45AM BLOOD WBC-7.8 RBC-2.78* Hgb-9.2* Hct-25.9*
MCV-93 MCH-33.1* MCHC-35.5 RDW-16.4* RDWSD-53.9* Plt ___
___ 04:45AM BLOOD Glucose-221* UreaN-20 Creat-0.6 Na-133*
K-4.6 Cl-97 HCO3-28 AnGap-8*
___ 04:45AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg NG Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Clopidogrel 75 mg NG DAILY
4. Gabapentin 400 mg NG TID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Methadone (Oral Solution) 2 mg/1 mL 10 mg PO Q6H
8. Polyethylene Glycol 17 g NG DAILY:PRN constipation
9. Senna 17.2 mg NG BID Constipation
10. Sertraline 50 mg PO QHS
11. Sodium Chloride 3% Inhalation Soln 4 mL NEB Q6H
12. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 40 mg PO QPM
15. Calcium Carbonate 500 mg PO QID
16. Miconazole Powder 2% 1 Appl TP TID:PRN Fungal infection
17. Multivitamins W/minerals 1 TAB PO DAILY
18. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
19. Ramelteon 8 mg PO QHS:PRN sleep
20. Ondansetron 4 mg PO BID
21. Omeprazole 40 mg PO DAILY
22. Metoprolol Tartrate 6.25 mg PO Q6H
23. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
24. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Lisinopril 30 mg PO DAILY
4. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
5. Glargine 5 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
6. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO Q6H
RX *methadone 5 mg/5 mL 5 mL by mouth q6hours Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*21 Capsule Refills:*0
8. Polyethylene Glycol 17 g NG BID constipation
9. Acetaminophen 650 mg NG Q6H:PRN Pain - Mild
10. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Calcium Carbonate 500 mg PO QID
15. Gabapentin 400 mg NG TID
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Metoprolol Tartrate 6.25 mg PO Q6H
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Ramelteon 8 mg PO QHS:PRN sleep
Should be given 30 minutes before bedtime
21. Senna 17.2 mg NG BID Constipation
22. Sertraline 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Aspiration pneumonia
Toxic metabolic encephalopathy
Sepsis
Pleural effusion
Hypoxemia
Constipation
Hemoperitoneum
Stercoral colitis
SECONDARY DIAGNOSIS
CAD
Fibromyalgia
DM Type II
Depression
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chronic aspiration PNA and PICC in RUE presents
from rehab. Confirming PICC and coarse BS// Confirm L PICC placement, eval PNA
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Patient is rotated to the left. There is a moderate left pleural effusion
with overlying atelectasis. Left upper to mid lung opacity, likely
combination of chronic interstitial abnormality and pleural effusion and
atelectasis, but underlying consolidation due to pneumonia or aspiration could
be present. The right lung is similar in appearance compared to the prior
study.
Mediastinal contours are stable. No evidence of pneumothorax.
A right-sided PICC is seen, distal aspect not well seen, but likely terminates
in the mid SVC.
IMPRESSION:
Patient rotated to the left. Moderate left pleural effusion with overlying
atelectasis. Left upper to mid lung opacity, likely combination of chronic
interstitial abnormality, lung with pleural effusion and atelectasis, but
underlying consolidation due to pneumonia or aspiration may be present.
Right-sided PICC terminates in the region of the mid SVC.
Radiology Report
INDICATION: ___ year old man with left pleural effusion s/p chest tube
placement// ? chest tube placement Contact name: ___: ___
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
There has been interval placement of a left pigtail pleural drainage catheter
at the left lung base with marked interval decrease in left pleural effusion,
now trace to small. Ventilation of the left lung is also much improved.
There is no pneumothorax. Opacification within the right midlung appears new
and may represent superimposition of interstitial lung disease and bony
structures, although consolidation due to aspiration/pneumonia cannot be
excluded. The cardiomediastinal contour is stable. A right PICC terminates
in the mid SVC.
IMPRESSION:
Interval placement of left pigtail pleural drainage catheter with marked
interval decrease in left pleural effusion and increased ventilation of the
left lung. Opacification within the right midlung appears new and may
represent superimposition of structures, although consolidation due to
aspiration/pneumonia cannot be excluded.
Radiology Report
INDICATION: ___ year old man with aspiration pneumonia// post chest tube
removal
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
The left basilar chest tube has been removed in the interim. No obvious
pneumothorax is seen. Interstitial edema is unchanged. Cardiomediastinal
silhouette is stable. There is no pleural effusion. Right-sided PICC line
projects to the SVC and is unchanged
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with recurrent aspiration PNA, called out from
MICU, now febrile again with new altered mental status.// ? aspiration
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 12:53.
IMPRESSION:
There is essentially no change compared to the earlier same day examination
with unchanged position of a right-sided PICC, mild interstitial edema and
scattered streaky opacities affecting all lung lobes, which may reflect a
component of edema, though subtle infection is not excluded. There remains a
trace left-sided effusion. There is no pneumothorax.
Radiology Report
EXAMINATION: US ABDOMINAL WALL, SOFT TISSUE LEFT
INDICATION: ___ year old man with recent G-tube placement with pain around
stitch site// please assess for stitch abscess
TECHNIQUE: Targeted grayscale images were obtained in the left upper
quadrant, in the region of recently placed gastrostomy tube.
COMPARISON: Multiple prior examinations, none of which are relevant for
comparison to this exam.
FINDINGS:
Targeted ultrasound was performed in left upper quadrant, in the region of the
gastrostomy tube. There is mild overlying soft tissue swelling without
suggestion of underlying collection.
IMPRESSION:
Mild overlying soft tissue swelling without suggestion of underlying
collection.
Radiology Report
INDICATION: ___ year old man with history of CAD, L pontine stroke, recurrent
aspiration PNA with G-tube, admitted with fever and likely aspiration PNA s/p
7 day course of vanc/meropenem and parapneumonic effusion s/p chest tube
drainage and pull, now with persistent hypoxemia requiring 2L O2// Eval for
underlying reason for hypoxia, interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Interstitial abnormality is unchanged and could represent resolving pulmonary
edema. Small bilateral effusions left greater than right are stable.
Right-sided PICC line is unchanged. Cardiomediastinal silhouette is stable.
No pneumothorax is seen. No new consolidations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with history of L pontine stroke and recurrent
aspiration PNA with peg, s/p 7 day course of ___ for aspiration PNA, now
with up-trending leukocytosis with concern for recurrent aspiration// Eval for
recurrent PNA Eval for recurrent PNA
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
There are no clear findings of pneumonia. Pulmonary fibrosis is chronic and
extensive. Heart size is normal. No appreciable pleural effusion.
Right PIC line ends in the mid SVC.
Radiology Report
INDICATION: ___ year old man with history of L pontine stroke and recurrent
aspiration PNA with peg, s/p 7 day course of ___ for aspiration PNA, now
with up-trending leukocytosis also with abdominal pain and 5 day history of
constipation (previously had stool ball during last hospitalization)// Eval
for stool burden, cause for intra-abdominal pain
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is
extensive stool burden throughout the colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Surgical clips are seen overlying the
left flank.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Extensive colonic stool burden.
2. No evidence of bowel obstruction.
Radiology Report
INDICATION: ___ year old man with history of L pontine stroke and recurrent
aspiration PNA with J-tube, with erythema discharge and TTP surrounding J-tube
with frequent clogging, per ACS recommending ___ replacement.// J-tube
replacement
COMPARISON: Portable abdominal radiograph on ___
TECHNIQUE: OPERATORS: Dr. ___ (Interventional Radiology Fellow) and
Dr. ___ performed the procedure.
The attending, Dr. ___ was present and supervising throughout the
procedure. Dr. ___ radiologist, personally supervised the
trainee during the key components of the procedure and reviewed and agreed
with the trainee's findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: Fentanyl, Versed
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 5.5 min, 8 mGy
PROCEDURE:
1. Scout image of the abdomen.
2. Replacement of a clogged jejunostomy tube.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The tube site was
prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. Multiple attempts to inject the
existing tube with contrast to confirm positioning were unsuccessful as the
tube was clogged. Under fluoroscopic guidance, a stiff Glidewire was advanced
through the tube and into a loop of bowel. The tube was removed over the wire
and a 5 ___ Kumpe was advanced over the wire. The wire was removed and a
small amount of contrast was injected through the Kumpe catheter to confirm
positioning within the bowel. After positioning within bowel was confirmed, a
___ wire was advanced through the Kumpe catheter into the loop of jejunum.
At this time, the catheter was removed and a new 16 ___ MIC gastrostomy
tube (being used as a jejunostomy tube) was advanced over the wire into
appropriate positioning. The balloon was inflated using dilute contrast. A
final contrast injection confirmed positioning. The tube was secured in place
with 0 silk sutures. Sterile dressings were applied. Patient tolerated the
procedure well and there were no immediate post-procedure complications.
IMPRESSION:
Successful replacement of a jejunostomy tube. The indwelling, clogged tube
was replaced with a new, 16 ___ MIC gastrostomy tube functioning as a
jejunostomy tube. The tube is ready to use.
Radiology Report
INDICATION: ___ year old man with CAD s/p MI in ___ with stent, L pontine
stroke, recurrent aspiration PNA with 16 hospitalizations this year, p/w AMS
found to have aspiration PNA with distended abdomen// Eval for ileus?
obstruction?
TECHNIQUE: Supine and lateral decubitus abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dated ___ and J-tube replacement
dated ___.
FINDINGS:
There are multiple air-fluid levels as well as significantly dilated loops of
colon measuring up to 10.0 cm in the left upper quadrant, new since ___.
A moderate amount of stool is seen in the descending colon. A PEG tube
projects over the left upper quadrant. Small bowel loops are prominent,
however, they are not abnormally dilated.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Significant colonic dilatation and air-fluid levels suggest large-bowel
obstruction or colonic ileus. Recommend CT abdomen pelvis for further
evaluation.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:02 pm, 2 minutes after
discovery of the findings.
RECOMMENDATION(S): CT abdomen pelvis with contrast
Radiology Report
INDICATION: ___ year old man with CAD s/p MI in ___ with stent, L pontine
stroke, recurrent aspiration PNA with 16 hospitalizations this year, p/w AMS
found to have aspiration PNA with newly distended abdomen and abd pain// with
PO and IV contrast. Eval for large bowel obstruction, colonic ischemia
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE:
Total DLP (Body) = 862 mGy-cm.
COMPARISON: CT torso ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with associated
compressive atelectasis, similar to prior. Otherwise, visualized lung fields
are within normal limits. There is no evidence of pleural or pericardial
effusion. There are coronary artery calcifications.
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: There is a 1.3 cm hypodense lesion at the upper pole of the right
kidney, stable from prior study compatible with a cyst. There are additional
smaller bilateral hypodensities which are too small to characterize, but
likely representative of simple cysts. Otherwise, the kidneys are of normal
and symmetric size with normal nephrogram. There is no evidence of solid
focal renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is gaseous
distension throughout the colon to the level of the rectum where there is a
large rectal fecal load without obstructive lesions or tapered narrowing
identified in the colon and rectum. There is mild rectal wall circumferential
thickening. No regions of bowel wall pneumatosis identified to suggest
colonic ischemia. The appendix is normal.
PELVIS: The urinary bladder containing a Foley catheter is decompressed and
therefore suboptimally assessed. Otherwise, the distal ureters are grossly
unremarkable. There is trace pelvic/perisigmoid free fluid.
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. Moderate atherosclerotic
disease is noted.
BONES: There are nonacute compression fractures of the T11, L1 and L3
vertebral bodies. Otherwise, there is no evidence of worrisome osseous
lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Large rectal fecal load with diffuse gaseous distension of the entire colon
is likely secondary to constipation, with some associated rectal wall
thickening suggesting stercoral proctitis. No evidence of obstructing mass or
abrupt transition point.
2. No specific evidence of bowel wall ischemia although not totally excluded
by this exam.
3. Small bilateral pleural effusions with compressive atelectasis.
4. Although likely atelectasis, superimposed infection cannot be excluded
within the left lower lobe consolidation in the appropriate clinical setting.
Radiology Report
INDICATION: ___ year old man with stercoral proctitis// please evaluate for
bowel obstruction air fluid levels
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
There is significant distention of the rectosigmoid, descending, and
transverse colons. No air-fluid levels are seen to suggest obstruction. Air
is seen to the level of the sigmoid colon. No dilated loops of small bowel
are seen. No free intraperitoneal air. Imaged lung bases notable for left
basilar atelectasis.
IMPRESSION:
Persistent distension of colonic loops. No air-fluid levels to suggest
obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recurrent aspiration pneumonia and stool
burden got 2L ivf yesterday// please evaluate for pulmonary infiltrates vs.
consolidations please evaluate for pulmonary infiltrates vs.
consolidations
IMPRESSION:
As compared to the previous radiograph, the lung volumes have decreased and
the patient now shows signs of mild to moderate pulmonary edema. There are no
pleural effusions. Mild retrocardiac atelectasis. Borderline size of the
cardiac silhouette.
Radiology Report
INDICATION: ___ year old man with large stercoral proctitis with increasing
abdominal pain// please evaluate for free air or obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dated ___ and CT abdomen pelvis
dated ___.
FINDINGS:
Re-demonstrated is significant distension of the large bowel measuring up to
7.8 cm in the right upper quadrant. However, there has been interval increase
in small bowel dilatation. As before, there is a paucity of bowel gas in the
rectum where there appears to be a large stool ball. There are no air-fluid
levels to suggest obstruction. A PEG tube projects over the left upper
quadrant.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative change in the lower lumbar
spine and bilateral hips. Rounded opacities in the lower pelvis likely
represent phleboliths.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
There is persistent distension of colonic loops. However, there has been
interval increase in small bowel distention, likely secondary to the large
rectal stool burden as seen on prior CT.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with aspiration PNA with increasing WBC and
hypoxia// eval for pneumonitis/ PNA eval for pneumonitis/ PNA
IMPRESSION:
Compared to chest radiographs ___ through ___.
Large region of consolidation right midlung is smaller today and mild
pulmonary edema has improved since ___. Heart size normal. Small
pleural effusions probably unchanged.
Radiology Report
INDICATION: ___ man with a history of aspiration pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___ at ___.
FINDINGS:
There is a right upper extremity PICC with tip overlying the mid SVC. The
cardiomediastinal silhouette is stable and within normal limits. Prominence
of the right hilum likely reflects prominent central pulmonary vasculature, as
on priors. There is unchanged moderate pulmonary edema. There is linear
atelectasis at the left lower lung. Slight opacification of the left lung
base is minimally increased from prior exams. Otherwise, no new focal
consolidation. No pneumothorax or sizable pleural effusion.
IMPRESSION:
1. Slightly increased left lung base opacification may reflect atelectasis or
possibly infection/aspiration in the appropriate clinical setting.
2. Unchanged moderate pulmonary edema.
Radiology Report
INDICATION: ___ year old man with ileus and abd distention// eval NGT
placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube projects over the upper stomach. A right PICC
line tip projects over the mid SVC. The size of the cardiac silhouette is
within normal limits. Unchanged moderate pulmonary edema and atelectasis in
the left lower lung. No pneumothorax.
IMPRESSION:
The nasogastric tube projects over the upper stomach, the side port appearing
in close proximity to the GE junction. Continued advancement by several cm is
recommended.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with aspiration pneumonia and some mild bilateral
lower leg swelling// please evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and left peroneal
veins. Thrombus is seen in one of the right peroneal veins, however detailed
evaluation is limited due to suboptimal sonographic penetration.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep vein thrombosis in one of the right peroneal calf veins.
2. No evidence of deep venous thrombosis in the otherlower extremity veins
bilaterally.
NOTIFICATION: The findings were discussed with ___, MD, by ___
___, MD, on the telephone on ___ at 20:31.
Radiology Report
INDICATION: ___ year old man with worsening abdominal pain and now s/p large
BM with underlying concern for ileus.// Please evaluate for improvement in
colonic distention
TECHNIQUE: Supine portable frontal views of the abdomen and pelvis.
COMPARISON: ___.
IMPRESSION:
Upper enteric tube tip terminates in the proximal stomach with the side port
at the GE junction and should be advanced by 3 cm from ideal placement. There
remains diffuse distention of the large bowel to a maximum caliber of roughly
10 cm, similar to minimally increased compared the prior study. Multiple
small bowel loops are also mildly distended. The this is compatible with
ileus. There is no supine radiographic evidence of free air. There is no
pneumatosis.
Radiology Report
EXAMINATION: CT scan of the torso with intravenous contrast
INDICATION: ___ year old man with hypoxia, worsening anemia and no clear GI
source// eval for acute PE, eval for RP bleed or other intra-abdominal bleed
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the thorax, abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 38.9 cm; CTDIvol = 7.5 mGy (Body) DLP = 290.6
mGy-cm.
2) Spiral Acquisition 4.4 s, 57.7 cm; CTDIvol = 21.7 mGy (Body) DLP =
1,251.1 mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.8
mGy-cm.
4) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 6.8 mGy (Body) DLP = 3.4
mGy-cm.
Total DLP (Body) = 1,546 mGy-cm.
COMPARISON: CT scan of the abdomen and pelvis dated ___.
FINDINGS:
CHEST:
LUNGS AND AIRWAYS: There is diffuse ground-glass density involving both lungs
with relative sparing of the left lower lobe. There is mild associated
interlobular septal thickening. Patchy areas of atelectasis/consolidation are
noted within the lingula and left lower lobe. Background peripheral
reticulation is suggestive of chronic interstitial lung changes.
PLEURA/PERICARDIUM: Small left and trace right pleural effusions. No
pericardial effusion.
MEDIASTINUM: There is mediastinal and bilateral hilar adenopathy, measuring up
to 16 mm in the subcarinal region and 13 mm in the bilateral hilar regions.
HEART AND VESSELS: There is marked cardiomegaly, which appears new in
comparison to the prior CT scan of the abdomen pelvis dated ___. the
aorta and major vessels to the neck are unremarkable. The main pulmonary trunk
is enlarged, measuring up to 35 mm in diameter. There is satisfactory
opacification of the pulmonary arteries without evidence of acute pulmonary
emboli.
BONES AND SOFT TISSUES: No worrisome osseous or soft tissue lesion.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. No biliary ductal dilatation. The
gallbladder is distended but appears otherwise unremarkable.
PANCREAS: Unremarkable.
SPLEEN: Unremarkable.
ADRENALS: The adrenal glands are unremarkable.
URINARY: Bilateral renal cortical cysts. No hydronephrosis. The bladder is
collapsed with a Foley catheter in situ.
GASTROINTESTINAL: The stomach is unremarkable. The small bowel is normal in
caliber. There is a left-sided percutaneous jejunostomy tube in situ. There
is high-density material noted within the cecal pole (axial series 304, image
61), likely retained oral contrast. There is continued colonic dilatation
with new wall thickening without pneumatosis.
LYMPH NODES: No retroperitoneal or mesenteric adenopathy. No pelvic or
inguinal adenopathy.
PERITONEUM, RETROPERITONEUM, MESENTERY: There is a moderate volume diffuse
high attenuation fluid throughout the abdomen and pelvis, suggestive of
hemoperitoneum. More confluent areas of higher attenuation within the right
hemipelvis (axial series 304, image 72) are suggestive of areas of more formed
clot.
VASCULAR: No abdominal aortic aneurysm. No active contrast extravasation
demonstrated.
BONES: Stable appearance of the bones with multilevel compression fractures.
No suspicious osseous lesion.
IMPRESSION:
1. New moderate to large amount of hemoperitoneum. The site of hemorrhage is
not elucidated.
2. Persistent colonic dilatation with new wall thickening. Findings may be
infectious/inflammatory or related to colonic ileus. However, ischemia may be
considered given the persistent dilatation and wall thickening
disproportionate to distension.
3. No acute pulmonary embolism. Patchy consolidation within the lingula and
left lower lobe and mild to moderate pulmonary edema in a background of upper
lobe predominant fibrotic interstitial lung disease.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:35 pm, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with recurrent aspiration pneumonia, acute blood
loss anemia and right lower calf perineal vein DVT// please re-evaluate the
size of the right perineal calf vein DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Ultrasound dated ___
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 tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins. Peroneal veins are no fully patent.
Radiology Report
INDICATION: ___ year old M with history of CAD s/p MI with stent, L pontine
stroke, recurrent aspiration PNA with G-J tube, ___ rehab with fever
and AMS c/f aspiration PNA also hypotensiverequiring ICU admission did not
require pressors, s/p 2 7 day courses of Vancomycin/meropenem for recurrent
aspiration PNAs, s/p clogged G-J tube exchange ___, constipated and now
bleeding// eval for obstruction
TECHNIQUE: Portable supine frontal views of the abdomen and pelvis.
COMPARISON: Abdominal radiograph pole ___. CTA torso ___
IMPRESSION:
There is persistent large bowel dilatation up to 11 cm at the level of the
cecum, appearing grossly unchanged compared the prior study. The few
visualized small bowel loops do not appear distended and there is no evidence
of small-bowel obstruction. There is no supine radiographic evidence of free
air. There is no pneumatosis. There is transition of gas is distention of
the large bowel near the level of the descending colon, and this likely
relates to the bowel wall thickening seen on the prior CT.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ year old man with recurrent aspiration pneumonia and new
abdominal pain and hemoperitoneum with concern that the J tube has been pulled
and is causing some erosion of the bowel.// J tube study, please also perform
this CT with gastrografin through the feeding tube to evaluate placement and
look for signs of bowel erosion.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Enteric contrast was administered through the J-tube.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 60.2 cm; CTDIvol = 19.1 mGy (Body) DLP =
1,146.0 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 20.1 mGy (Body) DLP =
10.1 mGy-cm.
Total DLP (Body) = 1,158 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Increased consolidation left lower lobe with air bronchograms.
Small left greater than right-sided pleural effusions are increased from prior
exam. Trace pericardial effusion is likely physiologic.
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.
Small volume perihepatic ascites is similar to prior.
PANCREAS: Pancreas is markedly atrophic without evidence of focal lesions or
pancreatic ductal 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 of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. 1.6 cm simple
cyst arises from the interpolar region of the right kidney. There is no
perinephric abnormality.
GASTROINTESTINAL: Gastric wall appears diffusely thickened as on prior, though
this may be due to underdistention. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Left lower quadrant
J-tube is noted. Contrast injected through this J-tube opacifies the distal
ileal loops and passes into the colon to the level of the proximal descending
colon. No extraluminal contrast to suggest leak. The sigmoid colon is
markedly distended measuring up to 10.1 cm, worsened compared to prior. There
is rapid tapering of the lumen at the level of the rectum, similar prior.
High-density material layering in the sigmoid colon is present on the prior
exam. There is also mild diffuse wall thickening of the colon, particularly
of the sigmoid and descending colon, similar prior. No significant
surrounding inflammatory changes. There is small to moderate volume
high-density ascites throughout the abdomen and pelvis, slightly decreased
compared to prior exam. Confluent areas of high density material in the right
hemipelvis again suggestive of formed clot.
PELVIS: Bladder contains a Foley catheter and is otherwise unremarkable.
REPRODUCTIVE ORGANS: Prostate seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Impression fractures involving the L3, the L1, T11 vertebral bodies are
unchanged from prior.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Mild
diffuse anasarca is noted.
IMPRESSION:
1. No evidence of bowel obstruction or extraluminal contrast to suggest leak
from the J-tube.
2. Worsened dilation of the sigmoid colon with persistent colonic wall
thickening again concerning for mild colitis. Caliber change between the
rectum and the anal canal as also noted on multiple prior scans this is
concern for a stricture, correlation with clinical exam findings to look for
the same to be considered.
3. Interval decrease in small to moderate volume hemoperitoneum.
4. Worsened left lower lobe consolidation with air bronchograms concerning for
pneumonia.
5. Worsened small left greater than right-sided pleural effusions.
Radiology Report
INDICATION: ___ year old man with PICC that has been pulled out 2cm// Assess
PICC placement
TECHNIQUE: Portable chest x-ray
COMPARISON: Portable chest x-ray ___
FINDINGS:
The tip of the right PICC is in the mid SVC. The heart is not enlarged. The
trachea is midline. The aorta is atherosclerotic. There is mild pulmonary
edema. Atelectatic changes are seen at the left lung base. Degenerative
changes are evident in the spine.
IMPRESSION:
As above
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Lethargy
Diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism, Altered mental status, unspecified
temperature: 101.0
heartrate: 100.0
resprate: 16.0
o2sat: 96.0
sbp: 102.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male with history of CAD s/p MI
with stent, L pontine stroke, recurrent aspiration PNA with
more than 15 hospitalizations this year for recurrent
aspirations, with J tube, who presented from rehab with fever
and AMS concerning for aspiration PNA, was also hypotensive
requiring a brief ICU admission however did not require
pressors, completed a 7 day course of vancomycin and meropenem.
He also had a parapneumonic effusion and underwent chest tube
placement and drainage. Hospital course was complicated by a
recurrent aspiration pneumonia and he completed a second 7 day
course of Vancomycin and meropenem. Due to frequent clogging of
his J tube, he underwent ___ exchange. He also had an acute
bleed in the setting of heparin for a right calf DVT that was
identified. He was found to have a hemoperitoneum thought to be
from an abdominal wall bleed or bowel wall bleed at the
insertion of the PEJ tube. We stopped anticoagulation and his
bleed spontaneously stopped. At time of discharge based on
ongoing goals of care conversation patient was transitioned
from strict NPO to NPO allowing for ice chips with nursing
supervision. He developed severe constipation and was found on
CT A/P to have ileus/stercoral colitis. The patient was started
on aggressive bowel regimen. Bowel regimen was held for a
period of time while patient was having diarrhea. The patient's
bowel regimen was restarted prior to discharge and patient was
having regular bowel movements.
# Recurrent aspiration pneumonia
# Acute hypoxic respiratory failure
# Sepsis
# Toxic metabolic encephalopathy - Patient has had recurrent
aspiration pneumonias in the setting of a left pontine stroke,
with PEJ tube and > 15 admissions this year for recurrent
aspiration pneumonia. He presented with altered mental status
and fevers consistent with sepsis secondary to aspiration
pneumonia. He was initially hypotensive, requiring an ICU
admission, however never required vasopressors. He was started
on vancomycin and meropenem for coverage of resistant organisms
given a history of MRSA, multi-drug resistant Klebsiella and
acinetobacter. He completed a 7 day course (___). Sputum
cultures were unrevealing. He had a recurrent aspiration
pneumonia and completed a ___ 7 day course of vancomycin and
meropenem through ___. Sputum culture was ultimately
contaminated and unable to obtain an adequate repeat specimen.
He required frequent suctioning. Of note, his CXR showed
extensive pulmonary fibrosis thought to be secondary to his
chronic aspirations. In consultation with palliative care, he
was initially made strict NPO however based on goals of care
conversations, allowed for ice chips with nursing supervision
for comfort. He was weaned to room air at time of discharge.
# Pleural effusion - Patient likely had a parapneumonic
effusion in the setting of pneumonia per above. He had a chest
tube placed that drained serosanguinous fluid. Pleural fluid
studies were consistent with a parapneumonic effusion. The
pleural fluid was also notable for atypical lymphocytes
initially concerning for malignancy. Flow cytometry was
consistent with a reactive process however. Pleural effusion
was drained and chest tube was removed.
# Acute on chronic Anemia
# Hemperitoneum: Baseline Hb 7.0-8.0 thought likely due to
anemia of chronic disease. Patient with sudden onset
downtrending in his hemoglobin. This occured 24 hours after
being placed on heparin for a right calf DVT. A CTA showed a
hemoperitoneum but no identifiable bleeding vessels. ACS
evaluated and thought that the PEJ tube likely was causing some
irritation accompanied by the heparin gtt causes a vessel to
slowly bleed. Heparin was stopped and his bleed ceased. We got
a repeat US to eval for the DVT and it was no longer
visualized. We stopped all anticoagulation for him.
# Right Calf DVT: patient noted to have right lower extremity
edema. Bilateral ultrasounds were performed which demonstrated
a right peroneal vein DVT. He was started on heparin gtt but in
the setting of the bleed as noted above this was stopped. A
repeat US showed resolution of this DVT. At this time,
anticoagulation was discontinued due to hemoperitoneum. CTA
chest with no sign of PE.
# Goals of care
# Chronic dysphagia and aspiration
# Nutrition - With chronic G-J tube for enteral feeding. He was
initially noted to have mild tenderness to palpation and
erythema surrounding his G-J tube. ACS was consulted however
there was lower suspicion for infection. His G-J tube
frequently became clogged and was later replaced by ___. Given
the patient's recurrent hospitalizations for aspiration
pneumonia, palliative care was consulted to help clarify goals
of care. He is very interested in being able to eat/drink, but
does not want to stop being treated for recurrent pneumonias.
He continued tube feeds and was made NPO with aspiration
precautions, eventually allowing ice chips with nursing
supervision for comfort.
# Stercoral Colitis:
# Constipation - Patient had ongoing issues with constipation,
was on an aggressive standing bowel regimen however had
worsening abdominal distention, KUB showed severely dilated
loops of bowel. CT Abdomen and Pelvis was obtained which showed
a large fecal load, no evidence of obstruction, with some
thickening suggestive of stercoral colitis. Constipation was
relieved with mineral oil enemas and manual disempaction.
Patient then developed profuse diarrhea for which aggressive
bowel regimen was held. C. diff was negative. His bowel regimen
was restarted when his diarrhea resolved and he was having
regular bowel movements before he left the hospital.
# Hypernatremia - The patient had hypernatremia to 150 likely
from insensible loses and too few free water flushes. This
improved with increasing free water flushes and with D5W.
# Hyponatremia - The patient developed hyponatremia, which was
likely due to combination of hypovolemic hyponatremia and
SIADH. The hyponatremia was resolving with IVF and decreasing
free water flushes at time of discharge.
# Coagulase negative staph bacteremia - Was noted to have
positive blood cultures, but this was most likely a
contaminant. He was already on vancomycin for HAP coverage as
above. Repeat blood cultures were obtained which were negative. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ h/o pAF on Eliquis, SSS s/p PPM/ICD, mac deg and spinal
stenosis, dHF on Bumex, c/f h/o TIA/CVA although never with
positive MRI, presenting with a report of slurred speech and
right sided facial droop as well as worsening anemia concerning
for GI bleed.
History provided by patient's son via phone. Of note, he is a
physician at the ___. He explains that 1 week ago, the
patient had severe constipation, so she took a large amount of
laxatives and subsequently had significant profuse non-bloody
diarrhea. She has also had decreased appetite. The son called
her this morning, she was speaking normally but said she was
very weak. Her other son visited her subsequently and said she
was unable to speak, so she went to the ED at ___.
Her son (HCP) met her there around 2:30, at which time she was
back to baseline, speaking normally and oriented. This
afternoon, her main complaints were hand pain, heel pain, and
rectal irritation (she did not complain of these with the
interpreter on arrival to the floor). She did not complain of
chest pain or dizziness, but endorsed mild HA.
At baseline, paitent walks with a walker. She can only walk to
bathroom and back. She has ___ services at home and took her
medications today.
At OSH today had stat NCHCT which was normal for bleed or acute
stroke. CTA could not be obtained due to Cr 2.5. tPA was
deferred as patient is on eliquis. Neurology consulted at
___ and felt the facial droop was a baseline asymmetry.
Diagnosis was ultimately of dehydration and given IVF 100cc/hr
(h/o CHF), no UA performed as no urine available. Family felt
they were treated poorly at OSH and requested transfer to ___
for further care.
In the ED, initial vitals were: 0 96.7 70 115/32 20 96% RA
Exam notable for:
on eval, appears well
mild R NLF
CN intact
str intact, BLE unable to be raised off the bed due to
"heaviness" from "fluid buildup" which is chronic for her, but
plantar/dorsiflexion intact
sensation intact
gait baseline with walker
no asymmetry in lower extremities: 2+ edema to mid-shin. No s/o
CP, SOB that would warrant ___ DVT or CTA chest.
rectal occult positive
Labs showed Hgb 7.8, Cr 2.4
Received Pantoprazole 40 IV and 100cc/hr NS
Decision was made to admit to medicine for further management.
History obtained with assistance of ___ interpreter
On arrival to the floor, patient reports that she came to the
hospital because she was feeling unwell. She endorses diarrhea
without blood, headache, chest pain (none currently), dizziness,
abdominal pain (none currently), generalized weakness. Denies
F/C, N/V, SOB. Endorses b/l leg pain, L>R.
Past Medical History:
#Multivessel CAD, s/p LAD PCI ___, s/p urgent 4v-CABG (LIMA-LAD,
SVG-OM-ramus, SVG-RCA) ___.
#Sick sinus syndrome and AV nodal disease, s/p pacemaker ___
(dual chamber, ___ Sensia).
#Mild AS.
#Dyslipidemia.
#HTN.
#Paroxysmal atrial fibrillation.
#Diastolic heart failure
#Large ventral hernia s/p reductin
#DM
Social History:
___
Family History:
Parents both died during war at young age. Unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.4PO 126 / 70 78 18 97 RA
General: Alert, oriented to self and location, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP elevated to 4cm above clavicle with HOB at 20 deg.
CV: Regular rate and rhythm, + systolic murmur
Lungs: Crackles at bases R>L
Abdomen: Soft, non-tender, non-distendedobese
GU: No foley
Ext: Warm, well perfused, 2+ edema, 2cm blister on L heel.
Neuro: Face symmetric to raised eyebrows and smile, however
droop of L lip, ___ strength upper extremities, 4+/5 in lower
extremities (L>R dorsiflexion of foot, unclear if volitional),
gait deferred.
DISCHARGE PHYSICAL EXAM:
VS - Tmax 98.7 BP 90-140/40-60s HR 70-80s RR ___ on
RA
General: NAD, NC/AT, difficult to understand speech and slow
Neuro: Leaning head to one side but no face is symmetric to
eyebrows, smile; L lip slightly drooped
CV: ___ holosystolic murmur
Lungs: CTA bl
Abdomen: sntnd
GU: no Foley
Ext: wwp, 2+ pitting edema to knees bilaterally (son notes
chronic), blister on L heel
Pertinent Results:
ADMISSION LABS
___ 07:27PM WBC-8.2 RBC-2.83* HGB-7.8* HCT-26.0* MCV-92
MCH-27.6 MCHC-30.0* RDW-15.7* RDWSD-52.1*
___ 07:27PM NEUTS-73.0* LYMPHS-14.8* MONOS-8.9 EOS-2.7
BASOS-0.4 IM ___ AbsNeut-5.96 AbsLymp-1.21 AbsMono-0.73
AbsEos-0.22 AbsBaso-0.03
___ 07:27PM NEUTS-73.0* LYMPHS-14.8* MONOS-8.9 EOS-2.7
BASOS-0.4 IM ___ AbsNeut-5.96 AbsLymp-1.21 AbsMono-0.73
AbsEos-0.22 AbsBaso-0.03
___ 07:27PM GLUCOSE-181* UREA N-71* CREAT-2.4* SODIUM-135
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
___ 08:15PM ALBUMIN-3.6
___ 08:15PM cTropnT-0.04*
___ 08:15PM ALT(SGPT)-8 AST(SGOT)-10 ALK PHOS-114* TOT
BILI-0.5
DISCHARGE LABS
___ 07:44AM BLOOD WBC-10.1* RBC-3.56* Hgb-9.8* Hct-32.6*
MCV-92 MCH-27.5 MCHC-30.1* RDW-15.6* RDWSD-52.1* Plt ___
___ 07:44AM BLOOD Glucose-148* UreaN-68* Creat-2.8* Na-143
K-3.4 Cl-92* HCO3-32 AnGap-22*
___ 07:44AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.8*
MICRO
___ 9:52 pm URINE Source: ___.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD #1. 10,000-100,000 CFU/mL.
IMAGING
___ LENIs
Limited study without evidence of deep venous thrombus in the
right common
femoral vein or proximal left lower extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bumetanide 4 mg PO TID
2. Docusate Sodium 100 mg PO BID constipation
3. DULoxetine 60 mg PO DAILY
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Gabapentin 100 mg PO TID
6. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
7. Lubiprostone 24 mcg PO DAILY:PRN constipation
8. Omeprazole 20 mg PO DAILY
9. RisperiDONE 1.5 mg PO QHS
10. Senna 8.6 mg PO PRN constipation
11. Spironolactone 25 mg PO DAILY
12. Apixaban 2.5 mg PO BID
13. glimepiride 2 mg oral 2X/WEEK
14. Metolazone 2.5 mg PO PRN fluid overload
15. Metoprolol Succinate XL 25 mg PO BID
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
17. linaclotide 145 mcg oral Q24H
18. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Gabapentin 100 mg PO DAILY
Dose decreased due to kidney injury
RX *gabapentin 100 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
2. RisperiDONE 1 mg PO QHS
Dose decreased due to kidney injury
RX *risperidone 1 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Apixaban 2.5 mg PO BID
4. Bumetanide 4 mg PO TID
5. Docusate Sodium 100 mg PO BID constipation
6. DULoxetine 60 mg PO DAILY
7. Ferrous GLUCONATE 324 mg PO DAILY
8. glimepiride 2 mg oral 2X/WEEK
9. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
10. linaclotide 145 mcg oral Q24H
Do not take more than instructed
11. Lubiprostone 24 mcg PO DAILY:PRN constipation
Do not take more than instructed
12. Metolazone 2.5 mg PO PRN fluid overload
13. Metoprolol Succinate XL 25 mg PO BID
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
15. Omeprazole 20 mg PO DAILY
16. Senna 8.6 mg PO PRN constipation
17. Simvastatin 40 mg PO QPM
18. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Anemia
SECONDARY DIAGNOSIS
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with TIA history, pAFib R>L asymmetric weakness
and edema // R>L asymmetric weakness and edema
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
This examination is incomplete due to patient's preference to reschedule.
There is no evidence of deep venous thrombus in the right common femoral, left
common femoral or left proximal or mid superficial femoral veins.
IMPRESSION:
Limited study without evidence of deep venous thrombus in the visualized right
common femoral vein or proximal left lower extremity.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Transfer, R Facial droop
Diagnosed with Anemia, unspecified
temperature: 96.7
heartrate: 70.0
resprate: 20.0
o2sat: 96.0
sbp: 115.0
dbp: 32.0
level of pain: 0
level of acuity: 3.0 | ___ with CAD s/p CABG, pAfib on apixaban, SSS s/p PPM/ICD,
spinal stenosis, dCHF on Bumex, ?TIA h/o but never with positive
imaging, presented with worsening anemia c/f GI bleed after
diarrhea and facial droop.
# Anemia: baseline Hgb is ~9, presented at 7.8, no reported
melena or hematochezia, rectal occult positive in ED. No
symptoms/signs c/f other sources of bleeding, history of large
volume transfusion back in ___ but none since then; no
abdominal tenderness. Perhaps secondary to diarrhea but given
h/o constipation and then followed by significant diarrhea with
bowel reg, bleeding likely in setting of abnormal GI motility
rather than GI pathology (diverticular, malignancy). Patient was
transfused 1u RBC given her anemia and likely dehydrated state.
She was encouraged to take in PO fluids but IV fluids were not
given in the setting of congestive heart failure. Her H/H at the
time of discharge improved 9.8/32.6%.
# Facial droop: initially c/f stroke given prior history of
TIAs. Difficulty with anticoagulation due to bleeding although
now on eliquis. Had severe epistaxis on xarelto in the past; has
had repeat epistaxis on eliquis and thus switched to aspirin
until recent TIA, then put back on eliquis 2.5mg bid. Carotid
duplex ___ without interventions; son, who is an ___
was contacted and was not concerned about acute neurologic
change; mild facial droops is likely baseline per son and speech
is normally slow; some asymmetric weakness in her R lower
extremity. Pt continued on apixaban 2.5mg bid throughout
hospitalization and had no further episodes concerning for
TIA/stroke.
# dCHF: last ECHO ___ with EF > 55%, dry weight 94.8kg on
previous admission. Chronic fatigue/SOB and chronic 2+ pitting
edema for decades, this has been documented in cardiology notes.
Given diarrhea in the setting of laxative overuse, dehydration
and intravascular depletion likely; stable respiratory status
with no oxygen requirement, pitting edema in legs is reported to
be chronic per son (however appears asymmetric R>L). She was
continued on Bumex 4mg tid and spironolactone 25mg qd. Dr.
___ cardiologist, was aware of this plan and involved
in the discussion to continue her on her diuretics. LENIs were
done to assess for the edema with no evidence of acute clot. She
was discharged on her home diuretic regimen with close follow up
with Dr. ___.
# Sick sinus syndrome: s/p PPM in ___, dual chamber, ___
Sensia. No reported abnormalities in PPM since placement,
followed by cardiology as outpatient. Concern for possible
arrhythmia at home given history of lethargy, but no syncopal
episode and no overt events on telemetry. PPM was interrogated
and found no arrhythmias at all since ___, where she had
several hours of AF with complete
heart block and demand V pacing.
# Acute on chronic renal failure: Cr 2.4 here, usually between
1.7 to 2.2; concern for dehydration and given IVF in ED. Pt was
continued on bumex and spironolactone per above. Discharge Cr
was 2.8 on ___ with repeat drawn and pending on discharge. Her
son (internist at ___ requested discharge and will draw
labs and results will be followed by Dr. ___ will make
adjustments to diuretic regimen as necessary.
# pAfib: V paced. Interrogated PPM per above. Continued on
apixaban and metoprolol.
# Troponinemia
# Multivessel CAD s/p LAD PCI ___, s/p urgent 4v-CABG ___.
Troponins were elevated in the setting ___ but CK-MB was
normal without chest pain. Pt continued on metoprolol,
simvastatin and apixaban.
# HTN: Fractionated metoprolol initially but later started home
metoprolol succinate upon discharge. Continued on spironolactone
per above.
# Diabetes: Continued on sliding scale and held home
glimepiride. Gabapentin dose reduced to 100mg QD due to ___.
Please dose adjust as necessary as renal function improves.
# Psych: Hx of hallucinations after husband passed away.
Continued on home duloxetine. Risperdal dose reduced to 1mg QHS
due to ___. Please dose adjust as necessary as renal function
improves.
TRANSITIONAL
===============
Please follow-up with Dr. ___ on ___
Patient discharge on home diuretic regimen: bumex 4mg tid and
spironolactone 25mg qd with PRN metolazone
Discharge weight: 84.2 kg (standing) * standing weight ___ was
89.4 kg - which was more closely correlated to bed weight 90.4
kg *
MEDICATION CHANGES
Gabapentin dose reduced to 100mg QD due to ___. Please dose
adjust as necessary as renal function improves.
Risperidone dose reduced to 1mg QHS due to ___. Please dose
adjust as necessary as renal function improves. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
___: Right craniotomy for subdural hemoatoma evacuation
___: Right craniotomy for re-evacuation of ___
History of Present Illness:
Patient is a ___ year old gentleman that for the last few
weeks has been noted to be "slower" overall by his family and
also exhibiting signs of clumsiness and forgetfulness. He has
been able to continue his work as a ___ during
this time. he was seen by his PCP ___ ___ and as part of a
dementia workup a MRI of the brain was ordered for today. he
underwent the scan earlier and he was noted to have a right
sided
SDH and was subsequently sent to ___ for further evaluation.
Upon arrival he is awake and alert and conversing, he has no
other complaints and denies nausea, vomiting, dizziness, changes
in vision, hearing, or speech. He was given platelets in the ED
by their team for ASA use.
Past Medical History:
alcohol abuse, hyperlipidemia, hypertension, pleural fibrosis,
colon polyps, proteinuria
Social History:
___
Family History:
CAD, Cancer
Physical Exam:
--------------
on admission:
--------------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL, has scarring on right ___ that is known
and followed by eye doctor EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, 3mm to 2mm
bilaterally. Visual fields are grossly 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.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger bilaterally
------------
at discharge:
-------------
A&OX3, PERRL, No drift, slight left facial droop and toungue
deviation, MAE ___, incision cd&I with staples.
Pertinent Results:
Postop CT HEAD W/O CONTRAST Study Date of ___ 2:36 ___
IMPRESSION:
1. Expected postoperative appearance after craniotomy for right
sided subdural hematoma evacuation with reduced but persistent
mass effect.
CT HEAD W/O CONTRAST Study Date of ___ 9:56 AM (due to
mental status changes)
IMPRESSION:
1. Enlarging right-sided subdural hematoma measuring up to 2 cm
and causing midline shift now 12 mm. Concerning for subfalcine
herniation.
2. Postoperative changes status post right-sided subdural
hematoma evacuation with corresponding pneumocephalus.
Post-op CT HEAD W/O CONTRAST Study Date of ___ 5:47 ___
IMPRESSION:
1. Right frontal extra-axial hematoma is essentially stable and
has a
lentiform shape, raising the question of an epidural rather than
subdural
location.
2. Along the more posterior right convexity, the prior subdural
hematoma has decreased in size.
3. Decreased leftward shift of midline structures and decreased
right lateral and third ventricular effacement, with resolution
of left lateral ventricle temporal horn dilatation.
CT HEAD W/O CONTRAST Study Date of ___ 10:11 ___ (concern
for ongoing hemorrhage)
IMPRESSION:
1. Redistribution of right subdural blood into more dependent
position, with slightly decreased blood in the frontal region
and slightly increased blood posteriorly. No new hemorrhage.
2. Stable mild leftward shift of midline structures.
3. Continued decreased effacement of the right lateral and third
ventricles compared to the ___EG Study Date of ___
IMPRESSION: This telemetry captured 4 pushbutton activations,
with 2 of the showing the patient's typical focal seizures, with
associated rhythmic muscle artifact but no clear electrographic
evidence of the seizure otherwise. It showed a normal background
in most areas and no clearly epileptiform features, but the
video record showed several episodes of left facial twitching
with associated left facial muscle artifact on the EEG. Events
were occurring about twice an hour for most of the recording but
decreased substantially in frequency by 4 in the morning, after
which there was just a single seizure.
BILAT LOWER EXT VEINS Study Date of ___ 9:37 AM
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT HEAD W/O CONTRAST Study Date of ___ 9:13 ___
IMPRESSION:
1. A right hyperdense subdural fluid collection is slightly
decreased in size.
2. Moderate mass effect and 5 mm of leftward midline shift are
unchanged.
CT HEAD W/O CONTRAST Study Date of ___ 4:11 ___ (prior to
drain removal)
IMPRESSION:
Right sided subdural hematoma minimally decreased but still
measuring 11 mm in the frontal region.
CT HEAD W/O CONTRAST Study Date of ___ 9:09 ___ (post
drain remocal)
IMPRESSION:
No significant interval change to the right frontal parietal
subdural hematoma measuring up to 13 mm in maximum thickness
with local mass effect. Associated 3 mm leftward shift of
midline structures. No new hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. amLODIPine 5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
6. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
Please do not exceed more than 4 grams in 24hrs.
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. LevETIRAcetam 500 mg PO BID
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
narcotics.
8. Phenytoin Sodium Extended 200 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Thiamine 100 mg PO DAILY
11. amLODIPine 5 mg PO DAILY
12. Atorvastatin 20 mg PO QPM
13. FoLIC Acid 1 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ year old man with SDH // Pre-op eval SUBDURAL HEMATOMA
IMPRESSION:
No comparison. Multiple calcified pleural and pericardial plaques, likely
following asbestos exposure. No pleural effusions. No pneumonia, no
pulmonary edema. Mild cardiomegaly, elongation of the descending aorta.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with R SDH s/p craniotomy for evac // evaluate
for post-op change. Please obtain between 1500 and 1600 on ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 17.2 cm; CTDIvol = 49.3 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: MR head dated ___
FINDINGS:
The patient is status post evacuation of a right-sided subdural hematoma with
drain placement. Expected postoperative changes are noted including small
pneumocephalus. Hyperdense blood is again seen along the right convexity
measuring up to 1.3 cm. Scalp staples are in place. There is effacement of
the right-sided sulci and the right lateral ventricle with mild right-to-left
midline shift of 4 mm.
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. Expected postoperative appearance after craniotomy for right sided subdural
hematoma evacuation with reduced but persistent mass effect.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with R. SDH and 4mm midline shift now with mental
status change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.7 cm; CTDIvol = 50.7 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Noncontrast CT head ___ and MRI brain ___.
FINDINGS:
There has been a marked enlargement in the size of the right subdural hematoma
since the comparison study of ___. The hematoma now measures up to 2
cm (series 4, image 20). A drainage catheter is in place. There is
corresponding pneumocephalus and and subcutaneous emphysema. There is
significant increase in midline shift with compression of the right lateral
ventricle and corresponding enlargement of the left lateral ventricle. There
is now a 12 mm of midline shift, series 4, image 14. There is also effacement
of the suprasellar cistern. These findings are suggestive of subfalcine
herniation.
The patient patient is status post right-sided craniotomy, with staples in
place. There is mild mucosal thickening primarily in the left maxillary
sinus. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Enlarging right-sided subdural hematoma measuring up to 2 cm and causing
midline shift now 12 mm. Concerning for subfalcine herniation.
2. Postoperative changes status post right-sided subdural hematoma evacuation
with corresponding pneumocephalus.
NOTIFICATION: The findings of enlarging right subdural hematoma were
discussed with ___, NP by ___, on ___ at 10:50 AM, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with history of right subdural hematoma with
shift of midline structures, s/p repeat evacuation. Please do portable head
CT if able. Assess for interval change, reaccumulation of bleeding.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.4 s, 18.3 cm; CTDIvol = 52.0 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
Patient is status post repeated evacuation of right subdural hematoma. A
percutaneous subdural drain is in place. There is increased right extra-axial
pneumocephalus. The extra-axial hematoma along the right convexity measures 2
cm in maximal width (previously 2.1 cm) at the level of the frontal lobe, and
its shape is lentiform, raising the question of epidural rather than subdural
location. Subdural hematoma along the more posterior right convexity has
decreased in size There is significant improvement in leftward shift of
midline structures which now measures 0.6 cm (previously 1.5 cm). There is
decreased effacement of the frontal horn of the right the ventricle and of the
third ventricle, but the posterior components of the right lateral ventricle
remain effaced. Temporal horn of the left lateral ventricle is no longer
dilated.
Postsurgical changes in the right scalp are noted. There is mucosal
thickening and a partially visualized mucous retention cyst in the included
portion of the left maxillary sinus.
IMPRESSION:
1. Right frontal extra-axial hematoma is essentially stable and has a
lentiform shape, raising the question of an epidural rather than subdural
location.
2. Along the more posterior right convexity, the prior subdural hematoma has
decreased in size.
3. Decreased leftward shift of midline structures and decreased right lateral
and third ventricular effacement, with resolution of left lateral ventricle
temporal horn dilatation.
NOTIFICATION: Multiple attempts were made to convey impression point 2
without success.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with subdural hematoma, s/p evacuation. Assess
for interval changes
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast head CT ___, 17:55
Noncontrast head CT ___ 10:00
Noncontrast head CT ___
FINDINGS:
Right craniotomy and right extra-axial percutaneous drainage catheter are
again seen. Right extra-axial pneumocephalus is not significantly changed.
Right frontal extra-axial hematoma measures 1.9 cm in maximal width
(previously 2 cm) and overall appears slightly decreased in extent. Small
subdural hematoma along the more posterior right convexity measures up to 8 mm
compared to 6 mm previously. These findings suggest redistribution of
subdural blood into more dependent position over time. There is no new
hemorrhage. Stable mild leftward shift of normally midline structures now
measuring 0.5 cm (previously 0.5 cm). Effacement of the right lateral
ventricle has slightly improved, and the third ventricle has slightly
re-expanded.
Mucosal thickening and a mucous retention cyst are again partially visualized
in the included portion of the left maxillary sinus. There is mild mucosal
thickening in the anterior ethmoid air cells. Mastoid air cells are well
aerated.
IMPRESSION:
1. Redistribution of right subdural blood into more dependent position, with
slightly decreased blood in the frontal region and slightly increased blood
posteriorly. No new hemorrhage.
2. Stable mild leftward shift of midline structures.
3. Continued decreased effacement of the right lateral and third ventricles
compared to the 2 prior CTs.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with subdural hematoma, with relative leg
immobility, evaluating whether to start SC heparin, please rule out DVT //
please rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
INDICATION: ___ year old man with post op fever s/p craniotomy, fever workup
// interval change, s/p extubation ___
TECHNIQUE: Portable chest radiograph
COMPARISON: ___ portable chest radiograph
FINDINGS:
When compared to ___ portable chest radiograph, lung volumes are
lower.
There is a concerning region of opacification in right lower lung that could
either either atelectasis, new consolidation, or even dependent pleural
effusion. Borderline cardiac enlargement is exaggerated by low lung volume.
There is mild pulmonary vascular congestion but no evidence of pulmonary
edema. Multiple calcified plaques are due to asbestos exposure..
IMPRESSION:
New, moderate, right basal consolidation--pneumonia or atelectasis--and
possible pleural effusion. Recommend PA and lateral chest radiographs if
feasible.
RECOMMENDATION(S): Recommend PA lateral chest radiograph for further
evaluation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ___ s/p crani and ___ evac with new onset
simple partial seizure. // Progression of bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
A right frontal, temporal and parietal hyperdense extra-axial fluid collection
is mildly decreased in size measuring up to 1.5 cm from the cranium. There is
again a moderate amount of air within the fluid collection. Local mass effect
and approximately 5 mm of leftward midline shift is unchanged. There is no
evidence of infarction.
There is mild effacement of the right lateral ventricle, unchanged.
The patient is status post right frontal craniotomy. There is mild mucosal
thickening in the left maxillary sinus. Otherwise, the visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. A right hyperdense subdural fluid collection is slightly decreased in size.
2. Moderate mass effect and 5 mm of leftward midline shift are unchanged.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old man with SDH // Interval changes
TECHNIQUE: Axial images of the head were obtained without contrast .
DOSE: Total DLP (Head) = 848 mGy-cm.
COMPARISON: ___.
FINDINGS:
Right-sided subdural hematoma with postoperative changes and subdural drain
again identified. Pneumocephalus is seen. Subdural hematoma appears
minimally decreased compared to the prior study measuring 11 mm. No new
hemorrhage is seen. There is no midline shift. Mass effect on the right
cerebral sulci again seen.
IMPRESSION:
Right sided subdural hematoma minimally decreased but still measuring 11 mm in
the frontal region.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with SDH, s/p crani x2 for evacuation of ___.
Interval changes after removal of subgaleal and subdural drains. Please do at
___ tonight.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Patient is status post right frontal parietal craniotomy. Again seen is a
right frontal parietal subdural hematoma measuring up to 13 mm in maximum
thickness from the inner table, previously 12 mm, unchanged in size.
Scattered foci of gas is noted within the hematoma. There is also subdural
blood layering along the falx as well as the right tentorium. There is a
minimal 3 mm leftward shift of midline structures, unchanged since the prior
study. Mass effect on the subjacent cerebral sulci is also unchanged. The
ventricles are stable in size. No new hemorrhage is identified. There is no
downward herniation.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable. Atherosclerotic calcifications of the bilateral carotid siphons
are noted.
IMPRESSION:
No significant interval change to the right frontal parietal subdural hematoma
measuring up to 13 mm in maximum thickness with local mass effect. Associated
3 mm leftward shift of midline structures. No new hemorrhage.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: ICH
Diagnosed with Nontraumatic subdural hemorrhage, unspecified
temperature: 98.6
heartrate: 83.0
resprate: 18.0
o2sat: 99.0
sbp: 133.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | ___ with R SDH crani evaculation s/p repeat crani for worsening
MLS now with post operative simple focal seziures and ICU
delirium with stable interval head CT after drain removal.
#Subdural hematoma: Patient was taken to the operating room on
___ for right craniotomy for evacuation of SDH with Dr.
___. Aspirin for cardioprotection was held and he was given
platelets in the ED. He underwent an uncomplicated procedure and
was successfully extubated. Postoperatively he was transferred
to the Neuro ICU. On ___ he was found to have increased
confusion and lower extremity weakness. Repeat STAT head CT
showed interval increase in SDH with increased midline shift to
14mm. He was emergently taken back to the operating room with
Dr. ___ re-do craniotomy for ___ evacuation. Procedure
was uncomplicated and 2 drains were placed (subdural and
subgaleal). Post operatively, the repeat head CT was still
concerning for continued bleeding, and he received DDAVP and
platelets. A TEG was performed inter-operatively without
deficiency and hematology was consulted. He was extubated on
___ without issue. He remained neurologically stable. Both
drains were removed on ___. Post-pull head CT was stable. He
was transferred to the neurosurgery floor on ___ and remained
stable.
over the weekend the patient continued do well, he was
discharged to rehab in stable conditions on ___. All discharge
instructions and follow up were given prior to discharge.
#Simple partial seizures: In the evening on ___ he was noted to
have multiple (14+) left simple motor seizures of the face,
necessitating Keppra load and increase to 1500mg bid as well as
Dilantin and 100mg q8h. EEG was applied. After 24 hours without
seizures, his EEG was removed and have begun AED taper.
Currently on Keppra to 500 mg BID and Dilantin 200mg to bid. The
patient will need to follow up with his neurologist as
scheduled. Dilantin level on ___ was 9.1.
#H/o alcohol abuse: He was started on daily thiamine and folic
acid PO. No evidence of withdrawal.
#Urinary retention: He had episodes of delirium d/t bladder
retention, which improved with foley placement. He was started
on Floman. Foley was subsequently removed on ___ and he was
voiding on his own without retention. Continued on Flomax. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right trimalleolar fracture with posterior subluxation
Major Surgical or Invasive Procedure:
Open reduction and internal fixation right ankle: ___,
___
History of Present Illness:
HPI: ___ female presents with the above fracture s/p mechanical
fall on ice earlier today. Initially seen at the outside
hospital reduced with conscious sedation placed in a splint
transferred here for surgical attention. She denies head
injury,
neck pain, anticoagulation, pain elsewhere on her body.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
General: Well-appearing female in no acute distress.
right lower extremity:
- Skin intact
- No deformity, erythema, induration
-Moderate ecchymosis over the anterior ankle
- Soft, non-tender thigh and leg
- Full, painless ROM at hip, knee
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
On discharge:
Exam:
Vitals: ___ 0337 Temp: 98.4 PO BP: 95/62 R Lying HR: 68 RR:
18 O2 sat: 94% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK: Right ankle in clean, dry, and intact splint. Strong right
DP pulse with warm and well-perfused toes. Sensation and motor
function of toes decreased but improved from yesterday. No pain
with passive extension of toes
Pertinent Results:
___ 07:47AM BLOOD WBC-7.4 RBC-3.72* Hgb-11.0* Hct-34.5
MCV-93 MCH-29.6 MCHC-31.9* RDW-13.5 RDWSD-45.9 Plt ___
___ 07:47AM BLOOD Plt ___
___ 07:47AM BLOOD Glucose-114* UreaN-16 Creat-0.6 Na-142
K-3.8 Cl-110* HCO3-20* AnGap-12
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with trimalleolar fracture, reduced. Evaluation for
post reduction radiographs.
TECHNIQUE: AP, oblique, and lateral views of the right ankle.
COMPARISON: Comparison to prior right ankle radiographs performed on ___.
FINDINGS:
Overlying splint material partially obscures fine bony and soft tissue detail.
Redemonstration of trimalleolar fracture of the right ankle status post closed
reduction. Persistent minimal posterior and lateral displacement of the
distal fibular fracture fragment. Mild posterior displacement of the fracture
fragment at the posterior malleolus of the distal tibia. Alignment of the
tibiotalar joint remains substantially improved compared to pre reduction
radiograph.
IMPRESSION:
Redemonstration of trimalleolar fracture of the right ankle status post closed
reduction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with right trimalleolar ankle fracture.
Preoperative evaluation for acute cardiopulmonary abnormality.
TECHNIQUE: Chest AP upright and lateral
COMPARISON: Comparison to prior chest radiograph from ___.
Comparison to prior CT chest from ___.
FINDINGS:
Cardiomediastinal silhouette is within normal limits. Linear opacities at the
bilateral lung bases likely represent atelectasis. No focal consolidation
identified. Mild lung hyperexpansion with subtle lucencies at the lung
apices, likely reflecting emphysematous change. No pleural effusion or
pneumothorax is seen.
IMPRESSION:
1. No focal consolidation identified.
2. Mild lung hyperexpansion with subtle lucencies at the lung apices, LIKELY
EMPHYSEMA.
3. Mild bibasilar atelectasis.
Radiology Report
EXAMINATION: Q61R
INDICATION: ___ year old woman with trimalleolar fracture.// Please obtain
right ankle CT for surgical planning.
TECHNIQUE: ___ MD CT imaging was performed through the right ankle without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 15.2 s, 32.3 cm; CTDIvol = 14.3 mGy (Body) DLP =
459.9 mGy-cm.
Total DLP (Body) = 460 mGy-cm.
COMPARISON: Right ankle radiographs ___ the ___
FINDINGS:
There is a trimalleolar fracture with a transverse medial malleolar fracture
which is minimally displaced and distracted by 2-3 mm. There are several
small bony fragment seen along the anterior posterior margin of the medial
malleolus (2:131).
There is an oblique fracture through the distal fibula extending to the level
of the syndesmosis (401:45). Separate from this there is a well corticated
ossific density adjacent to the tip of the lateral malleolus consistent with
remote avulsion injury (401:44).
There is a mildly displaced vertically oriented fracture through the posterior
malleolus with distraction of the articular surface of the tibiotalar joint by
approximately 3 mm (400:50). Tiny intra-articular fragments are seen in the
tibiotalar joint space (400:47).
No tendon entrapment seen. There is diffuse soft tissue edema around the
ankle.
IMPRESSION:
1. Trimalleolar fracture as described. Tiny intra-articular bone fragments
seen.
2. Diffuse soft tissue swelling around the ankle.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: Fracture ORIF.
COMPARISON: Plain radiograph of the right ankle ___, and CT of
the ankle performed on the same day at 0 2 5 1 hours.
FINDINGS:
3 intraoperative images were acquired without a radiologist present.
Images show ORIF of a trimalleolar fracture, with several plates, screws, and
tension band cerclage wires with percutaneous pins. Total fluoroscopic time
52.9 seconds.
IMPRESSION:
Please refer to the operative note for details of the procedure.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Ankle injury, s/p Fall
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall on same level due to ice and snow, initial encounter
temperature: 97.2
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 64.0
level of pain: 4
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right trimalleolar fracture with posterior subluxation
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for ORIF right
ankle, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / spironolactone / atorvastatin
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
Ms ___ is a ___ y/o F with PMH significant for
hepaticojejunostomy ___, due to bile duct leak after
cholecystectomy), cirrhosis ___ EtOH), who presented to outside
hospital for hematemesis, transferred to ___ for further care
for upper GI bleed.
She reports having occasional episodes of hematemesis for the
past year. In the last 24 hours, she notes multiple episodes of
emesis, which were dark. She denies any hematochezia or melena.
Along with this, she also notes diffuse epigastric abdominal
pain. At ___, she was given a Protonix drip and
ceftriaxone given concern for upper GI bleed. She was then
transferred to
___ ED.
The patient reports multiple hospitalizations over the last year
(most recently at ___, but she is unable to provide
further details.
At ___, she did not have any episodes of hematemesis. She did
however have an acute drop of hgb from 12 to 9.7, so she
received 1 u PRBC in the ED. She was also started on octreotide
and admitted to the MICU.
In the ED,
- Initial vitals were: 98.9 84 123/77 18 97% RA
- Labs notable for: Normal H/H, Tbili 2.9
- Imaging was notable for:
US Abd
1. Small volume ascites.
2. Patent main portal vein.
CXR
Small left pleural effusion is new. Superimposed pneumonia
cannot
be excluded.
- Patient was given:
___ 22:14 IV Pantoprazole 40 mg
___ 23:41 IVF NS 1000 mL
Upon arrival to the floor, patient reports that she is having
ongoing diffuse abdominal discomfort. She is frustrated by this
pain.
Past Medical History:
- Cirrhosis
- Hx of alcohol abuse
- CAD, s/p stent in ___
- depression and anxiety
- HTN
- HLD
- Chronic low back pain
PAST SURGICAL HISTORY:
- Whipple procedure for complications from a cholecystectomy,
___
- Status post cholecystectomy in ___, complicated by bile leak.
Social History:
___
Family History:
- Noncontributory to patient's presenting complaint
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Alert, NAD
HEENT: PERRL, EOMI, MMM, mild scleral icterus, poor dentition
CARDIAC: RRR, nl s1,s2, III/VI SEM
PULMONARY: CTAB
ABDOMEN: Mild diffuse epigastric tenderness without guarding. No
HSM. Scars noted in RUQ.
EXTREMITIES: Trace ___ edema, 2+ pulses bilaterally, wwp
SKIN: No rashes
NEURO: AOx3
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 98.2 | 102/71 | 94 | 18 | 94%Ra
GENERAL: Alert, nontoxic, eating breakfast and sitting at the
edge of her bed/
CARDIAC: RRR, nl s1,s2, III/VI SEM heard at all fields
PULMONARY: CTAB without adventitious sounds.
ABDOMEN: no tenderness. No HSM. Scars noted in RUQ.
EXTREMITIES: Trace ___ edema, 2+ pulses bilaterally, wwp
SKIN: No rashes
NEURO: AOx3. No asterixis.
PSYCH: Pleasant, appropriate.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-6.9 RBC-3.94 Hgb-12.3 Hct-37.8 MCV-96
MCH-31.2 MCHC-32.5 RDW-16.8* RDWSD-59.6* Plt Ct-78*
___ 09:30PM BLOOD Neuts-89.0* Lymphs-5.2* Monos-5.2
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.12* AbsLymp-0.36*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.01
___ 09:56PM BLOOD ___ PTT-34.1 ___
___ 09:30PM BLOOD Glucose-146* UreaN-7 Creat-1.0 Na-144
K-4.1 Cl-98 HCO3-30 AnGap-16
___ 09:30PM BLOOD ALT-14 AST-48* AlkPhos-119* TotBili-2.9*
___ 09:30PM BLOOD Albumin-2.6*
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:41PM BLOOD Lactate-4.2* K-3.4
IMAGING/STUDIES:
================
CXR ___:
Small left pleural effusion is new. Superimposed pneumonia
cannot be
excluded.
LIVER US ___:
1. Small volume ascites.
2. Patent main portal vein.
MICRO:
=================
___ 3:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
URINE
=================
___ 03:30AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:30AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:30AM URINE RBC-24* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-3
___ 03:30AM URINE CastHy-10*
___ 03:30AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 03:30AM URINE UCG-NEGATIVE
DISCHARGE LABS
===============
___ 06:30AM BLOOD WBC-4.8 RBC-3.16* Hgb-9.6* Hct-30.6*
MCV-97 MCH-30.4 MCHC-31.4* RDW-16.1* RDWSD-57.0* Plt Ct-66*
___ 06:30AM BLOOD ___ PTT-35.2 ___
___ 06:30AM BLOOD Glucose-89 UreaN-3* Creat-0.8 Na-138
K-3.2* Cl-99 HCO3-32 AnGap-7*
___ 06:30AM BLOOD ALT-9 AST-24 AlkPhos-124* TotBili-1.0
___ 06:30AM BLOOD Albumin-1.9* Calcium-7.4* Phos-2.7
Mg-1.4*
PERTINENT INTERVAL LABS
==========================
___ 01:50PM BLOOD calTIBC-98* TRF-75*
___ 01:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 01:50PM BLOOD ___
___ 01:50PM BLOOD HIV Ab-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID pain
2. DULoxetine 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
5. Nicotine Patch 21 mg/day TD DAILY
6. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
7. Alendronate Sodium 70 mg PO QMON
8. Rifaximin 550 mg PO BID
9. Midodrine 10 mg PO BID
10. Pantoprazole 40 mg PO Q24H
11. magnesium oxide 400 mg oral unknown
12. Lactulose 15 mL PO DAILY BM
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Estradiol 0.5 mg PO DAILY
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
16. melatonin 3 mg oral QHS
17. Metoclopramide 5 mg PO BID:PRN nausea
18. Ondansetron ODT 8 mg PO BID:PRN Nausea/Vomiting - First Line
19. Potassium Chloride 40 mEq PO DAILY
20. Simethicone 80 mg PO Q6H:PRN abdominal pain
21. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
2. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 mL by mouth four times a day Disp
#*1 Bottle Refills:*3
3. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
4. DULoxetine 20 mg PO DAILY
5. Estradiol 0.5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 600 mg PO TID pain
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
9. Lactulose 15 mL PO DAILY BM
10. Magnesium Oxide 400 mg oral Frequency is Unknown
11. melatonin 3 mg oral QHS
12. Metoclopramide 5 mg PO BID:PRN nausea
13. Midodrine 10 mg PO BID
14. Nicotine Patch 21 mg/day TD DAILY
15. Ondansetron ODT 8 mg PO BID:PRN Nausea/Vomiting - First
Line
16. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
17. Potassium Chloride 40 mEq PO DAILY
Hold for K >
18. Rifaximin 550 mg PO BID
19. Simethicone 80 mg PO Q6H:PRN abdominal pain
20. Spironolactone 25 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (___)
22. HELD- Alendronate Sodium 70 mg PO QMON This medication was
held. Do not restart Alendronate Sodium until discussion with
primary care
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Severe esophagitis
-Cirrhosis with portal hypertension and small volume ascites
-Roux-en-Y hepaticojejunostomy after bile duct injury from CCY
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 epigastric pain// PNA
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
There has been interval development of a small left pleural effusion, a
superimposed pneumonia cannot be excluded on the basis of this study. Lungs
are otherwise clear without evidence of pulmonary edema or pneumothorax.
Cardiomediastinal silhouette is unchanged and unremarkable. Visualized
osseous structures are unremarkable.
IMPRESSION:
Small left pleural effusion is new. Superimposed pneumonia cannot be
excluded.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ with cirrhosis and UGIB. Evaluate for ascites.
TECHNIQUE: Grayscale ultrasound images were obtained of the 4 quadrants of
the abdomen.
COMPARISON: None.
FINDINGS:
Targeted grayscale ultrasound images were obtained of the 4 quadrants of the
abdomen, revealing small volume ascites. The main portal vein is patent.
IMPRESSION:
1. Small volume ascites.
2. Patent main portal vein.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with cirrhosis now with GI bleed// full
abdominal ultrasound to eval ascites, portal HTN, OVT and liver and gall
bladder.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___.
FINDINGS:
LIVER: The patent parenchyma is coarsened. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. There is
small volume ascites.
The main portal vein is patent with hepatopetal flow. The right anterior and
posterior portal veins are also patent with hepatopetal flow. The left portal
vein is not well seen, but limited images demonstrate hepatopetal flow,
although this is not wall-to-wall.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The gallbladder is surgically absent.
PANCREAS: The pancreas is not well seen, largely obscured by overlying bowel
gas.
SPLEEN: Normal echogenicity.
Spleen length: 16.3 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 9.8 cm
Left kidney: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with splenomegaly and ascites consistent with portal
hypertension.
2. Poorly visualized left portal vein, with slightly diminished waveforms and
incomplete color flow may be technical, although it is difficult to exclude a
nonocclusive left portal vein thrombus. If clinically appropriate, a
dedicated liver CT with portal venous phase could be obtained.
3. Patent main, right anterior and right posterior portal veins.
RECOMMENDATION(S): Consider a CT liver CT with portal venous phase if
clinically appropriate.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.9
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 123.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | ========================
BRIEF SUMMARY
========================
___ is a ___ year old women with EtOH cirrhosis
complicated by portal hypertension, esophageal variceal
bleeding, and small volume ascites who presented with
hematemesis, found to have severe esophagitis on EGD with no
clear evidence for variceal hemorrhage.
She also has a history of a bile duct injury from a distant
cholecystectomy, and is s/p roux-en-Y hepaticojejunostomy with
separate hepaticojejunostomy to right posterior duct. Given the
findings on her EGD and that her bleeding stabilized, it was not
felt like she needed any additional evaluation to look for
alternative bleeding sites such as a marginal ulcer.
She was given 1 blood transfusion on admission but her counts
remained stable for 2 days and she was discharged with
hepatology follow up for repeat outpatient EGD, high dose PPI
therapy, and sucralfate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
AMS after fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of HTN, HLD,
hypothyroidism, mitral regurgitation, LVOT obstruction, presents
after being found down. Patient unable to give history due to
confusion. According to her close friend, she was last witnessed
as her regular self 3:30PM ___. She had driven her friend to
the mall to go shopping and was speaking completely normally.
She hadn't fallen recently, no bruises. Her friend called the pt
at 9:30am this morning and the pt said she'd fallen and couldn't
get up. Her friend arrived at the house at 9:50AM and found her
sitting on the floor in her clothes from yesterday. She was
speaking coherently but couldn't remember what had happened last
night. Her friend rode in the ambulance to the ED and noted that
she started talking strangely intermittently in the ambulance
and in the ED. Of note, her friend also reports that patient has
left eye droop/abnormality at baseline and is unchanged.
In the ED, initial vitals were 98.1 80 164/73 16 100%RA. Labs
were notable for WBC 22.1, CK 407, CKMB 11 with neg trop. UA was
negative. Lactate was 4.1 which improved to 2.4 after 2LNS. She
underwent CT head and CTA torso, and plain films R shoulder,
elbow, hip, pelvis and knee, all negative. She was given
levofloxacin and metronidazole, a dose of home verapamil, and
transfered to the ICU for ongoing tachycardia to the 130's
presumable from sepsis.
On arrival to the floor, the patient is unable to give a
coherent history. Her speech is rambling.
Past Medical History:
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM
OSTEOPOROSIS
MITRAL REGURGITATION
LVOT OBSTRUCTION
APPENDECTOMY
TONSILLECTOMY
CATARACT SURGERY
Social History:
___
Family History:
Unable to obtain
Per OMR: Mother: CAD age ___, father: ___ age ___
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.4 HR 123 BP 152/79 RR 24 Sa02 97/ra
General: Confused, oriented to self in a hospital
HEENT: Ecchymoses R forehead, MMM, left ptosis, pupils 4mm
equal, round, reactive, no nystagmus, no photophobia
Neck: Supple, no rigidity, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic rate, reg rhythm, normal S1 + S2, no murmurs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Bruising to R shoulder and elbow, R knee, R lateral foot,
warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: Aphasic with rambling nonsensical speech, no dysarthria,
no pronator drift, R upper and lower extrem weakness ___ pain,
finger to nose impaired on the right, left sided neglect
DISCHARGE EXAM:
Vitals: Tc 97.8 BP 153/69 HR 63 RR 18 SaO2 95/ra Glucose 147
Gen: NAD, up in chair
Neuro:
Awake. Alert. Oriented to ___, but not day of week,
month, or year. Speech fluent. No paraphasic errors. Some
inattention. Confused about care plan.
R superior quadrantanopsia (can identify hand waving but not
finger counting). OD ___ (cataract), OS ___. L pupil 4->2
and R 3->2, both briskly reactive. L eye slightly down and out
at rest. Marked left ptosis. L vertical gaze palsy, impaired
adduction. Other EOMI.
RUE 4+/5, LUE ___, IP 4+ bilaterally, other strength intact.
Dysmetria on FNF bilaterally, with past pointing L>R.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:00AM BLOOD WBC-22.1*# RBC-4.62 Hgb-13.8 Hct-39.8
MCV-86 MCH-29.8 MCHC-34.6 RDW-13.5 Plt ___
___ 11:00AM BLOOD Neuts-90.6* Lymphs-4.2* Monos-4.8 Eos-0.1
Baso-0.2
___ 11:49AM BLOOD ___ PTT-25.7 ___
___ 11:00AM BLOOD Glucose-150* UreaN-17 Creat-0.7 Na-138
K-2.6* Cl-94* HCO3-26 AnGap-21*
___ 11:00AM BLOOD ALT-19 AST-31 CK(CPK)-407* AlkPhos-77
TotBili-1.0
___ 11:00AM BLOOD Albumin-4.8 Calcium-9.8 Phos-1.8* Mg-2.0
___ 03:16PM BLOOD ___ Temp-38.0 Rates-/___ FiO2-21
pO2-19* pCO2-40 pH-7.43 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
___ 11:08AM BLOOD Lactate-4.1* Na-140
==============
PERTINENT LABS
==============
___ 04:06AM BLOOD WBC-17.1* RBC-4.01* Hgb-11.9* Hct-35.2*
MCV-88 MCH-29.8 MCHC-33.9 RDW-13.2 Plt ___
___ 02:09AM BLOOD WBC-17.2* RBC-3.91* Hgb-11.9* Hct-34.0*
MCV-87 MCH-30.4 MCHC-35.0 RDW-14.2 Plt ___
___ 07:10PM BLOOD WBC-14.1* RBC-3.97* Hgb-12.0 Hct-34.7*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.0 Plt ___
___ 05:20AM BLOOD WBC-12.7* RBC-4.01* Hgb-12.0 Hct-35.0*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.9 Plt ___
___ 11:28AM BLOOD ___ PTT-84.6* ___
___ 05:20AM BLOOD ___ PTT-58.6* ___
___ 05:00AM BLOOD ___ PTT-46.6* ___
___ 04:06AM BLOOD Glucose-165* UreaN-8 Creat-0.7 Na-138
K-3.2* Cl-102 HCO3-21* AnGap-18
___ 02:09AM BLOOD Glucose-142* UreaN-11 Creat-0.8 Na-137
K-3.6 Cl-103 HCO3-22 AnGap-16
___ 07:10PM BLOOD Glucose-143* UreaN-10 Creat-0.7 Na-140
K-3.6 Cl-101 HCO3-25 AnGap-18
___ 05:20AM BLOOD Glucose-114* UreaN-12 Creat-0.7 Na-141
K-3.3 Cl-102 HCO3-30 AnGap-12
___ 02:09AM BLOOD ALT-15 AST-28 AlkPhos-69 TotBili-0.4
___ 03:15PM BLOOD CK-MB-12* cTropnT-<0.01
___ 04:06AM BLOOD CK-MB-9 cTropnT-<0.01
___ 07:10PM BLOOD CK-MB-10 MB Indx-1.3 cTropnT-<0.01
___ 04:06AM BLOOD Calcium-8.1* Phos-1.7* Mg-2.1
___ 02:09AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0
___ 07:10PM BLOOD Albumin-3.6 Calcium-8.3* Phos-2.9 Mg-2.0
Cholest-166
___ 05:20AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2
___ 07:10PM BLOOD %HbA1c-5.9 eAG-123
___ 07:10PM BLOOD Triglyc-113 HDL-78 CHOL/HD-2.1 LDLcalc-65
___ 03:16PM BLOOD Lactate-2.4* K-3.3
==============
DISCHARGE LABS
==============
___ 05:58AM BLOOD WBC-12.9* RBC-4.20 Hgb-12.5 Hct-36.5
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.5 Plt ___
___ 05:58AM BLOOD Plt ___
___ 02:09AM BLOOD ___
___ 05:58AM BLOOD Glucose-111* UreaN-15 Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-29 AnGap-16
___ 05:58AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
=======
IMAGING
=======
ED IMAGING (___)
Pelvic XR: No fracture
Chest XR: Negative
CT Torso: 1. Diverticulosis without evidence of acute
diverticulitis. 2. No pulmonary embolism. 3. Fibroid uterus.
4.
Large hiatal hernia. 5. 4-mm nodule within the left lower lobe.
Followup as per ___ criteria.
Arm XR: No fracture
NCHCT: No evidence of acute intracranial process.
MRI/MRA BRAIN (___)
1. Late acute to subacute infarct of the medial left midbrain
extending to the cerebral peduncle as well as the left medial
temporal cortex in the left PCA distribution. 2. Focal stenosis
of the right proximal A1 segment. There is paucity of
flow-related signal of the left P2 segment which may be
artifactual in nature given motion artifact. 3. No aneurysms.
TTE (___)
Suboptimal image quality. Normal global and (likely) regional
left ventricular systolic function. Mild right ventricular
dilation and free wall hypokinesis in setting of moderate
elevation of pulmonary artery systolic pressure and
echo-evidence of pulmonary vascular disease/elevated resistance.
Moderate to severe mitral regurgitation. Compared with the prior
study (images reviewed) of ___, the increased severity in
mitral and tricuspid regurgitation is likely due to the
availability of off axis images allowing to assess more of the
color Doppler regurgitation area rather then valvular pathology
progression. In the prior study a somewhat late peaking aortic
flow envelope was visualized possibly indicating resting LVOT
obstruction and explaining the turbulent systolic LVOT flow in
the current study.
EEG ___ is an abnormal continuous EMU monitoring study
because of
borderline slow background rhythm for age and for asymmetric
slowing over the left lateral temporal region with two
associated interictal spikes in the same region. This is most
compatible with a mild diffuse encephalopathic process with
focal structural pathology.
EEG (___)
This telemetry captured no pushbutton activations. It showed a
borderline normal background in wakefulness and sleep. There was
occasional slowing over the left temporal region. There were no
epileptiform features or electrographic seizures.
EEG (___)
This is an abnormal continuous EMU monitoring study because of
borderline slow background rhythm for age and for asymmetric
slowing over the left lateral temporal region with two
associated interictal spikes in the same region. This is most
compatible with a mild diffuse encephalopathic process with
focal structural pathology.
TEE (___): Thickened mitral leaflets with moderate mitral
regurgitation. No valvular vegetations seen. Focal basal septal
hypertrophy with normal left ventricular systolic function.
Complex atheroma in the descending aorta.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Rosuvastatin Calcium 10 mg PO DAILY
3. Verapamil SR 120 mg PO Q24H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Rosuvastatin Calcium 10 mg PO DAILY
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. Heparin IV
No Initial Bolus
Initial Infusion Rate: 750 units/hr
Start: Today - ___, First Dose: 1200
Goal PTT 50-70, check PTT every 6 hours. Heparin can be stopped
once INR therapeutic at ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left midbrain, left medial temporal lobe, left occipital acute
infarcts
Valvular atrial fibrillation
Myxomatous mitral valve
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall with multiple abrasions to shoulders,
elbows, bilateral knees
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Heart size is mildly enlarged. The aorta demonstrates atherosclerotic
calcifications diffusely. The mediastinal and hilar contours are unremarkable.
The pulmonary vasculature is normal. Streaky right lower lobe opacity likely
reflects atelectasis. No pleural effusion or pneumothorax is seen. No
displaced fractures are identified.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: History: ___ status post fall multiple abrasions to shoulder,
elbow, bilateral knees
TECHNIQUE: Single AP view of the pelvis
COMPARISON: None.
FINDINGS:
There is no acute fracture or dislocation. Hips and sacroiliac joints are
preserved. No diastasis of the pubic symphysis or sacroiliac joints. No
concerning lytic or sclerotic osseous abnormalities are seen. Degenerative
changes are noted in the imaged lumbar spine. Assessment of the sacrum is
limited by overlying bowel gas.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
INDICATION: History: ___ status post fall, multiple abrasions to shoulder,
elbow, bilateral knees.
TECHNIQUE: Bilateral knees, three views each
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is identified in either knee. Joint spaces
are preserved with minimal degenerative changes noted in the left medial and
patellofemoral compartments with osteophytic spurring. No joint effusion is
identified. Small superior patellar enthesophytes are noted bilaterally. No
concerning lytic or sclerotic osseous abnormality is identified.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ status post fall with multiple abrasions to the
shoulder, elbow, bilateral knees and alert and orientated x 2
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 54 mGy
DLP: 891.93 mGy-cm
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
large territorial infarction. A small sublenticular cyst is seen on the
right.
Prominent ventricles and sulci suggest age-related involutional changes or
atrophy.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The visualized bony structures are grossly unremarkable. Mild mucosal
thickening is seen within the ethmoid air cells bilaterally, otherwise the of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Atherosclerotic mural calcification of the cavernous internal carotid arteries
is noted.
The globes are unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
INDICATION: History: ___ status post fall with multiple abrasions to
shoulder, elbow, bilateral knees
TECHNIQUE: Helical axial MDCT sections were obtained from the skull base
through the through the upper lungs. Reformatted images in sagittal and
coronal axis were obtained.
DOSE: DLP: 37 mGy-cm.
CTDIvol: 849.10 mGy.
COMPARISON: None available.
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. Multilevel mild to moderate degenerative
changes are noted within the spine with multilevel anterior and posterior
osteophytosis. There is mild narrowing of the cervical canal at C2-C3, C3-C4,
C4-C5 and C5-C6 with no critical stenosis. Facet arthropathy is seen at C5-6
on the right and C4-5 on the left.
No lymphadenopathy is present by CT size criteria. There is mild smooth
septal thickening in the lung apices, which may reflect mild volume overload.
Mild paraseptal emphysema is also noted in the lung apices. The thyroid gland
is unremarkable.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the spine.
Radiology Report
INDICATION: History: ___ status post fall, multiple abrasions to shoulder,
elbow, bilateral knees.
TECHNIQUE: Right shoulder, three views and right elbow, three views
COMPARISON: Right shoulder radiographs ___
FINDINGS:
Within the right shoulder, no acute fracture or dislocation is identified.
There is mild joint space narrowing and osteophytic spurring involving the
right acromioclavicular joint. The right glenohumeral joint is preserved. No
concerning lytic or sclerotic osseous abnormalities are visualized. There are
no soft tissue calcifications. Imaged aspect of the right lung is
unremarkable.
Within the right elbow, there is no acute fracture or dislocation. An elbow
joint effusion is not identified. There are mild degenerative changes
involving the humeroulnar joint. No concerning lytic or sclerotic osseous
abnormalities visualized. An intravenous catheter projects over the proximal
forearm.
IMPRESSION:
No acute fracture or dislocation in the right shoulder or right elbow.
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: ___ with tachycardia, altered mental status. Assess for
infectious source or pulmonary embolism.
TECHNIQUE: MDCT images were obtained through the torso, initially without
contrast, and subsequently in the arterial phase after administration of IV
Omnipaque contrast. Axial images were interpreted in conjunction with
coronal, sagittal, and MIP reformats.
DLP: ___ MGy-cm
COMPARISON: None.
FINDINGS:
CTA TORSO:
The thoracic and abdominal aorta are normal in caliber and without evidence of
aneurysm or dissection. The pulmonary arteries opacify to the subegmental
level. No evidence of filling defect to suggest pulmonary embolism. Mild
prominence of the main pulmonary artery is noted. The celiac axis, SMA,
bilateral renal arteries, and ___ are grossly patent. Moderate circumferential
atherosclerotic mural calcifications are seen throughout the aorta and its
major branches.
CHEST:
No axillary, supraclavicular, mediastinal, or hilar lymph node enlargement.
The heart is enlarged. Mediastinum is unremarkable. No pericardial
effusion.The airways are patent to the segmental levels. Bilateral lower lobe
atelectasis is noted as well as mild emphysematous changes within the upper
lobes. A 0.4 cm nodule is noted within the left lower lobe (3:131). No
pleural effusion or pneumothorax.
ABDOMEN:
The liver is normal in appearance.A 0.6 x 0.5 cm hypodensity within hepatic
segment 8 is too small to characterize (2b: 107). The portal vein, SMA, and
splenic vein are patent. No intra or extrahepatic biliary dilatation. The
gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.The
kidneys enhance symmetrically. Focal areas of scarring are noted within the
lower pole of the right kidney as well as in the upper pole of the left
kidney, possibly due to prior infectious or ischemic insult (2B: 125, 107).
Calcifications are seen at the ostium of the right and left single renal
arteries.
A large hiatal hernia is present.The small and large bowel are normal in
caliber and without evidence of wall thickening. The appendix is not
visualized however no secondary signs of acute appendicitis. Colonic
diverticulosis is present without evidence of diverticulitis. No
retroperitoneal or mesenteric lymph node enlargement by CT size criteria.No
free abdominal fluid, abdominal wall hernia, or pneumoperitoneum.
PELVIS:
The bladder is decompressed with a Foley catheter and air is seen within the
bladder consistent with recent Foley placement. No pelvic side-wall or
inguinal lymph node enlargement.No free pelvic fluid is identified. 3.8 x 3.3
cm (2b: 150) hyperenhancing fluid-filled lesion within the right lower pelvis
and appears to communicate with the uterine fundus is consistent with a
necrotic fibroid. The right ovary is unremarkable. The left ovary is not
visualized.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. Multiple healed right anterior rib
fractures are noted. No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Diverticulosis without evidence of acute diverticulitis.
2. No pulmonary embolism.
3. Fibroid uterus.
4. Large hiatal hernia.
5. 4-mm nodule within the left lower lobe. Followup as per ___
criteria.
The ___ society pulmonary nodule recommendations are intended as
guidelines for follow-up and management of newly incidentally detected
pulmonary nodules smaller than 8 mm, in patients ___ years of age or older. Low
risk patients have minimal or absent history of smoking or other known risk
factors for primary lung neoplasm. High risk patients have a history of
smoking or other known risk factors for primary lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if no change, no
further imaging needed.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with HTN, HLD presents s/p fall. Confused with
word finding difficulty. // signs of infacrt? mass?
TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR,
susceptibility and diffusion weighted images were obtained through the head.
Three dimensional time of flight MR arteriography of the head performed with
rotational reconstructions.
COMPARISON:
CT head without contrast of ___.
FINDINGS:
MRI HEAD: Sagittal T1 sequences is suboptimal secondary to motion. There is
diffusion-weighted hyperintense signal of the medial left midbrain extending
to the cerebral peduncle with suggestion of corresponding ADC hyperintense
signal. In addition, there is diffusion-weighted hyperintense signal of the
left medial temporal cortex with corresponding ADC hypointense signal. Both
these lesions demonstrate FLAIR/ T2 hyperintensity. The combination of
findings would suggest late acute to subacute infarcts of varying chronicity.
There is no evidence of intra or extra-axial mass effect. Sulci, ventricles
and cisterns are within expected limits given the degree of age-appropriate
volume loss. The major intracranial flow voids are preserved. The paranasal
sinuses are essentially clear. There is been a left lens replacement otherwise
orbits are unremarkable. The mastoid air cells are clear.
HEAD MRA: Focal stenosis at the proximal A1 segment. Otherwise, normal flow
related signal is seen in the intracranial internal carotid, middle cerebral
and remainder of the anterior cerebral arteries without significant mural
irregularity or stenosis. There is normal symmetric arborization of the MCA
branches. There is no aneurysm greater than 3 mm.
There is lack of flow related signal of the left posterior cerebral artery at
the P2 segment with distal reconstitution although there appears to be
relative paucity of related signal distally relative to the right, which may
be secondary to artifact.
Normal flow related signal is seen in the codominant intracranial vertebral
arteries, the basilar artery, and the bilateral superior cerebellar and right
posterior cerebral artery.
IMPRESSION:
1. Late acute to subacute infarct of the medial left midbrain extending to the
cerebral peduncle as well as the left medial temporal cortex in the left PCA
distribution.
2. Focal stenosis of the right proximal A1 segment. There is paucity of
flow-related signal of the left P2 segment which may be artifactual in nature
given motion artifact.
3. No aneurysms.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FEVER, UNSPECIFIED, LEUKOCYTOSIS, UNSPECIFIED , ELEV TRANSAMINASE/LDH, SYNCOPE AND COLLAPSE, ABNORM ELECTROCARDIOGRAM
temperature: 98.1
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 164.0
dbp: 73.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of hypertension
and hyperlipidemia who was found down in her apartment after a
fall on ___. She presented to the ED with altered mental
status and obvious trauma to the R forehead, arm, and knee. She
was found to have marked leukocytosis, elevated lactate, and
hypokalemia. Due to concern for sepsis she was rescusitated per
sepsis protocol and transferred to the medical ICU. She
developed Afib with RVR while in the ED and was successfully
converted with metoprolol. No source of infection was identified
on UA, CXR, or CT Torso. ___ revealed no acute intracranial
process. Due to concerns for ataxia and aphagia, she had an MRI
while in the medical ICU which showed infarcts in the L medial
midbrain, L medial temporal lobe, and L occipital lobe. This was
likely the result of a large clot that caused transient ataxia,
evolving into several discrete embolic infarcts. The most likely
etiology is cardiac embolism from paroxysmal valvular atrial
fibrillation.
She remained stable in the ICU and was transferred to the floor
on ___. There was initial concern that her aphasia may be
secondary to seizure (stroke in L medial temporal lobe), but EEG
was within normal limits. On discharge she continued to have
some confusion, limited attention, and amnesia. Her exam has
improved, but is still notable for L ptosis, limited L eye
movement, RUQ visual field cut, limited attention, and amnesia.
Her newly diagnosed Afib was investigated with TEE and TTE,
which showed myxomatous mitral valve with worsening mitral
regurgitation leading to valvular Afib. Per cardiology,
metoprolol was titrated for rate control. She was anticoagulated
with heparin gtt and coumadin was started on ___. She will be
sent to rehab on heparin gtt bridge and follow-up with
cardiology as an outpatient.
Her blood pressure was allowed to autoregulate in the acute
setting. On HD4 her home HCTZ was added to metoprolol. Blood
pressure control was suboptimal so lisinopril was titrated to
normotension.
# Neuro
- Left midbrain, temporal, and occipital acute infarcts
- Exam findings consistent with a ___ nerve palsy due to infarct
of the fascicle, R sided weakness from infarct of the cerebral
peduncle, and impaired coordination from infarct of the superior
cerebellar peduncle.
- Continue heparin gtt: check PPT q6h, goal 50-70, can stop
heparin gtt once INR theraputic
- Continue coumadin with heparin bridge, trend daily INR, goal
INR ___
- BP Control: Continue HCTZ 25mg PO daily, lisinopril to 20mg PO
daily, metoprolol succinate 75 mg PO daily
- Continue rosuvastatin 10mg PO daily
- Continuous EEG within normal limits
- Risk Factors: HbA1C (5.9) LDL (65)
#CV
- History of hypertension, hyperlipidemia, and myxomatous mitral
valve with worsening mitral regurgitation leading to Afib
- Continue coumadin with heparin bridge, trend daily INR, goal
INR ___
- BP Control: Continue HCTZ 25mg PO daily, lisinopril to 20mg PO
daily, metoprolol succinate 75 mg PO daily
- Continue rosuvastatin 10 mg daily
- TTE/TEE: Myxomatous mitral valve with worsening mitral
regurgitation leading to valvular Afib
#ID
- Initial concern for sepsis but no source of infection on UA,
CXR, or CT Torso (WBCs 22 -> 12.7)
- Briefly on broad spectrum abx for meningitis coverage, stopped
once MRI showed acute infarcts
#Endo
- HgbA1c 5.9
- History of hypothyroidism, continue home synthroid 75 mcg
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
65) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: LDL below goal on current regimen
]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfur-8 / ceftriaxone
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Ms. ___ is a ___ w/ afib/copd,
recent RP bleed R, nephrolithiasis on L, with recent admission
to medicine service for nephrolithiasis, CHF flare, a. fib with
RVR, disharged on ___, who was transferred back from rehab for
dizziness this AM and worsening SOB.
During last admission, patient came in with left flank pain
secondary to left nephrolithiasis. Her retroperitoneal bleed was
stable. Patient had A.fib w/RVR several times during this
admission, and subsequent flash pulmonary edema with SOB that
resolved with rate control and diuresis. Also with diffuse drug
rash secondary to ceftriaxone that was treated with topical
clobetasol.
Today at rehab she had increased shortness of breath and RR of
30. She received xopenox without effect. She was noted to have
wheezes and ___ edema, so she was sent to ___ for
further evaluation.
In the ED, initial vitals were: 97.5 88 117/61 24 98% 3L. Exam
was significant for bibasilar crackles; no wheezing; quiet
breath sounds in middle/upper lung fields, tenderenss to deep
palpation of left abdomen, neuro: ___ strength of right leg,
can't perform heel-shin w/ right leg, + dysmetria w/
finger/nose/finger on right, corrective saccade b/l to center.
She had a CXR showing a pleural effusion on R, not tremendously
fluid overloaded in comparison to previous. A CT abdomen pelvis
was performed, which showed decrease in the size of her RP
bleed. She was felt to have a likely COPD flare, so she received
duonebs x2, solumedrol. She also received lasix 40 mg IV x1.
Because of her dizziness and abnormal neuro exam, she got a
NCTHCT which showed hypodensity involving left temporal lobe
extending into the left parietal lobe, compatible with subacute
to chronic left MCA territory infarction. Neurology consulted in
the ED given head CT findings and that she had recrudescence of
old strokes that is related to worsening medical illness. They
recommended she be admitted to medicine for further work-up of
dyspnea. Vitals on transfer are 97.5 88 107/45 20 95%.
Past Medical History:
COPD (chronic obstructive pulmonary disease)
Pseudophakia
Macular Pucker
SACRAL SPINE DISORDER
ATRIAL FIBRILLATION paroxysmal
HYPERCHOLESTEROLEMIA
OSTEOPOROSIS, UNSPEC
DEPRESSIVE DISORDER
HYPOTHYROIDISM
CVA at Age ___ with R sided hemiparesis since resolved
History of Rheumatic Heart Disease of mitral valve
.
Social History:
___
Family History:
Brother Cancer; ___
Mother Cancer
Sister ___
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.9 BP: 112/46 P: 82 R: 18 O2:96% on 3L
General: Chronically ill appearing frail woman, sleeping,
appears tired
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 10 cm, no LAD
Lungs: Bibasilar crackles ___ way up lung fields, diffuse
end-expiratory wheezes.
CV: Irregular rhythm, 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, ___ pitting edema.
Neuro: A&Ox3, CN II - XII grossly intact
Skin: Healing rash on abdomen, trunk, and back, now with dry
flaking skin.
Discharge Physical Exam:
VS: 97.6 112/53 74 18 96% 2LNC, I/O ___
GEN Alert, awake, no acute distress
PULM Crackles bilaterally at bases
CV Irregularly irregular, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, no edema
Pertinent Results:
Admission:
___ 10:30PM BLOOD WBC-14.7* RBC-3.58* Hgb-11.6* Hct-35.4*
MCV-99* MCH-32.3* MCHC-32.7 RDW-16.6* Plt ___
___ 10:30PM BLOOD Neuts-74.7* Lymphs-12.9* Monos-4.3
Eos-7.5* Baso-0.7
___ 10:30PM BLOOD ___ PTT-28.0 ___
___ 10:30PM BLOOD Glucose-119* UreaN-22* Creat-0.6 Na-142
K-3.8 Cl-101 HCO3-35* AnGap-10
___ 10:30PM BLOOD ALT-91* AST-64* AlkPhos-101 TotBili-0.5
___ 10:30PM BLOOD Albumin-3.5 Calcium-9.9 Phos-3.2 Mg-1.7
___ 10:00AM BLOOD %HbA1c-5.6 eAG-114
___ 10:00AM BLOOD Triglyc-64 HDL-63 CHOL/HD-2.4 LDLcalc-74
___ 10:42PM BLOOD Lactate-0.8
Discharge:
___ 07:45AM BLOOD WBC-8.2 RBC-3.66* Hgb-12.2 Hct-36.3
MCV-99* MCH-33.5* MCHC-33.7 RDW-15.6* Plt ___
___ 07:25AM BLOOD ___ PTT-34.3 ___
___ 07:25AM BLOOD Glucose-113* UreaN-23* Creat-0.6 Na-143
K-4.1 Cl-100 HCO3-35* AnGap-12
___ 07:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
Microbiology:
___ Blood Culture: Negative
___ Urine Culture: Negative
___ Blood Culture: Negative
___ Urine Culture:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Imaging:
___ CXR: Mild pulmonary edema with small right pleural effusion
and
adjacent atelectasis.
___ CT Head: Old left MCA superior division infarction. No
evidence of
hemorrhage or mass effect
___ CT Abdomen:
1. Interval decrease in size of right retroperitoneal hematoma,
now 9.3 x 6.1 cm.
2. Interval increase in right pleural effusion with stable
trace left pleural effusion and adjacent atelectasis.
3. Two 3-mm nonobstructive left renal stones. No hydroureter
or
hydronephrosis.
___ MRI/MRA Head and Neck:
1. No evidence of hemorrhage or recent infarction.
2. White matter T2/FLAIR hyperintensities likely the sequelae
of chronic
microangiopathy.
3. Decreased caliber of the M1 segment of the left middle
cerebral artery
with little vascularity distally, chronic in nature.
___ TTE:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. The mitral valve shows characteristic
rheumatic deformity. There is moderate thickening of the mitral
valve chordae. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Mild to moderate (___) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are similar.
___ CXR: Pulmonary vascular congestion with right-sided pleural
effusion,
somewhat improving over the last two days. No evidence of new
infiltrates.
Radiology Report
INDICATION: ___ female with dizziness and neurologic deficits.
Evaluate for head bleed.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Axial images were interpreted in
conjunction with coronal and sagittal reformats.
FINDINGS:
There is well-developed encephalomalacia of the left temporal lobe that
extends into the left parietal lobe white matter. This likely represents a
chronic superior division left middle cerebral artery infarction. There is no
evidence of hemorrhage or mass effect. Ventricles and sulci are prominent,
compatible with age-related volume loss. The basal cisterns appear patent.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Bilateral ocular lenses have been
replaced.
IMPRESSION: Old left MCA superior division infarction. No evidence of
hemorrhage or mass effect.
Radiology Report
INDICATION: ___ female with abdominal tenderness with deep palpation.
Evaluate for retroperitoneal bleed.
COMPARISON: Multiple prior CTs, most recently CT abdomen and pelvis of
___.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without administration of IV contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats.
FINDINGS:
The visualized portion of the heart is unremarkable. A moderate-sized
nonhemorrhagic right pleural effusion has increased since ___.
Trace left pleural effusion is similar to prior. There is bilateral adjacent
compressive atelectasis. No pericardial effusion.
ABDOMEN:
Evaluation of the intra-abdominal organs is limited without administration of
IV contrast. Within this limitation, the liver, gallbladder, intra- and
extra-hepatic bile ducts, pancreas, spleen, and adrenal glands are normal.
3-mm left upper pole and 3-mm left lower pole non-obstructing calcified stones
are similar to prior. No evidence of hydronephrosis or hydroureter. The
ureters appear to have a normal course and caliber.
The stomach is normal. The small and large bowel have a normal course and
caliber.
A large right retroperitoneal hematoma measures up to 9.3 x 6.1 cm, previously
10.8 x 9.3 cm in similar ___. Metallic coil, likely within a right
lumbar artery, is similar in position to prior. No retroperitoneal or
mesenteric lymphadenopathy. Dense atherosclerotic calcification of the
abdominal aorta is similar to prior. No free abdominal fluid,
pneumoperitoneum, or abdominal wall hernia.
PELVIS: The Foley catheter appears to terminate beyond the confines of the
bladder wall, but this is likely artifactual due to slice thickness. The
bladder is decompressed. The uterus is unremarkable. No pelvic sidewall or
inguinal lymphadenopathy. No free pelvic fluid or inguinal hernia.
OSSEOUS STRUCTURES: Compression deformity of L1 is similar to prior. No
focal lytic or sclerotic lesion concerning for malignancy.
IMPRESSION:
1. Interval decrease in size of right retroperitoneal hematoma, now 9.3 x 6.1
cm.
2. Interval increase in right pleural effusion with stable trace left pleural
effusion and adjacent atelectasis.
3. Two 3-mm nonobstructive left renal stones. No hydroureter or
hydronephrosis.
Radiology Report
INDICATION: ___ woman with atrial fibrillation, COPD, history of
cerebrovascular accident, presents with right-sided dysmetria and dizziness.
Evaluate for carotid stenosis.
TECHNIQUE: Multiplanar, multisequence MRI of the brain and MRA of the neck
before and after the administration of IV contrast was obtained. MRA of the
brain was obtained without IV contrast.
COMPARISON: CT scan head of ___ at 01:25 hours.
FINDINGS:
There is an area of encephalomalacia in the left temporal lobe, in keeping
with prior inferior division of middle cerebral artery territory infarction.
There are scattered T2/FLAIR hyperintensities in the subcortical and
periventricular white matter, which are nonspecific, but are likely the
sequelae of chronic microangiopathy.
There is prominence of the ventricles and CSF spaces consistent with global
cerebral volume loss. There is no acute infarct or hemorrhage. There is no
evidence of abnormal enhancement, mass, or midline shift. The basal cisterns
are patent.
There is mucosal thickening of the frontal, ethmoidal, and sphenoid sinuses.
Minimal fluid is noted in the mastoid air cells.
MRA HEAD: The intracranial vertebral and internal carotid arteries appear
patent. There is mild irregularity of the supraclinoid segments of the
internal carotid arteries, likely related to mild atherosclerosis.
There is decreased caliber of the proximal M1 segment of the left middle
cerebral artery with little vascularity of the distal branches. The right
middle cerebral, anterior cerebral, and posterior cerebral arteries are patent
with normal branching pattern.
There is no evidence of aneurysm. The origin of the vertebral arteries are
patent. The origins of the common carotid arteries are patent.
There is no evidence of stenosis or aneurysm. The internal carotid arteries
appear patent. The diameter of the proximal carotid arteries is larger than
the distal diameter, therefore, there is no stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of hemorrhage or recent infarction.
2. White matter T2/FLAIR hyperintensities likely the sequelae of chronic
microangiopathy.
3. Decreased caliber of the M1 segment of the left middle cerebral artery
with little vascularity distally, chronic in nature.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ female patient with COPD, atrial fibrillation,
presents with shortness of breath and new leukocytosis. Patient's condition
required examination in sitting upright position using AP single view
technique. Comparison is made with a similar preceding study of ___. Heart size undetermined; however, some moderate cardiac enlargement is
likely to be present. Pulmonary vasculature again shows a congestive pattern
with perivascular haze and blunting of the right lateral pleural sinus
indicates presence of pleural effusion that obscures the diaphragmatic
contour. There is no evidence of new acute pulmonary parenchymal infiltrates
in comparison with the next preceding study of ___ where the
pulmonary congestive pattern was more marked.
IMPRESSION: Pulmonary vascular congestion with right-sided pleural effusion,
somewhat improving over the last two days. No evidence of new infiltrates.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIZZINESS , SOB
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 97.5
heartrate: 88.0
resprate: 24.0
o2sat: 98.0
sbp: 117.0
dbp: 61.0
level of pain: 3
level of acuity: 2.0 | Brief Course:
___ w/ afib/copd, recent RP bleed R, nephrolithiasis on L, with
recent admission to medicine service for nephrolithiasis, CHF
flare, a. fib with RVR, disharged on ___, who was transferred
back from rehab for dizziness and worsening SOB. Patient was
presumed to have preserved ejection fraction CHF and was
diuresed aggressively with improvement in the patient's
respiratory symptoms. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Seconal Sodium / Erythromycin Base / Doxycycline /
Latex / Adhesive Tape / Peanut / Tomato / raw fruit
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo with h/o male with a history HTN, HLD, CAD (sp DES to RCA
in ___, has known diffuse LAD 60%, OM1 70% from ___ cath) who
presents with chest pain that started yesterday.
Pt states that CP started at rest after breakfast. Upper chest
in a band-like distribution, radiating to jaw. Concomitant with
mild SOB. Pain is differenr from prior MI, but it is difficult
for her to compare the pain to her prior shingles episode which
occured on her mid to right chest. Pain is non-positional. not
associated w/ food. takes ASA 81 daily. R>L leg swelling. Denies
fever, chills, URI symptoms. 1 week ago had nausea, emesis,
intense fatigue, now resolved. Had flu shot this season.
.
She was seen by her cardiologist Dr ___ this month
for exertional chest pain and jaw pain felt to be stable angina.
A stress echo in ___ was positive for symptoms and ECG
changes without echo evidence of ischemia. He felt that her
symptoms were due to stable angina, and medical management was
reasonable as long as her symptoms remained stable.
In ED initial VS were T: 97.8 BP 164/51 89 18 97%
CBC shows HCT 34.5(baseline 35). Cr 1.2 (baseline 1.0). D-dimer
700s. Trop neg x1. INR 0.8. A CT chest was negative for PE or
aortic pathology. ___ was negative for DVT. CXR was
negative.
EKG: sinus, HR 70, nl axis, q in V2 and V3. Unchanged compared
to prior.She was given asa 325mg and morphine IV and admitted to
medicine for further management.
Transfer vitals: 72 124/56 21
On arrival to the floor she endorses constant, stable mid chest
pressure. She did not take any SL nitrogen with onset of
symptoms. She denies current dyspnea.
Past Medical History:
1. CAD
- NSTEMI 40% mid-LAD, 70%OM1, 60%midcirc, 100%pRCA
with thrombus s/p PCI with thrombectomy of RCA with Cypher stent
to pRCA and MiniVision stent to distal RCA
- s/p PCI in ___ with 20% LMCA, 60% LAD, OM1 70%, and RCA with
diffuse disease with widely patent stent.
2. OSA - CPAP 7
3. DM2 x ___ years c/b mild proteinuria and peripheral neuropathy
4. HTN
5. Hypercholesterolemia
6. Mild centrilobular emphysema ___ CTA)
7. Hepatitis B cirrhosis - followed by Dr. ___
8. anti-c RBC alloantibody (can cause hemolytic transfusion
rxns)
9. Mild right hydronephrosis ___ CTA)
Past Surgical History
1. TAH
2. 4 benign breast masses removed
3. cholecystectomy
4. Hiatal hernia
Social History:
___
Family History:
There is a family history of premature coronary artery disease
or sudden death. Mother - DM2, CAD s/p CABG at ___, father - CVA
at the age of ___, son and grandaughter with hemachromatosis
Physical Exam:
Physical exam (admitted/discharged same day)
97.6 147/55 68 18 ___ RA 94.8kg
GENERAL: well appearing woman in NAD NT ND
HEENT: NC/AT, sclerae anicteric, MMM
NECK: supple, JVP approximately 13cm
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2, mildly TTP in mid sternum. No
erythema, no vesicles, no bullae.
CHEST: TTP, but does not reproduce symptoms that prompted
admission
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, alert, fluent, linear, prompt, appropriate
Pertinent Results:
___ 12:35AM BLOOD WBC-6.3# RBC-3.58* Hgb-11.4* Hct-34.5*
MCV-96# MCH-31.9 MCHC-33.0 RDW-14.3 Plt ___
___ 09:24AM BLOOD WBC-5.3 RBC-3.39* Hgb-11.1* Hct-32.0*
MCV-94 MCH-32.9* MCHC-34.9 RDW-14.2 Plt ___
___ 12:35AM BLOOD Neuts-61.9 ___ Monos-5.4 Eos-1.7
Baso-0.6
___ 12:35AM BLOOD ___ PTT-28.2 ___
___ 12:35AM BLOOD Glucose-260* UreaN-26* Creat-1.2* Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
___ 09:24AM BLOOD Glucose-109* UreaN-23* Creat-1.0 Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
___ 12:35AM BLOOD cTropnT-<0.01
___ 09:24AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:24AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7
___ 12:49AM BLOOD D-Dimer-763*
___ EKG: No ischemic changes.
___ LENIs:
IMPRESSION: No deep vein thrombosis in the right lower
extremity
___ CTPA:
1. No pulmonary embolism or aortic pathology.
2. Background emphysematous changes.
3. 4 mm right lower lobe and 5 mm left perifissural nodule are
stable since
___. No further followup needed.
4. Cirrhotic appearing liver.
___ CXR: No acute intrathoracic process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Entecavir 0.5 mg PO DAILY
3. Vitamin D 50,000 UNIT PO EVERY OTHER ___
4. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
5. Hydrochlorothiazide 25 mg PO DAILY
6. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for BP <100, HR<60
8. NIFEdipine CR 60 mg PO DAILY
HOLD FOR bp<100, hr<60
9. Lorazepam 1 mg PO BID:PRN anxiety
hold for sedation, RR<12
10. Metoprolol Succinate XL 100 mg PO BID
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
12. Lisinopril 40 mg PO DAILY
hold for BP<100, HR<60
13. Omeprazole 20 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Entecavir 0.5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for BP <100, HR<60
6. Lisinopril 40 mg PO DAILY
hold for BP<100, HR<60
7. Lorazepam 0.5 mg PO BID:PRN anxiety
hold for sedation, RR<12
8. NIFEdipine CR 60 mg PO DAILY
HOLD FOR bp<100, hr<60
9. Omeprazole 20 mg PO BID
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
11. Metoprolol Succinate XL 100 mg PO BID
12. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
13. Vitamin D 50,000 UNIT PO EVERY OTHER ___
Discharge Disposition:
Home
Discharge Diagnosis:
GI illness
Chest pain NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of MI in ___, presenting with shortness of breath and
chest pain.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS: Frontal and lateral chest radiograph demonstrates unremarkable
cardiomediastinal and hilar contours. Lungs are clear. No pleural effusion
or pneumothorax evident. Anterior osteophyte formation noted in the
midthoracic spine. No compression deformities evident.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: Shortness of breath with right greater than left leg swelling.
Assess for deep vein thrombosis.
COMPARISON: No prior studies available for comparison.
FINDINGS: Grayscale and color Doppler sonograms performed of the right common
femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins.
Normal compressibility, flow and augmentation noted throughout.
IMPRESSION: No deep vein thrombosis in the right lower extremity.
Radiology Report
INDICATION: Shortness of breath, chest pain, elevated D-dimer, evaluate for
pulmonary embolism.
COMPARISON: Comparison is made to chest-CTPA performed ___.
TECHNIQUE: Intravenous contrast was administered and arterial phase imaging
was acquired. Coronal and sagittal reformations were provided.
FINDINGS:
CTA CHEST: The pulmonary arterial vasculature is well opacified and without
filling defect to suggest embolus. The main pulmonary artery is not enlarged.
Atherosclerotic calcifications are noted in the thoracic aorta as well as
throughout the coronary vasculature. No pericardial effusion identified.
CT CHEST: There is no lymphadenopathy identified. The airways are normal to
the subsegmental level. Background emphysema identified. Minimal atelectatic
changes are noted in the lung bases. No concerning focal opacification is
evident. A 4-mm right lower lung (2:67) and 5mm left perifissural pulmonary
nodules are unchanged compared to ___.
Small hiatal hernia is present. Limited assessment of the upper abdomen
demonstrates a normal-appearing spleen. The liver appears cirrhotic.
The patient has evidence of prior left breast surgery with surgical clips
identified. No large enhancing mass identified.
Anterior osteophyte formation noted in the lower thoracic spine. No
suspicious lytic or blastic lesion is identified.
IMPRESSION:
1. No pulmonary embolism or aortic pathology.
2. Background emphysematous changes.
3. 4 mm right lower lobe and 5 mm left perifissural nodule are stable since
___. No further followup needed.
4. Cirrhotic appearing liver.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 89.0
resprate: 18.0
o2sat: nan
sbp: 164.0
dbp: 51.0
level of pain: 2
level of acuity: 2.0 | ___ yo with h/o HTN, HLD, CAD (sp DES to RCA in ___, has known
diffuse LAD 60%, OM1 70% from ___ cath) who presents with chest
pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
nelfinavir / vancomycin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic converted to open appendectomy
History of Present Illness:
___ w/ h/o HIV, prostate CA s/p brachytherapy, and suprapubic
tube placement with increased WBC and CT consistent with
appendicitis. Patient reports feeling a nonmigrating, sharp ___
pain in the RLQ around 6:00pm the day prior to ED
presentation, after eating dinner. The pain was constant
throughout the night but subsided after a few hours, after which
a dull ___ pain has come in waves. Patient reports feeling
chills throughout the night. Patient denies N/V but endorses
constipation and no BMs since the pain started. The pain
prompted
him to present to the ___ the day of admission, where
he got a CT scan that showed periappendiceal fat stranding
consistent with appendicitis with no evidence for perforation or
drainable fluid collections. Patient currently reports no pain,
with the latest wave coming briefly around 6:30pm
tonight.Patient reports blood in the urine, but that it happens
when he is dehydrated. He has had a fever of 100.3 after
admission and WBC of 19. He has not taken any pain medications.
Patient is not on anticoagulants or antibiotics.
Past Medical History:
Past Medical History:
HIV, well-controlled with antiretrovirals
Prostate CA
Hepatitis B
multiple urethral strictures s/p correction
urinary retention requiring self cath
condyloma accuminata
recurrent UTIs
rhinitis
obstructive sleep apnea
prior syphilis
prior chlamydia
Past Surgical History:
Brachytherapy (___)
Suprapubic tube placement (___)
prostate cancer s/p brachytherapy
Social History:
___
Family History:
+ diabetes (mother)
+ prostate cancer (dad)
+ CAD (dad)
Physical Exam:
Admission Physical Exam:
Vitals: (17:14) T:100.3 HR: 104 RR: 18 BP: 162/64 O2: 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Tenderness in RLQ, nonperitoneal, equivocal Rovsing's sign.
normoactive bowel sounds.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
GEN: NAD
HEENT:EOMI, MMM
CV: RRR
PULM: non-labored breathing
ABD: soft, appropriately tender to palpation, incision c/d/I
with staples, no rebound, no guarding
EXT: no edema
PSYCH: appropriate mood, appropriate affect
NEURO: A&Ox3
Pertinent Results:
IMAGING:
___: CT from OSH. Evidence of ___ fat
stranding consistent with appendicitis with no drainable fluid
collections or free air.
LABS:
___ 02:51AM GLUCOSE-135* UREA N-20 CREAT-2.2* SODIUM-131*
POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-22 ANION GAP-18
___ 02:51AM CALCIUM-8.1* PHOSPHATE-4.2 MAGNESIUM-1.8
___ 02:51AM WBC-21.6* RBC-4.28* HGB-13.1* HCT-39.4*
MCV-92 MCH-30.6 MCHC-33.2 RDW-13.2 RDWSD-44.5
___ 02:51AM PLT COUNT-198
___ 07:44PM LACTATE-1.5 NA+-132* K+-3.7
___ 07:41PM ___ PTT-26.4 ___
___ 07:35PM GLUCOSE-102* UREA N-18 CREAT-1.6* SODIUM-128*
POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-21* ANION GAP-21*
___ 07:35PM ALT(SGPT)-25 AST(SGOT)-44* ALK PHOS-84 TOT
BILI-2.1*
___ 07:35PM LIPASE-20
___ 07:35PM ALBUMIN-3.9
___ 07:35PM WBC-19.0*# RBC-4.63 HGB-14.0 HCT-40.6 MCV-88
MCH-30.2 MCHC-34.5 RDW-13.1 RDWSD-41.9
___ 07:35PM NEUTS-72.7* LYMPHS-17.7* MONOS-8.5 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-13.77*# AbsLymp-3.36
AbsMono-1.62* AbsEos-0.00* AbsBaso-0.03
___ 07:35PM PLT COUNT-186
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN allergy
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Do not exceed 4000 mg daily.
2. Docusate Sodium 100 mg PO BID
Hold for loose or frequent stool.
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN allergy
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ hx of HIV, Hep B, prostate cancer with suprapubic tube in
place, p/w acute appendicitis, now s/p lap converted to open appendectomy now
with abd distension and vomiting.// ? post-op ileus/ obstruction?
TECHNIQUE: Portable spine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___ (___)
FINDINGS:
There are multiple mildly distended loops of small bowel with air-fluid levels
on upright imaging with air in the large bowel that could be compatible with
ileus. Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for multilevel degenerative changes of the
lower lumbar spine
Skin staples overlie the lower abdomen and pelvis.
IMPRESSION:
Multiple mildly distended loops of small bowel with air-fluid levels on
upright radiographs that could represent with ileus given large bowel gas
pattern.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Appendicitis
Diagnosed with Unspecified acute appendicitis
temperature: 100.3
heartrate: 104.0
resprate: 18.0
o2sat: 98.0
sbp: 162.0
dbp: 64.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ presented to the ___ ED on ___ with
abdominal pain that began one day prior. CT at an outpatient
facility on ___ showed acute appendicitis. He started on IV
antibiotics, admitted and taken to the Operating Room where he
underwent a laparoscopic converted to open appendectomy. For
full details of the procedure, please refer to the separately
dictated Operative Report. He was returned to the PACU in stable
condition. After satisfactory recovery from anesthesia, he was
transferred to the Surgical Floor for further monitoring.
He was kept NPO with IV fluids and urine output was monitored
via suprapubic catheter which patient had in place at time of
admission. On POD1, patient had worsening abdominal distention
and bilious emesis. An NGT was placed with symptomatic relief.
White count continued to decrease post-operatively. Pain was
managed initially with IV medications and transitioned to oral
medications once he was tolerating PO.
On POD1, patient was noted to have ___ and ___ HIV medications
were renally dosed. ___ resolved and creatinine was back at
baseline on POD2 after adequate fluid resuscitation.
Patient was discharged home on ___. At the time of discharge,
he was tolerating a regular diet, ambulating independently,
voiding via suprapubic catheter, and pain was well controlled
with oral medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, L leg pain, R hand pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HIV, on ART (last
CD4 799 in ___ p/w oxycodone and Valium overdose on day prior
to admission, now presenting with altered mental status, L leg
pain and R hand pain.
Patient initially presented on day prior to admission ___ with
unresponsive episode while being seen in his PCP's office. He
was
found to have Utox + for benzodiazepines and opiates (patient
prescribed dilaudid and alprazolam at home), which patient's
partner states he was not taking as prescribed. The patient came
into the ED and was observed overnight for social work placement
and was discharged with resources for substance abuse.
Per the patient's partner, the patient was found confused in
___, and was brought back to ___. At
time of presentation today, the patient stated that he was
tackled by the police; his partner states this may have been due
to the patient's confusion. Patient was complaining of L leg
pain, R hand pain.
Notably, the patient's partner says that the patient has been
taking his prescribed alprazolam and dilaudid not as prescribed.
He says he has brought the patient into the ED 1/month over the
last 6 months due to this issues. He says the patient is often
very sedated when taking his medications more than prescribes,
and he becomes very confused/disoriented when he is sobering up.
In the ED, initial vitals were: T98.5 HR81 BP113/75 RR18
O2Sat100% RA.
- Exam notable for: Abrasion to left face; CN III - XII intact,
strength ___ throughout, sensation to light touch intact; no
C/T/L spine tenderness, full ROM of neck; no abdominal
tenderness
- Labs notable for: WBC 2.4, Hgb 8.8, Plt 46. Cr 0.9. INR 1.2.
ALT 76, AST 18, Lipase 10. Utox + for benzos and opiates. UA
with
trace protein otherwise unremarkable.
- Imaging was notable for:
1. CT sinus/mandible/maxillofacial with no evidence of acute
fracture, L odontogenic maxillary sinusitis
2. CT ___ without acute fracture
3. CT head without acute intracranial abnormality
4. Ankle XR with right lateral malleolar fracture with very mild
displacement posterior and laterally, no fractures of left
ankle.
- Patient was given: Ketorolac 15 mg
- Ortho saw the patient for R mildly displaced malleolar
fracture
and recommended walking boot and ___ with ortho in ___
days.
- Plan was to discharge patient, but patient was noted to be
persistently altered, did not know his age, where he was, or who
his partner was, and it was felt he was not safe to be
discharged.
Upon arrival to the floor, patient reports that he overall has
pain from where he was "kicked". He states bilateral shoulders,
elbows, hips, knees, and ankles hurt, and points out abrasions
over his L shoulder, L elbow, L knee. Denies fevers, chills, HA,
CP, SOB, dysuria, diarrhea.
Past Medical History:
PAST MEDICAL HISTORY:
- NAFLD
- HIV on HAART
- Seizures
- Type II diabetes (diet controlled)
- Gastroparesis
- CAD s/p MI ___ and ___ (no asa)
- Migraine
- Anxiety
- History of acute hepatitis/pancreatitis
- History of internal hemorrhoids
PAST SURGICAL HISTORY:
S/p cholecystectomy
S/p appendectomy
s/p inguinal hernia repair
Social History:
___
Family History:
Father: deceased, ___
Mother: healthy
Sister: S/p hysterectomy
No children
Uncle dx with colon and lung cancer
Physical Exam:
ADMISSION EXAM
=========================
VITAL SIGNS: T98.9 BP134/79 HR82 RR18 O2Sat100%RA
GENERAL: Thin appearing man in no acute distress.
HEENT: L cheek with ecchymosis. PERRL, EOMI, MMM, oropharynx
clear.
NECK: Supple.
CARDIAC: RRR, no MRG.
LUNGS: CTAB. Mildly tender to palpation over L lower rib, no
evidence of displacement in rib.
ABDOMEN: Soft, mildly tender to deep palpation over LUQ, but
points to L lower rib as site of pain, otherwise ___.
No guarding.
EXTREMITIES: No lower extremity edema. R foot in boot.
NEUROLOGIC: A&Ox3, does not know the name of his partner of ___
years, PERRL, EOMI, no facial droop, palate elevates
symmetrically, tongue protrudes midline. ___ strength in
bilateral upper and lower extremities. Sensation intact to light
touch throughout.
SKIN: Abrasion over L shoulder, small cuts over L elbow and L
knee.
DISCHARGE EXAM
==========================
VITAL SIGNS:
24 HR Data (last updated ___ @ 1143)
Temp: 98 (Tm 98.9), BP: 176/90 (___), HR: 68
(___), RR: 18, O2 sat: 98% (___), O2 delivery: ra
GENERAL: thin man, NAD, alert and interactive
HEENT: L cheek with ecchymosis, PERRL, EOMI
CARDIAC: RRR, no murmurs, rubs, or gallops
PULM: CTAB, unlabored respirations, no wheezes
GI: abdomen soft, NTND, +BS
MSK: No lower extremity edema, right lower extremity in walking
boot. Left shoulder mildly TTP anteriorly, but no deformity
NEUROLOGIC: A&Ox3, PERRL, EOMI
SKIN: Abrasion over L shoulder, small cuts over L elbow and L
knee.
Pertinent Results:
ADMISSION LABS
==========================
___ 05:50PM BLOOD ___
___ Plt ___
___ 05:50PM BLOOD ___
___
___ 05:50PM BLOOD ___
___
___ 07:03PM BLOOD ___
DISCHARGE LABS
========================
___ 06:35AM BLOOD ___
___ Plt ___
___ 06:35AM BLOOD ___
___
___ 07:10AM BLOOD ___
IMAGING
=======================
CXR ___ - Low lung volumes. No consolidation.
R Ankle XR ___. Right lateral malleolar fracture with very
mild displacement posterior and laterally.
2. No fractures at the left ankle.
CT Head ___ -
1. No acute intracranial abnormality.
2. Soft tissue swelling overlying the left frontal bone and
maxilla without evidence of underlying fracture.
3. Severe left paranasal sinus disease and mild right paranasal
sinus disease. Please refer to ___ CT facial bones for
further details.
CT Sinus ___ -
1. No acute fracture.
2. Severe left paranasal sinus disease concerning for
odontogenic maxillary sinusitis given direct communication with
left maxillary molar periapical lucency.
CT ___ ___ -
Multilevel degenerative changes of the cervical spine. No acute
fracture or traumatic malalignment.
Shoulder XR ___ -
Healed fracture of the left humeral neck with persistent valgus
angulation
without suggestion of acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. ALPRAZolam 1.5 mg PO TID:PRN anxiety
3. LevETIRAcetam 1000 mg PO BID
4. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN Pain - Severe
5. Genvoya ___ ALAFEN) ___ mg
oral DAILY
6. Gabapentin 400 mg PO TID
7. FLUoxetine 60 mg PO DAILY
8. Propranolol 40 mg PO BID
9. Prazosin 5 mg PO DAILY
10. NIFEdipine (Extended Release) 30 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Aspirin 81 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
14. Metoclopramide 10 mg PO TID
15. Methotrexate 7.5 mg PO BID Q ___
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Loratadine 10 mg PO DAILY
18. GlipiZIDE XL 5 mg PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. Erythromycin 250 mg PO Q12H
21. BusPIRone 30 mg PO BID
22. Methotrexate 5 mg PO 1X/WEEK (SA)
23. Ranitidine 150 mg PO BID:PRN Dyspepsia
24. LORazepam 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. ALPRAZolam 1.5 mg PO TID:PRN anxiety
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. BusPIRone 30 mg PO BID
5. Erythromycin 250 mg PO Q12H
6. FLUoxetine 60 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 400 mg PO TID
9. Genvoya ___ ALAFEN) ___ mg
oral DAILY
10. GlipiZIDE XL 5 mg PO DAILY
11. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN Pain - Severe
12. LevETIRAcetam 1000 mg PO BID
13. Loratadine 10 mg PO DAILY
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Methotrexate 5 mg PO 1X/WEEK (SA)
16. Methotrexate 7.5 mg PO BID Q ___
17. Metoclopramide 10 mg PO TID
18. NIFEdipine (Extended Release) 30 mg PO DAILY
19. Ondansetron 8 mg PO Q8H:PRN nausea
20. Prazosin 5 mg PO DAILY
21. ProAir HFA (albuterol sulfate) 90 mg inhalation Q6H:PRN
shortness of breath
22. Propranolol 40 mg PO BID
23. Ranitidine 150 mg PO BID:PRN Dyspepsia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Toxic Metabolic Encephalopathy in the setting of Substance use
disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with right facial trauma, ankle trauma, assault, c-spine
tenderness// fracture or hemorrhage
COMPARISON: None
FINDINGS:
AP, lateral and oblique views of both ankles.
On the right, there is an oblique fracture through the lateral malleolus
extending to the inferior aspect of the syndesmosis. There is mild lateral
and posterior displacement of the distal fracture fragment. The mortise
remains largely symmetric. No additional fractures are seen involving the
right ankle.
On the left, no fracture or dislocation. Mortise is symmetric. Talar dome is
smooth.
IMPRESSION:
1. Right lateral malleolar fracture with very mild displacement posterior and
laterally.
2. No fractures at the left ankle.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with right facial trauma, ankle trauma, assault, c-spine
tenderness// fracture or hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
There is no evidence of acute vascular territorial
infarction,hemorrhage,edema,or discrete mass. There is prominence of the
ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. There is soft tissue swelling overlying the
left frontal bone and maxilla. There is opacification of the left frontal
sinus, multiple left ethmoid air cells, in the left maxillary sinus. There is
mild mucosal thickening of the right maxillary sinus, and several right
maxillary air cells. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. There are multiple periapical
lucencies seen along bilateral maxillary teeth concerning for period.
IMPRESSION:
1. No acute intracranial abnormality.
2. Soft tissue swelling overlying the left frontal bone and maxilla without
evidence of underlying fracture.
3. Severe left paranasal sinus disease and mild right paranasal sinus disease.
Please refer to same-day CT facial bones for further details.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with right facial trauma, ankle trauma, assault, c-spine
tenderness// fracture or hemorrhage
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 506 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel degenerative
changes are seen, most extensive at C3-4 and notable for loss of
intervertebral disc height, anterior osteophytosis, ligamentum flavum
thickening, and facet and uncovertebral hypertrophy causing mild neural
foraminal and spinal canal narrowing.There is no prevertebral edema.
A 1.2 cm right thyroid nodule is seen. The included lung apices are
unremarkable.
IMPRESSION:
Multilevel degenerative changes of the cervical spine. No acute fracture or
traumatic malalignment.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ with right facial trauma, ankle trauma, assault, c-spine
tenderness// fracture or hemorrhage
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: DLP: 546.25 mGy-cm
CTDI: 25.81 mGy
COMPARISON: None.
FINDINGS:
There is no facial bone fracture. Pterygoid plates are intact. There is no
mandibular fracture and the temporomandibular joints are anatomically aligned.
The orbits are intact. The globes and extra-ocular muscles are unremarkable.
There is no orbital hematoma. There are multiple dental caries and periapical
lucencies involving the maxillary teeth. Periapical lucencies surrounding the
single remaining left maxillary molar communicates directly with the left
maxillary sinus. There is complete opacification of the left maxillary sinus
with sclerosis of the surrounding bone suggestive of chronic inflammation.
There is opacification of multiple left ethmoid air cells and the left frontal
sinus. There is mild mucosal thickening of the right maxillary sinus, the
right ethmoid air cells, in the right frontal sinus. There is mild soft
tissue swelling overlying the left frontal bone and left maxilla.
IMPRESSION:
1. No acute fracture.
2. Severe left paranasal sinus disease concerning for odontogenic maxillary
sinusitis given direct communication with left maxillary molar periapical
lucency.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ___ year old man with fall and traumatic injury, now with L
shoulder pain// L shoulder fracture/injury? L shoulder
fracture/injury?
TECHNIQUE: Internal and external rotation frontal views as well as axillary
view of the left shoulder
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
There is irregularity of the left humeral neck in the region of previously
seen surgical neck fracture with residual valgus angulation suggestive healed
fracture. No acute fracture line is identified. Glenohumeral joint appears
well aligned. There are minimal degenerative changes in the left
acromioclavicular and glenohumeral joints. No suspicious lytic or sclerotic
lesions are identified. No periarticular calcification or radio-opaque foreign
body is seen.
Partially visualized left lung field appear clear.
IMPRESSION:
Healed fracture of the left humeral neck with persistent valgus angulation
without suggestion of acute fracture or dislocation.
Gender: M
Race: WHITE
Arrive by WALK IN
AMBULANCE
Chief complaint: L Leg pain, R Hand pain
Assault, Jaw pain
Diagnosed with Jaw pain, Contusion of other part of head, initial encounter, Laceration without foreign body of left ear, init encntr, Asslt by strike agnst or bumped into by another person, init
Altered mental status, unspecified
temperature: 98.5
98.5
heartrate: 81.0
73.0
resprate: 18.0
14.0
o2sat: 100.0
100.0
sbp: 113.0
112.0
dbp: 75.0
68.0
level of pain: 10
7
level of acuity: 3.0
3.0 | Mr. ___ is a ___ male with history of HIV on
ART (last CD4 799 in ___ and Polysubstance use (opioid,
benzo), who presented with oxycodone and valium overdose on the
day prior to admission, was then discharged to home. Patient
___ with altered mental status and right lateral
malleolar fracture.
# Toxic Metabolic Encephalopathy
# Benzodiazepine and opiate intoxication/withdrawal:
Patient presented with altered mental status, with concern that
he became intoxicated between time he left the ER and then
___. He was monitored with CIWA protocol and given
diazepam. CT head showed no acute intracranial process and
neurologic exam was ___. CT ___ was unremarkable.
Social work was consulted to evaluate patient as partner stated
he wanted patient to get treatment for substance use disorder.
He had been taking both Xanax and Ativan at the same time. He
was told to stop the Ativan, and use the Xanax and Dilaudid only
as prescribed, to minimize polypharmacy. This was discussed at
length with the patient and his partner/HCP on the day of
discharge.
# R lateral malleolar fracture:
Mildly displaced R malleolar fracture seen on XR ___.
Orthopedics evaluated in ED and recommended walking boot to R
ankle with outpatient f/u in 2 weeks, with weight bearing as
tolerated.
# L shoulder pain:
XR negative for acute fracture, did show an old Healed fracture
which the patient was able to report having in the past.
# L odontogenic maxillary sinusitis:
Incidentally found on CT maxillofacial/sinus. Patient was
asymptomatic and had prior CT with similar findings suggesting a
chronic process. Given patient's neutropenia, OMFS was consulted
and recommended outpatient ___ given stability of imaging
findings and lack of symptoms
# Vertebral fracture:
Prescribed hydromorphone in the past for this. Plan was made at
rehab to wean this. Held Hydromorphone on admission given AMS,
OK to resume at home dose on discharge but did extensive
counseling on proper taking of this medication.
# HIV: Last CD4 count 799 in ___.
Patient is on Genvoya at home which was ___. Thus
patient was treated with Stribild. CD4 count was drawn, and
pending on discharge.
# Pancytopenia
Stable. Thought due to T cell LGL lymphoproliferative disorder.
# T2DM
Held home metformin and glipizide while admitted, but OK to
resume on discharge.
# Anxiety
Continued home fluoxetine, buspirone, and prazosin. Held home
alprazolam while patient received diazepam on CIWA protocol
initially, but can resume on discharge. Stop Lorazepam.
# Seizures
Continued home Keppra
# HTN:
Continue home meds
#CAD:
Continue atorvastatin/ASA on discharge
#Gastroparesis:
Continued home metoclopramide, zofran, erythromycin
#Asthma/COPD
Continued home proair
#Allergies:
Continued home loratadine.
TRANSITIONAL ISSUES
==================================
- Wean Xanax and Dilaudid as tolerated. Will require long term
discussion and management with PCP
- ___ using Ativan given already on Xanax
- Extensive counseling done with patient and partner re:
importance of adhering to medications as prescribed
- Outpatient Ortho in next 2 weeks for malleolar fracture follow
up (could not schedule for them on weekend; gave them the number
of clinic)
- CD4 count pending on discharge |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old non-verbal man with Down Syndrome, VSD s/p
repair and dysphagia who presented to the ED due to nausea and a
rash. The history was obtained from his family, who is
___, as the patient is non verbal.
His family reports that since 3 days ago, he has had a rash on
his right neck which now appears more prominent. He seems
nauseated this morning. He has not been using his neck as much
as normal. He is nonverbal at baseline. No fevers per family. He
has otherwise been acting like himself.
His family is unsure if he has had chicken pox before.
In the ED, initial vitals were: T97.2, HR 74, BP 82/43, RR 16,
SpO2 98% RA. Later spiked a fever to 102.1 while being observed
overnight.
- Exam notable for: rash on the right neck and shoulder
- Labs notable for: normal CBC, coags, chemistries. AST 45. UA
bland with 30 protein. Trop negative x2. Lactate was 3.1 and
then normalized on multiple rechecks after IVF.
- Imaging was notable for: CT abd/pelvis with no acute
findings, CT neck with contrast without mass or abscess. CT head
without acute process. CXR with low lung volumes with mild
bibasilar patchy opacities, likely atelectasis.
- Patient was given: valacyclovir 1g Q8H, morphine, diazepam,
Tylenol and 5 liters of IVF
Upon arrival to the floor, patient is nonverbal. Above history
is confirmed with family.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Down's syndrome
- Dysphagia (on pureed solids, ground/moist foods, and thin
liquids
- VSD s/p repair with Gore-Tex patch
- 1+ TR
- Seborrheic dermatitis
- Hypothyroidism
Social History:
___
Family History:
(According to outpatient notes): Father died of stomach cancer
in his ___. Mother is alive, age ___ years old, with
hypertension. He has two sisters. No family history of stroke,
hyperlipidemia, diabetes mellitus, early coronary artery disease
or sudden cardiac death.
Physical Exam:
PHYSICAL EXAM:
Vitals: 99.5 100 / 63 98 18 96 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, bounding carotid pulse observed 1cm above clavicle
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, 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
Derm: Vesicular rash noted on the right back. Does not cross
midline. The superior portion of the rash follows a dermatomal
distribution, but there are extra lesions lower down on the back
and wrapping around to the chest. There is no obvious area of
erythema concerning for superinfection.
Pertinent Results:
==============
ADMISSION LABS
===============
___ 07:30AM BLOOD WBC-10.0 RBC-4.46* Hgb-15.4 Hct-43.6
MCV-98 MCH-34.5* MCHC-35.3 RDW-13.7 RDWSD-49.8* Plt ___
___ 07:30AM BLOOD WBC-10.0 RBC-4.46* Hgb-15.4 Hct-43.6
MCV-98 MCH-34.5* MCHC-35.3 RDW-13.7 RDWSD-49.8* Plt ___
___ 07:30AM BLOOD Neuts-64.2 ___ Monos-9.5 Eos-1.0
Baso-0.8 Im ___ AbsNeut-6.44* AbsLymp-2.34 AbsMono-0.95*
AbsEos-0.10 AbsBaso-0.08
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-26.2 ___
___ 07:30AM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-140
K-5.0 Cl-103 HCO3-22 AnGap-20
___ 07:30AM BLOOD ALT-29 AST-45* AlkPhos-64 TotBili-0.7
___ 03:55PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Lipase-26
___ 07:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.0 Mg-2.2
___ 08:22AM BLOOD Lactate-3.1*
==============
DISCHARGE LABS
==============
___ 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
___ 02:42PM BLOOD Lactate-1.5
___ 06:45AM BLOOD WBC-8.1 RBC-3.92* Hgb-13.4* Hct-39.4*
MCV-101* MCH-34.2* MCHC-34.0 RDW-14.2 RDWSD-51.8* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-25 AnGap-15
___ 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
============
IMAGING
============
CT Abd/Pelvis ___: 1. Normal appendix.
2. Top-normal heart size.
3. Bibasilar atelectasis
4. Small fat and fluid containing right inguinal hernia.
CT Neck ___: Posterior hypopharyngeal and retropharyngeal
soft tissue fullness at the C3-4
level. No evidence of discrete mass or abscess. Further
assessment with
endoscopy is suggested given the history of dysphagia.
RECOMMENDATION(S): Recommend further evaluation with endoscopy
given history
of dysphagia.
CT Head ___: 1. No acute intracranial process.
2. Global atrophy, advanced for age.
3. Prominent extra-axial CSF density spaces within the anterior
middle cranial fossa bilaterally suggestive of arachnoid cysts
or focal temporal lobe atrophy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with nonverbal. Here with neck stiffness, altered
mental statusc/gas just right/mass? RPA? pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Patient is status post median sternotomy. Lung volumes are slightly low which
accentuates the size of the cardiac silhouette which appears mildly enlarged.
The mediastinal and hilar contours are unremarkable. Crowding of
bronchovascular structures is present with no overt pulmonary edema. Patchy
opacities in the lung bases likely reflect areas of atelectasis. No pleural
effusion or pneumothorax is seen. No acute osseous abnormalities visualized.
IMPRESSION:
Low lung volumes with mild bibasilar patchy opacities, likely atelectasis.
Please note that aspiration or infection, however, cannot be excluded in the
correct clinical setting.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with AMS, neck stiffness// RPA? mass?
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 no evidence of acute territorial infarction, hemorrhage, or edema.
Prominence of the ventricles and sulci is suggestive of involutional changes,
advanced for age. Minor periventricular white matter hypodensities are
suggestive of chronic small vessel ischemic disease. Bilateral basal ganglia
calcifications are noted. Prominent extra-axial CSF spaces bilaterally within
the anterior middle cranial fossa are suggestive of symmetric arachnoid cysts
or focal temporal lobe atrophy.
No osseous abnormalities seen. Bilateral nasal polyps are noted. There is
minimal mucosal thickening of the left maxillary sinus. Bilateral mastoid air
cells are hypoplastic and partially opacified. Otherwise, the remaining
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Global atrophy, advanced for age.
3. Prominent extra-axial CSF density spaces within the anterior middle cranial
fossa bilaterally suggestive of arachnoid cysts or focal temporal lobe
atrophy.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: History: ___ with AMS, neck stiffness// RPA? mass?
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 3.4 s, 27.1 cm; CTDIvol = 12.8 mGy (Body) DLP = 346.7
mGy-cm.
Total DLP (Body) = 347 mGy-cm.
COMPARISON: Video oropharyngeal swallow ___.
FINDINGS:
There is prominence of the supraglottic posterior hypopharyngeal and
retropharyngeal soft tissue at the C3-4 level with effacement of the piriform
sinuses bilaterally (02:43, 602:30). There is no definite mass seen. There is
no evidence of abscess. There digestive tract remains patent.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears normal. There is no lymphadenopathy by
CT criteria. The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There is unchanged loss of height of C3 and C4 with similar
irregularity of the C2-3 and C3-4 intervertebral levels. No evidence of acute
fracture.
IMPRESSION:
Posterior hypopharyngeal and retropharyngeal soft tissue fullness at the C3-4
level. No evidence of discrete mass or abscess. Further assessment with
endoscopy is suggested given the history of dysphagia.
RECOMMENDATION(S): Recommend further evaluation with endoscopy given history
of dysphagia.
NOTIFICATION: Updated recommendations were discussed with Dr. ___
by Dr. ___ on the telephone at 16:00 on ___.
Radiology Report
EXAMINATION: CT abdomen pelvis.
INDICATION: ___ with abd pain, vomting//appendicitis? colitis
TECHNIQUE: CT through the abdomen pelvis performed without IV contrast. Oral
contrast was not administered. Multiplanar reformations were provided. IV
contrast withheld due to recent IV contrast administration.
DOSE: Total DLP (Body) = 695 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate bibasilar atelectases. There
is no evidence of pleural or pericardial effusion. The heart appears
top-normal in size. Partially visualized lower median sternotomy wires are
aligned and intact.
ABDOMEN:
HEPATOBILIARY: The unenhanced appearance of the liver appears normal. The
gallbladder contains hyperdense material likely sludge or stones. No CT
evidence of acute cholecystitis.
PANCREAS: The pancreas is grossly unremarkable.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable.
URINARY: No kidney stone or hydronephrosis.
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 and fills with
contrast.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a right inguinal hernia containing fat and a small
amount of fluid.
IMPRESSION:
1. Normal appendix.
2. Top-normal heart size.
3. Bibasilar atelectasis
4. Small fat and fluid containing right inguinal hernia.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Hypotension
Diagnosed with Dehydration
temperature: 97.2
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 82.0
dbp: 43.0
level of pain: ua
level of acuity: 1.0 | SUMMARY: ___ year old man non-verbal man with Down's Syndrome,
VSD s/p repair and hypothyroidism presenting with acute painful
vesicular rash consistent with localized herpes zoster. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RIGHT Flank Pain and Fevers
Major Surgical or Invasive Procedure:
Right IJ placed and removed.
History of Present Illness:
___ w/ hx HTN (on Amlodipine) p/w urgency, dysuria, R flank
pain, and fevers.
Pt reports onset of symptoms 3 days prior starting with urgency
and frequency, then progressed to dysuria and chills during day
and sweats at night. Two days prior started having R flank pain.
Daughter noticed she was febrile to low 100's yesterday evening.
Today continued to be febrile and somewhat nauseated with food
intake. Reports she's never had symptoms like this before.
Otherwise had been healthy leading up to this episode. Other ROS
negative except for some nasal congestion. This AM she took old
Abx that was in fridge at home so she took 1 pill of
Amoxicillin, 500mg. Came to ER with daughter for above symptoms.
In the ED, initial VS were: 101.5 95 114/68 18 99% ra. In ED,
___ found elevated at ___ and urine suggestive of UTI. Cr 1.0
(near baseline). Given a dose of CTX and initial plan was to
send home if improving. Given 30mg Toradol, 1g Tylenol, and 4mg
Zofran. However, BPs later dropped to ___ systolic and IVF
started. Despite 2L BPs fell to ___ and stayed there despite ___
L of IVF. Patient continued to mentate well but central line
(RIJ) and foley were placed over concern for developing septic
shock and possible pressor need. Admitted to unit for possible
development of septic shock. VS on transfer: HR 80, 97% on RA,
BP 103/62, Foley in place.
On arrival to the MICU, patient is comfortable. No longer
reporting pain. Reports above history and says its okay to call
her daughter to confirm. Currently no complaints - would like
ice water to drink. Feels hungry but afraid she will get
nauseated with food.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- HTN (on one med for couple yrs)
- HLD (based on labs - no meds)
- Hx of "weak stomach" with pain and need to use bathroom
- One past admission for diarrhea, fall, head strike
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission exam:
VS on arrival: BP 152/69, HR 97, Sat 97% on RA
General: A&O x 3, no acute distress, speaks broken ___
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Boarderline tachy, hyperdynamic, S1, S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds
hyperactive
GU: foley in place, no CVA tenderness currently
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE exam:
VS: 98.0, 101/63, 65, 18, 97% RA
I/O: 880+ unrecorded intake/BRP
CV: RRR, No m/r/g
Lungs: CTAB
Abomden: Soft, NT/ND, normoactive bowel sounds, no HSM
Extremities: No c/c/e, w/w/p, 2+ pulses b/l in UE and ___, moves
all ext to gravity
Back: No CVA tenderness
Incision: dressing removed from R IJ site, c/d/i, no
bleeding/infxn
Pertinent Results:
Admission labs:
___ 06:55PM BLOOD WBC-13.3*# RBC-4.23 Hgb-13.2 Hct-39.5
MCV-94 MCH-31.3 MCHC-33.5 RDW-12.2 Plt ___
___ 06:55PM BLOOD Neuts-85.9* Lymphs-8.6* Monos-4.3 Eos-1.0
Baso-0.2
___ 03:01AM BLOOD ___ PTT-42.7* ___
___ 06:55PM BLOOD Glucose-135* UreaN-11 Creat-1.0 Na-136
K-3.9 Cl-100 HCO3-22 AnGap-18
___ 03:01AM BLOOD ALT-57* AST-76* CK(CPK)-41 AlkPhos-93
TotBili-0.6
___ 03:01AM BLOOD Albumin-3.1* Calcium-7.3* Phos-2.0*
Mg-2.0
___ 07:02PM BLOOD Lactate-1.2
___ 06:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 06:40PM URINE RBC-15* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-1 TRANS EPI-<1 RENAL EPI-<1
___ 04:37PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:37PM URINE RBC-15* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-<1 TRANS EPI-<1
Relevant Labs:
___ 03:01AM BLOOD WBC-11.3* RBC-3.77* Hgb-11.5* Hct-35.6*
MCV-95 MCH-30.5 MCHC-32.2 RDW-12.7 Plt ___
___ 07:45AM BLOOD WBC-7.5 RBC-3.71* Hgb-11.3* Hct-34.6*
MCV-93 MCH-30.6 MCHC-32.8 RDW-12.4 Plt ___
___ 03:01AM BLOOD Neuts-84.9* Lymphs-11.4* Monos-3.0
Eos-0.4 Baso-0.4
___ 07:45AM BLOOD Neuts-69.6 ___ Monos-6.7 Eos-0.3
Baso-0.5
___ 02:02PM BLOOD ALT-67* AST-71* CK(CPK)-54 AlkPhos-115*
TotBili-0.5
___ 07:45AM BLOOD ALT-80* AST-64* AlkPhos-128* TotBili-0.4
___ 05:35AM BLOOD ALT-81* AST-61* AlkPhos-137* TotBili-0.3
___ 06:55PM BLOOD Lipase-20
___ 03:21AM BLOOD Lactate-2.5*
___ 06:51AM BLOOD Lactate-0.8
___ 04:11PM URINE RBC-7* WBC-17* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
Cardiac enzymes:
___ 03:01AM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:02PM BLOOD CK-MB-1 cTropnT-<0.01
Pending labs:
___ 07:45AM BLOOD HCV Ab- no evidence of infection
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-5.8 RBC-3.77* Hgb-11.5* Hct-35.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.4 Plt ___
___ 06:00AM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-141
K-3.9 Cl-108 HCO3-23 AnGap-14
___ 06:00AM BLOOD ALT-94* AST-70* LD(LDH)-210 AlkPhos-137*
TBili-0.3
___ 06:00AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.3
Micro data:
Urine culture (___) x 2 = Negative
Blood culture (___) x 2 = Negative
Cdiff assay (___) = Negative
Imaging:
___ CXRay:
FINDINGS: Right IJ central venous catheter with the distal lead
tip at the cavoatrial junction. Some mild prominence of the
pulmonary interstitial markings is suggestive of mild fluid
overload. The cardiac
silhouette and mediastinum is normal. There is no focal
consolidation or
pneumothoraces.
___ Complete Abdominal Ultrasound:
The liver is normal in echogenicity with no focal lesions
present. The
gallbladder is normal. The common bile duct measures 5 mm and
is normal. The portal vein is patent with hepatopetal flow.
The head of the pancreas is partially imaged and it appears
unremarkable. The right kidney measures 11 cm and is normal.
The spleen measures 7 cm and is normal. The left kidney
measures 10.4 cm and is normal. No significant ascitic fluid is
noted. A small right pleural effusion is noted. The IVC was
patent and the abdominal aorta is normal in caliber.
___ CXRay: no acute processes, pleural effusion very small.
Medications on Admission:
Amlodipine 10mg daily
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: Day 1 of ___.
Disp:*20 Tablet(s)* Refills:*0*
(holding amlodipine as patient normotensive in house)
Discharge Disposition:
Home
Discharge Diagnosis:
Uncomplicated Pyelonephritis (sterile cultures).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: Patient with central line placement.
FINDINGS: There is a right IJ central venous catheter with the distal lead
tip at the cavoatrial junction. Some mild prominence of the pulmonary
interstitial markings is suggestive of mild fluid overload. The cardiac
silhouette and mediastinum is normal. There is no focal consolidation or
pneumothoraces.
Radiology Report
INDICATION: ___ woman with flank pain, fever and initially presumed
pyelo but negative urine culture. Please evaluate for cholecystitis or
choledocholithiasis.
COMPARISON: No relevant comparisons available.
FINDINGS:
The liver is normal in echogenicity with no focal lesions present. The
gallbladder is normal. The common bile duct measures 5 mm and is normal. The
portal vein is patent with hepatopetal flow. The head of the pancreas is
partially imaged and it appears unremarkable. The right kidney measures 11 cm
and is normal. The spleen measures 7 cm and is normal. The left kidney
measures 10.4 cm and is normal. No significant ascitic fluid is noted. A
small right pleural effusion is noted. The IVC was patent and the abdominal
aorta is normal in caliber.
IMPRESSION:
Small right pleural effusion, otherwise unremarkable abdominal ultrasound.
Radiology Report
REASON FOR EXAMINATION: Fever of unknown origin.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
The right internal jugular line has been removed. Heart size and mediastinum
are stable. Lungs are clear with interval resolution of interstitial
pulmonary edema. There is no pleural effusion or pneumothorax demonstrated
except for minimal blunting of the left costophrenic sulcus on the lateral
view, most likely reflecting lobulation of the diaphragm and unlikely to
reflect pleural effusion. There is no pneumothorax.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: ? PYELO R FLANK PAIN
Diagnosed with PYELONEPHRITIS NOS, HYPERTENSION NOS
temperature: 101.5
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 114.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | ___ yr/o ___ speaking female with past medical history of
hypertension presenting to the ER with 3 days of symptoms
consistent with pyelonephritis also found to have elevated
WBC/dirty urine and admitted to the MICU for Sepsis.
# Sepsis/Pyelonephritis: Patient with hypotension and SBP in
___, likely urinary source. BP responsive to fluids after 3L -
received a total of 6L between the emergency department and
MICU. Had CVL placed in ED over concern for development of
septic shock, but never required pressors. Source is presumed
urinary in setting of classic pyelo symptoms and UA evidence of
infection. Ceftriaxone started in ED and urine cultures remained
negative, though the patient had taken amoxicillin at home that
could have cleared culture. No evidence of infection on CXR. Bcx
negative. No other obvious source. Patient remained
hemodynamically stable following IVF and was called out to
medicine floor. On the medicine floor, the patient was
transitioned from ceftriaxone to PO ciprofloxacin. She appeared
clinically very well and felt back to her baseline state of
health. However, urinalysis returned demonstrating that her UA
was sterile which was confusing as 90% of pyelonephritis cases
have positive urine cultures. Due to the uncertainty caused by
this result, the patient was kept for further observation and
investigation. It is possible that her dose of amoxicillin
which she took prior to presentation was enough to wipe out
growth from the urine vs she has some sort of perinephric
abscess that is not draining into her kidneys vs her source is
not the kidneys. Pt did have rise of LFTs so a complete
abdominal ultrasound was conducted which did not visualize any
abnormalities of her liver or gallbladder. Lipase on
presentation was normal. Abdominal exam was completely benign
throughout her hospital course. Ultrasound did now show any
abnormalities of kidneys, and though this isn't as sensitive as
a CT scan for pyelonephritis or abscess visualization, given her
well appearance, more aggressive imaging was deemed unnecessary.
As she was doing well, she was discharged to follow up with her
PCP.
# Elevated LFTs and alk phos: Unclear cause. Possibly related
to ceftriaxone. US results showed normal liver and gallbladder
and patient was asymptomatic without right upper quadrant pain.
She is documented HbS ag negative, ab positive. Given stable
values, no signs of acute hepatitis, and no symptoms further
work up was deferred to the outpatient setting.
# HTN: Amlodipine held at presentation given hypotension. This
was not restarted due to normal BPs. This should be restarted
as an outpatient when blood pressure rises.
#. Chest pressure: Pt ruled out for MI. ECG non concerning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Avandia / Glucophage / Lactose / aspirin / Actos /
Benicar
Attending: ___.
Chief Complaint:
Vertigo with nausea / vomiting
Major Surgical or Invasive Procedure:
Pt received non-contrast ___ CT, non-contrast brain MRI - no
evidence of acute infarct / bleed / demyelination / other lesion
on either scan
History of Present Illness:
Ms. ___ is an ___ old woman with a past medical history
of stage V CKD, HTN, hyperlipidemia, and IDDM who presents with
an episode of room spinning vertigo on awakening. When she woke
up, she immediately felt like the room was spinning and had to
hold onto the side of her bed. She also felt nauseous and was
vomiting bile and gagging. A nurse, who lives with the patient,
said that Ms. ___ was acting unresponsive with some possible
arm shaking, concerning for seizure, so she gave the patient
sugar and juice. A few seconds after this, the patient began
interacting normally again. The patient says she did not have
any recurrent episodes of vertigo after the juice, but she did
feel intermittently dizzy / lightheaded throughout the day. Her
family says that she did have two additional episodes of vertigo
during the day, but the patient denies this. Her blood sugar
after the juice was 165, but it was not recorded before.
Before today, she had felt well. She says that she doesn't eat
much at baseline (she only "picks at" meals before supper, and
only takes novolog with her supper). She has been having regular
bowel movements, one per day.
Of note, the patient says she had brief vertigo (with room
spinning) one time in the past, about ___ year ago. At this time,
she was found to have a blood glucose of 400.
In the ED, neuro was consulted to rule out stroke. See their
plan below:
Neuro Consult Plan:
-Please add on stox, LFTs, UA/Ucx, utox, troponin
-MRI brain without to look for stroke, MRA ___ and neck with
time of flight (cannot get contrast due to kidney disease)
-Please replete Mg
-Will need admission, given worsening CKD and anion gap, will
follow along as stroke consult service.
Staffed with ___, neurology attending.
___ ___
In the ED, initial vitals: T 97.1F HR 72 BP 150/70 RR 16 SpO2
100% RA Pain ___
- Exam notable for: difficulty with tandem gait but no
nystagmus, dysmetria, negative ___ and negative ___
Impulse Test
- Labs notable for:
Bicarb: 16 (Agap: 23) Ca: 7.7 Mg: 1.0
WBC: 11.5 Hb: 9.2 Hct: 28.1 Plat: 302
Trop-T: 0.03 Cr 6.0 BUN 86 Lactate: 1.5
- Imaging notable for: CT ___ w/o contrast: No acute
intracranial process. MR ___ w/o contrast: Chronic findings:
likely prior strokes in R parietal lobe, L frontal
microhemorrhage. No evidence of recent hemorrhage or
infarction.
- EKG notable for: PVC's and T-wave inversions in lateral
leads; QTc approx. 465
- Patient given: Magnesium Sulfate 2 gm IV, Calcium Gluconate
1 g IV, Ondansetron 4 mg IV, 2L NS bolus
On arrival to the floor, pt reports that her vertigo has ended.
She no longer feels nauseous, but earlier in the day she had
slight nausea and "dizziness" (without feeling like the room was
spinning). However, later in the evening, she reported a
few-second episode of room-spinning that self-resolved.
REVIEW OF SYSTEMS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance other than transient
vertigo this morning. No cough, no shortness of breath, no
dyspnea on exertion. No chest pain. No nausea or vomiting. No
diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits. No increased lower extremity edema.
+Notable for R ear fullness/pain for the last 2 weeks
+Notable for intermittent palpitations, not daily
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
Stage V CKD
Hypertension
Hypercholersterolemia
Insulin-dependent diabetes mellitus
Prior cholecystectomy
Obesity
History of palpitations
Cholecystectomy surgery in ___
Colonoscopy ___ normal: repeat ___ years
Social History:
___
Family History:
No known family history of kidney disorders
+diabetes, +colon CA, -heart disease, +ovarian CA
Physical Exam:
Admission Physical Exam:
VITALS - T 98.1F BP 144/52 HR 60 RR 20 O2 100% RA FSBG 96
GENERAL - Tired-appearing woman, lying in her side at bed,
surrounded by 2 daughters.
___ - ___, mucus membranes moist. L TM normal; R TM obscured
by cerumen, unable to be visualized. No post-auricular
tenderness.
NECK - Supple
CARDIAC - Regular rate and rhythm. No murmurs noted.
PULMONARY - Clear to auscultation bilaterally.
ABDOMEN - BS present. Non-tender. No masses. Protuberant
abdomen.
EXTREMITIES - Pitting edema to knees bilaterally
SKIN - No rashes noted
NEUROLOGIC - CN II-XII intact
PSYCHIATRIC - Affect normal, pleasant and interactive
Discharge Physical Exam:
Vitals: T 97.8F 158/63 65 18 99%
I/O: 24H +255/-350+ void
wt 66 kg (admit 65.2kg)
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
___ - PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
HEART - RRR, nl S1-S2, no MRG
LUNGS - very faint crackles in L base, otherwise clear
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no lower ext edema
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Initial labs:
___ 06:40AM BLOOD WBC-11.5* RBC-3.10* Hgb-9.2* Hct-28.1*
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.3 RDWSD-42.8 Plt ___
___ 09:44PM BLOOD ___ PTT-27.6 ___
___ 06:40AM BLOOD Glucose-135* UreaN-86* Creat-6.0*# Na-143
K-3.8 Cl-108 HCO3-16* AnGap-23*
___ 06:40AM BLOOD ALT-10 AST-14 AlkPhos-121* TotBili-<0.2
___ 09:44PM BLOOD CK-MB-3 cTropnT-0.03*
___ 06:40AM BLOOD Albumin-3.5 Calcium-7.7* Phos-5.8*
Mg-1.0*
___ 01:13PM BLOOD %HbA1c-5.7 eAG-117
___ 09:44PM BLOOD Triglyc-120 HDL-40 CHOL/HD-4.9
LDLcalc-130*
___ 09:06AM BLOOD CRP-28.5*
___ 06:48AM BLOOD Lactate-1.5
Discharge labs:
___ 08:00AM BLOOD WBC-8.8 RBC-2.84* Hgb-8.6* Hct-25.5*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.3 RDWSD-43.1 Plt ___
___ 08:00AM BLOOD ___ PTT-42.6* ___
___ 08:00AM BLOOD Glucose-130* UreaN-74* Creat-5.9* Na-141
K-4.2 Cl-107 HCO3-18* AnGap-20
___ 08:00AM BLOOD ALT-11 AST-14 LD(LDH)-223 AlkPhos-117*
TotBili-<0.2
___ 08:00AM BLOOD Calcium-8.3* Phos-5.9* Mg-2.4 Cholest-PND
___ 08:00AM BLOOD %HbA1c-6.0 eAG-126
___ 09:06AM BLOOD CRP-28.5*
STUDIES:
MRI ___ w/o contrast ___
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or recent infarction. There is a focus of
subcortical white matter hyper intensity on FLAIR images in the
right parietal lobe. This may represent an old insult. There
is a tiny left frontal micro hemorrhage best seen on image 14 of
series 7. The ventricles and sulci are enlarged in an atrophic
pattern, appropriate to age.
CT ___ w/o contrast ___
There is no intra-axial or extra-axial hemorrhage, mass, midline
shift, or
acute major vascular territorial infarct. Small region of
encephalomalacia seen in the right postcentral gyrus likely from
prior infarct. Atherosclerotic calcifications noted within the
intracranial ICAs and vertebral arteries.
Included paranasal sinuses and mastoids are essentially clear
besides single opacified left mastoid air cell. Skull and
extracranial soft tissues are unremarkable.
KUB ___
Clips are noted in the right upper quadrant likely related to
prior
cholecystectomy. There are no abnormally dilated loops of large
or small bowel. There is no free intraperitoneal air. Osseous
structures are unremarkable. There are no unexplained soft
tissue calcifications or radiopaque foreign
bodies.
CXR ___
Lung volumes are low. Hazy bibasilar opacities are likely
atelectasis. There is no effusion, edema or pneumothorax. The
cardiomediastinal silhouette is stable. No acute osseous
abnormalities. Surgical clips are noted in the upper abdomen.
EKG ___
Sinus rhythm with a premature atrial contraction, secondary
repolarization changes. Compared to the previous tracing of
___ sinus rate is slightly faster. Other findings similar.
Rate PR QRS QT QTc (___) P QRS T
68 ___ -___
Medications on Admission:
Confirmed with patient:
Procrit ___ ___
Torsemide 5mg - 2 tablets PO qD
Glipizide ER 10mg - PO BID
Amlodipine 5mg - PO BID
Metoprolol succ ER 25mg - PO qD
Lantus ___ solostar 5x3mL - 30 units qD qHS
Novolog with meals (she only takes it with supper)
Omeprazole 20mg PO qD
Atorvastatin 40mg PO qD
Allopurinol ___ PO qD
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Sodium Bicarbonate 650 mg PO TID
5. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
6. Vitamin D ___ UNIT PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Torsemide 5 mg PO BID
9. Allopurinol ___ mg PO DAILY
10. GlipiZIDE 10 mg PO BID
Glipizide ER
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Amoxicillin 500 mg PO Q24H
Take one pill (500mg) every day for 8 days. Start on ___
(tomorrow). Stop on ___.
14. Calcium Carbonate 500 mg PO TID with meals
Take one pill with each meal.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Needs home ___ safety evaluation
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dizziness // Eval for pna
TECHNIQUE: AP and lateral views the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. Hazy bibasilar opacities are likely atelectasis. There
is no effusion, edema or pneumothorax. The cardiomediastinal silhouette is
stable. No acute osseous abnormalities. Surgical clips are noted in the
upper abdomen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dizziness and headache // sdh? sah? eph? mass?
ischemia?
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Small region of encephalomalacia
seen in the right postcentral gyrus likely from prior infarct.
Atherosclerotic calcifications noted within the intracranial ICAs and
vertebral arteries.
Included paranasal sinuses and mastoids are essentially clear besides single
opacified left mastoid air cell. Skull and extracranial soft tissues are
unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old woman with dizziness // look for stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or recent infarction. There is a focus of subcortical white matter hyper
intensity on FLAIR images in the right parietal lobe. This may represent an
old insult. There is a tiny left frontal micro hemorrhage best seen on image
14 of series 7. The ventricles and sulci are enlarged in an atrophic pattern,
appropriate to age. .
IMPRESSION:
1. Chronic findings as noted above. No evidence of recent hemorrhage or
infarction.
Radiology Report
INDICATION: ___ year old woman with nausea/vomiting/distended abdomen. Assess
for SBO vs. dilation
TECHNIQUE: Upright and supine abdominal radiographs.
COMPARISON: Chest radiograph ___.
FINDINGS:
Clips are noted in the right upper quadrant likely related to prior
cholecystectomy.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Normal abdominal radiograph. Specifically, no small-bowel obstruction or
ileus.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Nausea
Diagnosed with Dizziness and giddiness
temperature: 97.1
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 150.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ old woman with a past medical history
of stage V CKD, HTN, hyperlipidemia, and IDDM who presented with
an episode of room spinning vertigo on awakening during episode
of AM hypoglycemia.
#Vertigo, nausea/vomiting
Initially thought hypoglycemic + seizure
In the ED, had neuro consult (no
___, negative vertigo
maneuvers), ___ CT and brain MRI (no acute process, no stroke /
lesion)
Neuro thought peripheral vertigo, rec'd otitis->labrynthitis
workup, vestibular ___.
Pt had fullness and pain in R ear; unable to visual R TM (even
with flushing with warm fluid)
-Began 500mg amoxicillin q24H on ___: to receive 10 day course
for severe (presumed labrynthitis complication), with final day
___
-WBC trended down to 8.8K
-Will begin ear wax softening ear drops on discharge with
instructions
-___ recs: home ___ for home safety evaluation; once at baseline
mobility, rec outpt vestibular ___ for assessment +
exercises/training
#Electrolyte disturbance: Initially Mg 1.0 HCO3 16 with AGap 23
(metabolic acidosis), Ca 7.7, Phos 5.8. Likely wasting Mg from
chronic diarrhea.
-Mg repleted (6g IV total), 2.4 on discharge
-Started calc carb PO with meals on ___ for phos binding per
renal
-1g IV Calcium gluconate given in ED
#Acute worsening of Stage V CKD: Cr bump 4->6.0, BUN ___,
large proteinuria; likely secondary to diabetic nephropathy. ___
___ ATN vs. prerenal or worsening of baseline CKD. Patient being
worked up for dialysis in next few weeks (Dr. ___, Dr.
___. Seen by Dr. ___ vascular team);
previously saw them in clinic for vein mapping, will get AVF
placed in a few weeks. There was not time in the schedule for
her to get AVF placed while inpatient.
-Started calc carb PO with meals on ___ for phos binding per
renal
-Home torsemide 5mg PO BID restarted ___ euvolemic without
___ edema on discharge
-Increased bicarb to TID per renal
-Renal, diabetic diet while in hospital
-Strict I/O to monitor urine output
-Renally dosed all medications
#Insulin-dependent diabetes, on Lantus 30 units + novolog with
meals at home. A1C 5.7.
Reported hypoglycemia with episode of dizziness each morning
after waking.
-Renal diabetic diet, as above
-Fingerstick blood glucose and insulin sliding scale; no ___
basal dosing (held lantus) because patient was not eating much,
and wanted to avoid morning hypoglycemia.
-No glipizide while inpatient, ISS only
#Diarrhea - patient reports frequent / daily diarrhea (worse
after eating dairy, vegetables, glucerna shakes). She says that
___ year ago, she lost her sense of taste (she now can only taste
salt and sugar). Loss of taste likely secondary to late stage
CKD. Diarrhea likely due to known lactose intolerance. Chronic
diarrhea may be causing Mg wasting.
-No known diarrhea during this admission
-C-dif negative
-Provided teaching on lactose free diets and lactase pills
-Consider testing for celiac as an outpt given diarrhea
history**** - transitional
#Abnormal EKG: Initial EKG with QTc 465, frequent PVC's, and
T-wave inversion in lateral leads with Trop 0.03 (repeat = 0.03;
likely chronic trop retention in CKD)
-Given 1g IV Calcium gluconate in ED
-Lytes repleted as above
-On continuous telemetry
-Fewer PVC's after Mg repletion, lyte correction
-no chest pain / palp during admission
#Hypomagnesaemia: in the setting of chronic diarrhea ___ year)
and nausea/vomiting (1 day). Re: diarrhea, hypomagnesaemia might
represent chronic magnesium wasting. frequent PVCs on tele, less
after Mg repletion
- Mg 2.4 at discharge
- Trended and repleted Mg >2.2
#Noted to have post-menopausal vaginal bleeding, thickened
endometrium on US in ___. Patient previously
recommended to make follow-up appointment with gyn.
-Will include as transitional issue
#Anemia: Hb 9.2, Hct 28.1
-At her baseline. Monitored here, stable.
-Baseline Hb: 8.3-8.5; Baseline Hct: ___ in ___.
#Elevated Alk Phos: 121
-Noted to be at her baseline. Baseline: 121-124 in ___
-Likely due CKD-MBD (mineral bone disease) with high bone
turnover; normal transaminases
================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of right
shoulder pain. The patient was riding his bicycle when he was
struck by a car at low speed. The patient went up on the
windshield and fell onto the curb. Patient complaining of ___
right shoulder pain. Patient remembers the entire event. The
patient denies any neck pain. Patient denies any other injury.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION Upon admission: ___
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: r shoulder deformity, r shoulder hematoma
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, pulse 2+ R radial
Neuro: Speech fluent
Psych: Normal mood
Physical examination upon discharge: ___:
vital signs: t=98.1, hr=58, bp=116/72, rr=16, 96% room air
General: NAD, right arm in sling, skin warm and dry
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: + radial pulse bil., localized tenderness right clavicle,
limited ROM right shoulder, full ROM left shoulder, no calf
tenderness bil, no pedal edema bil, decreased inversion,
eversion, flex/ext. left wrist.
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 08:01AM BLOOD WBC-4.2 RBC-4.79 Hgb-14.5 Hct-42.2 MCV-88
MCH-30.3 MCHC-34.4 RDW-12.1 RDWSD-39.1 Plt ___
___ 08:01AM BLOOD Plt ___
___ 08:01AM BLOOD ___ PTT-25.0 ___
___ 08:01AM BLOOD ___ 08:01AM BLOOD UreaN-12 Creat-0.9
___ 08:01AM BLOOD Lipase-23
___ 08:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:02AM BLOOD freeCa-1.01*
___: cxr/pelvis:
1. Distal right clavicular fracture. The acromio-clavicular and
sterno-clavicular joints appear intact.
2. No acute cardiopulmonary process.
3. No pelvic fracture or dislocation.
___: ct of the c-spine:
1. Displaced distal right clavicular fracture with overriding is
noted on
scout image. This is better evaluated on CT torso from the same
date.
2. No acute cervical spine fracture or malalignment.
___: ct of the head:
No acute intracranial abnormality.
___: ct abdomen and pelvis:
Hyperdense focus adjacent to the sigmoid colon with adjacent
stranding may be from mesenteric trauma. There is no
hemoperitoneum or evidence of bowel injury. Follow-up imaging
should be based on clinical evaluation.
2. Right distal clavicular fracture with inferior medial
displacement of the distal fragment. There is associated
axillary hematoma without active
contrast extravasation or pseudoaneurysm.
3. Soft tissue swelling hematoma anterior to the right
sternoclavicular joint however the joint appears intact.
___: right humerus x-ray:
Displaced distal right clavicular fracture with bony overriding,
as above. Intact right acromioclavicular joint.
___: left wrist:
Swelling of the dorsum of the wrist without acute fracture or
dislocation.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
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. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
please take with foood
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*40 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
right distal clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: AP radiographs of the chest, right shoulder and pelvis.
INDICATION: ___ status post mva. Evaluate for traumatic injuries.
TECHNIQUE: AP views of the chest, right shoulder and pelvis appear
COMPARISON: CT torso from ___.
FINDINGS:
RIGHT SHOULDER: Displaced distal right clavicle fracture is seen with bony
overriding. The acromioclavicular and sternoclavicular joints appear intact.
CHEST: The lungs are clear without areas of focal consolidation. There is no
pneumothorax or pleural effusion. The cardiomediastinal and hilar contours
are unremarkable.
PELVIS: No fracture or dislocation. No significant degenerative disease.
IMPRESSION:
1. Distal right clavicular fracture. The acromioclavicular and
sternoclavicular joints appear intact.
2. No acute cardiopulmonary process.
3. No pelvic fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ status post bicycle versus car collision. Evaluate for
traumatic injuries.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are normal in size and configuration.
No acute fracture is seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ status post bicycle versus car collision. Evaluate for
fractures.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 850 mGy-cm.
COMPARISON: None.
FINDINGS:
On the scout films, an inferiorly and medially displaced right distal
clavicular fracture is seen.
Alignment is normal. No cervical spine fractures are identified.There is no
significant canal or foraminal narrowing.There is no prevertebral edema.
There is a small calcification noted in the right thyroid lobe without a
discrete nodule identified. The lung apices are clear.
IMPRESSION:
1. Displaced distal right clavicular fracture with overriding is noted on
scout image. This is better evaluated on CT torso from the same date.
2. No acute cervical spine fracture or malalignment.
Radiology Report
INDICATION: History: ___ mva *** WARNING *** Multiple patients with same last
name! // trauma
TECHNIQUE: Right glenohumeral joint and right humerus, 6 total images
COMPARISON: None.
FINDINGS:
There is a displaced distal right clavicular fracture with greater than 1
shaft width of superior displacement of the proximal portion and bony
overriding of approximately 3.5 cm. The right acromioclavicular joint appears
intact. No fracture of the right humerus is seen. The right glenohumeral
joint is intact.
IMPRESSION:
Displaced distal right clavicular fracture with bony overriding, as above.
Intact right acromioclavicular joint.
Radiology Report
EXAMINATION: CT TRAUMA TORSO
INDICATION: ___ status post bicycle versus car collision. Evaluate for
traumatic injuries.
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,588 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is a right axillary hematoma inferior to
the right distal clavicular fracture (series 2, image 27; series 601b, image
68). There is no active extravasation or pseudoaneurysm in the right
subclavian or axillary arteries. The venous system is not well evaluated as
contrast is in the arterial phase. There is also soft tissue swelling and
hematoma anterior to the right sternoclavicular joint (for example series 2,
image 36), which does not appear dislocated. No axillary, mediastinal, or
hilar lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild bilateral dependent atelectasis. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Punctate hypodensities in the right thyroid lobe do not warrant
specific follow up. 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 not visualized.
There is a small hyperdense focus adjacent to the sigmoid colon in the midline
with adjacent stranding, which is nonspecific finding but may be posttraumatic
a mild mesenteric injury (series 2, image 211 and series 601b, image 67).
There is no hemoperitoneum or evidence of bowel wall injury. There is no
pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: Right distal clavicular fracture with inferior and medial displacement
of the distal fragment (series 307b, image 83). There is associated axillary
hematoma without active contrast extravasation or pseudoaneurysm. There is
soft tissue swelling and hematoma anterior to the right sternoclavicular
joint, however the joint appears intact.
SOFT TISSUES: There is a small fat containing umbilical hernia. .
IMPRESSION:
1. Hyperdense focus adjacent to the sigmoid colon with adjacent stranding may
be from mesenteric trauma. There is no hemoperitoneum or evidence of bowel
injury. Follow-up imaging should be based on clinical evaluation.
2. Right distal clavicular fracture with inferior medial displacement of the
distal fragment. There is associated axillary hematoma without active
contrast extravasation or pseudoaneurysm.
3. Soft tissue swelling hematoma anterior to the right sternoclavicular joint
however the joint appears intact.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old cyclist struck with right clavicle fracture, now with
increased pain left wrist // evaluate for fracture left wrist evaluate
for fracture left wrist
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist.
COMPARISON: None
FINDINGS:
Soft tissue swelling is noted along the dorsum of the wrist. No fracture,
dislocation, or gross degenerative change is detected. No bony erosion,
periostitis, or soft tissue calcification is identified. No suspicious lytic
or sclerotic lesion is identified. No radiopaque foreign body is detected.
IMPRESSION:
Swelling of the dorsum of the wrist without acute fracture or dislocation.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 3:06 ___, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with Fracture of unsp part of right clavicle, init for clos fx, Ped on foot injured pick-up truck, pk-up/van, unsp, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ year old male admitted to the hospital after he was struck by
a car while riding his bicycle. The patient went up on the
windshield and fell onto the curb. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging of
his head, neck, and torso. On review of the imaging, the
patient was reported to have a displaced distal right clavicle
fracture. The Orthopedic service was consulted and determined
that no surgical intervention was indicated. No neurovascular
compromise was present. A sling was recommended for comfort.
The patient's pain was controlled with oral analgesia. He
resumed a regular diet and was voiding without difficulty. He
was evaluated by Occupational therapy and techniques for ADL's
were outlined. On tertiary exam, the patient was noted to have
left wrist pain. Imaging studies of his left wrist showed no
fracture or dislocation. The patient was discharged home on HD
#2 in stable condition. An appointment for follow-up was made
with Dr. ___. The patient was instructed to call the
Orthopedic service for a follow-up appointment. Discharge
instructions were reviewed and questions answered. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Bilious Vomiting, abdominal pain, decreased ostomy output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of Chron's disease s/p multiple abdominal operations
with recurrent bowel obstructions managed conservatively
presents
today with 2 days of worsening abdominal pain, nausea, vomiting,
and decreased ostomy output. He denies fever/chills. He has been
having multiple episodes of bilious emesis. No recent illness.
He
was recently admitted in ___ for bowel obstruction managed
conservatively and per patient this feels like his usual
obstructive symptoms.
Past Medical History:
PMH: Crohns disease, chronic bronchitis, asthma, hyperlipidemia,
anxiety
PSH:
-___ proctocolectomy, end ileostomy
-___ takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass, Segmental
enterectomy X2
-___ Exploratory laparotomy, control of multiple small
bleeding points.
Social History:
___
Family History:
No family history of IBD. Father with lung cancer.
Physical Exam:
On Admission:
Vitals: 97.2 126 ___ 97%
Gen: Alert, NAD
CV: RRR
Pulm: CTAB
Abd: Soft, mild distension, mild tenderness to palpation in
the RLQ. The midline incision is well healed. No overlying skin
changes. Ostomy in the LLQ with liquid stool, no significant
gas.
Ext: no c/c/e
On discharge:
Vitals: 99 98.8 77 110/60 96 RA
Gen: NAD, Alert
CV: RRR, Normal S1, S2
Pulm: CTAB
Abd: Large right hernia, reducible. Nontender. Soft,
nondistended. Ostomy in LLQ with pasty stool output and gas
production.
Extr: No c/c/e
Pertinent Results:
___ 11:46PM GLUCOSE-111* UREA N-36* CREAT-2.4*#
SODIUM-135 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
___ 11:46PM CALCIUM-9.3 PHOSPHATE-4.8* MAGNESIUM-1.9
___ 11:46PM WBC-11.4* RBC-5.51 HGB-16.2# HCT-47.2 MCV-86
MCH-29.4 MCHC-34.4 RDW-14.9
___ 11:46PM PLT COUNT-303
___ 09:42PM LACTATE-1.3
___ 12:17PM LACTATE-5.2*
___ 12:00PM GLUCOSE-180* UREA N-39* CREAT-3.8*#
SODIUM-133 POTASSIUM-4.4 CHLORIDE-88* TOTAL CO2-15* ANION
GAP-34*
___ 12:00PM ALT(SGPT)-49* AST(SGOT)-34 ALK PHOS-102 TOT
BILI-1.3
___ 12:00PM LIPASE-120*
___ 12:00PM ALBUMIN-5.6*
___ 12:00PM WBC-18.1*# RBC-6.62*# HGB-19.7*# HCT-56.8*#
MCV-86 MCH-29.7 MCHC-34.7 RDW-15.2
Medications on Admission:
None
Discharge Medications:
1. Loperamide 2 mg PO QID
RX *loperamide [Anti-Diarrhea] 2 mg 1 tab by mouth four times
daily Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Acute Renal insufficieny due tovolume depletion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of small bowel obstruction with abdominal pain and emesis.
COMPARISON: Multiple prior studies with the most recent CT abdomen and pelvis
from ___.
TECHNIQUE: MDCT acquired axial images are obtained through the abdomen and
pelvis after administration of oral contrast only. No IV contrast was
administered. Multiplanar reformatted images were prepared and reviewed
FINDINGS:
CT ABDOMEN WITH ORAL CONTRAST:
Evaluation of visceral organs is limited due to lack of intravenous contrast.
The visualized lung bases are clear. The liver is diffusely hypodense
consistent fatty deposition within the liver. The gallbladder, pancreas,
bilateral adrenal glands, bilateral kidneys, and spleen are within normal
limits. No biliary dilatation is present.
A nasogastric tube tip terminates in the proximal duodenum. Again noted is
focal dilatation of the proximal jejunum measuring up to 5.8 cm, in a similar
appearance as before, with the dilated jejunal loop protruding through the
superior aspect of a large complex ventral hernia, with a sharp transition
point in the caliber of the small bowel at the right edge of this ventral
hernia (2: 47). At this transition point, there is a swirling of small bowel
loops and mesenteric vessels, along with mesenteric edema and prominent lymph
nodes measuring up to 1.2 x 1.1 cm (2:55), as seen previously. Findings again
likely reflect a small bowel obstruction as a result of an internal hernia
through the transverse mesocolon.
The remainder of the small bowel loops remain decompressed, many of which are
contained within a large complex ventral hernia. The patient is status post
proctocolectomy with a left ileostomy. There is no free fluid or free air.
There is no retroperitoneal lymphadnopathy. Abdominal aorta is normal in
caliber.
CT PELVIS WITH ORAL CONTRAST:
Evaluation of visceral organs is limited due to lack of intravenous contrast.
The patient is status post colectomy. A Foley catheter is noted in the
bladder with air distending the bladder, likely post-procedural. The prostate
is unremarkable. There is no free fluid or free air. There is no pelvic or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy.
IMPRESSION:
1. Small-bowel obstruction involving the proximal jejunum in a similar
appearance as before with the dilated jejunal loop protruding through the
superior aspect of a large complex ventral hernia and transition point noted
at the right superior edge of the ventral hernia, likely due to an internal
hernia through the transverse mesocolon with swirling of the mesenteric
vessels and small bowel loops at the point of obstruction. Mesenteric edema
and prominent lymph nodes at the transition point are also similar compared to
the prior exam.
2. Large complex ventral hernia containing multiple loops of decompressed
small bowel.
3. Hepatic steatosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.2
heartrate: 126.0
resprate: 16.0
o2sat: 97.0
sbp: 109.0
dbp: 91.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was admitted to ___ Surgery for 2 days of
worsening abdominal pain, nausea, and bilious vomiting. CT scan
in the ED showed small bowel obstruction involving proximal
jejunum with dilated jejunal loop through ventral hernia.
Patient was admitted to ___ 3 surgery for conservative
management of SBO. He arrived on the floor NPO, IV fluids, NG
tube, and foley for urinary output monitoring. Patient's
creatinine in the ED was 3.8 consistent with renal insufficiency
for which he was given fluid rehydration. Additionally he had a
lactate of 5.2 and wbc of 18.1 at time of admission.
Hospital day 2: patient had flatus and stool in his ostomy bag.
Pain was better controlled and he was ambulating with no
difficulties. He was advanced to sips. He remained afebrile with
wbc of 11.4, renal function improved with Cr value of 2.4, and
lactate was at 1.3
Hospital day 3: Patient self removed his NG tube overnight. He
was doing well with sips. His ostomy bag was full of flatus and
he felt better.
Hospital day 4: Patient was advanced to fulls and IV fluids were
discontinued as he was toleating the diet. In the afternoon
patient began experiencing nausea and emesis. An NG tube was
reinserted which produced 2 L of bilious fluids upon insertion.
Ostomy bag was producing minimal flatus. Patient was
transitioned back to NPO, IV fluids, and IV medications. Foley
was removed and patient had no difficulties voiding afterwards.
Hospital day 5: Patient remained NPO,IVF, with NG tube.
Creatinine rose to 1.6 from 1.2 the day prior with a decrease in
urinary output for which patient received IV fluid boluses.
Urinary output responded appropriately to the boluses.
Hospital day ___: NGT with decreased output. Patient's ostomy
showed increased flatus and stool output. NGT was removed after
a successful clamp trial. Patient was out of bed. Improved
urinary output with creatinine of 1.3. Patient was started on
clears with continuing IV fluids given high ostomy output.
Hospital day ___: Patient started on regular diet which he
tolerated well. Patient was maintaining adequate urinary output
with creatinine of 1.3 and IV fluids were discontinued. Patient
had chronic contact dermatitis surrounding ostomy site for which
ostomy nurse evaluated the patient and left appropriate supplied
by bedside.
Hospital day ___: Patient was started on loperamide 2 mg TID
for increased ostomy output which decreased his ostomy
output,although it still remained high. Patient's loperamide was
increased to 2mg QID.Patient was taught to titrate his ostomy
output to 1.5L/day. He was also told to measure the output
daily. He was tolerating regular diet, producing good urinary
output, and ambulating. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ergotamine / Codeine
Attending: ___.
Chief Complaint:
Dizziness, Influenza-like illness, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with the past medical history of
opiate use disorder on methadone, depression with a history of
ECT treatment, homelessness who presents with fever, nausea and
vomiting, and generalized malaise x3 days.
Three days prior to presentation, ___ felt mild neck pain and
total body aches with a productive cough, and had intermittent
nausea and vomiting (bilious, non-bloody vomit). PO intake has
been poor all week. ___ does not have chest pain, abdominal pain,
diarrhea, or back pain. Last BM today. ___ reports syncopizing
yesterday on ___. Was feeling increasingly weak, feel to
knees and then into a ___, no head strike. While down, ___ was
robbed of his wallet, ID, and cellphone.
Has been sleeping in a T stop, avoids shelters because being
around many people injecting drugs threatens his sobriety.
During ___ admission for CAP, flu swab was negative,
CXR without infiltrate. ___ was thought to have atypical
community
acquired pneumonia and treated with doxycycline for 5 days
(azithromycin was avoided because of compounding QTc
prolongation
with methadone). Breathing returned to normal at discharge and
___
was well after discharge. ___ was given supplements for severe
malnutrition-- ensure enlive, gelatin, pudding. Workup for HIV,
diabetes, hypothyroidism, liver disease were all unremarkable.
Quant gold was negative. ___ was evaluated by physical therapy
who
recommended rehab but then ___ improved after working with them
for two days and ___ was discharged with crutches to the street
___ is homeless).
___ has a history of severe major depressive disorder. This has
been a barrier for him to follow up with services such as food
stamps and to following up with a physician. ___ stated ___ feels
hopeless and occasionally feels like giving up. ___ denies having
an active suicidal plan. ___ is proud of his sobriety ___ years)
and also finds solace in his faith. SW communicated with his
___
case manager and offered multiple services. Psychiatry team was
consulted last admission for assistance with management of his
severe depression, though patient says ___ would not like to meet
with them this admission. ___ would like to resume ECT and prozac
outpatient. ___ has not been taking prozac or going to ECT since
___, not sure why ___ stopped going. ___ has not seen his
psychiatrist in over ___ year.
In the ED, initial vitals:
T 101.8 HR 114 BP 97/53 RR 24 SaO2 96% RA
- Exam notable for:
Ill-appearing, speaking full sentences
Decreased breath sounds on the right with scattered wheezes and
crackles
Neck no nuchal rigidity, Kernig, or Brudzinski sign
Normal her exam, abdomen nontender, normal neurologic exam
- Labs notable for:
The patient was unable to tolerate flu swab. Sample returned
negative but was not deep enough per respiratory notes.
Lactate 0.9
Na 135 K 3.9 Cl 101 HCO3 20 BUN 17 Cr 0.8 Glc 90
CBC: 4.3>12.6/38.2<194
- Imaging notable for:
CXR
The heart size is normal. The mediastinal and hilar contours are
unremarkable. The lungs are clear. No pleural effusion or
pneumothorax.
- Pt given:
___ 22:05 PO Meclizine 25 mg
___ 22:05 IH Ipratropium-Albuterol Neb 1 NEB
___ 23:20 PO Acetaminophen 1000 mg
___ 00:07 IVF NS 1000 mL
___ 03:10 IVF NS 1000 mL
___ 08:00PO/NGMethadone 153 mg
___ 08:00PO/NGMultivitamins W/minerals 1 TAB
___ 08:00PO/NGAcetaminophen 1000 mg
___ 08:00PO/NGOSELTAMivir 75 mg
___ 09:20 Albuterol 0.083% Neb Soln 1 NEB
___ 09:20POOndansetron ODT 4 mg
___ 11:32PO/NGLORazepam .5 mg
On the floor, the patient also states that the only way ___ can
stay clean from drugs is if ___ avoids homeless shelters and
therefore ___ has been sleeping outside. ___ feels that as result
of sleeping outside, ___ has been sick very often this ___. ___
has not had any sexual partners or injected drugs in a long
time,
certainly not since extensive testing at ___ last month. No
recent rashes, no fevers before this episode. Reports albuterol
has made him feel ansty and "hopped up."
Past Medical History:
OUD on methadone
Depression s/p ECT
R parathyroidectomy and radioablation of thyroid per patient
Appendectomy as child
Anxiety
PTSD
Tachycardia
Chronic hepatitis C
Migraines
Social History:
___
Family History:
Does not know family history, adopted.
Physical Exam:
PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 1657)
Temp: 97.8 (Tm 97.8), BP: 125/75, HR: 108, RR: 18, O2 sat:
96%, O2 delivery: RA, Wt: 117.28 lb/53.2 kg
General: slim, ill-appearing middle-aged gentleman sitting
upright in bed, alert and conversant with mild distress
HEENT: atraumatic, PERRL, EOMI, MM dry
CV: nl rate, reg rhythm, nl s1 and s2, no mrg
Lungs: diffuse wheezes
Abdomen: nl BS, ND, NT all 4 quadrants
Ext: no cyanosis, clubbing, or edema. Legs symmetric, not
erythematous.
Skin: no rashes
Neuro: AAOx3, face symmetric, moves all 4 with purpose.
Psych: appears anxious with frequent sighing and holding head in
hands, thought process linear and goal oriented
DISCHARGE PHYSICAL EXAM:
VITALS: 98.0 PO 120 / 66 L Sitting 88 18 98 Ra
General: NAD
HEENT: Sclerae anicteric, MMM, EOMI
CV: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: Diffuse abdominal pain, NABS, + guarding
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
==================
___ 09:03PM BLOOD WBC-4.3 RBC-4.27* Hgb-12.6* Hct-38.2*
MCV-90 MCH-29.5 MCHC-33.0 RDW-12.7 RDWSD-41.8 Plt ___
___ 09:03PM BLOOD Neuts-85.1* Lymphs-7.1* Monos-7.1
Eos-0.0* Baso-0.5 Im ___ AbsNeut-3.69 AbsLymp-0.31*
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.02
___ 09:03PM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-135
K-3.9 Cl-101 HCO3-20* AnGap-14
___ 09:03PM BLOOD ALT-82* AST-97* LD(LDH)-256* AlkPhos-73
TotBili-0.2
___ 06:35AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
___ 09:11PM BLOOD Lactate-0.9
___ 11:15PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
PERTINENT INTERVAL LABS
========================
___ 06:35AM BLOOD ALT-435* AST-459* AlkPhos-226*
TotBili-1.1
___:40AM BLOOD ALT-1397* AST-1588* LD(LDH)-973*
CK(CPK)-95 AlkPhos-237* TotBili-2.3*
___ 05:30PM BLOOD ALT-2083* AST-2475* LD(LDH)-1691*
AlkPhos-189* TotBili-2.7*
___ 05:10AM BLOOD ALT-3556* AST-4436* LD(LDH)-2660*
AlkPhos-197* TotBili-4.4* DirBili-3.6* IndBili-0.8
___ 01:12PM BLOOD ALT-4179* AST-5389* AlkPhos-188*
TotBili-4.5*
___ 04:17AM BLOOD ALT-3854* AST-3584* LD(LDH)-850*
AlkPhos-187* TotBili-4.0*
___ 09:03PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:35AM BLOOD HAV Ab-POS* IgM HAV-NEG
___ 06:40AM BLOOD ___ Titer-1:40*
___ 06:40AM BLOOD IgG-1027 IgA-283 IgM-73
___ 06:35AM BLOOD HIV Ab-NEG
___ 06:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:03PM BLOOD HCV Ab-POS*
___ 10:05AM BLOOD HCV VL-6.0*
___ 05:36PM BLOOD Lactate-2.4*
___ 10:56PM BLOOD Lactate-1.7
___ 01:12PM BLOOD HBV VL-NOT DETECT
___ 13:12 EBV PCR, QUANTITATIVE, WHOLE BLOOD
SOURCE Whole Blood
EBV DNA, QN PCR 324 H <200 copies/mL
___ 13:12
HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA, QUANTITATIVE REAL TIME PCR
Test Result Reference
Range/Units
SOURCE Serum
HSV 1 DNA, QN PCR <100 <100 copies/mL
HSV 2 DNA, QN PCR <100 <100 copies/mL
___ 13:12
VARICELLA ZOSTER ANTIBODY, IGM
Test Result Reference
Range/Units
VARICELLA ZOSTER VIRUS <=0.90 <=0.90
ANTIBODY (IGM)
< or = 0.90 Negative
___ 05:10
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 109 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 26.1 ___ mg/dL
IMMUNOGLOBULIN G, SERUM ___ mg/dL
MICROBIOLOGY
================
___ 8:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 6:35 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
___ 5:10 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ BLOOD CULTURE x2: NGTD
___ URINE CULTURE (Final ___: NO GROWTH.
IMAGING STUDIES
==================
CXR ___
No acute cardiopulmonary abnormality.
RUQUS WITH DOPPLER ___. 1.4 cm hypoechoic lesion in the pancreatic head/neck may
represent a mass or peripancreatic lymph node. Consider further
evaluation with dedicated nonurgent CTA of the pancreas.
2. No identified gallstones. Gallbladder wall thickening/edema
in a partial
gallbladder may represent changes of hepatitis, third-spacing.
There was no sonographic ___ sign, but cholecystitis cannot
be excluded in the
appropriate clinical presentation.
3. Horseshoe kidney.
CT ABDOMEN/PELVIS ___. Small left pleural effusion with associated atelectasis.
2. No evidence of cirrhosis or suspicious liver lesion.
3. Small volume ascites.
4. 2.5 cm hepatic cyst.
PORTABLE ABDOMEN ___
Moderate fecal load. No signs of bowel obstruction.
RUQUS ___
1. Diffuse periportal echoes could be secondary to known acute
hepatitis.
2. Interval decrease in size of the known periportal lymph node
currently
measuring up to 1.6 cm, likely reactive.
3. No evidence of acute cholecystitis, or biliary obstruction.
Please note ascending cholangitis remains a clinical diagnosis
however.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 153 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN Anxiety
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
3. LORazepam 1 mg PO Q12H:PRN anxiety or nausea
4. Methadone 153 mg PO DAILY
Consider prescribing naloxone at discharge
5. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
Primary:
acute severe hepatitis, likely viral
fever
abdominal pain
generalized weakness
severe malnutrition
Secondary:
major depressive disorder
anxiety
opioid use 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
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fever and cough// eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___.
FINDINGS:
The heart size is normal. The mediastinal and hilar contours are
unremarkable. The lungs are clear. No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with opiate use disorder, depression, HepC p/w
fever, nausea, vomiting, malaise found to be flu negative with elevated
transaminases// gallstones? evaluation of liver given severe LFT elevation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is a hypoechoic lesion in the right lobe of the
liver likely segment VII measuring 2.5 x 1.9 x 2.0 cm compatible with a
hepatic cyst, similar to prior. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 7 mm
GALLBLADDER: There is gallbladder wall thickening/edema in a minimally
distended gallbladder, which may reflect chronic liver disease or third
spacing. There was non sonographic ___ sign.
PANCREAS: In the imaged portion of the pancreas, there is a hypoechoic 1.1 x
0.7 x 1.4 cm lesion in the pancreatic head/neck concerning for a mass. No
pancreatic ductal dilatation. The remaining pancreatic parenchyma appears
normal in echogenicity.
SPLEEN: Normal echogenicity.
Spleen length: 10.5 cm
KIDNEYS:
There is a horseshoe kidney.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. 1.4 cm hypoechoic lesion in the pancreatic head/neck may represent a mass
or peripancreatic lymph node. Consider further evaluation with dedicated
nonurgent CTA of the pancreas.
2. No identified gallstones. Gallbladder wall thickening/edema in a partial
gallbladder may represent changes of hepatitis, third-spacing. There was no
sonographic ___ sign, but cholecystitis cannot be excluded in the
appropriate clinical presentation.
3. Horseshoe kidney.
4. 2.5 cm hepatic cyst.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with PMH opiate use disorder on methadone, depression,
homelessness presenting with fever/nausea/vomiting, generalized malaise, found
to be flu negative. Recent hospitalization at which point patient treated for
CAP but low suspicion given CXR. LFTs also elevated on this admission. Of note
had ___ HepC viral load in ___, then spontaneously resolved as of ___.
HepC VL pending for this admission. Admitted w/ relatively mild elevation in
LFTs w/ subsequent rapid increased in ALT/AST to 1397/1588, respectively. LDH
also elevated at 973, AlkPhos 237, and TBili 2.3. No known hypotensive events
and
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 49.9 cm; CTDIvol = 5.1 mGy (Body) DLP = 253.8
mGy-cm.
Total DLP (Body) = 254 mGy-cm.
COMPARISON: Multiple prior CT abdomen pelvis examinations most recent dated
___.
FINDINGS:
LOWER CHEST: There is a small left pleural effusion with associated
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Segment 4 cyst is unchanged from prior exam. There is no evidence of new
focal lesions. There is mild periportal edema.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits. There is a small volume ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is slightly prominent measuring 12.7 cm, without evidence
of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. There is 1 cm
left adrenal nodule, unchanged.
URINARY: Again seen is a horseshoe kidney without evidence of hydronephrosis
or stone. Punctate low-density lesion in the upper pole of the left kidney,
unchanged from prior exam and too small to characterize. There is no
hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. There is no obstruction.
PELVIS: The urinary bladder and distal ureters are unremarkable.
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.
There are bone islands in the right symphysis previous and right femoral head.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Small left pleural effusion with associated atelectasis.
2. No evidence of cirrhosis or suspicious liver lesion.
3. Small volume ascites.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with opioid use disorder and acute hepatitis
presents with constitutional symptoms.// Assess for pneumonia
IMPRESSION:
In comparison with study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or pleural effusion.
Radiology Report
INDICATION: ___ year old man with acute viral hepatitis, ongoing nausea and
abdominal pain// any e/o obstruction? large stool burden?
COMPARISON: Prior CT abdomen pelvis from ___
FINDINGS:
Supine KUB. No signs of ileus or obstruction. Moderate fecal load within the
colon. No worrisome calcifications. Bony structures are intact.
IMPRESSION:
Moderate fecal load. No signs of bowel obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with the past medical history opiate use
disorder on methadone, depression with a history of ECT treatment,
homelessness who presents with cough, fever, and generalized malaise// ?pna
IMPRESSION:
In comparison with the study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or pleural effusion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with acute viral hepatitis, has been improving
but now with fever and worsening abd/RUQ pain, ? liver pathology, biliary
infection// ___ year old man with acute viral hepatitis, has been improving but
now with fever and worsening abd/RUQ pain, ? liver pathology, biliary
infection
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT from CT abdomen pelvis ___.
FINDINGS:
LIVER: Increased periportal echoes having a "starry sky" appearance, could be
secondary to known acute hepatitis. A 3 x 1.8 x 1.6 cm simple cyst in the
right hepatic lobe is again seen. The contour of the liver is smooth. The
main portal vein is patent with hepatopetal flow. There is no ascites. A 1.6
x 0.7 x 1.3 cm hypoechoic oval structure in the periportal space represents a
lymph node which has decreased in size since recent CT previously measuring
2.3 x 1.6 cm, likely reactive.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4-6 mm
GALLBLADDER: Gallbladder is contracted, with mild concentric thickening,
likely reactive to the liver process or low albumin states.
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: 11.5 cm
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Diffuse periportal echoes could be secondary to known acute hepatitis.
2. Interval decrease in size of the known periportal lymph node currently
measuring up to 1.6 cm, likely reactive.
3. No evidence of acute cholecystitis, or biliary obstruction. Please note
ascending cholangitis remains a clinical diagnosis however.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, ILI, N/V
Diagnosed with Cough, Fever, unspecified, Dizziness and giddiness, Tachycardia, unspecified, Essential (primary) hypertension
temperature: 101.8
heartrate: 114.0
resprate: 24.0
o2sat: 96.0
sbp: 97.0
dbp: 53.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ year old male with opioid use disorder
on methadone, depression (untreated), HCV (previously recorded
as spontaneously cleared but now with positive viral load), and
homelessness who presented with nonspecific complaints (fevers,
nausea, myalgias) and developed acute hepatitis of unclear
etiology, likely viral, with overall improvement but continued
hospitalization for abdominal pain, nausea, decreased PO intake,
and generalized weakness, ultimately attributed to hepatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
MS ___ / ___
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
-
History of Present Illness:
___ female with hx of sickle cell anemia here with chest pain
and fever. Pt reports that in the past ___ weeks she has been
having an upper respiratory infection with coughing, nasal
congestion, feeling like she has a cold. She was feeling like
she was getting over it and she has not been coughing much.
However, she had been having intermittent sickle cell pain with
it, but now the sickle pain is much worse. It is present across
the chest and in the right arm and right thigh. Pt reports that
it is often worse on the right and this feels like a sickle cell
flare. She reports that she was at the mass eye/ear ED last
night due to eye mircohemorrhage, got home this AM at 5 and then
at 9am woke up with fever. She had about 4 hours of taking her
temp and it was between 99 and 101. She also has diffuse body
and muscle aches. She reports being a ___ with
friends and kids that are getting sick with gastroenteritis.
She had some nausea this AM, but no vomiting. She now has some
mild abd tenderness, diffuse.
10 systems reviewd and are otherwise negative.
Past Medical History:
SUMMARY OF TREATMENT HISTORY: HGB SC disease with high HGB F
levels while previously on hydroxyurea at ___. Off hydroxyurea,
her HGB F level declined to 6%. She resumed hydroxyurea in
___ with rise in Hgb F level to 26%. With a dose increase in
hydroxyurea from 1000 mg daily to 1500 mg daily, she developed
symptomatic anemia, with thrombocytopenia. We stopped
hydroxyurea
with subsequent hematologic recovery accompanied by a
vaso-occlusive crisis requiring hospitalization in ___. During
hospitalization she required a basal infusion rate of
dihydromorphine 1.25 mg/hr, with 1 mg boluses as needed. At the
height of pain, she was self-administering up to two 1 mg
boluses
on top of her basal rate. Since discharge from hospital in
___, she has remained off hydroxyurea, with hematologic
recovery to former baseline levels.
She has been admitted to the hospital approximately ___ times a
year for vasoocclusive pain crises. In ___, she was admitted
in ___, and ___.
PMH :
(1) Bilateral core decompressions of the hips in ___ by Dr. ___ at ___ for avascular necrosis followed
by right core decompression on ___ with orthopedic surgeon
Dr. ___, who also evaluated right knee concerns with MRI,
which did not show avascular necrosis.
(2) Left ovarian cyst with small dermoid tumor, resected in ___
by gynecologist Dr. ___ at ___. She has follow-up with Dr. ___ on
___.
(3) SC retinopathy (following bilateral laser surgery in ___
by
Dr. ___ at ___. In ___, she saw Dr. ___ and Dr. ___ at ___ for laser therapy.
(4) She reports developing fever when traveling to ___ in
___, associated with substernal pain. She used
supplemental oxygen on her return flight, and she felt fine. In
___, she traveled to ___, and ___ where she did
well during her plane flight. However, she was at an altitude of
8,000 feet at one point, and she suffered vaso-occlusive
symptoms
in her bones and abdomen, requiring a dose escalation in
oxycodone tablets (5 mg/tablet) from 4 daily to ___ daily. She
developed scleral icterus. She did not develop chest pain,
although her breathing felt "heavy."
(5) Thyroid nodules.
(6) Vitamin D deficiency (followed by Dr. ___.
(7) In ___, right hand dactylitis.
Social History:
___
Family History:
Brother with SC disease, one cousin with sickle cell disease of
unknown genotype, and another cousin with sickle cell trait. HTN
in mother and father.
Physical Exam:
physical exam
Afeb, VSS
Cons: NAD, sitting up in bed, appears tired
Eyes: EOMI, no scleral icterus
ENT: MMM right shoddy LAD worse than left.
Cardiovasc: tachycardic no murmur, no edema
Resp: CTA B
GI: +bs,soft, nt, nd
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: full range of affect
\
afebrile
soft non tender exam
no lymphadenopathy other than slight symmetric non tender mobile
submandibular adenopathy <1cm
trace R and L foot edema, non pitting
Pertinent Results:
___ 01:45PM BLOOD WBC-7.7 RBC-4.34 Hgb-12.6 Hct-33.5*
MCV-77* MCH-29.0 MCHC-37.5* RDW-17.6* Plt ___
___ 01:45PM BLOOD Neuts-88.1* Lymphs-8.0* Monos-3.1 Eos-0.8
Baso-0.1
___ 01:45PM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-136
K-4.3 Cl-100 HCO3-24 AnGap-16
___ 03:05PM BLOOD Lactate-0.9
CXR:
IMPRESSION:
As compared to the previous radiograph, no relevant change is
seen. Normal
lung volumes. Normal size of the cardiac silhouette. Normal
hilar and
mediastinal contours. No pleural effusions. No pneumonia, no
pulmonary
edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU BID
2. FoLIC Acid 5 mg PO DAILY
3. Nortriptyline 25 mg PO QHS
4. Omeprazole 40 mg PO BID
5. Ranitidine 300 mg PO QHS
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness
8. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
9. Vitamin D 1000 UNIT PO BID
10. Ascorbic Acid ___ mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation qd
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Ferrous GLUCONATE 324 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. FoLIC Acid 5 mg PO DAILY
5. Nortriptyline 25 mg PO QHS
6. Omeprazole 40 mg PO BID
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 2 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Ranitidine 300 mg PO QHS
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness
10. Vitamin D 1000 UNIT PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION QD
14. Magnesium Citrate 300 mL PO ONCE MR1 constipation Duration:
1 Dose
15. Bisacodyl 10 mg PR QHS:PRN constipation
16. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral
daily
17. Outpatient Lab Work
CBC with diff, retic, T bili, LDH, haptoglobin send report to
Dr. ___: ___ OF HEMATOLOGY/ONCOLOGY
Address: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
sickle cell disease pain crisis
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 sickle cell, cough, pain // ? acute chest, PNA
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Normal
lung volumes. Normal size of the cardiac silhouette. Normal hilar and
mediastinal contours. No pleural effusions. No pneumonia, no pulmonary
edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fever, SICKLE CELL
Diagnosed with HB-SS DISEASE W/CRISIS
temperature: 98.0
heartrate: 147.0
resprate: 21.0
o2sat: nan
sbp: 147.0
dbp: 81.0
level of pain: 9
level of acuity: 1.0 | ___ female with hx of sickle cell disease here with fever and
a
pain crisis.
Sickle Cell Pain crisis No evidence for bacterial infections,
no end organ dysfunction, infiltrate on chest xray. management
involved supportive care with ivf, iv dilaudid and then
transition to oral opiod. Hgb 9.6 and stable for 48hrs prior to
discharge with elev ldh, retic and bili. Pain at discharge was
focused on R leg, some radiation from hip where she has known
avascular necrosis.
I was not able to feel the R neck nodule described by past MD,
Dr. ___. Patient aware and can bring it to attention of her
PCP if it changes.
gerd
continue home ppi, h2 blocker |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Lisinopril / omeprazole / OxyContin
Attending: ___
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ ESRD on HD, DMII, and CAD s/p LAD DES x1 on ___ who
presents with chest discomfort after cath. Patient had cath on
___ for renal transplant work-up and ___ placed to
LAD. Patient went home and at 6:30pm ___, she developed R
sided chest "pressure, not pain" after drinking a Boost drink;
no radiation. Initially she thought was indigestion, but then
pain persisted reaching maximal intensity of ___. Associated
with SOB and nausea (no vomiting). No diaphoresis. Denies reflux
like symptoms. On arrival to ED, given SL nitro x2 which led to
pain of ___, also given aspirin 325. Patient has never had this
type of pain before. Last HD was ___.
In the ED intial vitals were: 98.3 82 175/81 18 99% RA.
Patient was given: Nothing in the ED.
Labs were notable for K of 5.2, trop of 0.82 -> 0.78. blood cx
also sent.
EKG was read by Cardiology who thought that the EKG looked
relatively unchanged, admit to ___ for serial enzymes and EKGs.
Vitals on transfer: 98.1 84 170/83 19 95% RA
On the floor, pt feels much better, no chest discomfort, wanted
to eat despite mild nausea.
ROS: Per HPI
Past Medical History:
-PVD s/p right BKA after failed re-vasc in 1990s, s/p left AKA
___
-ESRD on HD MWF since ___ due to DM/BP- on translpant list
-Left hand vascular steal due to dialysis fistula - improved
after fistula revision
-Hypertension
-coronary artery disease
-CHF - last EF 35-40%
-DM II x years - since age ___ complicated by retinopathy,
neuropathy, nephropathy, PVD
-Stroke ___
-Asthma
-chronic pain
PSH: fem-AT bypass graft (___), L third digit amputation
(___), R fem-pop bypass w/ contralateral SVG, excision of
infected R fem-pop vein graft, R BKA, CCY, c-section x2, LUE,
left AKA ___
Social History:
___
Family History:
- Father: deceased, ___, diabetes, bilat BKA, CAD
- Mother: died ___: HTN, DM II, CHF
- Brother died of hepatitis
- Paternal aunt: HTN, DM II
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.7 150/72 85 18 94%RA
Gen: Female with AKA and BKA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Mild lower basal crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: S/p AKA and BKA.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
SITES: RRA site c/d/i, RFV site c/d/i.
DISCHARGE PHYSICAL EXAM
VS: 98.3 153/84 130s-170s 72 70s-80s 18 98%RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation except diminished breath sounds at
R base, otherwise no w/r/r
HEART: RRR
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: b/l ___ amputation
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 02:05AM GLUCOSE-189* UREA N-56* CREAT-5.7* SODIUM-134
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
___ 02:05AM estGFR-Using this
___ 02:05AM cTropnT-0.78*
___ 02:05AM CALCIUM-10.0 PHOSPHATE-6.0* MAGNESIUM-2.5
___ 02:05AM WBC-5.9 RBC-3.81* HGB-11.8* HCT-38.0 MCV-100*
MCH-30.9 MCHC-31.0 RDW-16.2
___ 02:05AM NEUTS-74.8* LYMPHS-14.0* MONOS-7.9 EOS-2.7
BASOS-0
___ 02:05AM PLT COUNT-146*
___ 02:36PM CK(CPK)-55
___ 02:36PM cTropnT-0.82*
___ 09:40AM cTropnT-0.74*
___ 09:36AM TYPE-ART PO2-124* PCO2-35 PH-7.43 TOTAL
CO2-24 BASE XS-0
___ 09:36AM O2 SAT-96
___ 07:07AM ___
CARDIAC ENZYMES
___ 02:36PM BLOOD CK(CPK)-55
___ 02:05AM BLOOD cTropnT-0.78*
___ 02:36PM BLOOD cTropnT-0.82*
DISCHARGE LABS:
___ 07:47AM BLOOD WBC-6.3 RBC-3.77* Hgb-11.7* Hct-39.6
MCV-105* MCH-31.1 MCHC-29.6* RDW-16.3* Plt ___
___ 07:47AM BLOOD Plt ___
___ 07:47AM BLOOD Glucose-134* UreaN-45* Creat-5.0* Na-138
K-5.4* Cl-100 HCO3-24 AnGap-19
___ 07:47AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.2
IMAGES/STUDIES
___ CXR
FINDINGS: As compared to the previous radiograph, there is
unchanged
moderate-to-severe cardiomegaly and evidence of moderate
pulmonary edema. The lung volumes are relatively low compared
to the previous examination. There is no evidence of a pleural
effusion, an apical cap or a contour irregularity along the
aortic arch or the descending aorta. Nevertheless, if the
clinical symptoms persist, evaluation with CT should be
performed.
___ CTA
IMPRESSION:
1. No pulmonary embolism or aortic dissection.
2. Small right pleural effusion otherwise clear lungs.
3. Anasarca.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chest pain, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged
moderate-to-severe cardiomegaly and evidence of moderate pulmonary edema. The
lung volumes are relatively low compared to the previous examination. There
is no evidence of a pleural effusion, an apical cap or a contour irregularity
along the aortic arch or the descending aorta. Nevertheless, if the clinical
symptoms persist, evaluation with CT should be performed.
Radiology Report
HISTORY: ___ year old woman status post catheterization w/DES x1, with chest
pressure radiating to back, dyspnea. Evaluate for dissection or other
pathology.
COMPARISON: Chest CTA from ___
TECHNIQUE: Volumetric CT acquisition of the chest was performed per CTA
protocol after administration 100 mL of Omnipaque 350 IV contrast material.
Post-processing reconstruction was performed in the coronal and sagittal
planes as well as bilateral oblique MIP imaging.
DLP: 280 mGy-cm
FINDINGS:
Vasculature: The pulmonary arteries are normal in caliber and without filling
defect. The thoracic aorta is also normal in caliber without evidence of
acute abnormality. Atherosclerosis.
Lungs: Centrilobular emphysema, but clear. Small right pleural effusion.
Mediastinum: No enlarged lymphadenopathy. No pericardial effusion.
Heart: Cardiomegaly. Coronary artery calcification.
Bones: Normal.
Soft tissues: Anasarca. No enlarged axillary lymph nodes are present.
Upper abdomen: Visualized structures are within normal limits.
IMPRESSION:
1. No pulmonary embolism or aortic dissection.
2. Small right pleural effusion otherwise clear lungs.
3. Anasarca.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CHEST DISCOMFORT
Diagnosed with CHEST PAIN NOS, HYPERKALEMIA, 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: 98.3
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 175.0
dbp: 81.0
level of pain: 4
level of acuity: 2.0 | ___ y/o female w/ CAD, DM, ESRD, PVD s/p DES to LAD the day prior
to admission who presents with chest discomfort.
# Chest Discomfort/CAD: Given recent cath ___ there
was intial concern for ___. Troponins were flat. CTA
was negative for dissection or PE, but did show a right pleural
effusion. Patient was continued on aspirin, plavix. Metoprolol
was increased and amlodopine was added.
# ESRD: Currently being evaluated for transplant. Renal
medications were continued and Patient received HD during which
4L of fluid was taken off.
# HTN: Patient had SBPs in the 170's. She was continued on
losartan, metoprolol was increased and amlodopine was added.
# sCHF: EF ___ in ___. She was continued on home lasix and
cardiac medications as above.
# DM: Continued on home insulin.
# Chronic Pain: Continue on home narcotics regimen.
# HLD: Continue Rovustatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Codeine / Biaxin / Solu-Medrol/Diluent / Prednisone /
Enalapril / shellfish derived
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with h/o HTN, CHB (s/p PPM), prior CVA
(residual R sided weakness + dysarthria), who complains of acute
on chronic chest/epigastric pain, and R shoulder pain s/p
mechanical fall.
Ms. ___ reports that at midnight prior to admission she
rose her recliner chair which forced her to fall out of chair,
struck R head on door, then struck R head + R shoulder on floor,
then down for 7 hours. No prodromal symptoms or non-mechanical
cause of fall. Around 4pm she reports worsening diffuse
body/muscle pain that prompted call for EMS.
She also reports several months of diffuse dull chest/epigastric
pain, positional in nature while lying supine at night and
improved with sitting up. Today reports a brief worsening of
this
along with diffuse muscle pain throughout her body that worsened
throughout day.
She endorses chronic palpitations, chronic lightheadedness (iso
amlodipine), dark stool, chronic constipation. No diaphoresis,
N/V, SOB, cough. Incontinent at baseline. Wheelchair bound,
lives
in senior home.
In the ED workup for head trauma, rhabdo, ischemia, CT abd, all
negative. UA showed 46 WBCs + leukocyte esterase. She was
admitted to medicine as she "is ___ years old and a poor
historian with many vague symptoms, treatment for presumed UTI
is
warranted." She received Ceftriaxone and while awaiting a
medicine bed became agitated and requested repeatedly to go home
per the patient. She was then given Haldol and sent to the
floor. Troponin was negative x 2. CK WNL. EKG: LBBB pattern w
nonspecific ST changes iso PPM.
- Initial Vitals/Trigger: 98.6, HR 63, 153/93, 97%
- BMP, CBC, LFTs wnl
On arrival to the floor the patient is feeling well save for
right shoulder pain and feeling a bit "off after the shot they
gave me around 2am." She denies fevers, chills, nausea,
vomiting,
dysuria. She has chronic urinary incontinence and wears depends.
She denies diarrhea and verifies that the fall she had at home
resulted from "getting ejected from a new recliner she obtained
from ___ and ___ She had no surrounding dizziness,
light-headedness, pre-syncope and only her chronic chest pain
prior to falling.
Past Medical History:
- Asthma, FEV1 of 60% in ___, on Advair, inhaler
- Hypertension, longstanding, difficult to control, question
about medication adherence
- AV block s/p permanent pacemaker
- Bipolar disorder previously followed by Dr. ___ current
psychiatry care or medications
- OSA, no CPAP
- Cervical stenosis
- Breast nodule
- Pulmonary nodule
- Former cocaine use
- Back pain
- Remote stab wounds to neck, back, abdomen s/p ex lap
- Hyperparathyroidism
- Urinary incontinence
Social History:
___
Family History:
Mother died at age of ___ from stroke
Father smoker with arthritis, died from unknown cause
Sister with COPD on oxygen, diabetes mellitus, unknown cancer,
heart problems
Oldest son with asthma
___ son with h/o kidney stones
No family history of hyperparathyroidism, osteoporosis or
fractures, early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death
Physical Exam:
ADMISSION EXAM:
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, no JVD,
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, ___ RUSB SEM, no rubs or
gallops
Gastrointestinal: nd, +b/s, soft, nt,
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact save for mild dysarthria.
___
strength throughout. No asterixis, fluent but slowed speech.
Psychiatric: inappropriate but pleasant affect
GU: no catheter in place
DISCHARGE EXAM:
97.9 PO 132/95 65 18 98% RA
General: in NAD, sitting in chair, appears stated age
HEENT: OP moist, no LAD
Resp CTA bilaterally, no rales or wheezes
CV RRR without murmurs
GI soft, NT, ND, NABS
MS: no edema, slight pain with movement of right arm.
Neuro: alert/oriented X3, moving all extremities. full strength
with foot movement bilaterally.
Pertinent Results:
ADMISSION
___ 05:36PM BLOOD WBC-7.9 RBC-4.34 Hgb-11.9 Hct-37.9 MCV-87
MCH-27.4 MCHC-31.4* RDW-13.6 RDWSD-43.4 Plt ___
___ 05:36PM BLOOD ___ PTT-29.4 ___
___ 05:36PM BLOOD Glucose-100 UreaN-21* Creat-0.8 Na-144
K-4.0 Cl-107 HCO3-23 AnGap-14
___ 06:20PM BLOOD ALT-9 AST-14 CK(CPK)-185 AlkPhos-113*
TotBili-0.5
DISCHARGE
___ 07:35AM BLOOD WBC-8.0 RBC-4.37 Hgb-12.1 Hct-38.0 MCV-87
MCH-27.7 MCHC-31.8* RDW-13.8 RDWSD-43.8 Plt ___
___ 07:35AM BLOOD Glucose-74 UreaN-20 Creat-0.7 Na-142
K-4.3 Cl-105 HCO3-25 AnGap-12
___ 07:35AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
2. Atorvastatin 20 mg PO QPM
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Acetaminophen ___ mg PO TID:PRN Pain - Mild
7. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection AS NEEDED
8. Losartan Potassium 100 mg PO DAILY
9. Polyethylene Glycol 17 g PO EVERY OTHER DAY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
11. Aspirin 81 mg PO DAILY
12. amLODIPine 10 mg PO DAILY
13. HydrALAZINE 10 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO TID:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection AS NEEDED
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. HydrALAZINE 10 mg PO BID
10. Losartan Potassium 100 mg PO DAILY
11. Polyethylene Glycol 17 g PO EVERY OTHER DAY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Urinary tract infection
Secondary:
CVA
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with upper abd pain, h/o abd
surgery- ex lap.NO_PO contrast// eval for hernia, colitis
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.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 45.1 cm; CTDIvol = 27.0 mGy (Body) DLP =
1,216.9 mGy-cm.
Total DLP (Body) = 1,217 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. Partially
visualized pacemaker terminal leads are noted within the right atrium and
right ventricle. 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 is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. The subcentimeter
hypodensity within the midpole of the right kidney is too small to
characterize but likely represents a simple renal cyst. 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. Extensive diverticulosis of the
sigmoid colon is noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized however there are no secondary CT signs of
acute appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Normal sized uterus containing calcified fibroids. No
abnormal 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. 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 acute abnormality within the imaged abdomen and pelvis. No evidence of
colitis or bowel obstruction.
2. Extensive diverticulosis without evidence of acute diverticulitis.
3. The appendix is not seen however there are no secondary CT signs of acute
appendicitis.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT
INDICATION: ___ year old woman with right shoulder pain after fall// fracture?
fracture?
COMPARISON: None
FINDINGS:
The study is compromised secondary to technique. There is no displaced
fracture or dislocation involving the glenohumeral or AC joint. Subtle
abnormalities could be missed. Mild degenerative changes are seen involving
the AC joint. Calcifications are seen overlying the humeral head, calcific
tendinitis should be considered.
IMPRESSION:
Compromised study. No gross displaced fracture.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, s/p Fall
Diagnosed with Urinary tract infection, site not specified
temperature: 98.6
heartrate: 64.0
resprate: 18.0
o2sat: 98.0
sbp: 165.0
dbp: 66.0
level of pain: 5
level of acuity: 2.0 | ## Acute encephalopathy - Resolved. Likely related to possible
UTI, which was treated with ceftriaxone. No electrolyte
abnormalities. No e/o seizure activity.
## Fall
Clear description of mechanical fall. Denied loss of
consciousness, seizure activity, chest pain, SOB. Difficulty
getting up likely due to underlying difficulty with ambulating
due to CVA, also may be due to UTI. No head strike from fall.
## Right shoulder pain, after fall. Shoulder xrays with no overt
fracture, improving.
## Chronic asthma, hyperlidipdemia, neuropathy, hypertension -
continued home medications. BPs stable.
##CVA
##Deconditioning
Worked with ___ during hospitalization, they felt that the
patient was limited by impaired balance and functional mobility
___ decreased strength and endurance consistent with
hospitalization and prolonged time on floor after fall before
being found. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Bactrim / nitrofurantoin
Attending: ___.
Chief Complaint:
Hip pain
Major Surgical or Invasive Procedure:
___ Left hip hemiarthroplasty
History of Present Illness:
Patient is a ___ female with a history of atrial
fibrillation, HFpEF (LVEF 58%), s/p DC PPM placement iso
tachy-brady syndrome ___, hypothyroidism, GERD, depression,
and prior left femoral/femoral neck fracture who presents after
a fall at home.
Patient reportedly fell on her left side, was seen on the ground
unable to get up by her family via a remote camera. Patient
denies any prodrome prior to falling, no palpitations or
lightheadedness/dizziness. She fell backwards while trying to
make her bed. Of note, patient is on apixaban 5 mg twice daily
for atrial fibrillation. Though she stopped taking this ___
days ago in the setting of recurrent rectal bleeding thought to
be secondary to hemorrhoids. Patient denies any loss of
consciousness or head strike. Given significant pain, patient
was transferred to the ___ emergency
department
for urgent evaluation/management.
In the ED, initial vitals: 97 ___ 24 94% RA
- Exam notable for:
No C-spine or back tenderness to palpation, patient is awake and
active. Severe left hip tenderness to palpation, but with a
stable pelvis. Palpable distal pulses.
- Labs notable for:
White blood cell count 11.6 (71.5% PMNs), hemoglobin 10.3 (MCV
90), hematocrit 31.2, platelets 293
Sodium 127, potassium 4.6, chloride 87, bicarbonate 21, BUN 17,
creatinine 1.0, glucose 157 Calcium 9.7, magnesium 2.0,
phosphorous 0.2
___ 10.8, PTT 23.9, INR 1.0
Troponin T less than 0.01
Digoxin level less than 0.4
- Imaging notable for:
CXR
FINDINGS:
There is enlargement of the pulmonary vasculature with mild
interstitial pulmonary edema and stable moderate cardiomegaly.
There is no focal consolidation, pleural effusion, or
pneumothorax. A left pectoral dual lead pacemaker is seen in
unchanged position. Moderate degenerative changes are seen
involving the right glenohumeral joint. Aortic knob
calcifications are noted.
IMPRESSION: Mild interstitial pulmonary edema.
Pelvis/L femur X-ray
Left subcapital femoral neck fracture with superior displacement
of the distal fracture fragment. Left femoral neck fracture with
superior displacement of the
distal fracture fragment.
NCCTH
No acute intracranial process.
CT C-spine
1. No acute fracture or traumatic subluxation.
2. Bilateral cervical ribs.
- Pt given:
___ 19:16 IV HYDROmorphone (Dilaudid) .25 mg
___ 19:51 IV HYDROmorphone (Dilaudid) .5 mg
___ 21:21 IVF LR Started 250 mL/hr
___ 22:03 IV HYDROmorphone (Dilaudid) .5 mg
___ 23:12 PO/NG Diltiazem 120 mg
___ 23:12 IV Diltiazem 10 mg
___ 23:12 IV HYDROmorphone (Dilaudid) .5 mg
___ 23:22 IV Acetaminophen IV 1000 mg
Orthopedics was consulted given displaced left femoral neck
fracture. Plan for OR ___.
- Vitals prior to transfer: Afebrile, 115 132/82 19 95%
Upon arrival to the floor, the patient is in marked pain,
calling out for help from her son who acts as a ___.
Patient is alert and oriented x3. She complains of significant
pain in her L hip and asks that a pillow be placed under her L
foot. She has started to experience diffuse pruritus after
receiving hydromorphone. Additional questioning is limited by
the severity
of patient's pain, though patient does endorse some shortness of
breath and understands that she must wear supplemental oxygen.
As for her hemorrhoidal bleeding, patient's son says that she
will have this from time to time, thought to be a combination of
constipation and ongoing AC. She is scheduled for a surgical
procedure ___. Patient says that she last took apixaban
three
days ago given recurrent bleeding. 10-point ROS is unable to be
obtained given patient's frequent distraction by intense pain.
Of note, patient was last seen in ___ clinic ___. At that
time her pacemaker was functioning well and there were no side
effects from amiodarone. Diltiazem was stopped. Plan had been
for discussion of AVJ ablation should she have recurrence of
atrial fibrillation with fast ventricular rates.
Last pacer transmission was received ___ and showed heart
rates greater than 100 bpm 50% of the time. It seems that
patient was noted to be back in atrial fibrillation by her
family for nearly 3 weeks at the end of ___. Patient's
nephew who is a cardiol___ started her back on diltiazem.
Amiodarone was subsequently discontinued ___.
Past Medical History:
Atrial fibrillation
Sick sinus syndrome/tachybradycardia syndrome s/p PPM placement
___
HFpEF (LVEF 58%)
GERD
Hypothyroidism
Dyslipidemia
Rectal bleeding due to hemorrhoids, has refused colonoscopy in
past
Prior left femoral/femoral neck fracture
Restless leg syndrome
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
=========
VITALS: 98.4 132/63 101 22 94 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear with MMM. EOMI,
PERRL.
Neck: JVP elevated to 3cm below mandible with patient
layingflat.
CV: Tachycardic, irregular rhythm, normal S1 + S2,
systolicmurmur heard throughout the precordium, no rubs or
gallops.
Lungs: Inspiratory crackles to the mid lung fields bilaterally.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding.
Rectal: No external hemorrhoids. No palpable rectal masses. No
blood on glove.
Ext: Warm, well perfused. ___ edema of the bilateral lower
extremities. L hip is internally rotated, skin is intact with
significant tenderness to palpation in the area. L thigh is soft
and L leg is otherwise WWP, DP pulse is 1+.
Skin: Warm, dry, no rashes or notable lesions.
DISCHARGE
=========
PHYSICAL EXAM:
VITALS: Reviewed in OMR
GENERAL: Alert, oriented x3, no acute distress
ENT: NT/AC, MMM, EOMI.
CV: Irregularly irregular, no murmurs, rubs, or gallops
RESP: Mild crackles at the bases bilaterally, normal work of
breathing
GI: NT/ND, BS+
EXT: Warm and well perfused, LEs with 1+ pitting edema.
NEURO: CNII-XII grossly intact, no focal neurologic deficits
Pertinent Results:
ADMISSION
=========
___ 07:10PM WBC-11.6* RBC-3.45* HGB-10.3* HCT-31.2*
MCV-90 MCH-29.9 MCHC-33.0 RDW-13.2 RDWSD-43.6
___ 07:10PM NEUTS-71.5* LYMPHS-18.1* MONOS-8.4 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-8.31* AbsLymp-2.10 AbsMono-0.98*
AbsEos-0.09 AbsBaso-0.03
___ 07:10PM ___ PTT-23.9* ___
___ 07:10PM DIGOXIN-<0.4*
___ 07:10PM TSH-3.0
___ 07:10PM GLUCOSE-157* UREA N-17 CREAT-1.0 SODIUM-127*
POTASSIUM-6.7* CHLORIDE-87* TOTAL CO2-21* ANION GAP-19*
___ 07:10PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.0
DISCHARGE
=========
___ 04:09AM BLOOD WBC-8.9 RBC-3.20* Hgb-9.4* Hct-30.9*
MCV-97 MCH-29.4 MCHC-30.4* RDW-15.8* RDWSD-53.6* Plt ___
___ 11:15AM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-136
K-4.7 Cl-97 HCO3-28 AnGap-11
___ 11:15AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
IMAGING
=======
___ CT Head: No acute intracranial process.
___ CT Spine:
1. No acute fracture or traumatic subluxation.
2. Bilateral cervical ribs.
___ L Knee XR:
1. Severe degenerative changes of the medial and lateral
compartments, which have progressed compared to ___.
2. No acute fracture or subluxation.
___ Pelvis and Femur XR: Left subcapital femoral neck fracture
with superior displacement of the distal fracture fragment.
___ CXR: Mild interstitial pulmonary edema.
___ TTE:
The left atrium is mildly dilated. The right atrium is markedly
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. The inferior vena cava diateter is normal.
There is mild symmetric left
ventricular hypertrophy with a small cavity. There is normal
regional and global left ventricular systolic function. There is
beat-to-beat variability in the left ventricular contractility
due to the irregular rhythm. The visually estimated left
ventricular ejection fraction is >=65%. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Moderately dilated right ventricular cavity with mild
global free wall hypokinesis. Tricuspid annular plane systolic
excursion (TAPSE) is depressed. Intrinsic right ventricular
systolic function is likely lower due to the severity of
tricuspid regurgitation. There is abnormal interventricular
septal motion c/w right ventricular volume overload. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is moderate to
severe [3+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. In the setting of at
least moderate to severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size, and regional/ global systolic function and
beat to beat variability in systolic fucntion. Moderate right
ventricular cavity dilation with mild systolic dysfunction.
Moderate to severe tricuspid regurgitation. At least
moderate to severe pulmonary artery systolic hypertension.
Compared with the prior TTE ___ , there is now volume
overload of the right ventricle. The pulmonary artery pressure
is now severe.
___ CXR: In comparison with the study of ___, there is
little overall change. Cardiomediastinal silhouette is stable
and there is again engorgement of indistinct vessels consistent
with elevated pulmonary venous pressure. Pacer leads remain in
good position. No definite acute focal consolidation.
MICRO/OTHER PERTINENT LABS
===========================
___ 07:10PM BLOOD cTropnT-<0.01 proBNP-1603*
___ 07:10PM BLOOD TSH-3.0
___ 03:43AM BLOOD PTH-100*
___ 03:43AM BLOOD 25VitD-35
___ 07:10PM BLOOD Digoxin-<0.4*
___ 10:17 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. rOPINIRole 0.5 mg PO QAM
6. Sertraline 100 mg PO DAILY
7. Torsemide ___ mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
9. diclofenac sodium 1 appl topical Q12H:PRN pain
10. Docusate Sodium 100 mg PO DAILY:PRN constipation
11. Hydrocortisone (Rectal) 2.5% Cream ___ID
12. melatonin 2 mg oral QHS
13. Psyllium Powder 1 PKT PO DAILY:PRN constipation
14. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
15. rOPINIRole 0.5 mg PO QPM:PRN Pain
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
5. Diltiazem Extended-Release 180 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Torsemide 10 mg PO EVERY OTHER DAY
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
9. Apixaban 2.5 mg PO BID
10. diclofenac sodium 1 appl topical Q12H:PRN pain
11. Docusate Sodium 100 mg PO DAILY:PRN constipation
12. Hydrocortisone (Rectal) 2.5% Cream ___ID
13. Levothyroxine Sodium 100 mcg PO DAILY
14. melatonin 2 mg oral QHS
15. Psyllium Powder 1 PKT PO DAILY:PRN constipation
16. rOPINIRole 0.5 mg PO QAM
17. rOPINIRole 0.5 mg PO QPM:PRN Pain
18. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
19. Sertraline 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
=======
Displaced Left Femoral Neck Fracture
Acute on Chronic Diastolic Heart Failure
Secondary
=========
Atrial Fibrillation
Urinary Tract Infection
Depression
Hypothyroidism
Restless Leg Syndrome
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with s/p fall// eval for acute pathology
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
There is enlargement of the pulmonary vasculature with mild interstitial
pulmonary edema and stable moderate cardiomegaly. There is no focal
consolidation, pleural effusion, or pneumothorax. A left pectoral dual lead
pacemaker is seen in unchanged position. Moderate degenerative changes are
seen involving the right glenohumeral joint. Aortic knob calcifications are
noted.
IMPRESSION:
Mild interstitial pulmonary edema.
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: ___ with left hip pain, s/p fall// eval for fx, acute hemorrhage
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
lateral views of the left hip and femur.
COMPARISON: Radiograph from ___
FINDINGS:
There is an acute fracture through the left femoral neck with superior
displacement of the distal fracture fragment. Chronic fractures are seen
involving the left pubis and inferior pubic ramus. There are severe medial
and lateral compartmental degenerative changes of the left knee. There is no
soft tissue calcification or radio-opaque foreign body.
IMPRESSION:
Left subcapital femoral neck fracture with superior displacement of the distal
fracture fragment.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with TTP overlying the knee. The leg is shortened
and internally rotated// eval for fx
TECHNIQUE: Frontal and lateral view radiographs of the left knee.
COMPARISON: Radiographs of the bilateral knees ___.
FINDINGS:
There is diffuse osteopenia. No fracture or dislocation is seen. There are
severe degenerative changes of the medial and lateral compartments with joint
space narrowing, bone-on-bone contact, subchondral sclerosis and osteophyte
formation. Mild degenerative changes are seen in the patellofemoral
compartment. There is a small suprapatellar joint effusion.
IMPRESSION:
1. Severe degenerative changes of the medial and lateral compartments, which
have progressed compared to ___.
2. No acute fracture or subluxation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with left hip pain, s/p fall// eval for fx, acute hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 8.4 cm; CTDIvol = 47.6 mGy (Head) DLP =
401.4 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
This exam is limited by motion artifact.
There is no evidence of acute territorial infarction,hemorrhage,edema, or
mass. Confluent periventricular and subcortical white matter hypodensities
are nonspecific, l but likely represent sequelae of chronic small vessel
ischemic disease. There is prominence of the ventricles and sulci suggestive
of involutional changes.
There is no evidence of fracture. There is mild mucosal thickening of the
right maxillary sinus and ethmoid air cells. There is partial opacification
of the left mastoid air cells. The visualized portions of the remaining
paranasal sinuses, right mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with left hip pain, s/p fall// eval for fx, acute
hemorrhage
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 24.0 cm; CTDIvol = 22.8 mGy (Body) DLP = 548.8
mGy-cm.
Total DLP (Body) = 549 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No acute fractures are identified.Multilevel
degenerative changes are seen, most extensive at C2-3 and C4-5 and notable for
intervertebral disc height loss, endplate sclerosis and osteophytosis. No
high-grade spinal canal or neural foraminal narrowing.There is no prevertebral
edema. Secretions are demonstrated trachea.
The thyroid and included lung apices are unremarkable. Incidental note is
made of bilateral cervical ribs. Left-sided cardiac pacing leads pass below
the field of view.
IMPRESSION:
1. No acute fracture or traumatic subluxation.
2. Bilateral cervical ribs.
Radiology Report
INDICATION: Left hip hemiarthroplasty.
COMPARISON: Radiographs from ___
IMPRESSION:
There has removal of the left femoral head and placement of a new
hemiarthroplasty. Cerclage wires are seen about the femoral cemented
component. There are no hardware related complications.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF and Afib now with new oxygen
requirement and cough, question pulmonary edema versus pna.// ? Pulmonary
Edema versus pna
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Cardiomediastinal silhouette is stable and there is again engorgement of
indistinct vessels consistent with elevated pulmonary venous pressure. Pacer
leads remain in good position.
No definite acute focal consolidation.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: L Leg injury, s/p Fall
Diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Other fall on same level, initial encounter
temperature: 97.0
heartrate: 118.0
resprate: 24.0
o2sat: 94.0
sbp: 160.0
dbp: 100.0
level of pain: 9
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
Discharge Cr: 0.9
Discharge Hgb: 9.4
[ ] Follow up heart rates on increased diltiazem and new
metoprolol. If persistently well controlled would stop
metoprolol then decrease her diltiazem XR back to 240MG daily.
[ ] Currently on Tylenol, oxycodone 2.5MG Q4PRN for pain,
continue to wean opiates as tolerated. ___ need to decrease
bowel regimen off of opiate medication.
[ ] Monitor volume status with daily weights; decreased
torsemide to 10mg QOD given fluctuating renal function (was on
20mg QOD)
[ ] Would recheck CBC and CHEM7 at PCP follow up from rehab
discharge to ensure stable kidney function and anemia. Consider
repeat iron studies and iron repletion as needed.
[ ] Vitamin D low-normal this admission, continue to monitor and
start supplementation as needed.
[ ] Follow up with orthopedic surgery at outpatient appointment,
may need repeat imaging at this time
[ ] Follow up with Dr. ___ cardiology
#CODE: Full (patient and family have been urged to discuss this
further, apparently patient's husband was given CPR when he did
not want it and this has left its mark on the family)
#CONTACT: ___ (DAUGHTER) ___ |