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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / oxycodone / desmopressin
Attending: ___.
Chief Complaint:
Chest pain/LUQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o GERD, a fib, HTN, HLD who
presents for chest pain.
In the ED, ___ reported having left chest sided chest pain
last night that woke her up from sleep. Reported felt her BP was
high, and reports 213/11. Reported pain felt like it was going
through to her back but was a pressure, ___ that started 11
___
but was "on and off". Reported took Tylenol for the pain. Had
difficulty sleeping ___ pain. Denied numbness or weakness in the
legs or abdominal pain, swelling in LEs but endorsed feeling
weak
and dizzy. Reported the pain is not exertional or change with
movement. Reportd felt very weak. Daughter reports she seemed
lethargic and was shaking and had a little bit of chills; denied
fever. On arrival, pain improved. Denied fever. Endorsed + mild
cough, nonproductive after a cold she had the last few days.
Reported occasional nausea with cough, but no other nausea or
vomiting. Reported 2 episodes of diarrhea, last night, NB.
Denied
dysuria.
Past Medical History:
HTN
Hyperlipidemia
Atrial fibrillation
Anxiety
Arthralgias
h/o colonic polyps
h/o cystocoele
Social History:
___
Family History:
Mom had stroke at age ___, brother had stroke at age ___.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
ADMISSION PHYSICAL EXAM:
VS: 2214 97.3 PO 124 / 60 61 16 96 Ra
GENERAL: NAD, appears comfortable, speech clear and interactive
with interpreter
HEENT: AT/NC, EOMI grossly, PERRL, anicteric sclera, pink
conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, strength
___
in UE and ___ bilaterally, CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: 97.8, 98/58, 60, 18, 97% RA
GENERAL: NAD, appears comfortable, speech clear and interactive
HEENT: AT/NC, EOMI grossly, PERRL
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, strength
___
in UE and ___ bilaterally, CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 12:00PM BLOOD WBC-5.1 RBC-3.61* Hgb-11.2 Hct-31.9*
MCV-88 MCH-31.0 MCHC-35.1 RDW-13.2 RDWSD-43.1 Plt ___
___ 12:00PM BLOOD ___ PTT-36.3 ___
___ 12:00PM BLOOD Glucose-131* UreaN-22* Creat-0.5 Na-121*
K-4.2 Cl-86* HCO3-26 AnGap-12
___ 12:00PM BLOOD Calcium-9.0 Phos-3.0 Mg-1.5*
___ 06:13PM BLOOD Osmolal-258*
___ 06:17PM BLOOD Glucose-130* Na-121* K-3.6 Cl-90*
calHCO3-25
___ 06:17PM BLOOD Hgb-11.8* calcHCT-35
========================
PERTINENT INTERVAL LABS:
========================
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:13PM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
===============
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-3.8* RBC-3.52* Hgb-10.6* Hct-32.6*
MCV-93 MCH-30.1 MCHC-32.5 RDW-13.9 RDWSD-47.2* Plt ___
___ 07:00AM BLOOD Neuts-53.8 ___ Monos-19.7*
Eos-2.1 Baso-0.5 Im ___ AbsNeut-2.04 AbsLymp-0.89*
AbsMono-0.75 AbsEos-0.08 AbsBaso-0.02
___ 07:00AM BLOOD Glucose-137* UreaN-16 Creat-0.6 Na-141
K-4.8 Cl-103 HCO3-26 AnGap-12
___ 07:00AM BLOOD Calcium-9.6 Phos-3.2 Mg-1.9
================
IMAGING STUDIES:
================
CXR (___): No acute cardiopulmonary process.
EKG (___): Normal sinus rhythm at 67bpm, NA, first degree AV
block with PR interval of 250, no ischemic changes
=============
MICROBIOLOGY:
=============
___ 12:49 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Radiology Report
INDICATION: History: ___ with chest pain// acute process?
TECHNIQUE: AP and lateral chest radiograph.
COMPARISON: Chest x-ray ___.
FINDINGS:
EKG leads overlie the chest. The cardiomediastinal silhouette is likely
accentuated due to AP technique. The hila are unremarkable. The lungs are
clear without focal consolidation. There is no pulmonary vascular congestion
or pulmonary edema. There is no pneumothorax or pleural effusion. Severe
bilateral glenohumeral and moderate to severe AC degenerative changes are
incidentally noted, likely with intra-articular bodies seen on the left.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, LUQ abd pain
Diagnosed with Hyperosmolality and hypernatremia
temperature: 97.7
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 143.0
dbp: 75.0
level of pain: 7
level of acuity: 2.0 | ====================
ASSESSMENT AND PLAN:
====================
Ms. ___ is a ___ with h/o GERD, a fib on rivaroxaban, HTN,
HLD who presents for atypical chest pain and found to have
hyponatremia.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Tetracycline
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
L tibia IMN
History of Present Illness:
___ presents s/p fall with left tib/fib fracture. Patient
reports on the day of presentation she was walking over a
slippery area near the beach and slipped and fell. She noted
immediate onset of pain in her left lower extremity. She was
taken to an outside hospital where she underwent plain films
which demonstrated a middle third tib-fib fracture of the left
lower extremity. She additionally obtain some abrasions of the
bilateral lower extremities. She has no focal numbness or
weakness distal to her injury. She is otherwise well.
Past Medical History:
PMH/PSH: Depression and osteoarthritis
Social History:
___
Family History:
Non contributory
Physical Exam:
AFVSS
Gen: A&Ox3, no actue distress
Ext: LLE ___, SILT ___, WWP
Pertinent Results:
___ AP of tib/fib in O.R.:Total fluoroscopy time of 115.2
seconds was recorded. The 10 spot images obtained during
fluoroscopy were brought to our review. Note is made that the
radiologist was not attending the procedure. The findings
demonstrated the process of open reduction internal fixation of
the tibia. Note is made of the presence of comminuted fracture
of the fibula as well.
___ 07:35AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-138
K-3.7 Cl-98 HCO3-33* AnGap-11
___ 07:35AM BLOOD WBC-9.5# RBC-3.41* Hgb-10.2* Hct-29.6*#
MCV-87# MCH-29.9 MCHC-34.4# RDW-12.6 Plt ___
___ 08:25AM BLOOD WBC-6.7 RBC-3.29* Hgb-10.1* Hct-28.9*
MCV-88 MCH-30.7 MCHC-34.9 RDW-13.2 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.1 mg PO DAILY
2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
3. desvenlafaxine succinate 100 mg Oral QD
Discharge Medications:
1. CloniDINE 0.1 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY Duration: 10 Days Start:
___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sub-q Daily for 10 days
following d/c to rehab Disp #*10 Syringe Refills:*0
6. Milk of Magnesia 30 ml PO BID:PRN Constipation
7. Multivitamins 1 CAP PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed for pain control Disp #*70 Tablet Refills:*0
9. Senna 2 TAB PO HS
10. Vitamin D 400 UNIT PO DAILY
11. desvenlafaxine succinate 100 mg Oral QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left tib/fib 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
REASON FOR EXAMINATION: Open reduction internal fixation of the tibial
fracture.
Total fluoroscopy time of 115.2 seconds was recorded. The 10 spot images
obtained during fluoroscopy were brought to our review. Note is made that the
radiologist was not attending the procedure. The findings demonstrated the
process of open reduction internal fixation of the tibia. Note is made of the
presence of comminuted fracture of the fibula as well.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L LEG INJURY
Diagnosed with FX TIBIA W FIBULA NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, TETANUS-DIPHT. TD DT
temperature: 98.9
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 166.0
dbp: 88.0
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 a left tib/fib fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
left tib/fib fracture which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Left craniotomy for ___ Dr. ___
___ of Present Illness:
Patient is a ___ year old female who had a mechanical fall 203
weeks ago striking the left side of her head. She did not lose
consciousness at that time. She had been doing well until
recently when she developed left frontal headaches and
tremulousness of her extremities left greater than right. She
went to the ER at ___ today at the urging of her
family and friends as they felt she had been not acting herself.
While there a Head CT was performed which showed a left SDH
1.5cm in greatest diameter with 1.4cm of midline shift. She was
subsequently sent to ___ for further management and care. She
had been taking asa and naproxen for her headaches. Upon arrival
she complained of left frontal headaches, mild lethargy. She
denies dizziness, nausea, changes in bowel or bladder
habits,difficulty ambulating, or changes in vision, hearing, or
speech
Past Medical History:
HLD, DM2
Social History:
___
___ History:
___
Physical Exam:
On Admission:
Gen: slightly lethargic, WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 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, 4mm to
3mm 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.
Some delayed response to commands at times
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch and proprioception bilaterally
Toes downgoing bilaterally
Coordination: tremulous on FNF L>R but hits target
Upon Discharge:
Awake, alert, aphasic but improving, says her name, "hospital",
month and year. MAE, follows commands. Incision C/D/I.
Pertinent Results:
___ 07:37PM ___ PTT-29.9 ___
___ 07:37PM PLT COUNT-267
___ 07:37PM NEUTS-66.6 ___ MONOS-5.4 EOS-1.9
BASOS-0.5
___ 07:37PM WBC-7.0 RBC-4.02* HGB-11.4* HCT-34.4* MCV-86
MCH-28.3 MCHC-33.1 RDW-13.3
___ 07:37PM estGFR-Using this
___ 07:37PM GLUCOSE-198* UREA N-17 CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ CT head
1. No evidence for fracture or dislocation. Slight
subluxations can probably be explained by substantial facet
joint degenerative changes.
2. Rightward shift of the mid brain associated with uncal
herniation and mass effect from a large left-sided subdural
hematoma, difficult to precisely compare for change compared to
the prior CT.
___ CT head
Post-surgical changes involving the left frontal, temporal, and
parietal regions with small amount of hemorrhage,
pneumocephalus, catheter in place, and effacement of the
adjacent sulci. There is a decreased rightward shift of
normally midline structures to 8 mm compared to 10 mm
previously. Continued followup is recommended
___ CT head
Postsurgical changes along the left convexity with small
amounts
of blood products and pneumocephalus, similar in extent to prior
study;
followup imaging as clinically indicated
MR HEAD W & W/O CONTRAST ___
Status post left frontoparietal craniotomy, in comparison with
the prior head CT, there is a persistent subdural collection,
causing mild
effacement of the sulci and midline shifting towards the right
as described above, followup with head CT is recommended. Small
locules of intracranial gas are redemonstrated. No diffusion
abnormalities are detected to suggest acute or subacute ischemic
changes. There is mild dural enhancement, likely consistent
with the surgical approach
CT head ___:
Improvement of midline shift and L SDH, L hemispheric vasogenic
edema. No acute infarct.
Medications on Admission:
glipizide, metformin, lovastatin,
asa 81
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Phenytoin Sodium Extended 100 mg PO TID
5. Senna 1 TAB PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hemorrhage
Cerebral edema
Altered mental status
Dysphagia
Aphasia
Metabolic Acidosis
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
CT OF THE CERVICAL SPINE
HISTORY: Trauma with subdural hematoma.
COMPARISONS: Prior head CT from earlier on the same day from outside hospital
as scanned into the ___ pacs system.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDINGS:
From C3-C4 through C7-T1, there are moderate facet joint degenerative changes.
These are milder on the right side, noting mild leftward convex curvature
centered along the lower cervical spine, although moderate facet joint
degenerative changes are noted from C5-C6 through C7-T1 on the right side as
well. This appearance may explain why there is mild spondylolisthesis of C5
on C6 and C7 on T1. There is moderate narrowing of the C6-C7 interspaces with
subchondral sclerosis and small marginal osteophytes. There are also small
anterior osteophytes at the C5-C6 level anteriorly. The C1-C2 articulation is
moderately narrowed as well. Although facet hypertrophy is prominent along
the lower levels as described above, there is no evidence for substantial bony
neural foraminal narrowing. There is no evidence for fracture, dislocation,
or prevertebral soft tissue swelling.
There is a large partly visualized left-sided subdural hematoma, which is
difficult to compare directly to the prior imaging for any potential small
changes owing to differences in technique including orientation, uncal
herniation with substantial rightward shift of the brainstem by 6 mm can be
visualized. The partly visualized right lateral ventricle is also dilated up
to 20 mm suggesting a trapped ventricle owing to midline shift.
Interlobular septal thickening at the lung apices and ground glass suggests
mild fluid overload.
IMPRESSION:
1. No evidence for fracture or dislocation. Slight subluxations can probably
be explained by substantial facet joint degenerative changes.
2. Rightward shift of the mid brain associated with uncal herniation and mass
effect from a large left-sided subdural hematoma, difficult to precisely
compare for change compared to the prior CT.
This was discussed at 9:10 p.m. with Dr. ___ immediately after
discovery time by telephone.
Radiology Report
INDICATION: Evaluation of patient status post left subdural hematoma
evacuation.
COMPARISON: Outside hospital head CT from ___.
FINDINGS: Post-surgical changes are noted along the left
frontotemporoparietal region with pneumocephalus, small amount of hyperdense
material suggestive of blood, and hyperdense fluid, and catheter which
terminates at the level of the inferior left temporal lobe. There is
continued mass effect on the adjacent left frontotemporal parietal region with
effacement of the sulci. Additionally, there is a rightward shift of normally
midline structures by 8 mm, decreased in comparison to prior study from
yesterday when it measured 10 mm. The right lateral ventricle appears
dilated. No other new foci of hemorrhage are identified. The patient is
status post left frontal and parietal craniotomy. The visualized mastoid air
cells and paranasal sinuses are clear.
IMPRESSION: Post-surgical changes involving the left frontal, temporal, and
parietal regions with small amount of hemorrhage, pneumocephalus, catheter in
place, and effacement of the adjacent sulci. There is a decreased rightward
shift of normally midline structures to 8 mm compared to 10 mm previously.
Continued followup is recommended.
Radiology Report
HISTORY: ___ female with a history of subdural hemorrhage, status
post craniotomy, now in need of followup.
STUDY: CT of the head without contrast.
COMPARISON: ___ at 3:56 a.m. and outside hospital head CT from ___.
FINDINGS: Again are seen post-craniotomy changes. On the left, the skin
staple line and a drain in place in the subdural space. Collection
demonstrated on outside hospital CT. There is still persist locules of gas
and scattered areas of blood products which appear similar in extent to the
prior exam. There is 6 mm of left-to-right shift of midline structures which
is slightly decreased from prior exam. There continues to be sulcal and left
lateral ventricle effacement on the left. There is no evidence of ventricular
entrapment. The basilar cisterns are patent. The visualized paranasal
sinuses and mastoid air cells are clear.
IMPRESSION: Postsurgical changes along the left convexity with small amounts
of blood products and pneumocephalus, similar in extent to prior study;
followup imaging as clinically indicated.
Radiology Report
INDICATION: ___ female status post craniotomy for evacuation of
subdural hemorrhage. Evaluate for interval change.
COMPARISON: NECTs on ___ and ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
FINDINGS: Again are seen post-craniotomy changes in the left frontoparietal
bones, with skin staples and a drain placed in the subdural space of the left
frontoparietal convexity. There is persistence of locules of gas and
scattered areas of blood products which appear similar in extent to the prior
exam. There is a 6.3 mm left to right shift in the midline structures which
is not significantly changed compared with prior exam. There continues to be
sulcal and left lateral ventricle effacement in the left. There is no
evidence of ventricular entrapment. The basal cisterns are patent. The
visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION: Post-surgical changes along the left convexity with small amount
of blood products and pneumocephalus, similar to prior study.
Radiology Report
STUDY: MRI of the head with and without contrast.
CLINICAL INDICATION: ___ woman with dysphagia, status post
craniotomy.
COMPARISON: Prior head CT dated ___.
TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,
axial FLAIR, axial T2, axial magnetic susceptibility and axial
diffusion-weighted sequences. The T1-weighted images were repeated after the
administration of gadolinium contrast in axial T1, sagittal MP-RAGE and
multiplanar reconstructions were provided.
FINDINGS: The patient is status post left frontoparietal craniotomy and
evacuation of subdural hematoma. There is a drain in place in the subdural
space. Subdural collection remains similar in extension in comparison with
the prior head CT dated ___. Small locules of gas are present.
There is persistent effacement of the sulci and minimal shifting of the
normally midline structures towards the right with approximately 7.5 mm of
rightward deviation. The perimesencephalic cisterns are patent and there is
no evidence of uncal herniation. The maximum thickening of the subdural
collection is approximately 6.9 mm. No diffusion abnormalities are detected
to suggest acute or subacute ischemic changes. The major vascular flow voids
are present with normal distribution. The orbits are unremarkable. The
paranasal sinuses again demonstrate bilateral mucus retention cysts. The
mastoid air cells are clear.
IMPRESSION: Status post left frontoparietal craniotomy, in comparison with
the prior head CT, there is a persistent subdural collection, causing mild
effacement of the sulci and midline shifting towards the right as described
above, followup with head CT is recommended. Small locules of intracranial
gas are redemonstrated. No diffusion abnormalities are detected to suggest
acute or subacute ischemic changes. There is mild dural enhancement, likely
consistent with the surgical approach.
Radiology Report
INDICATION: ___ woman status post NG tube placement, assess for tube
placement.
COMPARISONS: None.
Portable AP upright radiograph of the chest was obtained. Nasogastric tube
courses into the stomach, terminating at the level of pylorus. The lungs are
well expanded and clear. There is no pleural effusion or pneumothorax. The
heart is normal in size. Normal cardiomediastinal contours.
Radiology Report
INDICATION: ___ woman with left subdural, assess NG tube placement.
COMPARISONS: ___.
FINDINGS: Nasogastric tube courses into the stomach, terminating in the
region of pylorus. The lungs are otherwise clear. No pleural effusion or
pneumothorax. The heart is normal in size with normal cardiomediastinal
contours.
Radiology Report
HISTORY: ___ female with subdural hematoma and NG tube placement.
COMPARISON: ___ and ___.
FINDINGS: The lungs are well expanded and clear. There is no pleural
effusion or pneumothorax. Cardiac silhouette and mediastinal contours are
normal. An NG tube is in place, the tip projects over the expected location
of the first portion of the duodenum.
IMPRESSION: No acute chest abnormality.
Radiology Report
INDICATION: Left subdural hematoma. Evaluate for change.
COMPARISONS: CT head ___. CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: There is a hyperdense subdural collection layering over the left
cerebral convexity. The transcalvarial drain has been removed from the
collection, but the collection is unchanged in size and appearance from the
prior exam. Specifically, the distribution of the blood products is
unchanged. The associated mass effect is stable with effacement of the
adjacent sulci and 6 mm of rightward shift of the normal midline structures.
There is mild compression of the right lateral ventricle and effacement of the
left lateral ventricle, but no evidence of entrapment. There has been a slight
decrease in the amount of pneumocephalus. There is no evidence of new
hemorrhage. The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. An NG tube is present.
IMPRESSION:
Unchanged appearance of left subdural hematoma and its associated mass effect,
s/p drain removal.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with SUBDURAL HEM W/O COMA, FALL ON STAIR/STEP NEC, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 76.0
resprate: 16.0
o2sat: 99.0
sbp: 155.0
dbp: 91.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ was admitted to ___ under the care of Dr.
___ and On ___ she was taken emergently to the OR for a
craniotomy. She was trasnferred to the TSICU post-op erativeyl,
CT imaging showed expected post-op changes.
On ___: Repeat Head CT was done earlier due to concern for
increased confusion in TICU; There was slight improvement.
Sutures placed around JP drain site due to bleeding. She was
transferred to the SDU in stable condition on ___. MRI done on
___ was negative for acute or subacute stroke. On ___, her
HCO3 was low at 13, an ABG was ordered which then showed she was
metabolic acidotic. Renal was consulted for further management.
She remained aphasic, following commands, and noded her head
appropriately intermittently. EEG monitoring was started on ___
to further evaluate her aphasia as her MRI head was negative for
stroke. on ___ her NG tube was replaced and tubefeeds were
started. Medicine was consulted for further management of her
DKA. They recommended changing her insulin to regular and when
TF to goal can d/c IVF. Repeat head CT was performed for R
pronator drift which was stable. EEG showed no seizure activity.
NG tube was pulled out by patient overnight.
On ___, her exam improved, she was able to say her name and
hospital. She continued to follow commands. She was able to take
her pills craushed with ice cream, a formal speech and swallow
evaluation was ordered. Her HA1C was 7.8. EEG showed no seziure
activity for 48 hrs and was discontinued.
Patient's examination continued to improve on ___ with her
aphasia demonstrating signs of resolving by her ability to say
her name and current location.
On ___, her staples were removed. Her exam continues to
improve. She received a bed 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:
hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of bladder cancer since ___, prostate cancer,
TCC,left nephroureterectomy with PERC nephrostomy, right renal
pelvic tumor presents from clinic for hyperkalemia and frequent
PVCs on EGK.
Preop appointment for ureteroscopy and ablation next week. He
denies chest pain, shortness of breath, decreased or change in
output from PERC nephrostomy tube, abdominal pain, nausea,
vomiting, diarrhea, fevers or chills. Does endorse some
constipation, sacral pain, PERC nephrostomy discomfort. Last
bowel movement was today and was not black or bloody. He
endorses
occasional red tinge to his PERC neph drain output, but no
clots,
thick or other abnormal drainage.
In the ED, initial VS were:
99.0 76 124/62 18 98% RA
Exam notable for:
Red tinged clear output from PERC nephrostomy tube. No erythema
around the tube site. Mild tenderness to palpation over the tube
site, no CVA tenderness, NTND abd. RRR. CTAB. AAOx3. No c/c/e
Labs showed:
K 5.6, 12.5>11.___/36.5<448
Positive UA
Imaging showed:
CT chest: IMPRESSION:
1. Foci of sclerosis involving the left lateral sixth rib and
T7
vertebral body are new from ___, concerning for
osseous metastatic disease.
2. Unchanged bilateral pulmonary nodules measuring up to 4 mm.
3. Moderate to severe centrilobular emphysema.
CT abdomen:
1. 3.7 x 4.1 cm soft tissue mass likely arising from the
prostate, and obliterating the right seminal vesicles, with
possible early invasion into the adjacent rectum, concerning for
progression of prostate carcinoma in the setting of markedly
elevated PSA.
2. New osseous metastases within L2, L4, L5, left ilium,
sacrum,
and right aspect of the pubic symphysis.
3. New bilateral external iliac and right obturator
lymphadenopathy.
4. New prominent para-aortic and paracaval nodes do not meet
strict criteria
for adenopathy, but are also concerning for metastatic
involvement.
5. Mild right hydronephrosis. Percutaneous nephrostomy tube and
nephroureteral stent in situ. Right peripelvic stranding may
reflect
underlying pyelitis.
6. Post left nephroureterectomy. No recurrent mass at the
nephrectomy bed.
7. Please refer to the separate chest CT dictation regarding
intrathoracic
findings.
Patient received:
___ 21:09 IV CefTRIAXone
___ 22:32 IV CefTRIAXone 1 g
___ 23:15 PO Acetaminophen 1000 mg
Urology was consulted and will continue to follow. No urgent
interventions done given good UOP and no significant change in
baseline GFR.
Transfer VS were:
97.6 71 132/60 20 96% RA
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
1. Bladder cancer since ___, several TURBTs.
2. ___, TURBT low-grade TCC, T1 (microscopic), PNLMP in
urethra.
4. ___, CT chest, multiple bilateral pulmonary nodules
sub-5-mm, nonspecific T8 vertebral body abnormality.
5. ___, CT abdomen, multifocal urothelial CA with
thickened bladder and left renal pelvis with hydronephrosis.
6. ___,, left percutaneous nephroscopy, renal pelvic biopsy
of
low-grade TCC. Ureteroscopy negative, bladder biopsy C/W
low-grade TCC.
7. ___: Robotic left nephroureterectomy: pTa, low grade TCC.
8. ___: Cystoscopy/ureteroscopy, right renal pelvic tumor
ablation, right JJ stent placement.
9. ___, admitted OSH, ___ - Cr 4.3, UTI,
hydronephrosis/ureter
- right perc NT placed, ___.
Social History:
___
Family History:
Diabetes; no GU malignancy
Physical Exam:
================================
ADMISSION PHYSICAL EXAM:
================================
VS: 97.5PO 118 / 69R Sitting 65 18 97 RA
GENERAL: sleepy, NAD, very pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART:distant heart sounds
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. right nephrostomy tube
in place, dressing CDI, right sided positive CVAT
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
====================================
DISCHARGE PHYSICAL EXAM:
====================================
VS: 97.4, 132 / 77, 71, 18, 95 Ra
GENERAL: WD male in bed in NAD, very pleasant
HEENT: AT/NC, EOMI, anicteric sclera
NECK: supple
HEART: distant heart sounds, RRR, no m/r/g
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. right nephrostomy tube
in place, dressing CDI, no erythema or tenderness at the site.
no
CVAT
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
========================
ADMISSION LABS:
========================
___ 12:40PM BLOOD WBC-12.5* RBC-4.30*# Hgb-11.9*#
Hct-36.5*# MCV-85 MCH-27.7 MCHC-32.6 RDW-14.3 RDWSD-43.8 Plt
___
___ 06:00PM BLOOD Neuts-75.5* Lymphs-11.7* Monos-7.3
Eos-4.2 Baso-0.8 Im ___ AbsNeut-7.91* AbsLymp-1.22
AbsMono-0.76 AbsEos-0.44 AbsBaso-0.08
HEMOLYZED: ___ 12:40PM BLOOD UreaN-42* Creat-2.6* Na-138
K-6.3* Cl-98 HCO3-21* AnGap-19*
___ 12:40PM BLOOD PSA-388*
========================
RELEVANT LABS:
========================
___ 06:00PM BLOOD K-4.4
___ 03:05AM BLOOD K-4.9
========================
DISCHARGE LABS:
========================
___ 02:39AM BLOOD WBC-10.9* RBC-4.03* Hgb-11.2* Hct-34.4*
MCV-85 MCH-27.8 MCHC-32.6 RDW-14.2 RDWSD-43.7 Plt ___
___ 02:39AM BLOOD Neuts-75.4* Lymphs-11.8* Monos-7.0
Eos-4.8 Baso-0.6 Im ___ AbsNeut-8.21* AbsLymp-1.29
AbsMono-0.76 AbsEos-0.52 AbsBaso-0.07
___ 02:39AM BLOOD ___ PTT-28.5 ___
___ 02:39AM BLOOD Glucose-92 UreaN-41* Creat-2.4* Na-139
K-5.2* Cl-103 HCO3-21* AnGap-15
___ 02:39AM BLOOD ALT-8 AST-12 LD(LDH)-166 AlkPhos-113
TotBili-0.3
___ 02:39AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.7 Mg-2.3
=========================
IMAGING
=========================
CT CHEST W/O CONTRAST ___
1. Foci of sclerosis involving the left lateral sixth rib and T7
vertebral
body are new from ___, concerning for osseous
metastatic disease.
2. Unchanged bilateral pulmonary nodules measuring up to 4 mm.
3. Moderate to severe centrilobular emphysema.
4. Please refer to separate report for same day CT abdomen
pelvis study for
discussion of findings below the diaphragm.
CT ABD & PELVIS W/O CONTRAST ___
1. 3.7 x 4.1 cm soft tissue mass likely arising from the
prostate, and
obliterating the right seminal vesicles, with possible early
invasion into the
adjacent rectum, concerning for progression of prostate
carcinoma in the
setting of markedly elevated PSA.
2. New osseous metastases within L2, L4, L5, left ilium, sacrum,
and right
aspect of the pubic symphysis.
3. New bilateral external iliac and right obturator
lymphadenopathy.
4. New prominent para-aortic and paracaval nodes do not meet
strict criteria
for adenopathy, but are also concerning for metastatic
involvement.
5. Mild right hydronephrosis. Percutaneous nephrostomy tube and
nephroureteral stent in situ. Right peripelvic stranding may
reflect
underlying pyelitis.
6. Post left nephroureterectomy. No recurrent mass at the
nephrectomy bed.
7. Please refer to the separate chest CT dictation regarding
intrathoracic
findings.
Radiology Report
INDICATION: ___ year old man with h/o prostate ca, bladder ca, s/p
nephroureterectomy, elevated PSA// please evaluate for mets, any abnormalities
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 7.4 mGy (Body) DLP = 485.1
mGy-cm.
Total DLP (Body) = 485 mGy-cm.
COMPARISON: CT from ___. Reference CT from ___.
Abdominopelvic CT from ___.
FINDINGS:
Please refer to the separate chest CT dictation regarding intrathoracic
findings.
The liver density is within normal limits. There is a lobulated 1.4 x 1.2 cm
likely cyst within segment II (series 2, image 47). 6 mm, 8 mm, 10 mm, and 4
mm hypodensities within segments II (series 2, image 49), ___ (series 2, image
50), VI (series 2, image 51), and VI (series 2, image 66), respectively, are
less specific, but appear unchanged in comparison to the ___
study, and are likely benign cysts. No new hepatic lesion is detected. There
is no definite intra extrahepatic bile duct dilation. The gallbladder is
normal. No radiopaque ductal stones are detected.
The pancreas demonstrates normal density and bulk, without duct dilation or
focal lesion.
The spleen size is within normal limits.
The adrenal glands appear normal.
Patient is post left nephroureterectomy. There is mild right hydronephrosis.
A percutaneous nephrostomy tube and nephroureteral stent are present. There
is mild stranding along the right renal pelvis (series 2, image 67). No stone
is identified.
There are enlarged bilateral external iliac lymph nodes, measuring up to 1.5 x
1.2 cm on the left (series 2, image 95) and a 2.1 x 1.7 cm on the right
(series 2, image 97, 88). These are enlarged in comparison to the ___ study. There is a newly enlarged 10 mm obturator node on the
right (series 2, image 101). Prominent para-aortic and paracaval nodes are
new since ___, not meeting strict criteria for adenopathy, but
concerning for disease involvement (series 2, image 77, 70).
The stomach and intra-abdominal and intrapelvic loops of small and large bowel
are normal in caliber. There is no focal gastrointestinal lesion. The
appendix is normal (series 2, image 92).
The bladder is collapsed, and difficult to assess. Arising from the right
pelvis, between the bladder and the rectum, is a 3.7 x 4.1 cm soft tissue
mass, new since the ___ examination, replacing or encasing the
right seminal vesicles (series 2, image 104). This lesion appears contiguous
with the prostate (series 2, image 1017). There is loss of the fat plane
against the adjacent rectum (series 2, image 104, 105), and early invasion
cannot be excluded. A 8 mm right mesorectal node is concerning for tumor
involvement (series 2, image 106).
The abdominal aorta, celiac trunk, SMA, and iliac branches appear normal in
caliber. There is minimal atherosclerotic calcification.
There are multiple sclerotic lesions within the pelvic bones, sacrum, and
lumbar spine are suspicious for metastases, all new since ___:
Anterior L2 vertebral body, 9 mm, series 2, image 61
Anterior L4 vertebral body, 1 mm, series 2, image 74
Left anterior L5 vertebral body, 4 mm, series 2, image 80
6 mm left iliac, series 2, image 81
9 mm and 8 mm right hemi sacrum, series 2, image 86, 88
8 mm, left hemi sacrum, series 2, image 88
16 mm, right aspect of the pubic symphysis series 2, image 109, series 6,
image 27
A moderate left inguinal hernia contains a short segment of the sigmoid colon
(series 2, image 106), without obstruction. There are multiple small
supraumbilical ventral hernias containing fat (series 7, image 34), the
largest protruding through a fascial defect measuring 2.5 cm (series 2, image
60).
IMPRESSION:
1. 3.7 x 4.1 cm soft tissue mass likely arising from the prostate, and
obliterating the right seminal vesicles, with possible early invasion into the
adjacent rectum, concerning for progression of prostate carcinoma in the
setting of markedly elevated PSA.
2. New osseous metastases within L2, L4, L5, left ilium, sacrum, and right
aspect of the pubic symphysis.
3. New bilateral external iliac and right obturator lymphadenopathy.
4. New prominent para-aortic and paracaval nodes do not meet strict criteria
for adenopathy, but are also concerning for metastatic involvement.
5. Mild right hydronephrosis. Percutaneous nephrostomy tube and
nephroureteral stent in situ. Right peripelvic stranding may reflect
underlying pyelitis.
6. Post left nephroureterectomy. No recurrent mass at the nephrectomy bed.
7. Please refer to the separate chest CT dictation regarding intrathoracic
findings.
NOTIFICATION: The impression and recommendation above was entered by Dr. ___
___ on ___ at 17:53 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ man with history of prostate cancer, bladder cancer,
status post nephroureterectomy with elevated PSA. Evaluate for metastatic
disease.
TECHNIQUE: Multi-detector helical scanning of the chest was performed
without intravenous iodinated contrast agent and reconstructed as 5 and 1.25
mm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 7.4 mGy (Body) DLP = 485.1
mGy-cm.
Total DLP (Body) = 485 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: Same day CT abdomen pelvis. Chest CT from ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable.
UPPER ABDOMEN: There is a small hiatal hernia. Please refer to separate
report for same day CT abdomen pelvis study for discussion of findings below
the diaphragm.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. Coronary artery and aortic
annular calcifications are mild. The thoracic aorta is normal in caliber.
There is no pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: The left lung apex is incompletely imaged. Small bilateral
pulmonary nodules measuring up to 4 mm in the right middle lobe (3:179) are
unchanged, and are as follows (3: 106, 156, 84, 142). Biapical scarring is
noted. Moderate to severe centrilobular emphysematous changes are again seen,
worse in the upper lobes. Small bilateral calcified granulomas are again
noted.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally. There is mild-to-moderate diffuse bronchial wall thickening.
3. VESSELS: Main pulmonary artery diameter is within normal limits.
CHEST CAGE: Sclerosis of the left lateral sixth rib (3:106) and a sclerotic
focus in the T7 vertebral body (7:34) are new from ___. There is
no acute fracture. A hemangioma is again seen in the T8 vertebral body.
IMPRESSION:
1. Foci of sclerosis involving the left lateral sixth rib and T7 vertebral
body are new from ___, concerning for osseous metastatic disease.
2. Unchanged bilateral pulmonary nodules measuring up to 4 mm.
3. Moderate to severe centrilobular emphysema.
4. Please refer to separate report for same day CT abdomen pelvis study for
discussion of findings below the diaphragm.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified, Urinary tract infection, site not specified
temperature: 99.0
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 124.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ======================
BRIEF SUMMARY
======================
___ man with history of bladder cancer, prostate cancer,
TCC, left nephroureterectomy with percutaneous nephrostomy,
right renal pelvic tumor who presented from clinic with initial
concern for hyperkalemia and PVCs on ECG.
Initial presenting hyperkalemia was determined to be falsely
elevated from a hemolyzed sample, and repeat potassium was
within normal range.
He was monitored overnight on telemetry, which revealed
occasional PVCs, from which he was asymptomatic. Urine analysis
was possibly suggestion of a UTI, though difficult to interpret
in the setting of his complicated history with percutaneous
nephrostomy tube. Though he was asymptomatic, he did have mild
leukocytosis, so he was treated for UTI with ceftriaxone, then
transitioned to amoxicillin (history of enterococcus UTI in the
past, urine culture is pending), to complete a 7-day course of
antibiotics for complicated UTI.
CT chest/A/P revealed findings concerning for a recurrence of
his prostate cancer (PSA markedly elevated and imaging showing
numerous bone mets and a large mass arising from the prostate).
==========================
PROBLEM-BASED SUMMARY
==========================
ACUTE PROBLEMS:
#Hyperkalemia:
He was found to have K 6.3 at his outpatient urology visit, but
from a hemolyzed specimen. EKG at outpatient visit showed PVCs,
so he was referred to the ED. This admission, he was found to
have potassium levels within the normal range (ranging from 4.4
to 5.2 on nonhemolyzed samples). EKG and telemetry revealed
moderate PVC burden from which was asymptomatic, no other
changes. No intervention was required for pseudohyperkalemia. At
the time of discharge he did have a mild true hyperkalemia which
we did not treat as this is likely chronic and well tolerated in
the setting of his known CKD.
#Premature ventricular contractions:
Occasional PVCs were noted on EKG and telemetry, moderate
burden. Given that his potassium level was within the normal
range, and he was asymptomatic, he did not require further work
up.
#UTI:
He had a UA significant for large leukocytes and large blood, in
the setting of leukocytosis 12.5 on admission. He was
asymptomatic, but in the setting of his complicated medical
history, s/p L nephrectomy and now with R percutaneous
nephrostomy tube and ureter stent, as well as his leukocytosis,
he was treated for possible UTI. He received ceftriaxone
(___), then was transitioned to amoxicillin (as he grew
enterococcus in the past) to complete a total 7-day course of
antibiotics (last day on ___. Urine culture was pending at
discharge. Please follow up urine culture to guide treatment.
#R Nephrostomy tube, ureter stent
#R Hydronephrosis:
He was evaluated by urology who thought his nephrostomy tube to
be draining well, no concern for obstruction despite mild
hydronephrosis noted on CT, without indication for intervention.
He does have hydronephrosis seen at OSH abdominal ultrasound
with right indwelling ureteral stent. He should follow up with
urology regarding scheduled ureteroscopy and laser ablation with
Dr. ___ on ___.
#CKD vs ___:
Creatinine was elevated at 2.4 from prior baseline of around
1.8. Elevated creatinine at this admission likely represents new
baseline creatinine due to progression of his renal disease.
Less likely obstructive ___ from prostate mass. Low concern for
obstruction from nephrostomy tube given urology evaluation with
good urine output.
#Malignancy
#Suspicion for recurrent prostate cancer w/ bone metastasis
He has a history of prostate cancer previously treated in
___, with likely prostatectomy or partial prostatectomy
followed by radiotherapy in ___. PSA had resolved to ___ in
___. Recently, a PSA surveillance at PCP was elevated at 241.
Repeat PSA performed day prior to admission was elevated at 388.
CT torso showed a prostate mass and bony lesions concerning for
metastatic prostate cancer. Patient and his family were made
aware of the imaging findings, and the high suspicion for
recurrence of prostate cancer with metastases. Patient generally
defers medical decision making to his family, but he did ask
questions about the work up his cancer and appears to understand
the situation. Patient and family were informed of the necessity
of oncology follow-up as an outpatient. He has an appointment
scheduled with Dr. ___. He does complain of bony
sacral pain, controlled with Tylenol, possibly related to
malignancy.
CHRONIC PROBLEMS:
#HTN: He was normotensive and was continued on home amlodipine
5mg.
#Constipation: He was continued on home colace PRN.
#Depression: He was continued on home duloxetine.
==========================
TRANSITIONAL ISSUES
==========================
- He will finish total 7-day course of antibiotics, last day of
amoxicillin is on ___.
- Please follow up results of urine culture to guide treatment.
- He has CT findings suspicions for recurrent prostate cancer
with bony metastases, in the setting of elevated PSA. Patient
and family are aware.
New medications: amoxicillin
Changed medications: none
Stopped medications: none
#CODE: Full (presumed)
___
Relationship: wife
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of HTN, HLD, cholecystectomy who was transferred
from OSH for concern for ischemic colitis.
Pt was well until ___ afternoon when she developed sudden
onset of sharp, cramping, severe lower abdominal pain. Pain was
so severe that pt collapsed and briefly lost consciousness. She
then presented to OSH ED where CT scan showed collpase and
thickening of the colon c/w ischemic colitis. Pt was then
transferred to ___ for possible surgical management.
In ED initial vitals were 98.6 66 113/64 20 98%RA. Lactate was
1.0 and WBC was normal. Surgery was consulted and recommended
medical management. Pt given morphine for pain control,
cipro/flagyl for empiric coverage, 2L NS, and was transfered to
floor.
On floor, repeat lactate was 2.1. VS remained stable. This
morning, pt says that her pain was greatly improved and is ___
at rest. She reports three large bowel movements yesterday that
were blood streaked, but not bowel movements since. Denies
nausea, emesis, back pain, CP, SOB, fevers, chills, HA.
Past Medical History:
Lichen Sclerosis
Osteoporosis
HTN
vitiligo/sundamaged skin
polyps found on ___ colonoscopy
GERD
pancreatitis
Social History:
___
Family History:
___ Cancer, HTN died age ___
MGM- died age ___
MGF- died age ___ Hemorrhage
Father-DM, HTN, Heart Disease died age ___
Sister-HTN, one with cancer
Physical Exam:
VITALS: 100.7, 126/64, 70, 20, 97%RA
GENERAL: Sleepy, but in NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, but extremely tender to palpation in LLQ and
around epigastric region no rebound tenderness. BS+
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE:
VS 98-98.7 ___ 100-104/48-54 ___ 96-97%RA
GEN Alert, oriented, no acute distress. thin elderly woman.
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft ND normoactive bowel sounds, no r/g. Minimal TTP in
lower abdomen.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
___ 07:00AM BLOOD WBC-5.6 RBC-3.10* Hgb-10.0* Hct-29.9*
MCV-96 MCH-32.1* MCHC-33.3 RDW-13.1 Plt ___
___ 09:03PM BLOOD WBC-9.0 RBC-3.91* Hgb-12.4 Hct-37.7
MCV-97 MCH-31.8 MCHC-32.9 RDW-12.9 Plt ___
___ 07:00AM BLOOD WBC-6.3 RBC-3.02* Hgb-9.5* Hct-29.4*
MCV-97 MCH-31.4 MCHC-32.3 RDW-13.0 Plt ___
___ 09:03PM BLOOD Neuts-89.9* Lymphs-6.5* Monos-3.4 Eos-0.2
Baso-0.1
___ 07:00AM BLOOD Glucose-102* UreaN-5* Creat-0.5 Na-137
K-3.0* Cl-108 HCO3-22 AnGap-10
___ 09:03PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-143
K-3.6 Cl-109* HCO3-24 AnGap-14
___ 07:00AM BLOOD ALT-27 AST-22 LD(LDH)-151 AlkPhos-32*
TotBili-0.3
___ 09:03PM BLOOD ALT-36 AST-38 AlkPhos-37 TotBili-0.5
___ 09:03PM BLOOD Albumin-4.1
___ 07:20AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.6
___ 09:08PM BLOOD Lactate-1.0
___ 02:51AM BLOOD Lactate-2.1*
___ 08:36AM BLOOD Lactate-1.3
CTA abdomen/pelvis ___:
IMPRESSION:
1. Large bowel wall-thickening and submucosal edema in the
vascular
distribution of the ___. While there is no apparent stenosis or
thrombosis of the ___, proximally, a more distal arterial
occlusion cannot be excluded; however, this overall appearance
of bowel may also be seen with "low-flow" venous ischemia.
Inflammatory and infectious processes also remain differential
diagnostic considerations, that might be assessed by
colonoscopy.
2. Periportal edema and small ascites, particularly perihepatic.
This may relate to the process, #1, above and/or to volume
overload with "third-spacing."
3. Bilateral simple-appearing renal cysts.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
apply to affected area once daily
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
apply to affected area once daily
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with history of hypertension and
hyperlipidemia, presents with intermittent severe abdominal pain, and colonic
thickening seen on OSH NECT; rule out ischemic colitis.
COMPARISON: ___ abdomen and pelvis, ___.
TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis
after the administration of oral and IV contrast. Multiplanar reformatted
images were generated in the sagittal and coronal planes.
DLP: 418.80 mGy-cm.
FINDINGS: There is minimal bibasilar dependent atelectasis. Otherwise, the
visualized lung bases are clear with no nodules, pleural effusions, or
pneumothorax. The visualized portions of the heart and pericardium are
unremarkable in appearance.
CT ABDOMEN: The liver enhances homogeneously without focal lesion or
intrahepatic biliary duct dilatation. There is moderate periportal "lymphatic
tracking" edema, probably not much changed since the previous study. The
gallbladder is surgically absent with surgical clips in place. The spleen,
pancreas, and adrenal glands are unremarkable in appearance. There is a left
renal upper pole subcentimeter hypodensity, too small to fully characterize by
CT, but likely representing a simple renal cyst. There is a 1.7 x 0.9 cm
right renal interpolar simple-appearing cyst. Otherwise, both kidneys present
symmetric nephrograms and excretion of contrast without focal solid lesion,
pelvicaliceal dilatation, or perinephric abnormalities.
The stomach is distended but unremarkable in appearance. The duodenum and
small bowel are unremarkable in appearance with no focal wall thickening or
obstruction. Again seen is moderate bowel wall thickening in the ___ vascular
territory, starting proximally from the splenic flexure, and extending
distally to the proximal sigmoid colon. There is a "targetoid"
cross-sectional appearance of the thickened colon, indicative of
circumferential submucosal edema. However, the degree of mural enhancement in
this segment appears quite similar in comparison to the more normal-appearing
remainder of the large bowel. There is no pneumatosis or mesenteric or portal
venous gas. Overall, the appearance of the bowel is unchanged from previous
study. Of note is interval development of larger amount of ascites, in
particular, perihepatic.
There is moderate calcification of the abdominal aorta and its branches. The
celiac axis, SMA, and bilateral renal arteries appear patent at their origins.
Specifically, the origin and proximal portion of the ___ are visualized and
appear patent; however, its mid- and distal portions are not well-visualized,
due to scanning technique and contrast bolus timing. There is no
intraabdominal free air or hernia noted. There are no enlarged mesenteric or
retroperitoneal lymph nodes by CT size criteria.
CT PELVIS: The bladder is distended but unremarkable in appearance. The
uterus and bilateral ovaries are unremarkable in appearance. There is a small
amount of fluid in the cul-de-sac, unchanged from previous exam. The rectum
is unremarkable in appearance. There are no enlarged inguinal or pelvic wall
lymph nodes by CT size criteria.
OSSEOUS STRUCTURES: Degenerative changes of thoracolumbar spine, with most
severe disc space loss at L5/S1. There are no -blastic or -lytic lesions in
the visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Large bowel wall-thickening and submucosal edema in the vascular
distribution of the ___. While there is no apparent stenosis or thrombosis of
the ___, proximally, a more distal arterial occlusion cannot be excluded;
however, this overall appearance of bowel may also be seen with "low-flow"
venous ischemia. Inflammatory and infectious processes also remain
differential diagnostic considerations, that might be assessed by colonoscopy.
2. Periportal edema and small ascites, particularly perihepatic. This may
relate to the process, #1, above and/or to volume overload with
"third-spacing."
3. Bilateral simple-appearing renal cysts.
COMMENT: A "wet read" was entered into RIS-web by Dr. ___ discussed with
Dr. ___, ___ at 9:40 p.m. on ___. His preliminary findings
are concordant with the final interpretation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ISCHEMIC CHOLITIS
Diagnosed with NONINF GASTROENTERIT NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.6
heartrate: 66.0
resprate: 20.0
o2sat: 98.0
sbp: 113.0
dbp: 64.0
level of pain: 8
level of acuity: 2.0 | # Colitis - There was initial concern for ischemic colitis that
would require surgical intervention. Lactate was 1.0 on arrival,
increased to 2.0 several hours later, but repeat lactate was
1.3. Patient clinically improved quickly, and surgery was not
necessary. Presentation and CTA findings were consistent with
ischemic colitis in ___ distribution, but
infectious/inflammatory colitis could not be excluded as no
occlusion was seen in ___. Ciprofloxacin and flagyl were
continued throughout admission and stool studies were sent and
pending upon discharge. Patient was without abdominal pain and
was tolerating PO.
# Hypotension: Pt was borderline hypotensive with complains of
intermittent lightheadedness. Lisinopril was held and IVF @
125cc/hr given. When patient was able to take PO, fluid and salt
intake encouraged. BPs returned to normal when patient returned
to normal diet and she was no longer lightheadeded.
# Anemia: Patient reported bloody bowel movements, but they
ceased after admission. Hemoglobin decreased with hydration from
12.4 on admission to a low of 9.5. It rose to 10.0 on day of
admission. Transfusion was not required.
# Hypokalemia: Was likely due to GI losses. Resolved with
repletion.
# HTN: Lisinopril was held due to borderline hypotension. Pt
instructed not to restart his medication until she followed-up
with her PCP.
# Hyperlipidemia: Stable. Continued simvastatin, aspirin 81mg.
# GERD: Stable. Continued omeprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ s/p C6/C7 anterior discectomy/fusion on ___
for syrinx and C6/7 disc herniation who was recently discharged
on ___ and now presents with return of neck pain which she
describes as pulsatile and worse than any pain she had after the
surgery. She was actually off of pain medication from ___ -
___, however the pain returned yesterday and has gotten
progressively worse since. She was taking PO dilaudid w/o
relief. Had nausea w/3 episodes nbnb vomiting. No fevers/chills.
Feels fatigued from not eating/drinking, but no focal weakness.
No UE numbness or tingling.
Of note, she was admitted from ___ for her elective
surgery, as she wished to have decompression to avoid further
injury in the future. She also needed neurosurgery clearance for
her police academy given her cervical syrinx found on prior
imaging. Post-operatively, her pain had been controlled with
oxycodone and IV dilaudid that was switched to po dilaudid. She
also complained of numbness on the R side of her body. Her
symptoms improved by the time of discharge and she was
discharged on po dilaudid ___ mg q4hr:prn as well as bisacodyl.
She was scheduled to f/u with Dr. ___ on ___.
In the ED, initial vitals were: 99.6 78 128/83 18 100%. Labs
significant for a Hct 34.9 (was 38 on ___. Was given IV
zofran and dilaudid 1mg which improved pain temporarily. She
later received po dilaudid 4 mg and tizanidine with litting
improvement in her pain. On exam, she had neck pain and back
pain radiating down the R leg. Neurosurgery was consulted, and
after review of her C-spine imaging, did not feel that surgical
intervention was necessary. She was therefore admitted to
medicine for pain control. VS upon transfer: 98.0 71 101/69 18.
On the floor, Ms. ___ was very frustrated that she had
experienced no pain prior to surgery, essentially no pain
immediately after surgery, and now is in severe pain. She had
even requested to return to work early because she felt so well.
She complained of nausea, photophobia, shock-like sensations
down her neck, pain in her low back, "stabbing" pain in her R
leg, subjective L arm weakness, and subjective L leg weakness.
She also experienced significant itching from the dilaudid.
After admission to the floor, she was given dilaudid IV 2mg q2
and ondansetron. Her pain was poorly controlled and she required
an additional 2mg at 2:30. She also was nauseous after 8mg of
ondansetron and required compazine and lorazepam. Her itching
became severe and she required po and IV benadryl.
Review of systems:
(+) Per HPI, all other ROS negative
Past Medical History:
C6/7 disc herniation and syrinx that is causing central
stenosis, s/p formal decompression to avoid further injury, s/p
C6/7 anterior cerivcal discectomy/fusion on ___.
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
====================
Temp 97.8, BP 137/60, HR 71, RR 18, 100% RA
General: Alert, oriented, in significant distress from pain,
unable to lie flat on back
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Healing anterior incision covered in steri-strips, no erythema,
crepitus, or purulence.
Neck: difficulty moving neck due to pain
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Patient fully oriented.
+ photophobia, ___ strength in right upper extremity, ___
strenght in left upper extremity. Strength symmetric and ___ in
lower extremities (limited by pain.) Intact fine touch sensation
in all extremities. CN II-XII intact.
MSK: tenderness to palpation along spinous processes from the
T10-sacral region. Tenderness to palpation over the paraspinal
muscles on the right over the T10 to sacral distribution.
Positive straight leg raise.
PHYSICAL EXAM DISCHARGE:
==================
Temp 97.7, BP 101/53, HR 67, RR 18, 97% RA
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Healing anterior incision covered in steri-strips, no erythema,
crepitus, or purulence.
Neck: normal teck range of motion
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Patient fully oriented. CN II-XII intact.
___ strength in right upper extremity and left upper extremity.
Strength symmetric ___ in lower extremities (previously limited
by pain.) Intact fine touch sensation in all extremities.
MSK: Mild tenderness to palpation over the paraspinal muscles on
the right over the T10 to sacral distribution. Positive straight
leg raise.
Pertinent Results:
PERTINENT LABS:
==============
___ 02:28PM BLOOD WBC-5.3 RBC-3.85* Hgb-12.3 Hct-34.9*
MCV-91 MCH-32.0 MCHC-35.3* RDW-12.2 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-140 K-3.9
Cl-103 HCO3-29 AnGap-12
___ 06:10AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.9
___ 06:40AM BLOOD Ferritn-64
___ 06:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 Iron-121
IMAGING:
======
IMPRESSION:
Status post C6/7 anterior fusion without evidence of hardware
complications or
change in alignment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Bisacodyl 10 mg PO DAILY
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
4. Sarna Lotion 1 Appl TP TID:PRN Itchyness
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Cyclobenzaprine 5 mg PO TID:PRN back pain/muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN back pain Duration: 10 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN severe pain Duration: 3
Days
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Radiculopathy/Muscle Spasm
Nausea
Headache
Secondary:
C6/7 disc herniation and syrinx s/p C6/7 anterior cerivcal
discectomy/fusion on ___.
Secondary:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with recent diskectomy / anterior fusion
TECHNIQUE: Two views of the cervical spine
COMPARISON: ___
FINDINGS:
The patient is status post C6/C7 anterior fusion accomplished by an anterior
plate with 2 pairs of screws and intervertebral disc spacer device. No
evidence of hardware complications or change in alignment. No new fracture or
subluxation. Minimal prevertebral soft tissue swelling persists, and likely
reflective of recent surgery. Previously noted subcutaneous emphysema appears
improved. Visualized lung apices are clear.
IMPRESSION:
Status post C6/7 anterior fusion without evidence of hardware complications or
change in alignment.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Neck pain
Diagnosed with CERVICALGIA, ABN REACT-PROCEDURE NOS
temperature: 99.6
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 83.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a23F s/p C6/C7 anterior discectomy/fusion on ___
for syrinx and C67 disc herniation, discharged on ___ who
initially presented with acute neck pain. While in the hospital
she developed thoraco/lumbar/sacral musculoskeletal pain with
radation down the right posterior thigh concerning for muscle
spasm and radiculopathy.
#Radiculopathy
While the patient was in the ED and turning to her side she
noted sudden onset lower back pain with radiation down her right
posterior thigh. Her symptoms were thought to be consistent with
a radiculopathy and muscle spasm as she had tenderness to
palpation over the paraspinal muscles and positive straight leg
raise. Neurologically the patient's exam remained normal with
the exception of strength in the right lower extremity initially
that was limited by pain though improved prior to discharge.
Imaging of the region was not felt to be warranted given lack of
true focal neuro deficits on exam, patient's age, and no
previous history of malignancy, fevers or IVDU. She was
initially given dilaudid with minimal relief of her symptoms and
profuse itching secondarily. Dilaudid was subsequently
discontinued. She was then started on muscle relaxant, IV
toradol, ultram, and gabapentin with improvement of her pain.
She was discharged with a 10 day course of gabapentin, tramadol,
ibuprofen, flexeril for pain managment and plan for physical
therapy. She was also provided with omeprazole to take in the
setting of her high dose NSAID use. Prior to discharge she was
ambulating the floors without significant pain.
# Cervical syrinx s/p C6/C7 anterior discectomy/fusion with
anterior neck pain.
Ms. ___ was admitted to the hospital for neck pain and nausea.
She was assessed by the neurosurgery team and had imaging of her
C-spine that did not show any complications or change in
alignment from her recent surgery. In addition Ms. ___
incision site was without evidence of skin or soft tissue
infection with well-healing scar in the post-surgical period. It
was thought that her worsening neck pain that brought her into
the hospital was secondary to overuse/strain in the setting of
recently walking 6 miles after being relatively inactive.
#Headache
#Nausea
She was also noted to have a headache, nausea/dry heaving, and
dizziness. It was thought very unlikely that her symptoms were
due to meningitis because she was without elevated white count
or fever throughout the course of her hospitalization, no
meningismus or other infectious signs. It was thought that her
symptoms were most likely due to a viral syndrome and improved
prior to discharge. Her nausea was treated with zofran and
compazine with QTc monitoring.
#Normocytic Anemia Hg/Hct 12.3/ 34.9 MCV 91
Patient with anemia noted on CBC to somewhat be expected in the
setting of her age and menstruation with some drop likely
diluational in nature in setting of IVF. Iron studies including
ferritin and serum iron were obtained and normal. |
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:
Ms. ___ is a ___ otherwise healthy woman who presents
with 2 days of severe abdominal pain. She reports that the pain
started about 2 days ago and was mostly in her left lower
quadrant, radiates to the back. It became more severe over the
next few days she also had intermittent diarrhea. Her last
bowel movement was yesterday evening, described as nonbloody.
She has been able to tolerate p.o., and denies nausea or
vomiting. She does endorse subjective fevers and chills at
home. She has not had any urinary symptoms. Of note, she states
that
she had similar pain about 6 weeks ago that improved without any
intervention over the course of the week. She has not had any
prior episodes other than these 2.
Review of systems is negative other than noted in HPI.
Past Medical History:
None
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical examination upon admission:
T: 98.0, HR 81, BP 98/55, RR 18, 98% RA
GEN: Appears in no acute distress, alert and oriented ×3,
uncomfortable laying in bed
CV: Regular rate and rhythm
Pulm: Clear to auscultation
Abdomen: Soft, mildly distended, tender to palpation most
significantly in left lower quadrant, no rebound or guarding
Extremities: Warm and well perfused, no edema
Physical examination upon discharge
T: 97.6, BP 96 / 63, HR 77, RR 18, 99 % RA
GEN: Appears in no acute distress, alert and oriented ×3,
uncomfortable laying in bed
CV: Regular rate and rhythm
Pulm: Clear to auscultation
Abdomen: Soft, non distended, non tender to palpation, no
rebound or guarding
Extremities: Warm and well perfused, no edema
Pertinent Results:
Laboratory results:
___ 02:45AM BLOOD WBC-19.7* RBC-4.76 Hgb-13.6 Hct-41.3
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 RDWSD-42.1 Plt ___
___ 07:52AM BLOOD WBC-16.3* RBC-4.62 Hgb-13.4 Hct-41.2
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.4 RDWSD-44.0 Plt ___
___ 07:55AM BLOOD WBC-11.2* RBC-4.26 Hgb-12.2 Hct-37.5
MCV-88 MCH-28.6 MCHC-32.5 RDW-13.2 RDWSD-42.8 Plt ___
___ 07:30AM BLOOD WBC-9.6 RBC-4.04 Hgb-11.6 Hct-35.0 MCV-87
MCH-28.7 MCHC-33.1 RDW-13.2 RDWSD-42.3 Plt ___
Imaging:
CTU (ABD/PEL) W/O CONTRAST (___):
Impression: Diverticulitis with phlegmon and mild scattered
pneumoperitoneum, but no fluid collection.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with llq ttpNO_PO contrast// eval
diverticulitis, stone
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 5.1 s, 56.4 cm; CTDIvol = 15.0 mGy (Body) DLP = 848.1
mGy-cm.
Total DLP (Body) = 848 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
Evaluation is somewhat limited by respiratory motion artifact.
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There 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. There is diverticulosis of the
proximal sigmoid colon in the left lower quadrant with significant surrounding
fat stranding, moderate surrounding mesenteric haziness, and peritoneal
thickening. There is mild scattered pneumoperitoneum. No fluid collection.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
Diverticulitis with phlegmon and mild scattered pneumoperitoneum, but no fluid
collection.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding
temperature: 98.9
heartrate: 104.0
resprate: 20.0
o2sat: 100.0
sbp: 134.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | The patient presented to Emergency Department on ___. She
was diagnosed to have acute uncomplicated diverticulitis and was
admitted to Acute Care Surgery unit for appropriate management.
She was made NPO, put on antibiotics (IV ciproflagyl and PO
metronidazole) and IV fluids.
During the entire hospital course review of systems had as
follow:
Neuro: The patient was alert and oriented throughout
hospitalization and pain was well managed.
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. She was
therefore, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Her white cell count
trended from 19.7 to 9.6 on discharge.
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
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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
placement of IVC filter ___
History of Present Illness:
___ yo M h/o NSCLC with mets to brain p/w one week of dyspnea. Pt
reports one week of dyspnea with cough productive of blood
clots. Denies CP/abd pain. +mild nausea without vomiting.
.
Pt dx'd with lung CA in ___. He has declined chemotherapy
in the past due to negative experiences when wife had
chemotherapy for lung CA. Pt is now s/p whole brain XRT for
mets.
.
In the ED: T 98.4, 90/52, hr 80, 24, 89% ra. cxr showed large r
opacity and large pleural effusion. cta showed numerous large
segmental and lobar PEs with R-sided necrotic mass. LENIs showed
L DVT and R superficial clot. CT head showed multiple mets with
? internal hemorrhage. Pt given asa 325 mg po, levofloxacin 750
mg iv, morphine 15 mg po. Dr. ___ with oncology service had GOC
discussion with patient in the ED: Pt is now DNR/DNI and given
the risks for bleeding has declined heparin treatment of
DVT/PEs. Pt was amenable to IVC filter placement, which occured
via ___ prior to transfer to the floor.
.
ROS: as above. o/w complete ROS negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
He had acute onset of hemoptysis and cough in early ___.
He initially presented to ___ where he was given a course of
antibiotics; hemoptysis persisted and he presented to ___
___ on ___. Mr. ___ had a bronchoscopy
with bronchial washings and brushings in the right lower lobe on
___. The pathology noted atypical cells in the
washings; however, the brushings were negative for malignant
cells. No micro samples were sent.
A CT scan of the chest was performed on ___ with note
of a heterogeneous ~6 cm mass in the RLL. He had a CT-guided
biopsy of mass on ___. The pathology report from that
procedure
notes "acute and organizing pneumonia with abundant
lymphoplasmacytic chronic inflammation, reactive pneumocyte
atypia, and frequent hemosiderin-laden macrophages in the
alveolar spaces." Bug stains were negative and no malignancy
was
identified in that sample. Repeat CT-guided biopsy of the right
lower lobe mass was done on ___ which showed "lung
tissue with organizing pneumonia with areas of necrosis and
atypical type 2
pneumocyte hyperplasia." Bug stains were again negative.
On ___ he uderwent transbronchial biopsy at ___ which
yielded a sample that showed non-small cell lung cancer, facor
adenocarcinoma type.
PAST MEDICAL HISTORY:
1. Emphysema/COPD.
2. Hyperlipidemia.
3. GERD.
4. Prostate cancer (___) status post brachytherapy.
5. Status post back surgery (___).
6. Status post AAA repair (___).
7. Status post cholecystectomy (___).
8. Status post carotid artery endarterectomy on the left (___).
Social History:
___
Family History:
Mother - lymphoma (died at age ___.
Father - emphysema (died at age ___.
Brother - coronary artery disease.
Children - all healthy.
Physical Exam:
t 97.2 bp 120/70 hr 80 rr 24 sat 96% 6L FM
gen: nad, speaking in full sentences
eomi, perrl
no ___
neck supple
chest: clear
irreg irreg
abd benign
ext w/wp, trace pedal edema
neuro: non-focal
skin: no rash
ivc filter site: no hematoma/bruit, non-ttp
Pertinent Results:
___ 09:28PM ___
___ 03:05PM ___ COMMENTS-GREEN TOP
___ 03:05PM LACTATE-3.3*
___ 02:55PM GLUCOSE-141* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-20
___ 02:55PM estGFR-Using this
___ 02:55PM cTropnT-<0.01
___ 02:55PM WBC-12.9*# RBC-3.83* HGB-9.9* HCT-32.4*
MCV-85 MCH-25.9* MCHC-30.6* RDW-16.1*
___ 02:55PM NEUTS-88* BANDS-1 LYMPHS-6* MONOS-4 EOS-0
BASOS-0 ___ MYELOS-1*
___ 02:55PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+
PENCIL-1+ TEARDROP-OCCASIONAL
___ 02:55PM PLT SMR-HIGH PLT COUNT-546*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs bid
2. Metoclopramide 10 mg PO QIDACHS
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
4. Ranitidine 150 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Aspirin 81 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Ranitidine 150 mg PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs bid
7. Tiotropium Bromide 1 CAP IH DAILY
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
___
Secondary:
pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: History of lung cancer with hypoxia and tachycardia.
COMPARISON: Chest radiograph from ___ and CTA chest from ___.
FINDINGS:
Single portable chest radiograph was provided. Again seen is a large right
lower lobe opacity, representing known mass. Superinfection cannot be
excluded. A small small-to-moderate right pleural effusion is seen and
appears increased since the prior exam. Hyperlucency of the upper lung zones
and hyperinflation is consistent with known emphysema. There is no
pneumothorax. No left pleural effusion is identified. The cardiomediastinal
silhouette is normal. A VP shunt catheter courses along the right hemithorax
and is incompletely imaged.
IMPRESSION:
1. Large opacity within the right lower lobe representing known mass.
Superinfection cannot be excluded with subtle suggestio of associated air
bronchograms.
2. Increasing right pleural effusion.
Radiology Report
INDICATION: ___ with SOB, hypoxia, active cancer
COMPARISON: CTA chest ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest
after administration of 100 cc of Omnipaque IV contrast. Multiplanar axial,
coronal, sagittal and oblique maximum intensity projection images were
generated.
TOTAL BODY DLP: 314.67 mGy-cm.
FINDINGS:
CT CHEST WITH CONTRAST: There is no axillary, mediastinal, or hilar
lymphadenopathy. The partially visualized thyroid is unremarkable. The
airways are patent to the subsegmental level. The large mass in the right
lower lobe is larger now, approximately 7.9 x 8 cm and contains areas of
central hypodensity and locules of gas compatible with necrosis and increasing
liquefaction, more prominent since the prior study. There are adjacent
opacities, which may represent infection versus spread of malignancy.
Additionally, there is atelectasis and a small right pleural effusion. There
are several scattered calcified pleural plaques throughout the thorax. There
is a severe background of centrilobular emphysema.
Although this study is not designed for evaluation of intra-abdominal
structures, the visualized solid organs and stomach are unremarkable.
CTA OF THE CHEST: There are numerous lobar and segmental PEs bilaterally
involving the bilateral upper lobes, right middle and lingular lobes, and left
lower lobe. There is no evidence of parenchymal infarct. The heart shows
evidence of subtle flattening of the intraventricular septum, which may
represent early heart failure. There is no pericardial effusion. The aorta
and main thoracic vessels are well opacified. The aorta demonstrates normal
caliber throughout the thorax without intramural hematoma or dissection.
OSSEOUS STRUCTURES: There are no concerning blastic or lytic lesions.
IMPRESSION:
1. Numerous lobar and segmental PEs bilaterally as detailed above. Subtle
flattening of the interventricular septum of the heart may suggest early heart
failure. This can be further evaluated for on echocardiogram. There is no
evidence of parenchymal infarct.
2. Growing mass in the right lower lobe with liquefaction and locules of gas.
Opacities adjacent to the large mass may represent infection versus spread of
malignancy.
3. Severe background of centrilobular emphysema.
Radiology Report
EXAM: Bilateral lower extremity Doppler ultrasound.
CLINICAL INFORMATION: Metastatic lung cancer and new pulmonary embolism.
COMPARISON: None.
FINDINGS: Realtime grayscale, color and spectral sonographic evaluation of
bilateral common femoral, superficial femoral, and popliteal veins was
performed. On the right, thrombus is seen in the lesser saphenous vein with
close proximity to the popliteal vein, approximately within 1 cm. Otherwise,
there is normal compressibility and wall-to-wall color flow of the right
common femoral, superficial femoral, and popliteal veins. There is normal
compressibility and color flow seen in the right posterior tibial and peroneal
veins.
On the left, there is evidence of deep venous thrombosis involving the distal
popliteal vein extending into at least one of the posterior tibial veins. The
peroneal veins appear compressible. There is normal compressibility,
wall-to-wall color flow in the left common femoral and superficial femoral
veins. Some subcutaneous edema is seen in the left calf.
IMPRESSION:
1. Deep venous thrombosis involving the distal left popliteal vein with
extension into at least one of the left posterior tibial veins.
2. Thrombus in the lesser saphenous vein, which is a superficial vein,
however, comes in close proximity to the popliteal vein, approximately within
1 cm.
Radiology Report
EXAM: Non-contrast-enhanced CT of the head.
CLINICAL INFORMATION: Brain mets, need heparin for PE, question new mets.
COMPARISON: Head CT from ___ and ___, and brain MRI from
___.
TECHNIQUE: Non-contrast-enhanced CT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
FINDINGS: A right frontal approach ventricular shunt catheter is again seen,
terminating in the right lateral ventricle, near the midline. Prominence of
the ventricles and sulci is stable. Multiple hyperdense metastatic lesions
are seen, including involving the right midbrain, which grossly appears
smaller compared to the prior study, today measuring 0.9 x 0.7 cm compared to
the today's measurement of the prior study of 1.3 x 1.1 cm. However, full
extent is better assessed on MRI. Right temporal lobe lesion, which was
previously seen to be partially hyperdense, has now increased region of
hyperdensity, with the region of hyperdensity measuring approximately 0.8 x
0.3 cm with possible internal calcification. While the increase in
hyperdensity may relate to increase in cell content, hemorrhagic component is
not excluded. Hemorrhage could be better evaluated for/or excluded on
susceptibility sequences on MRI. Additional mets seen on prior MRI, including
in the right post-central gyrus, in the inferior right parietal lobe, and in
the right occipital lobe are better seen on MRI. Gray-white matter
differentiation is preserved. The visualized paranasal sinuses and the
mastoid air cells are clear. Right frontal burr hole is seen. No acute
fracture is seen.
IMPRESSION: Multiple metastatic lesions, as above, most of which are better
assessed on MRI. Right temporal lobe lesion has increased region of
hyperdensity on the current study, which may be due to increase in size of the
lesion/increase in cell content, however, hemorrhagic component is not
entirely excluded and could be excluded on MRI susceptibility sequence.
Radiology Report
HISTORY: Metastatic lung cancer with new bilateral pulmonary emboli and left
lower lobe extremity DVT with guaic positive stools.
COMPARISON: ___ PET CT from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 0.5 mg of Versed throughout the total intra-service
time of 23 minutes during which the patient's hemodynamic parameters were
continuously monitored.
MEDICATIONS: None.
CONTRAST: 50 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 4.6 min, 63 mGy
PROCEDURE:
1. Left common iliac vein and IVC venogram.
2. Infrarenal permanent Venentech IVC filter deployment.
3. Post filter placement venogram.
PROCEDURE DETAILS:
Following the explanation of the risks, benefits and alternatives to the
procedure, written informed consent was obtained. The patient was brought to
the angiography suite and placed supine on the imaging table. Both groins
were prepped and draped in the usual sterile fashion. A pre-procedure timeout
was performed using three patient identifiers.
Under ultrasound and fluoroscopic guidance, the right common femoral vein was
punctured using a 19 guage needle. A ___ wire was advanced through the
needle into the inferior vena cava. Next, an Omniflush catheter was advanced
over the wire into the IVC. The ___ wire was exchanged for an angled
Glidewire, which was advanced into the left common iliac vein and the catheter
tip was advanced into the left common iliac vein.
A left common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
permanent Venatech filter. The catheter and sheath were removed over the wire
and the sheath of an Venentech filter was advanced over the wire into the IVC
past the take off of the renal vessels. An Venentech inferior vena cava
filter was advanced over the wire until the cranial tip was at the level of
the inferior margin of the right renal vein. The sheath was then withdrawn
until the filter was deployed. The wire and loading device were then removed
through the sheath and a repeat contrast injection was performed, confirming
appropriate filter positioning.
The sheath was removed and pressure was held for 10 minutes, at which point
stasis was achieved. A sterile dressing was applied. The patient tolerated
the procedure well and there was no immediate post procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal permanent Venatech IVC filter.
IMPRESSION:
Successful deployment of permanent Venatech IVC filter.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 98.4
heartrate: 80.0
resprate: 24.0
o2sat: 89.0
sbp: 90.0
dbp: 52.0
level of pain: 4
level of acuity: 1.0 | ___ yo male with metastatic NSCLC now here with dyspnea, found to
have DVT and PE. CT head showed multiple metastatic lesions,
and
a hemorrhagic component could not be entirely excluded. Thus,
pt
was not started on anticoagulation. He did have an IVC filter
placed on ___.
# Metastatic NSCLC: discussed with Dr. ___ contacted Dr
___. Radiation oncology determinted that XRT to tumor
would not be beneficial from a palliative perspective for his
hemoptysis. Patient and family met with palliative care on ___
and elected for ___. I discussed his plan with his
daughter ___ on ___ and they would prefer to avoid outpatient
appointments for now. They know that they can call us in the
clinic at any point for assistance. He will be continued on
oxygen and morphine for pain and dyspnea control.
# DVT/PEs: Due to brain mets and intermittent hemoptysis as well
as pt's preference, pt was not started on anticoagulation. IVC
filter was placed. No concern for pneumonia.
# COPD: Continued Albuterol, Tiotropium, Symbicort for
symptomatic
relief.
# DVT ppx: Pneumoboots
# Code status: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Ultram / Motrin
Attending: ___.
Chief Complaint:
___ s/p L-S fusion by Dr. ___ on ___ complains of fevers,
chills, and pain. Patient states he has been having pain in his
right buttocks and RLE since before his surgery. He states it
has never improved and has in fact gotten worse. He also reports
fevers to 103 at home as well as chills. His physical therapist
noted drainage from the wound. He was started on bactrim by his
pcp which he finished yesterday. He denies focal weakness,
saddle anesthesia, urinary incontinence, cough, shortness of
breath, dysuria. He does report intermittent tingling in his RLE
which he had prior to the surgery.
Major Surgical or Invasive Procedure:
None
Past Medical History:
R shoulde surgery
ORIF R ankle ___
R L5-S1 discectomy
Social History:
___
Family History:
N/C
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hours
Disp #*60 Tablet Refills:*0
2. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
RX *oxycodone [OxyContin] 80 mg 1 tablet extended release 12
hr(s) by mouth q8hours Disp #*60 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN headache
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 900 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Postoperative fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Fever.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
right middle lobe opacity. There is eventration of the anterior right
diaphragm. Findings may in part relate to atelectasis, findings are
concerning for pneumonia given clinical scenario. The left lung is clear.
There is no pleural effusion or pneumothorax. The cardiac and mediastinal
silhouettes are unremarkable.
IMPRESSION: Right middle lobe consolidation worrisome for pneumonia.
Radiology Report
EXAM: Lumbar spine, AP and lateral views and coned-down lateral views, three
views.
CLINICAL INFORMATION: History of spinal fusion, now with severe lower back
pain and fever.
___ as well as spot fluoroscopic intraoperative images
from ___.
FINDINGS: Patient is status post posterior metallic fusion of L5 and S1.
Interbody disc spacer is also seen. Grossly anatomic alignment is maintained.
No definite cortical destruction is seen. There is no evidence of acute
fracture or dislocation. The pubic symphysis and sacroiliac joints are
intact.
IMPRESSION: Status post posterior metallic fusion of L5 and S1 in anatomic
alignment without evidence of acute fracture or dislocation. Please note that
CT may be more sensitive in evaluating for infection.
Radiology Report
LUMBAR SPINE CT WITHOUT CONTRAST, ___
INDICATION: History of two prior L5-S1 decompressions, now status post L5-S1
posterior interbody fusion and posterolateral fusion on ___. Patient
presents with worsening pain and reported history of fever, though afebrile in
the hospital. Concern for hardware shift.
COMPARISON: Intraoperative lumbar spine radiographs from ___ and
post-operative lumbar spine radiographs from ___. ___
lumbar spine MRI from ___.
TECHNIQUE: Axial non-contrast multidetector CT images of the lumbar spine
with sagittal and coronal reformatted images.
FINDINGS: Caudal to the most inferior rib-bearing vertebra, four lumbar-type
vertebrae are identified. The most caudal lumbar-type vertebra has been
labeled L5 on prior imaging studies and in the ___ surgical note. The
same numbering is continued in this report, with the lumbar vertebrae labeled
L2 through L5. The numbering is documented on series 7B, image 18.
At L5-S1, the interbody device is located to the right of midline, extending
to the ventral margin of the right neural foramen. It appears appropriately
centered in the anterior-posterior dimension. There is erosion of the right
inferior endplate of L5 overlying the device, concerning for loosening as well
as infection, given the history of fever. Alignment of L5 and S1 vertebral
bodies is normal.
There is evidence of partial right facetectomy at L5-S1. There is
instrumented posterior fusion of L5 and S1 with paired pedicle screws, which
appear well positioned, as well as two posterior plates.
Evaluation for an epidural collection on CT is markedly limited. There is
edema in the posterior paravertebral muscles and subcutaneous fat at the level
of the surgery. Evaluation for an associated fluid collection is limited, but
none is definitively identified.
Cranial to L5, vertebral body heights and disc space heights are preserved.
Alignment is normal. There is a mild disc bulge at L4-5, similar to the prior
MRI, without significant spinal canal or neural foraminal narrowing.
The imaged intra-abdominal soft tissues are grossly unremarkable on limited
non-contrast assessment.
IMPRESSION:
1. There are four lumbar-type vertebrae, labeled L2 through L5, congruent
with the numbering on prior imaging studies and the ___ operative note.
2. The intervertebral device at L5-S1 is located to the right of midline,
extending to the ventral margin of the right neural foramen. There is no other
post-operative CT for comparison.
3. Erosion of the right inferior endplate of L5 overlying the interbody
device, suggesting loosening and the possibility of infection, given the
history of fever. MRI would be more sensitive for evaluating extend of
infection, as well as detecting an epidural collection or paravertebral
collection, if clinically warranted.
4. Posterior fusion hardware at L5 and S1 appears unremarkable without
evidence for complications.
Findings were discussed by Dr. ___ with Dr. ___ over the
telephone on ___ at 4:30 pm.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: FEVER,CHILLS PAIN
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.0
heartrate: 108.0
resprate: 20.0
o2sat: 94.0
sbp: 130.0
dbp: 66.0
level of pain: 10
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service.
Intravenous antibiotics were not given. His inflammatory
markers were trended and improved through his hospital admission
as did his pain. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left-sided weakness, left visual field cut, headache
Major Surgical or Invasive Procedure:
___ angiogram with R ICA stenting
___ angiogram with clot aspiriation
History of Present Illness:
HPI: The patient is an ___ year old right handed woman who
presents with about 18 hours of headache, lightheadedness,
intermittent dysarthria, left lower face weakness, and
difficulty
using the left side. She only has a known history of
hypertension
(on two medications and aspirin) and possibly hyperlipidemia
(not
on medications). She has been feeling well recently with no
recent injury or illness. She was doing ___ cleaning in her
house yesterday but did not think she overexerted herself. She
has been eating and drinking okay. Last evening around 19:30 ___,
she developed a right temporal pulsatile headache; she has no
history of migraines and does not usually have unilateral or
pounding headaches. She typically has bifrontal dull achy
headaches once or twice per month that resolve with
acetaminophen. She took two acetaminophen and felt somewhat
better. She went to bed at 21:30 ___. She awoke at 06:30 AM and
felt lightheaded. There was no vertigo or gait imbalance. Her
husband (who has hearing loss) thought she may or may not have
been harder to understand in terms of her enunciation. She
reports feeling "odd" but denied any other symptoms including
neck pain, palpitations, chest pain, nausea, dyspnea on
exertion,
vision changes, or difficulty moving her arms and legs.
Nonetheless, she and her husband went to ___ in the
morning where some basic studies were performed, and she was
sent
back home. When her son took her home, he noticed as she was
getting out of the car that her left arm and leg didn't seem to
be moving in a coordinated fashion, and when she gave her
something to drink some of it spilled out of the left side of
her
mouth. He thought that she seemed "not herself" and had
asymmetry
of her face on the left. This prompted him to bring her to our
Emergency Department. Here, due to an unknown time of onset of
symptoms, a Code Stroke was not called, but Neurology was
consulted after it was discovered on examination that she had a
left-sided visual field cut.
The patient herself is only aware of the lightheadedness and
headache from last night. She denies any other symptoms and is
unaware of her deficits which include a left homonymous
hemianopia, mild left lower face weakness, and left sided
sensory
neglect. Her CT did not reveal a hypodensity to explain her
symptoms but the impression was for a small choroidal territory
stroke from hypoperfusion or embolization. A CTA revealed a very
stenotic right ICA origin. We discussed the case with Vascular
Surgery for possible carotid endarterectomy and were planning to
admit her to the Neurology service with efforts to maintain
perfusion and on a heparin infusion. However, in the ED, she
suddenly became less alert, had a right gaze deviation, and
stopped moving her left arm with her right arm raised above her
head. Her SBP was in the 140s (she presented in the 190s-200s).
This only lasted a minute or so but raised concern for seizure
activity from the EM team. When the EM physician evaluated her,
she was already improving and these symptoms had resolved by the
time we returned. A repeat NCHCT did not show hemorrhage but did
show more established mild hypodensities in a watershed
territory
in the right cerebral hemisphere. She did have left hemineglect
(did not initially recognize her hand) and brisker reflexes on
the left. In this setting Vascular Surgery decided that carotid
endarterectomy may be too risky and asked Neurosurgery to
consult
for possible stenting; our Neurosurgery colleagues evaluated her
and are planning to take her to the Neurointerventional suite
for
carotid angiography and possible carotid artery stenting.
On review of systems, the patient endorses: lightheadedness
(only), recent mild-moderate headache.
On review of systems, the patient denies the following:
- Neurologic: confusion, difficulty producing speech, difficulty
understanding speech, vision loss, diplopia, vertigo,
dysarthria,
dysphagia, focal limb weakness, sensory loss, gait imbalance.
- Constitutional: fever, rigors, night sweats, unintentional
weight loss.
- Cardiovascular: chest pain, palpitations.
- Gastrointestinal: nausea, emesis, diarrhea, constipation.
- Genitourinary: dysuria, urinary urgency, urinary incontinence.
- Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea,
odynophagia.
- Hematologic: bleeding, easy bruising.
- Musculoskeletal: arthralgia, myalgia.
- Psychiatric: anxiety, depression.
- Respiratory: dyspnea, cough, hematemesis.
- Skin: rash, new skin lesions.
Past Medical History:
HTN, HL
Social History:
___
Family History:
No known neurologic diseases including no
strokes. No MIs. Some hypertension in the family.
Physical Exam:
Physical Examination:
VS T: 99 HR: 75 BP: ___ RR: 20 SaO2: 99% RA
- General/Constitutional: Lying in bed comfortably,
well-appearing elderly woman.
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: Poor dentition, artificial upper teeth. No
oropharyngeal lesions. No external auditory canal lesions.
- Neck: No meningismus. No carotid, vertebral, or subclavian
bruits appreciated. No lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally. No focal spinal tenderness.
- Skin: No rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate. Regular rhythm. No murmurs,
rubs,
or gallops appreciated. Normal distal pulses.
- Respiratory: Lungs clear to auscultation bilaterally. No
crackles. No wheezes.
- Gastrointestinal: Soft. Nontender. Nondistended.
- Psychiatric: Mood congruent with affect. Intact insight.
Neurologic Examination (around 1330):
- Mental Status - Awake, alert. Oriented to name, birth place,
current location, year. Attention to examiner easily attained
and
maintained. Recalls a coherent history, but not aware of any
deficits. Speech is fluent with full sentences. Follows midline
and appendicular commands. Intact repetition. Intact high
frequency and low frequency naming. No paraphasias. Normal
prosody. No dysarthria. No ideomotor apraxia. Tactile
hemineglect
to DSS only.
- Cranial Nerves - [II] Pupils 2->1 brisk, right oblong and left
round (both post-surgical for cataracts). Left homonymonus
hemianopia. [III, IV, VI] EOMI, no nystagmus, saccadic
intrusions
with horizontal gaze bilaterally. [V] V1-V3 without deficits to
light touch bilaterally. [VII] No facial movement asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
- Motor - Diminished bulk of the small muscles of the hands,
normal tone. No pronation, left parietal drift (upwards). No
tremor, asterixis, or myoclonus.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5- 5 5 5 5 5
5-
R 5 5 5 5 5- 5 5 5 5 5
5-
- Sensory - No deficits to cold temperature or proprioception
(at
the feet) bilaterally. Extinction to double simultaneous tactile
stimulation on the left. Misses nose as target when retracting
hand from outstretched position with eyes closed.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response obscured by withdrawal bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Intact cadence and accuracy with rapid alternating
movements (finger tap).
- Gait - Normal initiation. Stable stance with narrow base.
Romberg sign is absent. Normal stride length. Normal arm swing.
No sway with standard gait. No sway with turns.
DISCHARGE EXAM:
MS - knows she is in a hospital, can sometimes say ___
as an answer, knows the year the month, but not the date. Can
follow simple commands, can say ___ word sentences, occasionally
getting up to 5 words in a row, but has not yet been 7 (fluent).
CN - left facial droop, right gaze preference
MOTOR - moves everything antigravity, but is weaker on the left
side.
SENSORY - mildly decreased sensation on the left side
GAIT - deferred
Pertinent Results:
Admission Labs:
___ 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:30PM ___ PTT-27.5 ___
___ 12:30PM PLT COUNT-221
___ 12:30PM NEUTS-76.6* LYMPHS-16.2* MONOS-5.0 EOS-1.2
BASOS-1.0
___ 12:30PM WBC-7.3 RBC-3.90* HGB-12.6 HCT-38.1 MCV-98
MCH-32.2* MCHC-33.1 RDW-13.0
___ 12:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:30PM URINE GR HOLD-HOLD
___ 12:30PM URINE HOURS-RANDOM
___ 12:30PM URINE HOURS-RANDOM
___ 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-6* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 12:30PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.1
MAGNESIUM-2.1
___ 12:30PM cTropnT-<0.01
___ 12:30PM LIPASE-27
___ 12:30PM ALT(SGPT)-16 AST(SGOT)-28 ALK PHOS-63 TOT
BILI-0.4
___ 12:30PM estGFR-Using this
___ 12:30PM GLUCOSE-99 UREA N-11 CREAT-0.7 SODIUM-135
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16
___ 12:50PM LACTATE-1.6
___ 08:50PM ___ PTT-30.0 ___
___ 08:50PM PLT COUNT-209
___ 08:50PM WBC-6.7 RBC-3.63* HGB-11.5* HCT-35.1* MCV-97
MCH-31.6 MCHC-32.7 RDW-13.1
___ 08:50PM CALCIUM-7.6* PHOSPHATE-3.1 MAGNESIUM-1.6
___ 08:50PM CK-MB-4 cTropnT-<0.01
___ 08:50PM CK(CPK)-152
___ 08:50PM GLUCOSE-131* UREA N-9 CREAT-0.6 SODIUM-127*
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-17* ANION GAP-13
___ 10:45PM freeCa-1.08*
___ 10:45PM HGB-10.9* calcHCT-33
___ 10:45PM GLUCOSE-133* LACTATE-1.1 NA+-131* K+-3.5
CL--100
___ 10:45PM PO2-315* PCO2-43 PH-7.36 TOTAL CO2-25 BASE
XS--1.
.
Dishcarge Labs:
___ 05:17AM BLOOD WBC-9.8 RBC-2.96* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.6 MCHC-32.2 RDW-14.9 Plt ___
___ 05:17AM BLOOD Glucose-128* UreaN-14 Creat-1.1 Na-137
K-4.3 Cl-103 HCO3-24 AnGap-14
___ 05:17AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0
___ 05:17AM BLOOD Vanco-17.9
.
Microbiology:
# Blood Culture x2 (___): Coag Negative Staph
# Urine Culture (___): No growth.
# Urine Culture (___): No growth.
# Blood Culture x2 (___): No growth.
.
Pathology: None.
.
Imaging/Studies :
# CTA Neck (___): High-grade stenosis (70-80%) at the
bifurcation the right internal carotid artery that extends
approximately 1 cm into the internal carotid artery. The 3D
reformations are pending. Once the 3D reformations are obtained
an addendum will be issued if any changes are identified.
# CXR (___): 1. No evidence of acute cardiopulmonary
process.
2. Moderately severe compression fracture at thoracolumbar
junction of
uncertain chronicity. Correlate clinically for acuity.
# CT Head W/O contrast (___): No evidence of acute
hemorrhage or infarct. 2. Interval placement of right internal
carotid artery metallic stent with complete occlusion of the
entire internal carotid artery. Minimal collateral retrograde
flow is seen at the most distal aspect of the supra clinoid
segment. The right MCA demonstrates markedly decreased flow. The
left-sided vasculature for is well patent with adequate arterial
flow.
# CT abd/pelvis (___): 1. No retroperitoneal hematoma. Mild
stranding in the right inguinal region and pelvis with a local
rectus sheeth expansion, compatible with a small amount hematoma
in this area.
2. 1.3 cm heavily calcified splenic artery aneurysm, located at
the hilum. 3. 2 hypodense lesions within the pancreas, likely
representing cystic lesions. Further evaluation with MRI is
recommended non emergently if clinically indicated. 4.
Indeterminate left renal hypodensity measuring 2.8 cm, which may
represent a cyst. This can be further evaluated at the time of
pancreatic MRI.
# Trans-Thoracic ECHO (___): No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Normal LV wall thickness, cavity size,
and global systolic function (biplane LVEF = 75 %). The
estimated cardiac index is high (>4.0L/min/m2). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension.
IMPRESSION: Normal biventricular regional/global systolic
function. Hyperdynamic left ventricle with high cardiac index.
Grade I diastolic dysfunction with elevated left ventricular
enddiastolic pressure. Mild to moderate mitral and mild aortic
regurgitation.
# MRI Head (___): Restricted diffusion in the right basal
ganglia, right insula and throughout the right parietal and
temporal lobes consistent with acute ischemia in the territory
of the M1 segment of the right middle cerebral artery.
# CXR (___): New nasogastric drainage tube ends low in
nondistended stomach.
# CXR (___): Endotracheal tube has been removed. A feeding
tube is again seen. Heart size is within normal limits. There
has been interval development of increased pulmonary
interstitial markings suggestive of pulmonary edema. There is
no focal consolidation, although there are more confluent
densities at the right base. There are no pneumothoraces
identified.
# CXR (___): Mild pulmonary edema developed between ___
and ___. Subsequently, the edema has improved somewhat,
but there is more consolidation at the right lung base that
could be due either to atelectasis or new pneumonia. The heart
size is top normal. Nasogastric tube passes into the stomach
and out of view. Pleural effusions are small. No pneumothorax.
Dr. ___ was paged at 12:30 as soon as the study was reviewed.
# Video Swallow Eval (___): Gross aspiration of nectar
thickened barium and inability to form bolus with pureed barium.
# CXR (___): As compared to the previous radiograph, the
patient has received a right-sided PICC line. The tip of the
line projects over the lower SVC. The course of the line is
unremarkable, no evidence of complications, notably no
pneumothorax. Otherwise, the radiograph is unchanged, including
the presence of a nasogastric tube.
# CT abd/pelvis (___): 1. Small right pelvic hematoma, likely
related to prior arterial puncture for cerebral angiography. 2.
Right colic venous gas as well as venous gas in the left hepatic
lobe, without associated pneumatosis, likely benign in nature.
Correlation with
serum lactate and serial physical exam is recommended. 3. New
moderate right and small left nonhemorrhagic pleural effusions.
4. 1.8 cm pancreatic cystic lesion. If serial CT imaging is
planned for this
patient, this lesion could be followed up on these studies.
Otherwise, the standard recommendation for followup would be an
MRCP in 6 months.
5. Unchanged benign appearing left renal cysts. 6. Extensive
diverticulosis, without evidence of diverticulitis. Rectal fecal
loading.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. ALPRAZolam 0.25 mg PO BID:PRN anxiety
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Acetaminophen 650 mg PR Q6H:PRN pain, fever
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fluconazole 200 mg PO Q24H
9. Metoprolol Tartrate 50 mg PO BID
Hold for HR < 60 or SBP < 110
10. Piperacillin-Tazobactam 4.5 g IV Q8H
11. Senna 8.6 mg PO BID
12. Vancomycin 1000 mg IV Q 12H
13. Amlodipine 10 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA infarct resulting from Right Carotid Stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with HTN p/w left lower face weakness,
homonymous hemianopia,tactile hemineglect; tight right ICA stenosis // assess
for cerebral infarction (embolic versus hypoperfusion), other pathology
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: CTA head of ___.
FINDINGS:
There is restricted diffusion in the right basal ganglia, right insula and
throughout much of the right parietal and temporal lobes consistent with acute
ischemia. There is corresponding FLAIR and T2 hyperintensity. There is no
evidence of intracranial hemorrhage or hemorrhagic conversion. A flow voids in
the M1 segment of the right middle cerebral artery appears attenuated compared
to the left M1 segment but patent.
Prominence of the ventricles and sulci likely represents age-related
involutional changes. Subcortical and periventricular FLAIR and T2
hyperintensities most likely the sequela of chronic small vessel ischemic
disease.
IMPRESSION:
Restricted diffusion in the right basal ganglia, right insula and throughout
the right parietal and temporal lobes consistent with acute ischemia in the
territory of the M1 segment of the right middle cerebral artery.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:13 ___, minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old woman with stroke and just got an intervention now
with worseningexam // eval for bleeding or extension of the stroke
TECHNIQUE: Using a multi detector CT scanner, volumetric data was acquired
through the head and collimated at 5 mm slice thickness. In addition,
contrast-enhanced volumetric data was acquired through the head following the
uncomplicated administration of intravenous contrast and collimated at 1.25 mm
slice thickness. Sagittal, coronal and axial maximum intensity projections
were also generated. Images were processed on a separate workstation with
display 3D volume rendered images, and maximum intensity projection images.
DOSE: DLP: 1721.28 mGy.cm
COMPARISON: CTA head and neck with and without contrast ___ at
14:19.
FINDINGS:
CT Head: There is no evidence of hemorrhage, midline shift, mass, mass effect,
or acute infarction. The ventricles, sulci and basal cisterns are normal in
caliber and configuration. No fractures are identified.
There is mild mucosal thickening of the maxillary and sphenoid sinuses.
CTA Head: A partially visualized right internal carotid artery metallic stent
has been placed in the interval. There is complete occlusion of the visualized
extracranial internal carotid artery including cervical, petrosal, cavernous
and supraclinoid segments. There is minimal contrast enhancement of the most
distal supra clinoid right ICA, from collateral flow. There is mild
opacification of the right MCA, which is markedly diminished compared to prior
study performed several hr earlier on the same date, as well as decreased flow
compared to the left-sided vasculature. The right A1 segment is not opacified,
although prior examination showed a hypoplastic right A1 segment.
The other vessels, including the left internal carotid artery, left middle
cerebral and anterior cerebral arteries and posterior circulation demonstrates
unchanged and adequate opacification, compared to earlier study. Again seen is
moderate atherosclerotic calcification of the bilateral carotid siphons.
There is adequate opacification of the right anterior cerebral artery distal
to the Acom. The posterior communicating arteries are not seen.
There is no evidence of aneurysm formation.
IMPRESSION:
1. No evidence of acute hemorrhage or infarct.
2. Interval placement of right internal carotid artery metallic stent with
complete occlusion of the entire internal carotid artery. Minimal collateral
retrograde flow is seen at the most distal aspect of the supra clinoid
segment. The right MCA demonstrates markedly decreased flow. The left-sided
vasculature for is well patent with adequate arterial flow.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 8:35 ___, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ year old woman with recent interventional procedure with groin
access ; evaluate for retroperitoneal hematoma
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
contrast. Coronal and sagittal reformations were performed.
DOSE: DLP: 669 mGy-cm.
COMPARISON: None.
FINDINGS:
ABDOMEN:
LUNG BASES: Clear. Normal heart size.
LIVER: Homogenous attenuation with no evidence of solid mass. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
GALLBLADDER: Normal.
PANCREAS: 0.9 cm hypodensity in the tail of the pancreas. A second hypodense
lesion is present at the neck of the pancreas measure 1.3 cm 7. There is no
ductal dilatation. The pancreas is otherwise normal in appearance.
SPLEEN: Normal.
ADRENALS: Normal.
KIDNEYS: Normal. There is no evidence of stones, solid mass, or
hydronephrosis. Two left renal hypodense lesions are present, larger
measuring 2.8 cm and the smaller measuring 1.7 cm. The smaller lesion is
compatible with a cyst, the larger is indeterminate.
BOWEL: Normal in caliber without evidence of obstruction.
RETROPERITONEUM: There is no enlarged retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: The abdominal aorta demonstrates significant atherosclerosis
throughout the aorta with atherosclerosis at the origin of the branch vessels.
The right groin catheter sheath is present and terminates in the infrarenal
abdominal aorta. There is a 1.3 cm heavily calcified splenic artery aneurysm
located at the hilum.
PELVIS:
URINARY BLADDER: Full contrast, likely due to recent procedure. There is a
small amount of urine within the bladder, despite the presence of a Foley
catheter.
LYMPHADENOPATHY: There are no enlarged pelvic or inguinal lymphadenopathy.
FREE FLUID: Small amount of stranding in the right pelvis near the groin,
likely representing a small amount of hemorrhage. Small hematoma in the
rectus musculature on the right at the inguinal canal, measuring 1.8 x 2.6 cm
(2: 71). There is no retroperitoneal hematoma.
BONES: There are no suspicious osseous lesions. Moderate to severe compression
fracture of the T12 vertebral body. There is mild compression of L1 vertebral
body as well. Degenerative disc disease at L5-S1.
IMPRESSION:
1. No retroperitoneal hematoma. Mild stranding in the right inguinal region
and pelvis with a local rectus sheeth expansion, compatible with a small
amount hematoma in this area.
2. 1.3 cm heavily calcified splenic artery aneurysm, located at the hilum.
3. 2 hypodense lesions within the pancreas, likely representing cystic
lesions. Further evaluation with MRI is recommended non emergently if
clinically indicated.
4. Indeterminate left renal hypodensity measuring 2.8 cm, which may represent
a cyst. This can be further evaluated at the time of pancreatic MRI.
Radiology Report
RADIOLOGY PROCEDURE NOTE
SERVICE: Neurosurgery.
PROCEDURE PERFORMED: Diagnostic cerebral angiography with acute right ICA
clot thrombolysis and aspiration.
INDICATIONS: Ms. ___ is an ___ white female who presented with
acutely symptomatic stroke and critical right ICA stenosis of 90% or greater.
She underwent uncomplicated carotid stenting and received aspirin and Plavix.
Postoperatively, she had done well initially and her exam was the same.
However, she became more somnolent and less interactive, so CT was done
demonstrating no flow to the carotid stent. After a long discussion with the
family regarding implications of retreatment, potential for thrombus or
thrombolysis, as well as the risk for reperfusion hemorrhage, decision was
made to give her IV Integrilin at a loading dose and then bring her down to
the angio suite for possible thrombo aspiration.
ATTENDING: Dr. ___.
ASSISTANT: Dr. ___, Dr. ___.
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF THE PROCEDURE: Ms. ___ was brought to the neuroangio suite,
immediately intubated, and placed on the neuroangio table. Bilateral groins
were prepped and draped in the usual sterile fashion. The sheath from the
previous procedure had been left in and an exchange for the ___ wire was
used to place a new 8 ___ sheath and then a 9 ___ sheath. A 5 ___
___ 2 catheter was then connected to an RSV, contrast power injector and
continuous heparinized saline flush, and used to in ___ configuration
access the right common carotid artery. Runs were used to demonstrate
occlusion of the stent. Next, under roadmap guidance, an exchange length
0.038 Terumo Glidewire was used to remove the ___ 2 for a 9 ___ ___
balloon guide catheter after the balloon had been prepped. This was placed
within the distal common carotid artery. 4MAX reperfusion catheter was then
brought up to the proximal face of the clot and then balloon catheter was
inflated and mechanical aspiration was used on the clock for roughly two
minutes. After this, the catheter was brought back with aspiration and then
the balloon was deflated. Intracranial runs were then performed and the
catheter was removed and the sheath was left sutured in place.
IMAGING FINDINGS:
1. Initial angiography demonstrates injection within the common carotid
artery with good filling down into the external carotid artery as well as
reflux down into the subclavian and vertebral artery. There is evidence of
in-stent thrombosis with complete occlusion in the mid stent with no filling
of the ICA distally. Intracranial runs demonstrate this further with
preserved external carotid artery filling and slow reflux and reperfusion of
the ICA and MCA distribution through collaterals through the external carotid
artery and the ophthalmic artery. Final post clot aspiration imaging
demonstrates good filling through the common carotid artery and the external
carotid artery with open flow through the ICA. There remains stenosis within
the actual stent and residual stenosis per NASCET criteria measures 49%. Flow
is seen at good timing through the internal carotid artery through the ICA and
out into the MCA distribution with no obvious complete cut-off in the distal
MCA distribution. There is a plaque and thrombus seen within the internal
carotid artery, both within the cervical ICA as well as higher at the ICA
bifurcation at the end of the procedure. Due to the risk of bleeding and
significant reperfusion hemorrhage, feeling was that adding any further
antiplatelet agent or anticoagulant at this point would lead to increased
reperfusion hemorrhage risk.
CONCLUSIONS:
1. Complete occlusion in her right ICA stent, status post thrombo aspiration
with recanalization of the ICA to 49% stenosis with some distal thrombus seen
within the ICA.
Radiology Report
AP CHEST, 12:43 P.M., ___
HISTORY: ___ woman with stroke and nasogastric tube placement.
IMPRESSION: AP chest compared to ___:
New nasogastric drainage tube ends low in nondistended stomach.
Lungs are fully expanded and clear. Pleural effusion is small, if any. ET
tube in standard placement. Heart size normal.
Radiology Report
STUDY: AP chest, ___.
HISTORY: ___ woman with stroke. Status post extubation.
FINDINGS: Comparison is made to previous study from ___.
Endotracheal tube has been removed. A feeding tube is again seen. Heart size
is within normal limits. There has been interval development of increased
pulmonary interstitial markings suggestive of pulmonary edema. There is no
focal consolidation, although there are more confluent densities at the right
base. There are no pneumothoraces identified.
Radiology Report
AP CHEST, 9:36 A.M., ___
HISTORY: An ___ woman with stroke. Rule out pneumonia.
IMPRESSION: AP chest compared to ___ and ___:
Mild pulmonary edema developed between ___ and ___. Subsequently,
the edema has improved somewhat, but there is more consolidation at the right
lung base that could be due either to atelectasis or new pneumonia. The heart
size is top normal. Nasogastric tube passes into the stomach and out of view.
Pleural effusions are small. No pneumothorax. Dr. ___ was paged at 12:30
as soon as the study was reviewed.
Radiology Report
EXAMINATION: Video oropharyngeal swallowing examination
INDICATION: Episodes of dysphagia and possible aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None
FINDINGS:
Limited examination was performed due to patient's clinical status. There is
gross aspiration of nectar with inadequate bolus formation attempted
swallowing of purees/thickened barium. Exam was halted at this point and the
residual barium was suctioned from the patient's oropharynx. Transferred
images are slightly limited due to degraded image quality injure in
transferring to the speech and language pathologist's workstation and then to
PACS. Original images, viewed at the fluoroscopy machine during the study were
of greater quality and satisfactory for diagnosis.
IMPRESSION:
Gross aspiration of nectar thickened barium and inability to form bolus with
pureed barium.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The tip of the line projects over the lower SVC. The
course of the line is unremarkable, no evidence of complications, notably no
pneumothorax. Otherwise, the radiograph is unchanged, including the presence
of a nasogastric tube.
Radiology Report
INDICATION: Recent stroke with decreasing hematocrit, status post cerebral
angiogram. Assess for pelvic bleed.
TECHNIQUE: Helical axial CT imaging was performed through the abdomen and
pelvis without the administration of either intravenous or oral contrast
material. Multiplanar formats were performed.
DOSE: DLP: 662 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
Abdomen CT: There are new moderate right and small left nonhemorrhagic
pleural effusions. Mild associated bilateral lower lobe compressive
atelectasis is noted.
Lack of intravenous contrast limits assessment of the abdominal organs. There
is portal venous gas within the left hepatic lobe (02:20). The liver is
otherwise unremarkable. Layering high density material in the gallbladder
could be due to vicarious excretion of intravenous contrast related to the
prior contrast enhanced CT from ___. The gallbladder is otherwise
unremarkable. The spleen is normal. Benign appearing left renal cysts are not
significantly changed in size compared to the recent CT from ___,
measuring up to 3.3 x 1.7 cm (02:19). The kidneys are otherwise unremarkable.
The adrenal glands are normal. There is a 1.8 x 1.7 cm cystic lesion within
the pancreatic neck, not significantly changed (02:20). The remainder of the
pancreas is unremarkable. There is a small hiatal hernia. An enteric catheter
ends within the lower aspect of the stomach. The stomach is otherwise
unremarkable. The small bowel is normal limits. There is extensive colonic
diverticulosis, without evidence of diverticulitis. Oral contrast material
within the colon relates to prior contrast administration for a video
oropharyngeal swallow from ___.
There is new gas within branches of the right colic vein, likely originating
from near the level of the ileocecal valve. There is no associated
pneumatosis. There are no pathologically enlarged abdominal lymph nodes. The
abdominal aorta is normal in caliber. Marked aortic calcifications are seen.
There is a 1.2 cm heavily calcified splenic artery aneurysm, not significantly
changed.
Pelvis CT: There is a 5.3 x 2.4 cm right groin hematoma, new compared to the
prior CT from ___ (02:55). A previously seen right common
femoral/external iliac arterial catheter has been removed.
A Foley catheter is seen within the bladder. Air within the nondependent
aspect of the bladder relates to aforementioned catheterization. There is no
free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are
seen. There is extensive rectal fecal loading.
Bone windows: No suspicious lytic or blastic lesions are identified.
Compression deformities of the T12 and L1 vertebral bodies are not
significantly changed, age indeterminate.
IMPRESSION:
1. Small right pelvic hematoma, likely related to prior arterial puncture for
cerebral angiography.
2. Right colic venous gas as well as venous gas in the left hepatic lobe,
without associated pneumatosis, likely benign in nature. Correlation with
serum lactate and serial physical exam is recommended.
3. New moderate right and small left nonhemorrhagic pleural effusions.
4. 1.8 cm pancreatic cystic lesion. If serial CT imaging is planned for this
patient, this lesion could be followed up on these studies. Otherwise, the
standard recommendation for followup would be an MRCP in 6 months.
5. Unchanged benign appearing left renal cysts.
6. Extensive diverticulosis, without evidence of diverticulitis. Rectal fecal
loading.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at
15:55 via telephone on the day of the study, 5 minutes after discovery.
Radiology Report
INDICATION: Altered mental status. Assess for pneumonia.
COMPARISONS: CTA head and neck of ___.
FINDINGS:
AP and lateral views of the chest demonstrate hyperexpanded lungs. There is
no pleural effusion, focal consolidation or pneumothorax. Hilar and
mediastinal silhouettes are unremarkable. Heart size is normal is size.
There is no pulmonary edema. Moderately severe compression fracture at
thoracolumbar junction is of uncertain chronicity.
IMPRESSION:
1. No evidence of acute cardiopulmonary process.
2. Moderately severe compression fracture at thoracolumbar junction of
uncertain chronicity. Correlate clinically for acuity.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with field cut on left and dizzy // CVA?
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast. Subsequently, rapid axial imaging was performed from the aortic arch
through the brain during infusion of Omnipaque intravenous contrast material.
Three dimensional images were generated on a separate workstation.
DOSE: DLP: 1393.86 mGy-cm; CTDI: 54.45 mGy
COMPARISON: None.
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or
infarction. The ventricles and sulci are minimally prominent consistent with
age-related atrophy. No fractures are identified.
Head CTA: The intracranial carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses, occlusions or aneurysm
formation. The right anterior communicating artery is hypoplastic. There are
calcifications in the cavernous portion of the internal carotid arteries.
Neck CTA: There is high-grade stenosis (70 80%) at the bifurcation of the
right internal carotid artery that extends approximately 1 cm into the
internal carotid artery. There is atherosclerotic calcification at the
bifurcation of the left carotid artery, however, there is no flow-limiting
stenosis. The right vertebral artery is congenitally small and has a calcified
plaque at its origin. The left vertebral artery is without flow-limiting
stenosis. No aneurysm or vascular malformation identified.
IMPRESSION:
High-grade stenosis (70-80%) at the bifurcation the right internal carotid
artery that extends approximately 1 cm into the internal carotid artery. The
3D reformations are pending. Once the 3D reformations are obtained an addendum
will be issued if any changes are identified.
Radiology Report
INDICATION: Left-sided weakness and possible seizure.
COMPARISONS: CTA of ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect or shift of
normally midline structures. Linear hyperdensity in right frontal region
(2A:25) is felt to be artifactual. No vascular territorial infarction. The
sulci and ventricles are prominent, likely age-related involutional changes.
The basal cisterns are patent. There is no evidence of herniation. No acute
fracture is seen. The imaged paranasal sinuses and mastoid air cells are well
aerated. The orbits are unremarkable. There is rotatory orientation of C1
and C2, which is new since study obtained two hours prior.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Rotatory orientation of C1 and C2 is most likely positional, however,
clinical correlation is recommended to exclude underlying ligamentous injury.
Radiology Report
RADIOLOGY PROCEDURE NOTE
SERVICE: Neurosurgery.
PROCEDURE PERFORMED: Diagnostic cerebral angiography with injections of the
right common carotid artery, right internal carotid artery stenting for acute
symptomatic carotid stenosis and stroke, in-stent balloon angioplasty.
INDICATIONS: Ms. ___ is an ___ white female who presented to the
emergency department with significant right-sided ICA stenosis. Her symptoms
initially started five hours ago; however, she improved back to her baseline.
Over the last hour, she has developed significant left-sided weakness and
neglect, indicative of a right parietal stroke syndrome and an ___ stroke
scale of 10. Her CTA demonstrates critical right ICA stenosis, indicative of
likely stroke. After discussion with the family, plan was made to bring the
patient to the neuroangio suite for potential intra-arterial stroke therapy.
ATTENDING: Dr. ___.
ASSISTANT: Dr. ___, Dr. ___.
ANESTHESIA: General endotracheal anesthesia.
MEDICATIONS EMPLOYED: The patient was brought to the angio suite after having
been loaded with 325 mg of aspirin rectally as well as 600 mg of Plavix
rectally in the emergency department. She had previously been on aspirin.
She was also on heparin drip at time of the procedure.
DESCRIPTION OF PROCEDURE: The patient was emergently brought to the
neuroangio suite and quickly intubated while a very brief timeout was
performed. Her bilateral groins were prepped and draped in the usual sterile
fashion and her right femoral artery was accessed using anatomic landmarks.
Using a micropuncture needle kit and Seldinger technique, an 8 ___ sheath
was placed in the right femoral artery, sutured in place and connected to a
continuous heparinized saline flush. Next, a 5 ___ ___ 2 catheter was
connected to an RHV, continuous heparinized saline flush, and a contrast power
injector and brought over the aortic arch using an 0.038 Terumo Glidewire. A
___ configuration was performed and the right common carotid artery was
accessed. Cervical and intracranial AP and lateral angiography was then
performed. Next, under roadmap guidance, the ___ 2 was brought into the
external carotid artery and exchanged with a 0.035 Amplatz exchange wire for a
6 ___ Cook shuttle; was used to place the Cook shuttle in the distal common
carotid artery. Next, under roadmap guidance, carefully an Emboshield NAV6
was placed within the distal internal carotid artery and deployed
successfully, and then over the Monorail system, an Xact carotid stent was
placed within the internal carotid artery and deployed without any problems.
AP and lateral angiography then followed. Next, a 5 x 30 ___
balloon was brought up within the stent and inflated and then deflated. Final
intracranial AP and lateral angiography then followed and the patient was
allowed to wake up and she was found to be extubated at her largely same
preoperative exam with an ___ stroke scale of ___.
IMAGING FINDINGS:
1. RIGHT COMMON CAROTID ARTERY: Injection is seen with the catheter in the
proximal common carotid artery with some reflux down into the subclavian and
the vertebral artery. Common carotid artery demonstrates good filling to the
common carotid and the external carotid artery, but sluggish flow through the
internal carotid artery. There is an obvious ulcerated and stenotic plaque at
the ICA bifurcation with thrombus associated with it, and significant stenosis
of the artery, measuring 91% per NASCET criteria. The distal flow through the
ICA is quite sluggish and fills in a delayed fashion. Intracranial AP and
lateral angiography demonstrates good rapid filling of the external carotid
artery branches and very slow sluggish filling through a normally contoured
distal ICA. The origins of the ophthalmic and anterior choroidal arteries
appear normal through this injection; however, there is no evidence of a PCom.
There is no communication with an ACA from this side and there is an isolated
right MCA distribution hemisphere. Subsequent imaging demonstrates guide
catheter position within the common carotid artery and stent deployment across
the ICA stenosis with improved flow through the ICA. Post-balloon angioplasty
demonstrates good position of the stent within the ICA down into the common
carotid artery and a smoothly contoured appearance of the ICA. The residual
stenosis measures 10% after procedure. Final intracranial AP and lateral
angiography demonstrates rapid filling of the ICA with no filling of the ACA
distribution and minimal PCom communication, but completely preserved and
intact appearance of the MCA vasculature with no appearance of cut-off and
good parenchymal filling and venous egress.
CONCLUSIONS:
1. Symptomatic right ICA stenosis with 91% degree of stenosis status post
carotid stenting with resolution of the ulcerated plaque and stenosis down to
9%. Markedly improved flow is seen distally within the ICA to the isolated
right MCA filling with no distal evidence of thromboembolic complications.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O STROKE
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ is an ___ year old woman who presented in the
evening of ___ complaning of progressive right temporal
pulsatile headache and acute onset left hemiparesis, facial
droop and vision loss. When she initially presented to the ED,
CT showed no clear infarct or hemorrhage but CTA reveled
high-grade stenosis of the right ICA. In the scanner in the ED
she became unresponse with right gaze deviation and less
movement in her left arm. SBP was in the 140s (down from 200s)
and the initial thought was that there may have been a brief
seizure or possible flow-related symptoms in the setting of BP
drop. Repeat CT showed developing right cerebral watershed
distribution infarcts. Neurosrugery was consulted urgently who
made a decision to take the patient to angio for R ICA stenting.
Post-angio scans showed improved flow and she was awake, alert,
with mild dysarthria, following commands antigravity in her LUE.
Per Nsurg ASA 325, plavix 75 was started. By 7:45 ___, however,
she was no longer following comands on the left, only
withdrawing to pain and triple flexing the left leg. Repeat CTA
showed restenosis of the R carotid, and M1 distribution
infarction on the R. Neurosurgery had a discussion with the
family about the risks and benefits integrelin and repeat angio
for aspiration of the clot, which they agreed to. She recieved
15mg integrelin and post-angio again had improved flow in the R
MCA territory. She has had improved spontaneous movement on the
left side and is following simple commands off sedation. MRI
showed patchy ischemia in the right MCA territory.
She was transferred to floor after extubation. She became
febrile and had a worsening leukocytosis. She underwent a fever
workup, which included blood cultures, urine cultures, and a
chest x-ray. Chest x-ray showed that she had a new right lower
lobe opacity concerning for pneumonia. She was given Vancomycin
and Zosyn for empiric treatment for pneumonia, for a planned 14
day course to finish on ___. A PICC line was placed
after antibiotics were started. Upon transferring to the floor
she was found to be in atrial fibrillation with rapid
ventricular response. She was given IV metoprolol and her oral
metoprolol dose was increased to 50mg BID. She spontaneously
converted to normal sinus rhythm and her rate has been while
controlled since. She was not started on warfarin because she
was already on Aspirin and Plavix for her carotid stent (which
she will continue for three months). Starting a third
anticoagulation agent would greatly increase her risk of
hemmorhage.
Her blood cultures grew out gram positive cocci in clusters
which speciated to staph epidermidis. Her urine culture grew out
yeast and she was started on fluconazole on ___, for a
planned 7 day course to be completed on ___.
Her physical exam improved and she had increased stregth in both
the left upper and left lower extermity. She became more
interactive and her mental status also improved. A repeat
bedside swallow evaluation found that she was still at increased
risk of aspiration. Her hematocrit continued to drop and a CT
abdomen/pelvis showed show a right groin hematoma that was
stable. An incidental finding of portal venous gas was noted as
well as a 1.8 cm pancreatic cystic lesion. Her lactate was
normal and the suspicion of bowel perforation was low.
Acute care surgery placed a PEG tube on ___, after her repeat
blood cultures were negative. Her blood pressure continued to be
difficult to controll and amlodipine 5mg was added. She resumed
tube feeds on ___ without incidence.
During the admission, her blood pressures have been mildly
difficult to control. She was put back on her home medications
and amlodipine was also started. If her blood pressures
continue to be above a systolic of 180, would uptitrate her oral
antihypertensives. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
possible seizure, AMS
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
___ female with h/o HTN, COPD, and PAD, presenting with
question of new seizure. Per husband, pt was feeling fine and
mentating at baseline yesterday afternoon. Husband noted
yesterday 5:30pm that the patient had gentle constant shaking of
her upper and lower extremities lasting approximately ___
with dry heaving for ___. During that time the patient had a
decreased level of responsiveness, did not recognize her
husband, and would not answer the husband's questions, speaking
"gibberish." No bleeding from tongue. Husband noticed diaper was
soaked with urine after shaking was over (has fecal and urinary
incontinence at baseline). Afterwards she seemed very sleepy and
slept for approximately 3 hours. Pt's husband and son woke pt up
and she had difficulty expressing that her chronic leg pain was
bothering her and spoke in broken sentences; also c/o HA. Pt was
given home Dilaudid and went to sleep. This am, pt still not
oriented and didn't recognize husband and had trouble finding
words. Pt received another dose of Dilaudid and husband called
PCP who recommended transfer to ___. She was complaining of some
lower abdominal pain. No shortness breath, cough, chest pain. No
weakness in her upper or lower extremities, headache.
L midline in for IVF ___ due to poor PO intake for past 2
months. 15# weight loss in past 2 months.
Last BM yesterday.
In the ___, initial vitals 7.9 95 124/62 16 93%
Had mild improvement of mental status per husband in ___
initially-
1pm- became agitated and had worsening of slurred speech.
Received Dilaudid and pt improved in terms of speech.
Exam notable for A&O to person
Labs notable for fs-123
The pt underwent an LP, traumatic after low-grade fever of 100.7
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:
PMH: Hypertension, emphysema, peripheral arterial disease, 4.5
cm thoracic aneurysm with ulcerative plaque, juxta renal
aneurysm ~ 4.9 cm, old cerebellar infarct, vitamin B12
deficiency, chronic back pain, gait instability, macrocytosis,
lung mass.
PSH:
- ___ Left common femoral artery to above-knee popliteal artery
bypass using 6-mm supported Maquet graft
- ___ Right femoral to popliteal bypass graft.
- "throat surgery",
Social History:
___
Family History:
FH: Non-contributory
Physical Exam:
On admission:
VS - 98.3 95 148/75 18 96% RA
GENERAL - NAD, comfortable, confused, thin
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no
facial asymmetry.
NECK - supple, no LAD
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 - hypoactive BS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - atrophic L calf, no calf tenderness bilaterally
SKIN - no rashes or lesions, no cyanosis of feet
NEURO - awake, A&Ox1 (not oriented to place or time), CNs II-XII
grossly intact, muscle strength ___ throughout, ___ strenght in
L foot plantar/dorsiflexion, sensation grossly intact
throughout, gait deferred, no Babinski's sign
On discharge:
Afebrile, BP 150s-160s, non-tachycardic, non-tachypneic,
saturating high ___ on RA
GA: NAD, comfortable, thin, pleasant, interacting appropriately
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no facial
asymmetry.
NECK - supple, no LAD
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 - normoactive BS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - atrophic L calf, no calf tenderness bilaterally
SKIN - no rashes or lesions, no cyanosis of feet
NEURO - awake, A&Ox2 (not oriented to time), CNs II-XII grossly
intact, muscle strength ___ throughout, ___ strenght in L foot
plantar/dorsiflexion, sensation grossly intact throughout, gait
deferred
Pertinent Results:
On admission:
___ 11:57AM BLOOD WBC-13.0*# RBC-3.49* Hgb-11.0* Hct-34.3*
MCV-98 MCH-31.6 MCHC-32.2 RDW-14.0 Plt ___
___ 11:57AM BLOOD Neuts-85.5* Lymphs-9.8* Monos-3.7 Eos-0.9
Baso-0.2
___ 11:57AM BLOOD ___ PTT-35.2 ___
___ 11:57AM BLOOD Glucose-103* UreaN-19 Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-30 AnGap-11
___ 11:57AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
___ 11:57AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:10PM BLOOD Glucose-91 Lactate-1.8 K-4.1
___ 02:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:49PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:49PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 09:49PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 02:30PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-0
On discharge:
___ 05:30AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.8* Hct-34.6*
MCV-98 MCH-30.4 MCHC-31.1 RDW-13.8 Plt ___
___ 05:30AM BLOOD ___ PTT-39.4* ___
___ 05:30AM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-144 K-4.1
Cl-108 HCO3-24 AnGap-16
___ 05:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
Radiology:
___ CT head
FINDINGS: There is no acute hemorrhage, edema, mass effect, or
large
territorial infarction. Hypodense areas within the left
cerebellar
hemisphere, left occipital lobe, and within the right pons are
consistent with
prior infarcts. There are multiple lacunar infarcts within the
basal ganglia
bilaterally. There is extensive periventricular white matter
hypodensity
consistent with chronic small vessel ischemic disease. The
ventricles and
sulci are prominent, likely due to age-related atrophy. Carotid
siphon
calcifications are noted. The visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear. There is no fracture.
IMPRESSION:
1. No acute intracranial process. However, if there is
clinical concern for
acute infarction, MRI is more sensitive.
2. Multiple areas of old infarction.
3. Chronic small vessel ischemic disease and atrophy.
Micro:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ MRI head
FINDINGS:
Motion degrades the quality of this study.
There is no evidence of recne t infarct. There are extensive
T2/FLAIR
hyperintensities in the periventricular and subcortical white
matter, which is
nonspecific but is likely related to small vessel ischemic
changes. There are
two old infarcts in the left occipital and left cerebellar
hemisphere. There
are also multiple deep white matter lacunes. There is a focus
of old
hemorrhage lateral to the atrium of the left lateral ventricle.
There is no
evidence of abnormal enhancement.
There is prominence of the extra-axial CSF spaces and ventricles
suggesting
global cerebral volume loss.
IMPRESSION:
No acute infarct. Extensive small vessel ischemic changes with
lacunar
infarcts and two larger infarcts in the left occipital and left
cerebellum as
described. No abnormal enhancement.
Neuro:
___ EEG 20 minute: slow background, sharps in L temporal
lobe.
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of ___
___ and
continued for 24 hours. At the beginning, it showed a
normal-appearing 8 Hz alpha frequency background bilaterally in
wakefulness. There were also bursts of mixed frequency slowing
in the left temporal region on a few left temporal spike
discharges, primarily at T3. T here were also occasional or
subtle
generalized slowing, some with mildly sharp features. Less
frequently, there were single generalized high voltage sharp
waves with a frontal maximum.
SPIKE DETECTION PROGRAMS: Showed the same fairly frequent left
temporal
spikes plus less frequent generalized sharp waves. There were no
repetitive
discharges.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: The patient progressed from wakefulness to sleep without
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The recording showed a normal background in wakefulness and
sleep. There were frequent
isolated and non-repetitive spike discharges in the left mid
temporal region, and there were several generalized sharp waves.
There were no repetitive
discharges or electrographic seizures. There was some focal
slowing in the left temporal region, as well.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 200 MCG Oral 1
daily anemia
2. Multivitamins 1 TAB PO DAILY
3. Gabapentin 300 mg PO TID pain
4. Clopidogrel 75 mg PO DAILY blood clot
5. Ranitidine (Liquid) 150 mg PO BID acid reducer
6. Docusate Sodium (Liquid) 100 mg PO BID stool softner
7. Acetaminophen (Liquid) 650 mg PO Q8H:PRN pain
8. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
9. Warfarin 1 mg PO DAILY16 blood clot
10. Pravastatin 20 mg PO DAILY cholesterol
11. Mirtazapine 7.5 mg PO HS mood
12. Polyethylene Glycol 17 g PO DAILY constipation
Discharge Medications:
1. Lorazepam 0.5-1 mg PO Q6H:PRN agitation
RX *lorazepam 0.5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*56 Tablet Refills:*0
2. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 200 MCG Oral 1
daily anemia
3. Warfarin 1 mg PO DAILY16
4. Ranitidine (Liquid) 150 mg PO BID acid reducer
5. Pravastatin 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY constipation
7. Multivitamins 1 TAB PO DAILY
8. Mirtazapine 7.5 mg PO HS
9. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
10. Gabapentin 300 mg PO TID pain
11. Docusate Sodium (Liquid) 100 mg PO BID
12. Clopidogrel 75 mg PO DAILY
13. Acetaminophen (Liquid) 650 mg PO Q8H:PRN pain
14. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*36 Capsule Refills:*0
15. Normal saline
Please administer 1L NS via IV three times a week (MWF)
16. Saline Flush
10cc saline flushes after each access from midline.
Discharge Disposition:
Home With Service
Facility:
___
___:
Seizure of unknown origin
Urinary tract infection, complicated
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with likely new onset seizure, evaluate for
intracranial hemorrhage or mass.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: There is no acute hemorrhage, edema, mass effect, or large
territorial infarction. Hypodense areas within the left cerebellar
hemisphere, left occipital lobe, and within the right pons are consistent with
prior infarcts. There are multiple lacunar infarcts within the basal ganglia
bilaterally. There is extensive periventricular white matter hypodensity
consistent with chronic small vessel ischemic disease. The ventricles and
sulci are prominent, likely due to age-related atrophy. Carotid siphon
calcifications are noted. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. There is no fracture.
IMPRESSION:
1. No acute intracranial process. However, if there is clinical concern for
acute infarction, MRI is more sensitive.
2. Multiple areas of old infarction.
3. Chronic small vessel ischemic disease and atrophy.
These findings were discussed with Dr. ___ by Dr. ___
telephone at 3:10 p.m, ___.
Radiology Report
HISTORY: New seizure.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: Chest radiograph ___. Chest CTA ___.
FINDINGS:
The heart size is normal. Aorta is tortuous with enlargement of the aortic
knob and displaced intimal calcifications compatible with known aortic arch
aneurysm, unchanged. The pulmonary vascularity is not engorged. The lungs
are hyperinflated with emphysematous changes again noted. Increased streaky
opacity in the right lung base may reflect atelectasis though infection cannot
be excluded. 15 mm lingular nodule is unchanged. No pleural effusion or
pneumothorax. A mid thoracic vertebral body compression deformity is re-
demonstrated.
IMPRESSION:
1. Increased streaky opacity within the right lung base which could reflect
atelectasis but infection cannot be excluded.
2. Emphysema.
3. Unchanged 15 mm nodule within the lingula. As noted on the prior PET CT
from ___, continued imaging followup of this lesion is
recommended, and a chest CT should be obtained at this time.
4. Aortic arch aneurysm, unchanged.
Radiology Report
INDICATION: ___ woman with hypertension, peripheral artery disease,
with aphasia and altered mental status, status post possible seizure, evaluate
for infarct or mass.
TECHNIQUE: Multiplanar, multisequence MRI of the brain was obtained before
and after the administration of IV gadolinium as per departmental protocol. 5
mL of Gadovist was administered.
COMPARISON: CT head of ___.
FINDINGS:
Motion degrades the quality of this study.
There is no evidence of recne t infarct. There are extensive T2/FLAIR
hyperintensities in the periventricular and subcortical white matter, which is
nonspecific but is likely related to small vessel ischemic changes. There are
two old infarcts in the left occipital and left cerebellar hemisphere. There
are also multiple deep white matter lacunes. There is a focus of old
hemorrhage lateral to the atrium of the left lateral ventricle. There is no
evidence of abnormal enhancement.
There is prominence of the extra-axial CSF spaces and ventricles suggesting
global cerebral volume loss.
IMPRESSION:
No acute infarct. Extensive small vessel ischemic changes with lacunar
infarcts and two larger infarcts in the left occipital and left cerebellum as
described. No abnormal enhancement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ? SZ YESTERDAY
Diagnosed with OTHER CONVULSIONS, FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, HX VENOUS THROMBOSIS/EMBOLISM, LONG TERM USE ANTIGOAGULANT
temperature: 97.9
heartrate: 95.0
resprate: 16.0
o2sat: 93.0
sbp: 124.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ___ female presenting with question of new seizure day
prior to admission, presenting with lower abdominal pain and
found to have complicated UTI.
#Possible seizure, AMS: According to pt's husband, episode day
prior to admission was most likely consistent with a seizure of
unknown etiology. As pt has had poor PO intake and malnutrition,
pt may have had hypoglycemia or electrolyte imbalance triggering
seizure. Acute stroke was considered especially with pt's
history of HTN and vasculopathy and husband endorsing pt having
aphasia, and imaging ruled out intracranial hemorrhage, acute
ischemic infarct and mass. Infectious process was considered and
LP was not consistent with bacterial meningitis or viral
encephalitis; HSV PCR of CSF negative. Pt was initially
empirically treated with IV acyclovir until PCR came back
negative on ___. CSF and blood cultures did not have
microbial growth. Neurology was consulted and recommended EEG.
Per neurology, L temporal sharps were seen on 24hr continuous
EEG which were indicative of being at risk for future seizures.
This L temporal activity would explain pt's seizure episode and
accompanying aphasia. Keppra seizure prophylaxis was held at
this time due to fact that this has sedating effects and pt was
already having waxing and waning delirium throughout hospital
course. Moreover, pt expressed wish to have her treatment
comfort-focused. It was recommended that the pt follow-up in
neurology clinic and if pt has future episodes of seizures,
Keppra will be re-considered. Pt was discharged alert and
oriented x2, and was given a prescription for Ativan 0.5-1mg PRN
agitation.
#UTI, complicated: Pt had leukocytosis initially which resolved
on hospital Day 2 and pt with lower abdominal pain after having
seizure day prior to admission, and this may have been related
to UTI. Urine culture grew out enterococcus and pt was treated
with ampicillin PO, and Foley catheter was discontinued. UCx
sensitivities returned on ___ which showed sensitivity to
ampicillin. Pt remained hemodynamically stable and did not
fulfill SIRS criteria. HD stable, no criteria for SIRS except
for fever. U/A rechecked as initial ua was not fully consistent
with infection- repeat clean but repeat UCx growing
enterococcus. Pt was discharged with Ampicillin 500mg q6H and
instructed to complete 10-day course for complicated UTI.
#Labile BP: Pt's BP initially 180s on ___. Pt was not on
antihypertensives as outpt but pt's chronic hypertension is most
likely reason for pt's past infarcts that were seen on imaging.
Pt was given a day of lisinopril 2.5 daily which brought
pressures were 140-150s but as pt had poor PO intake, she
triggered on ___ for SBP at 78. BP responded well to bolus
and was put on maintenance IVF to maintain BP for one night, and
lisinopril was discontinued. FeNa calculated to be 0.1% and thus
most likely hypovolemic ___ poor PO intake. Thereafter, BP
elevated to 170s and remained stable in 150-170s upon discharge.
As pt was asymptomatic with elevated BP, and pt wished to have
comfort-focused care, we deferred starting antihypertensive
although could be reconsidered if was symptomatic.
#Peripheral arterial disease: Pt was on coumadin and Plavix as
outpt. She had multiple vascular surgeries in past, most recent
surgeries in ___ on lower extremities. After intracranial
hemorrhage was ruled out with imaging, pt was cleared by
neurology to continue Plavix and coumadin throughout
hospitalization. INR remained therapeutic and no changes were
made to coumadin dose. Pt has a follow-up appt with vascular
surgery on ___.
#Chronic pain: Pt has chronic pain in lower extremities, mainly
in L leg. Per pt, there has been no acute worsening of chronic
pain and this was managed with
continued home medications: standing gabapentin, Dilaudid PRN,
Tylenol PRN.
#Palliative care: Upon admission, pt's husband (HCP) reversed
pt's DNR/DNI status to full code as he believed that pt agreed
to that code status without fully understanding the meaning of
DNR. As we have ruled out many acute processes which could have
caused pt's acute change in mental status besides UTI, and main
issues at time of discharge appeared to be chronic in nature
including pain control and poor PO intake/weight loss.
Palliative care was consulted and spoke to pt on goals of care-
pt expressed wish to have comfort focused care at home. A formal
meeting was done with ___ (pt's husband and proxy) on
___ and he was emotionally overwhelmed by pt's
hospitalization and was educated on pt's needs. He is amenable
to discussing goals of care at home with palliative care team
and is onboard in terms of being comfort-focused. Pt's husband
recommended that ___ work with pt in order to assist her out of
bed to wheelchair so that she can enjoy the outdoors. Social
work was also consulted and upon discharge, pt was set up with
___ services along with palliative care and social work
follow-up to visit home in order to further discuss goals of
care, code status and possible transition to hospice care. Pt is
to continue to have infusion therapy through midline three times
a week as before admission as pt continues to have poor PO
intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Zosyn / Penicillins / Indomethacin / epinephrine /
Versed
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history significant for CF with MAC,
temporal lobe epilepsy, stable carotid stenosis, depression, and
anxiety disorder, who was referred in from PCP after patient
reports 2 week history of increased falls and lower extremity
weakness. PCP is requesting coordination of care through
psychiatry and neurology.
He presented today reporting falling 5 times PTA with report
that legs feel weak and will not support him. The patient stated
that this has been going on for about 3 months. He also reports
that he has ongoing vertigo but this symptom does not always
precede weakness in his legs. He denies any vision changes,
headaches, N/V, paresthesias/decreased sensation,
myalgias/arthralgias, and endorses normal appetite recently. He
has not had loss of consciousness, or had any focal neurological
deficits. He does not feel lightheaded, and denies chest pain,
worsening shortness of breath, dyspnea on exertion or worsening
cough. Denies any shaking movements or stiffening. He notes that
he has become less active within the last year, but cannot
contribute his lack of activity to anything specifically.
He has a history of steatosis, chronic diarrhea, and
pancreatitis secondary to CF which he was diagnosed with in
___. However, he currently does not endorse any changes in
bowel habits or increase in diarrhea.
He does note he has a history of anxiety and depression, and is
being followed by psychiatry but is not on any SSRIs. He only
takes trazadone QHS. When asked about his mood and what
activities he enjoys, the patient notes he has depressed mood,
does not have much social or family support, and endorses work
stressors. He also is noted to be perserverating on his
diagnosis and consequences of his diagnosis.
Per report from ED staff, patient is also suicidal - has
intermittently gone to the roof and thought about jumping off.
No actual suicide attempts, sees a therapist and psychiatrist
but takes no medications for depression currently. Misunderstood
directions about taking citalopram and has not taken it
correctly.
In the ED, initial vital signs were:
- Exam was notable for: normal neurologic examination
- Labs were notable for Cr 1.3 (baseline 0.9-1), MCV 99
- Head imaging showed no acute intracranial process.
- Psychiatry was consulted, and recommended continuing 1:1
sitter at this point
Past Medical History:
- Cystic Fibrosis and diffuse bronchiectasis (___) - followed
by
___ at ___ Clinic
- Hepatic/Splenic steatosis (___)
- ?Chronic pancreatitis, chronic diarrhea
- Mitral valve prolapse (___)
- SVT s/p Cardiac ablation ___
- left temporal lobe epilepsy (___) - followed by Dr. ___
- ___ disorder, Insomnia
- Depression - tried various SSRIs without success
- Eczema
- GERD, esophageal spasm s/p fundoplication (___)
- Hypertension
- BPH s/p TURP (___)
- Primary nocturnal diuresis (___)
- chronic ___ pulmonary infection
- Carotid Stenosis
- Strabismus
Social History:
___
Family History:
- siblings heterozygous for cystic fibrosis gene (Delta 508)
- father died of esophageal cancer. h/o alcoholism
- 2 sisters with lung cancer (both smokers)
- paternal aunt with cystic fibrosis, died at age ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VITALS - T 98.9, BP 122/61, HR 69, R 18, SpO2 96%/RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear; no end gaze nystagmus
NECK - JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, audible systolic
click
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
GU - dark urine in urinal at bedside
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ in both proximal and distal upper and lower
extremities. Gait WNL. Heel walk and toe walk intact. Able to
stand from squatting position without difficulty.
PSYCHIATRIC - listen & responds to questions appropriately,
calm, perseverating on CF DX; occasionally losing train of
thought though redirectable
PHYSICAL EXAM ON DISCHARGE
VITALS - T 98.9, BP 120s-140s/60s, HR 69, R 18, SpO2 96%/RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear; no end gaze nystagmus
NECK - JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, audible systolic
click
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
GU - dark urine in urinal at bedside
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ in both proximal and distal upper and lower
extremities. Gait WNL. Heel walk and toe walk intact. Able to
stand from squatting position without difficulty.
PSYCHIATRIC - listen & responds to questions appropriately,
calm, perseverating on CF DX; occasionally losing train of
thought though redirectable
Pertinent Results:
LABS ON ADMISSION
___ 02:13PM BLOOD ___-6.2 RBC-4.70 Hgb-15.4 Hct-46.6
MCV-99* MCH-32.8* MCHC-33.0 RDW-13.4 RDWSD-48.5* Plt ___
___ 02:13PM BLOOD ___ PTT-30.1 ___
___ 02:13PM BLOOD Glucose-119* UreaN-16 Creat-1.3* Na-140
K-4.7 Cl-100 HCO3-27 AnGap-18
___ 02:13PM BLOOD ALT-40 AST-88* AlkPhos-141* TotBili-1.4
___ 02:13PM BLOOD Albumin-4.0
___ 02:20PM BLOOD Lactate-1.7
LABS ON DISCHARGE
___ 06:41AM BLOOD WBC-5.2 RBC-4.27* Hgb-13.6* Hct-41.9
MCV-98 MCH-31.9 MCHC-32.5 RDW-13.5 RDWSD-48.3* Plt ___
___ 06:10AM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-141
K-4.2 Cl-102 HCO3-27 AnGap-16
___ 06:41AM BLOOD LD(LDH)-150 CK(CPK)-59
___ 06:10AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.8
IMAGING
___ CT scan head
IMPRESSION:
No acute intracranial process.
___ CXR
IMPRESSION:
No acute cardiopulmonary process.
___ EKG
Sinus rhythm at the upper limits of normal rate. Single atrial
premature beat. Q waves in leads V1-V3. Consider anteroseptal
myocardial infarction. There is generalized low voltage.
Compared to the previous tracing of ___ no significant
change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
3. Diphenoxylate-Atropine 2 TAB PO BID
4. DiCYCLOmine 10 mg PO TID
5. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID
6. ClonazePAM 1 mg PO BID
7. ClonazePAM 0.5 mg PO QAFTERNOON
8. Ranitidine 150 mg PO QHS
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Desmopressin Acetate 0.2 mg PO QHS
11. Pantoprazole 40 mg PO Q12H
12. Aspirin 325 mg PO DAILY
13. Levalbuterol Neb 0.63 mg NEB TID
14. Cyanocobalamin 1000 mcg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. dornase alfa 2.5 mg inhalation BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. ClonazePAM 1 mg PO BID
3. ClonazePAM 0.5 mg PO QAFTERNOON
4. Cyanocobalamin 1000 mcg PO DAILY
5. Desmopressin Acetate 0.2 mg PO QHS
6. DiCYCLOmine 10 mg PO TID
7. Diphenoxylate-Atropine 2 TAB PO BID
8. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID
11. Levalbuterol Neb 0.63 mg NEB TID
12. Pantoprazole 40 mg PO Q12H
13. Ranitidine 150 mg PO QHS
14. Valsartan 160 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. dornase alfa 2.5 mg inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Weakness
Cystic Fibrosis
Depression
Acute Kidney Injury
SECONDARY DIAGNOSIS
===================
Gastroesophageal Reflux Disease
Temporal lobe epilepsy
Primary nocturnal enuresis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with progressive cognitive decline, unsteady gait w/recent
falls // eval for PNA
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___ chest x-ray and ___ chest CT.
FINDINGS:
Right middle lobe bronchiectasis and calcified granulomas explain the linear
and nodular opacities projecting over the right lung base. The lungs are
otherwise clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with frequent falls // r/o acute process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: Brain MRI from ___. Head CT from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Gray-white matter differentiation is
preserved. Ventricles and sulci are prominent compatible with global volume
loss. Basilar cisterns are patent.
Included paranasal sinuses and mastoids are essentially clear besides mild
mucosal thickening in the ethmoids and right maxillary sinus. Patient is
status post apparent endoscopic sinus surgery on the left. Stranding within
the posterior subcutaneous tissues is unchanged from prior exams. Skull and
extracranial soft tissues are otherwise unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Major depressive disorder, single episode, unspecified, Low self-esteem
temperature: 96.8
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 128.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Information for Outpatient Providers: Mr. ___ is a ___ with
a history significant for CF and anxiety disorder, as well as
depression, was referred in from PCP for further evaluation by
PCP after presenting today with falls and lower extremity
weakness.
ACTIVE ISSUES
# FALLS/WEAKNESS: patient reporting falls at home because felt
that "legs cannot support him." Not likely neurological in
nature. On neurological exam, patient exhibits ___ strength.
Gait WNL, but endorsed subjective weakness. He demonstrated heel
and toe walking, and was able to stand up from squatting
position without assistance. Further, MRA/V of head, noncon CT
were negative. Cardiogenic etiology not likely either as EKG
WNL, and no SOB/chest pain/ palpitations endorsed. ___ be due to
dehydration/possible malnutrition however patient states that
eating/drinking habits and bowel habits remain unchanged. Most
likely not related to chronic peripheral vertigo as dizziness
episodes did not always coincide with weakness. Physical therapy
cleared him as safe to go home, and psychiatry evaluated him and
was in agreement with primary team, that he does not currently
endorse any SI and is safe to discharge home.
# PASSIVE SUICIDAL IDEATION: patient with no prior history of
suicide attempts but active ideation in ___ and passive
suicidality currently. ED staff overheard what is to be though
of as active ideation. Psychiatry evaluated him and was in
agreement with primary team: that he does not currently endorse
any SI and is safe to discharge home. He will follow up with Dr.
___ as an ___.
# ACUTE KIDNEY INJURY: unclear precipitant but likely prerenal
in nature. After 1L NS and maintenance fluids, Cr normalized.
CHRONIC ISSUES
# MYCOBACTERIUM AVIUM INTRACELLULARE INFECTION: followed by ID.
Not currently in treatment, per last note, given stable symptoms
and difficulty with regimen.
# CYSTIC FIBROSIS: continued, levalbuterol,
fluticasone-salmeterol. Dornase was held ___ being non
formulary.
# GERD: Continued home pantoprazole, ranitidine.
# TEMPORAL LOBE EPILEPSY: continued home clonazepam. Not on
keppra.
# PRIMARY NOCTURNAL ENURESIS: home desmopressin.
# HYPERTENSION: home valsartan.
Transitional Issues
====================
[]Consider repeat UA for microscopic hematuria seen during this
admission
[]Patient hesitant to go to therapist in ___. ___ benefit
from referral to more local therapist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
doxycycline / lisinopril
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
This is a ___ with past medical history of hypertension, chronic
back pain attributed to lumbar disc disease, Diabetes type 2
complicated by Diabetic neuropathy, chronic opiates for above
issues complicated by constipation requiring movantik, GERD with
chronic reflux, COPD, ongoing tobacco abuse, schizoaffective
disorder with a prior suicide attempt, who presents with
progressive cough and dyspnea x 10 days. Patient reports that
10
days prior to presentation, she noticed symptoms of cough
productive of green sputum. Denies chest pain, palpitations,
lower extremity edema.
Patient initially presented to ___, but was transferred
to ___ ED due to concern about her respiratory status and
reported question of confusion. In the ___ ED, initial VS
were
96.7 ___ 20 90% Nasal Cannula ___ 323; exam was reported
as "exp wheezing throughout and rhonchi". labs were notable for
WBC 10.4, Hgb 14.5, Plt 224; Cr 0.6, HCO3 27, lactate 2.0, VBG
7.34/56 --> 7.33/60; CXR without acute cardiopulmonary
abnormality. Patient was given albuterol, ipratropium, Dilaudid,
clonazepam, IV mag sulfate, 6 units insulin, metoprolol and was
admitted to medicine for further management.
On arrival to the floor, patient confirmed above. Reported
feeling safe. Also reported she thinks she may have a
periumbilical hernia. Full 10 point review of systems positive
where noted, otherwise negative.
Past Medical History:
Hypertension
Hyperlipemia
Chronic back pain attributed to lumbar disc disease
Diabetes type 2 complicated by Diabetic neuropathy
Colon polyps
COPD
Schizoaffective disorder, bipolar type, with prior suicide
attempt
Social History:
___
Family History:
Mother had pulmonary embolism
Father had lung cancer
Physical Exam:
ADMISSION EXAM
VS: 98.1PO 141 / 92 107 22 95 4LNC
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - expiratory wheezing throughout, good air movement; no
ronchi no crackles;
Abd - soft nontender, normoactive bowel sounds; on coughing, has
small reducible periumbilical hernia, nontender; no
rebound/guarding
Ext - no edema
Skin - cool, no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, tangential with pressured speech, but
redirectable;
___ in extremities;
Psych - tangential as above;
DISCHARGE EXAM
VITALS: SATTING 92% ON RA; HR 100S SINUS
GENERAL: confused but calm, AO x name only
___ anicteric, MMM
NECK: JVP not elevated, no LAD
LUNGS: Wheezes throughout, poor air movement B/L
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes
NEURO: sedated
Pertinent Results:
LABS ON ADMISSION
___ 11:00AM BLOOD WBC-10.4* RBC-5.45* Hgb-14.5 Hct-43.9
MCV-81* MCH-26.6 MCHC-33.0 RDW-14.2 RDWSD-41.2 Plt ___
___ 11:00AM BLOOD Neuts-85.6* Lymphs-8.4* Monos-5.5
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.94* AbsLymp-0.88*
AbsMono-0.57 AbsEos-0.00* AbsBaso-0.02
___ 04:55AM BLOOD ___ PTT-30.2 ___
___ 11:00AM BLOOD Glucose-387* UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-97 HCO3-27 AnGap-16
___ 04:55AM BLOOD ALT-22 AST-22 LD(LDH)-246 AlkPhos-88
TotBili-0.4
___ 05:56AM BLOOD cTropnT-<0.01 proBNP-97
___ 04:55AM BLOOD cTropnT-<0.01 proBNP-90
___ 11:00AM BLOOD Calcium-9.8 Phos-1.7* Mg-1.9
___ 05:56AM BLOOD TSH-0.08*
___ 05:58AM BLOOD T4-6.9
___ 11:12AM BLOOD Lactate-2.0
___ 11:44AM BLOOD ___ O2 Flow-4 pO2-27* pCO2-56*
pH-7.34* calTCO2-32* Base XS-1 Intubat-NOT INTUBA
LABS ON DISCHARGE
___ 04:17AM BLOOD WBC-7.7 RBC-4.75 Hgb-12.7 Hct-40.0 MCV-84
MCH-26.7 MCHC-31.8* RDW-14.4 RDWSD-44.2 Plt ___
___ 04:17AM BLOOD Neuts-56.4 ___ Monos-8.7 Eos-1.2
Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-2.50 AbsMono-0.67
AbsEos-0.09 AbsBaso-0.02
___ 04:17AM BLOOD ___ PTT-28.0 ___
___ 04:17AM BLOOD Glucose-85 UreaN-13 Creat-0.4 Na-141
K-3.7 Cl-93* HCO3-39* AnGap-9*
___ 03:20AM BLOOD ALT-15 AST-18 AlkPhos-64 TotBili-0.2
___ 04:17AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1
___ 03:27AM BLOOD ___ Temp-37.1 ___ Tidal V-500
PEEP-5 FiO2-40 pO2-54* pCO2-66* pH-7.43 calTCO2-45* Base XS-15
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 04:57AM BLOOD Lactate-0.8
CULTURES
BCx ___ NGTD
UCx ___ NGTD
ET sputum ___ 12:12 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
IMAGING
ECHO ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
function. Mild aortic stenosis.
CXR ___
EXAMINATION: Chest portable radiograph
INDICATION: ___ year old woman with COPD, intubated for
AMS/delirium and
hypoxia// edema, consolidations
TECHNIQUE: Chest portable radiograph
COMPARISON: Chest radiograph most recently done on ___
FINDINGS:
Stable, mild interstitial edema. Unchanged position of
endotracheal tube and
nasogastric tube. Cardiomediastinal silhouette is stable.
There is bibasilar
atelectasis. No pneumothorax.
IMPRESSION:
Stable mild interstitial edema.
Unchanged position of supportive and monitoring devices.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN
2. Amitriptyline 125 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. QUEtiapine Fumarate 300 mg PO QHS
8. Rosuvastatin Calcium 40 mg PO QPM
9. ClonazePAM 1 mg PO Q6-8H:PRN anxiety
10. varenicline 1 mg oral BID
11. Nicotine Patch 21 mg TD DAILY
12. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
13. Cyclobenzaprine 10 mg PO HS:PRN back pain
14. Omeprazole 40 mg PO DAILY
15. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
17. Movantik (naloxegol) 25 mg oral DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
3. Thiamine 500 mg IV Q24H Duration: 5 Days
4. Amitriptyline 50 mg PO QHS
5. ClonazePAM 1 mg PO TID
6. Glargine 35 Units Bedtime
7. QUEtiapine Fumarate 75 mg PO TID
8. Aspirin 81 mg PO DAILY
9. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain
10. Nicotine Patch 21 mg TD DAILY
11. Omeprazole 40 mg PO DAILY
12. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Extended Care
Discharge Diagnosis:
COPD Exacerbation
Toxic metabolic encephalopathy
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: CHEST (PA AND LAT)
INDICATION: History: ___ with COPD here with hypoxia and shortness of
breath//pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Mediastinal contours are unremarkable. Prominence of
the hila bilaterally may suggest dilated pulmonary arteries. Lungs are
hyperinflated. No pulmonary edema is seen. No focal consolidation, pleural
effusion or pneumothorax is present. No acute osseous abnormalities
visualized.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Prominent hila bilaterally may reflect dilated pulmonary arteries and be
suggestive of pulmonary arterial hypertension.
3. Hyperinflated lungs compatible with history of COPD.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD, here for COPD exacerbation. Now with
worsening hypoxia// please eval for interval change please eval for
interval change
IMPRESSION:
Comparison to ___. There is an interval increase in interstitial
and vascular markings, suggesting the presence of mild pulmonary edema.
Borderline size of the cardiac silhouette persists. No larger pleural
effusions. No pneumonia.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old woman with COPD and possible CHF with acute hypoxia//
? evidence of volume overload
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
The lungs are hyperaerated. There is stable mild pulmonary edema. The heart
is normal in size. The trachea is midline. There are no large pleural
effusions.
IMPRESSION:
Hyperaeration. Mild pulmonary edema, similar to previous.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation // ?tube place/ interval
change ?tube place/ interval change
IMPRESSION:
ET tube tip is 7.5 cm above the carinal. Heart size and mediastinum are
stable. There is interval enlargement of the hila and development of bibasal
opacities potentially aspirations or progression of infectious process. It
might be in part exaggerated by low lung volumes compared to previous
examination but true progression of bibasal abnormality CIS breast an. No
definitive pleural effusion is seen. No pneumothorax is present. No
definitive evidence of pulmonary edema is noted.
Radiology Report
INDICATION: ___ year old woman with OG tube placed// ?placement
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. A NG tube has been placed in
the interim with its tip projecting below the diaphragm over the stomach. The
ET tube is unchanged. Cardiomediastinal silhouette is stable. No
pneumothorax is seen.
Radiology Report
INDICATION: ___ year old woman who was reintubated// tube in correct position?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with mild interstitial edema the ET tube, NG tube are
unchanged. There is bibasilar atelectasis. Cardiomediastinal silhouette is
stable. No pneumothorax is seen
Radiology Report
EXAMINATION: Chest portable radiograph
INDICATION: ___ year old woman with COPD, intubated for AMS/delirium and
hypoxia// edema, consolidations
TECHNIQUE: Chest portable radiograph
COMPARISON: Chest radiograph most recently done on ___
FINDINGS:
Stable, mild interstitial edema. Unchanged position of endotracheal tube and
nasogastric tube. Cardiomediastinal silhouette is stable. There is bibasilar
atelectasis. No pneumothorax.
IMPRESSION:
Stable mild interstitial edema.
Unchanged position of supportive and monitoring devices.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Transfer
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Dyspnea, unspecified
temperature: 96.7
heartrate: 116.0
resprate: 20.0
o2sat: 90.0
sbp: 179.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | ___ with history of COPD, HTN, DM2, chronic opioid use,
schizoaffective disorder who presented ___ to ___
with dyspnea x 10 days. Had concerning respiratory status with
tachypnea so transferred to ___ ED for further care. At ___
patient required intubation ___ for hypercarbia and altered
mental status. Extubated ___, now transferred to ___ per
patient and family request. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old lady with a history of MCTD
complicated by ILD, esophageal dysmotility, atypical chest pain,
asthma presenting with chest pain.
Patient reports that over the ~1 week she has been having
intermittent exertional precordial pain without radiation which
responded to SL nitroglycerin. Of note, she intermittently has
short episodes of palpitations (<1min) that follow mild-moderate
exertion, sometimes coinciding with chest pain. One day prior to
admission, while driving, she experienced ___ precordial chest
pain without exertion which did not respond to SL nitro but
resolved spontaneously. This AM she woke up to the same pain,
which resolved with sitting forward and taking SL nitroglycerin;
she decided to seek care for this in the ED.
In the ED initial vitals were: 98.4 | 79 | 135/77 | 18 | 100% RA
EKG: RBBB, but non-ischemic, no STTW changes or PR depression
Labs/studies notable for:
* Leukopenia 3.1, N57%, anemia 10.6, nl plt
* Chem: Phos 4.6
*Trop-T: <0.01 x2 (0605->1045)
*proBNP: <5
*Cardiology was consulted and recommended stress MIBI or echo in
AM
* Patient was given:
___ 05:53 PO Aspirin 324 mg
___ 06:06 SL Nitroglycerin SL .4 mg
___ 08:09 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 08:09 PO Donnatal 5 mL
___ 08:09 PO Lidocaine Viscous 2% 10 mL
___ 12:22 PO Omeprazole 40 mg
Vitals on transfer: 98.3 | 90 | 109/59 | 19 | 97% RA
On the floor, patient reports that her chest discomfort has
remained at ___ down from ___ when he came to the ED. She
does not feel uncomfortable. She complains of intermittent
cramping in her lower extremities but also in her abdominal
wall.
ROS:
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope. Denies exertional buttock or calf pain.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, cough, hemoptysis, black stools
or red stools. Denies recent fevers, chills or rigors. All of
the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: none
2. CARDIAC HISTORY:
- Bifasicular block (RBBB & LAFB)
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- mixed connective tissue disease (___)
- Interstitial lung disease
- Esophageal dysmotility
- GERD
- Peripheral neuropathy
Social History:
___
Family History:
Mother with MI and sister with hypertension
Physical Exam:
Exam at Admission
=================
VS: 98.4 | 125/70 | 98 | 16 | 100 RA
GENERAL: WDWN lady in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple without JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar dry crackles.
No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Mild bilateral calf
pain.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric `
Exam at Discharge
=================
98.3 114-123/57-60 99-104 ___ 99 ra
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP <8 cm.
CARDIAC: rapid rhythm, regular rhythm. no murmurs, rubs,
gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ b/l
Pertinent Results:
Labs at Admission
=================
___ 06:05AM BLOOD WBC-3.1*# RBC-3.86* Hgb-10.6* Hct-34.6
MCV-90 MCH-27.5 MCHC-30.6* RDW-13.7 RDWSD-44.1 Plt ___
___ 06:05AM BLOOD Neuts-57.1 ___ Monos-14.3*
Eos-2.3 Baso-0.3 Im ___ AbsNeut-1.76# AbsLymp-0.77*
AbsMono-0.44 AbsEos-0.07 AbsBaso-0.01
___ 06:05AM BLOOD Glucose-102* UreaN-14 Creat-0.7 Na-135
K-4.3 Cl-96 HCO3-22 AnGap-21*
___ 06:05AM BLOOD ALT-30 AST-22 LD(LDH)-234 AlkPhos-77
TotBili-0.2
___ 06:05AM BLOOD cTropnT-<0.01 proBNP-<5
___ 10:45AM BLOOD cTropnT-<0.01
___ 01:36AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:34AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:05AM BLOOD Albumin-4.6 Calcium-9.8 Phos-5.6* Mg-2.2
Cholest-285*
___ 06:05AM BLOOD Triglyc-205* HDL-71 CHOL/HD-4.0
LDLcalc-173*
Labs at Discharge
=================
___ 07:34AM BLOOD WBC-3.4* RBC-4.03 Hgb-11.1* Hct-35.6
MCV-88 MCH-27.5 MCHC-31.2* RDW-13.3 RDWSD-43.1 Plt ___
___ 07:34AM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-138
K-4.8 Cl-99 HCO3-28 AnGap-16
___ 07:34AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1
___ 03:56AM BLOOD %HbA1c-5.5 eAG-111
Important Studies
=================
CXR ___
Bibasilar interstitial lung disease has been more fully
characterized by a
recent CT. No definite superimposed secondary process such as
pneumonia,
although subtle new abnormalities may be difficult to detect in
the setting of
chronic lung disease.
Stress ___
INTERPRETATION: ___ yo woman with hx of SLE complicated by ILD
referred to evaluate an atypical chest discomfort and dyspnea.
The
patient was administered 0.142 mg/kg/min of Persantine over 4
minutes.
No chest, back, neck or arm discomforts were reported. No
significant ST
segment changes were noted. The rhythm was sinus with no ectopy
noted.
The hemodynamic response to the Persantine infusion was
appropriate.
Post-infusion, the patient was administered 125 mg Aminophylline
IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Nuclear
report sent separately.
Cardiac Perfusion Scan ___
The image quality is adequate but limited due to soft tissue and
breast
attenuation. There is activity adjacent to the heart in the
rest and stress images. Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium. Gated images reveal
normal wall motion. The calculated left ventricular ejection
fraction is 73% with an EDV of 69 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 1000 mg PO BID
2. Nitroglycerin SL 0.3 mg SL QID:PRN chest pain
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 10 mg PO QAM
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Pyridoxine 50 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Cyanocobalamin 500 mcg PO DAILY
5. Mycophenolate Mofetil 1000 mg PO BID
6. Nitroglycerin SL 0.3 mg SL QID:PRN chest pain
7. PredniSONE 10 mg PO QAM
8. Sulfameth/Trimethoprim DS 1 TAB 3x/week.
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
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: ___ woman with lupus, interstitial lung disease, and
esophageal dysmotility presenting with ___ chest pain radiating to the back
as well as shortness of breath. Evaluate for cardiopulmonary process causing
the patient's chest pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___. CT chest dated ___.
FINDINGS:
Persistent basilar predominant interstitial lung disease as evaluated on
recent chest CT. No focal consolidation, effusion, edema, or pneumothorax.
The heart remains mildly enlarged. Enlarged mediastinal lymph nodes on the
recent chest CT are not as well appreciated on this radiograph. A hiatal
hernia is small. No acute osseous abnormality. Multilevel degenerative
changes in the thoracic spine are mild.
IMPRESSION:
Bibasilar interstitial lung disease has been more fully characterized by a
recent CT. No definite superimposed secondary process such as pneumonia,
although subtle new abnormalities may be difficult to detect in the setting of
chronic lung disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.4
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | Mrs. ___ is a ___ y/o F with a history of mixed connective
tissue disease complicated by ILD, esophageal dysmotility,
atypical chest pain and asthma who presented with atypical chest
pain.
#Chest Pain:
She has had a history of atypical chest pain but this time she
noted that it lasted for much longer than it usually does. The
differential is broad including angina, pericarditis, esophageal
dysmotility, and MSK (myositis). In the context of having mixed
connective tissue disorder, she was considered to be at higher
risk for cardiovascular disease (Ungprasert ___, I___).
A pharmacologic stress test showed no abnormalities
(communicated to her cardiologist). A1c at 5.5. LDL at 173. The
results were inconclusive, but this was thought to be either due
to esophageal spasm/dysmotility or GERD. She was treated with
Maalox and lidocaine and she was discharged on omeprazole twice
a day. She was also discharged on atorvastatin 40 mg.
#Cramping
Has had leg cramps for many years. Electrolytes normal, CK
normal. Thought due to CellCept and Prednisone combination, but
etiology unknown. At discharge, cramps at baseline. Discharged
on Vitamin B6.
#Mixed Connective Tissue Disorder c/b ILD
Being managed by Pulmonology at ___ and Rheumatology at ___.
Pulmonology consulted in patient. Continued on prednisone 10 mg
daily, myocphenolate mofetil 1000mg BID. Bactrim for PCP
prophylaxis decreased to 3x/week. |
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 L vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ RH woman with a history of
significant psychiatric illness, hypothyroidism and right
retinal
microaneurysm who presents with monocular left visual changes.
The patient was doing eye exercises with a chart yesterday when
she suddenly noticed that the vision in her left eye "blacked
out" suddenly and completely, lasting several seconds. The
vision then returned to normal and she denied blurriness,
changes
in color saturation, diplopia or eye pain. She again had a
similar episode at 10am this morning, afterward she did feel
faint and light-headed so laid down. Her vision then returned
to
normal, though while we were testing her vision today, she noted
she had a circumferential "tire like ring of black" around her
vision in her left eye. She otherwise denies vertigo, changes in
strength, changes in hearing, trouble swallowing, headaches,
numbness/tingling and has otherwise been feeling normal. She
does
endorse a significant increase in personal stress, including her
mother being in the hospital in the last few days and her
husband
recently stopping his job.
After the second episode today, she spoke with her PCP and her
retinal specialist who recommended taking an aspirin and
evaluation in the hospital today.
Past Medical History:
Depression.
Schizoaffective disorder/Bipolar disorder.
Multiple psychiatric hospitalizations, the last in ___.
Drug toxicities: Elevated prolactin attributed to psychiatric
medication; mild CRI due to lithium now improved; hypercalcemia
due to lithium ___, now resolved.
Hypothyroidism and thyroid nodules
Benign positional vertigo.
Tremor: mostly affecting the UE, thought to be secondary to
psychiatric medications
Right retinal microaneursym, reportedly picked-up on routine
exam
Appendectomy in ___.
Deviated septum and turbinate extraction in the 1980s.
Ankle fracture (___): requiring surgery with placement of plate
and screws; reports that she was in the subway station, caught
her foot in her shopping cart and fell.
Tubal ligation
Social History:
___
Family History:
No thyroid disease or osteoporosis in the family.
Father died of MI at age ___, aunt died of CVA in her ___.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs. Dr. ___ a gallop on
exhalation.
Abdomen: soft, nontender, nondistended
Extremities: mild non-pitting edema through ankles, pulses
palpated
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. Prosody was quite varibale. 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. Pt. was able to register
3 objects and recall ___ at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect. Calculation was intact thoug slow (answers seven
quarters in $1.75). There was no evidence of left-right
confusion
as the patient was able to accurately follow the instruction to
tough left ear with right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 4mm and brisk. Acuity approximately ___ -1
bilaterally though patient took many attempts to achieve this.
On
VF testing, in the left eye only, there was a lower nasal field
cut (R inferior quadrant) but remainder of fields were intact
including entirely so on left. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages and microaneurysm was not
visualized.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ 4+ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. Vibration diminished bilaterally. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: There was a small amplitude postural tremor in
the
LUE, no dysdiadochokinesia noted. There was some dysmetria on
FNF
in the left hand but no rebound or past-pointing. The dysmetria
waxed and waned through the exam with the tremor.
-Gait: Deferred.
Pertinent Results:
ON ADMISSION:
___ 01:10PM BLOOD WBC-5.2 RBC-4.80 Hgb-13.4 Hct-40.4 MCV-84
MCH-27.9 MCHC-33.2 RDW-13.1 Plt ___
___ 01:10PM BLOOD Neuts-55.0 ___ Monos-7.1 Eos-1.2
Baso-0.7
___ 01:10PM BLOOD Plt ___
___ 01:16AM BLOOD ___ PTT-45.3* ___
___ 06:40AM BLOOD ESR-2
___ 01:10PM BLOOD Glucose-78 UreaN-27* Creat-1.3* Na-139
K-4.0 Cl-100 HCO3-33* AnGap-10
___ 07:03PM BLOOD cTropnT-<0.01
___ 01:10PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD TSH-0.99
___ 06:40AM BLOOD CRP-0.6
___ 06:40AM BLOOD Triglyc-87 HDL-65 CHOL/HD-2.6 LDLcalc-89
___ 06:40AM BLOOD %HbA1c-5.4 eAG-108
___ 06:40AM BLOOD Cholest-171
URINE CULTURE (Final ___: NO GROWTH.
CT head w/o contrast ___
No acute intracranial process.
CTA head and neck ___. Non-opacification of the left sigmoid sinus, new, with
apparent collateral vessels in this venous drainage pathway.
When correlated with the concurrent cranial MRI/MRV, the
constellation of findings most likely represents partial
thrombosis of the left sigmoid sinus.
2. No evidence of intra-orbital sequelae of cerebral venous
disease.
3. No intracranial hemorrhage, edema or mass effect.
4. No hemodynamically significant stenosis of the cervical
carotid arteries, by NASCET criteria.
MRI and MRV head ___. Hypoplastic left venous sinus system with diminished
flow-related
enhancement.
However, when correlated with the concurrent CTA, there is
non-opacification of the left sigmoid sinus and venous
collaterals are present along this venous drainage pathway. The
constellation of findings is most consistent with partial
thrombosis of the left sigmoid sinus, new since ___.
2. No acute infarct, edema or intracranial hemorrhage.
ECHO ___
The left atrium and right atrium are normal in cavity size. A
patent foramen ovale is present with premature appearance of
agitated saline in the left heart post-Valsalva release. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Patent foramen ovale. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. No pathologic flow identified..
===========
ON DISCHARGE:
___ 06:30AM BLOOD Glucose-92 UreaN-23* Creat-1.3* Na-143
K-4.4 Cl-107 HCO3-32 AnGap-8
___ 06:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 0.5 mg PO DAILY
2. ChlorproMAZINE 50 mg PO QHS
3. Divalproex (DELayed Release) 1250 mg PO QHS
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Paroxetine 20 mg PO DAILY
6. RISperidone 6 mg PO HS
7. Calcium Carbonate 600 mg PO DAILY
8. Ferrous GLUCONATE 324 mg PO DAILY
9. Fish Oil (Omega 3) ___ mg PO DAILY
10. ChlorproMAZINE 25 mg PO DAILY:PRN agitation
Discharge Medications:
1. Benztropine Mesylate 0.5 mg PO DAILY
2. Calcium Carbonate 600 mg PO DAILY
3. ChlorproMAZINE 50 mg PO QHS
4. ChlorproMAZINE 25 mg PO DAILY:PRN agitation
5. Divalproex (DELayed Release) 1250 mg PO QHS
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Fish Oil (Omega 3) ___ mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Paroxetine 20 mg PO DAILY
10. RISperidone 6 mg PO HS
11. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. left eye monocular vision changes
2. hypoplastic left sigmoid and transverse venous sinuses,
possible partially occlusive thrombus
Secondary diagnosis
1. Schizoaffective disorder/Bipolar disorder
2. Right retinal microaneursym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: no deficits
Followup Instructions:
___
Radiology Report
HISTORY: Sudden vision loss in right eye.
COMPARISON: Comparison is made with head MR 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.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
No fracture is identified. Minimal mucosal thickening is seen in the left
maxillary sinus. Otherwise, the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are intact.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: ___ female with left eye vision loss.
TECHNIQUE: Multidetector axial CT images were obtained through the head
without intravenous contrast. Following the administration of intravenous
contrast, CT angiogram of the head and neck was performed. Coronal and
sagittal images were reformatted from the source data. At a separate
workstation, 3D images were constructed.
COMPARISON: MRI IAC ___.
FINDINGS:
NECT: No intracranial hemorrhage is identified. There is no mass, mass
effect or midline shift. There is no evidence for a territorial infarct. The
gray-white matter differentiation is well preserved. The ventricular system
is normal in size and configuration.
CTA head: The major intracranial vessels are patent. There is no evidence
for hemodynamically significant stenosis or occlusion. No aneurysm or
arterial venous malformation is present. The basilar tip is patulous, a
normal variant.
Non opacification of the a left sigmoid sinus and the left jugular vein is
present. The left transverse sinus is hypoplastic. Collateral vessels are
present along this venous drainage pathway.
There is no evidence of intra-orbital sequelae of venous disease. No stranding
is present in the orbital fat. The superior and inferior ophthalmic veins are
symmetric and normal in caliber, and demonstrate normal enhancement. The
cavernous sinuses are symmetric.
CT angiogram neck: The bilateral common carotid, internal carotid, and
external carotid arteries are patent. Both vertebral arteries are patent.
The left vertebral artery is dominant.
Measurements of minimal diameters as follows:
Right ICA:
Proximal: 6.0 mm
Distal: 3.5 mm
Left ICA:
Proximal: 6.5 mm
Distal: 4.0 mm
Therefore, there is no evidence for hemodynamically significant stenosis by
NASCET criteria.
Multiple small to borderline in size cervical lymph nodes are present.
Mild scarring and atelectasis is present in the lung apices.
There are cervical spine degenerative changes most notable at C5-C6 and C6-7
where there is mild to moderate left neural foraminal narrowing secondary to
uncinate and facet hypertrophy.
IMPRESSION:
1. Non-opacification of the left sigmoid sinus, new, with apparent collateral
vessels in this venous drainage pathway. When correlated with the concurrent
cranial MRI/MRV, the constellation of findings most likely represents partial
thrombosis of the left sigmoid sinus.
2. No evidence of intra-orbital sequelae of cerebral venous disease.
3. No intracranial hemorrhage, edema or mass effect.
4. No hemodynamically significant stenosis of the cervical carotid arteries,
by NASCET criteria.
COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___
___ at 11:30 hours on ___, at the time of discovery.
Radiology Report
HISTORY: ___ woman with sudden left vision loss and inferior temporal
quadrantanopia of the left eye now with possible occlusion of the left sigmoid
sinus.
TECHNIQUE: Sagittal T1, axial FLAIR, axial T2, axial susceptibility and axial
diffusion weighted images were obtained. An MRV was obtained using a 2D
time-of-flight technique (no gadolinium)..
COMPARISON: CT angiogram head and neck ___ and MR ___ ___.
FINDINGS:
MRI brain: There is no acute infarct or intracranial hemorrhage. No mass,
mass effect or midline shift is present. The ventricular system is normal in
size and configuration.
Coarctation of the frontal horn of the left laterla ventricle is present with
a stable appearance dating back to examinations from ___.
MR venogram: The left transverse and sigmoid sinuses are hypoplastic with
diminished flow related enhancement. There was a normal caliber and
enhancement of the left sigmoid sinus on MRI ___ from ___. The
superior sagittal sinus, right transverse sinus, right sigmoid sinus,
visualized right jugular vein, straight sinus and vein ___ and are
patent.
IMPRESSION:
1. Hypoplastic left venous sinus system with diminished flow-related
enhancement.
However, when correlated with the concurrent CTA, there is non-opacification
of the left sigmoid sinus and venous collaterals are present along this venous
drainage pathway. The constellation of findings is most consistent with
partial thrombosis of the left sigmoid sinus, new since ___.
2. No acute infarct, edema or intracranial hemorrhage.
COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___
___ at 1130H on ___, at the time of discovery.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L VISION CHANGES
Diagnosed with CHEST PAIN NOS, VISUAL DISTURBANCES NEC
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | # Transient visual loss: Pt initially presented with 2 episodes
of transient monocular vision loss, and had other instances of
visual abnormalities during daily examinations by the neurology
team in the ED and each morning. In the ED, pt reported seeing a
ring of black, while during subsequent exams, pt reported
blacking out of central vision and "cracked" appearance of her
visual field in the left eye. She was worked up for multiple
etiologies. No apparent neurologic pathology on CT, MRI, MRA/MRV
scans. Scans were normal, with the exception of a hypoplastic L
sigmoid sinus and partial thrombus of unclear chronicity and
likely unrelated to current presentation. Ocular etiologies were
investigated with ophthalmology slit lamp exam, which showed no
abnormalities. Of note, visual fields were not completed (to be
completed in Neuro-ophthalmology visit). CTA showed normal
vasculature/no significant atherosclerosis in the aortic arch
and TTE showed a PFO but no thrombus. Hematologic causes (i.e.,
hypercoagulable diseases) were not investigated due to low risk
factor profile; pt is a non-smoker, has never been on estrogen,
has no h/o prior clots, and has no significant FH. Thus, the
etiology of her symptoms is unclear. She was started on ASA 81mg
during this admission. She will be followed in ___
clinic with VF testing, and will also follow up with her regular
ophthalmologist. She was instructed to make an appt for MRI of
orbits prior to her neuro-ophtho appt.
# L sigmoid sinus partial thrombosis: seen on MRV. This was felt
to be an incidental finding unrelated to the patients
presentation. She was started on ASA 81. She will need a repeat
MRV and follow up with Stroke neurology. She was given the
number to schedule her outpt MRV.
#Chronic kidney disease: pt was noted to have an elevated Cr of
1.3-1.4 during admission. Her baseline is 1.3-1.5 for the past
several years due to prior ___ nephrotoxicity. Her Cr
levels remained stable during admission (based on baseline
levels.) Pt is being followed by PCP and nephrology for this
issue.
#Hypernatremia: pt was noted to have slightly elevated Na at 146
on day of admission. Etiology was unclear, and her level was
tracked during admission. Her baseline Na has previously been in
high 130s-140s, and she has had previous issues with
hypernatremia. Her Na level came WNL at 143 at the time of
discharge. Pt is being followed carefully by her PCP and
nephrologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female who is s/p an MVC this morning with + LOC and
+SB. There was no air bag deployment. She was driving in a
parking lot at low speed when another vehicle struck her car at
approximately 30mph. She was initially transported to ___
___ for evalaution and workup revealed a small right parietal
SDH. She was neurologically intact and trasnferred to ___ for
further management and care. She reports of a mild ___
headache. She denies nasuea, vomiting, dizziness, difficulty
ambulating, changes in vision, hearing, or speech.
Past Medical History:
Borderline DM, HTN, chronic LBP, depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 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, 4mm to
3mm 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 bilaterally
Coordination: normal on finger-nose-finger
Discharge exam:
Neurologically intact
Pertinent Results:
CT HEAD ___ (Preliminary Report)
FINDINGS:
There is interval increase in size of the acute right cerebral
subdural hematoma, previously 4mm in thickness, now 10mm in
thickness. No significant mass effect or shift of midline
structures. Ventricles and sulci are normal in overall size and
configuration. The imaged paranasal sinuses are clear. Mastoid
air cells and middle ear cavities are well aerated. The bony
calvarium is intact.
IMPRESSION:
Right cerebral subdural hematoma, increased in size, now 10mm.
CT HEAD ___ (Preliminary Report)
FINDINGS:
A stable acute right frontoparietal subdural hematoma which
extends along the temporal convexity, measuring 9 mm in
thickness (previously 9 mm in
thickness). There is no evidence of infarction, new hemorrhage,
edema, or
mass. The ventricles and sulci are normal in size and
configuration.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The orbits are
unremarkable. Calcification of cavernous portions of bilateral
internal carotid arteries are noted.
IMPRESSION:
Stable acute right subdural hematoma, measuring 9 mm in
thickness. No shift of midline structures.
Medications on Admission:
Lisinopril, Celexa
Discharge Medications:
Lisinopril, Celexa, Keppra 500mg BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal 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 (PORTABLE AP)
INDICATION: Status post MVA, question internal injury
COMPARISON: Outside hospital chest radiograph from earlier today.
FINDINGS:
AP portable supine view of the chest. There is no focal consolidation or
supine evidence for effusion or pneumothorax. The cardiomediastinal silhouette
is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with MVC, Rt SDH, followup.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 892 mGy-cm
COMPARISON: OSH HEAD CT from earlier today.
FINDINGS:
There is interval increase in size of the acute right cerebral subdural
hematoma, previously 4mm in thickness, now 10mm in thickness. No significant
mass effect or shift of midline structures. Ventricles and sulci are normal in
overall size and configuration. The imaged paranasal sinuses are clear.
Mastoid air cells and middle ear cavities are well aerated. The bony calvarium
is intact.
IMPRESSION:
Right cerebral subdural hematoma, increased in size, now 10mm. No significant
mass effect or midline shift.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with minor MVC, expansion of right parietal SDH
on repeat imaging. Assess stability of subdural hematoma.
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1014 mGy-cm
CTDI: 54.21 mGy
COMPARISON: Noncontrast head CT ___.
FINDINGS:
The hyperdense subdural hematoma along the right convexity is stable compared
to 1 day earlier. There is no significant sulcal effacement and no shift of
midline structures. There is no new hemorrhage or edema. The ventricles and
basal cisterns remain normal in size.
The partially paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
Stable right subdural hematoma compared to 1 day earlier, without sulcal
effacement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, MVC
Diagnosed with SUBARACHNOID HEM-NO COMA, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | The patient was transferred from ___ for small R
parietal SDH and admitted to the Neurosurgery Service on ___.
Her initial head CT showed expansion of right parietal SDH. She
was started on levitiracetam for seizure prophylaxis and
monitored with serial neurologic checks per routine.
On ___, the patient remained neurologically stable. Repeat
head CT on ___ showed stable right parietal SDH. She was
deemed ready for discharge home. A thorough discussion was had
regarding post-discharge instructions. She was provided with a
prescription for levitiracetam to continue until follow up and
she was instructed to follow up with Dr. ___ in ___ weeks
with repeat head CT at that time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Bilateral lower abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G3P3 with a PMH significant for AML s/p treatment, now in
remission, presents to the ED with 1 day of bilateral lower
abdominal pain. Pain started last night (___) around 2200. Is
constant and aching, rated initially ___, throughout the lower
abdomen but slightly more right than left-sided. She tried OTC
meds at home with little relief. She was seen in ___ clinic
this morning for routine follow-up and was sent to the ED given
her significant pain.
She denies any fevers, chills, vomiting, dysuria, vaginal
discharge or bleeding, diarrhea, constipation. She has nausea
with the pain. She did have intercourse on ___ with her
partner (of one week), and the condom did break. The intercourse
was only uncomfortable in that it was with a relatively new
partner but described as non-painful. She does not believe her
partner has had any sexually transmitted infections.
Past Medical History:
OB/GYN:
G3P3, s/p LTCS x ___
s/p Bilateral tubal ligation
History of latent syphilis diagnosed ___, s/p PCN tx x 14d
and
w/ f/u negative LP. No other h/o STIs.
Regular menses, heavy ___ days of bleeding
Does not remember last pap - prob w/in last ___ years
? h/o HSV but denies genital outbreaks - had rash on back (pt
says the rash comes when she has eaten nuts)
PMH: Acute myelogenous leukemia in remission with last cycle of
chemo completed in ___ also part of experimental vaccine
trial. H/o shingles on back (pt believes this to be due to nut
allergy, not shingles).
PSH: LTCS x 3; tubal ligation; vein stripping in L leg
Social History:
___
Family History:
noncontributory
Physical Exam:
on admission, by Dr. ___:
VS initially in ED: T 99.6 HR 80 BP 111/95 O2 sat 100% on RA
NAD, sleeping in stretcher curled on side
RRR
CTAB
Abdomen significantly tender to both light and deep touch.
Voluntary guarding present. No rebound. Abdomen warm to touch.
No
distinct masses palpated. +BS.
Pelvic: Normal external genitalia, normal vaginal mucosa. Cervix
appears normal. There is some milky white discharge in the
posterior fornix and coming from the os, but this does not
appear
prurulent and could be consistent with recent intercourse/condom
breakage.
Bimanual exam: No cervical motion tenderness when internal hand
used to manipulate cervix. Additionally no right or left adnexal
tenderness with only internal palpation. Significant abdominal
tenderness elicited with use of external hand to palpate, worse
on right compared to left.
on day of discharge:
98.2, 94/55, 96, 16, 100%RA
Gen: NAD, AxO
Abd: normoactive bowel sounds, soft, nondistended, minimally
tender to palpation diffusely, no rebound or guarding
Pertinent Results:
___ 06:50AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.6* Hct-31.4*
MCV-93 MCH-31.5 MCHC-33.9 RDW-12.5 Plt ___
___ 09:59PM BLOOD WBC-17.3* RBC-3.33* Hgb-10.9* Hct-30.7*
MCV-92 MCH-32.7* MCHC-35.3* RDW-12.4 Plt ___
___ 06:55AM BLOOD WBC-18.4* RBC-3.49* Hgb-11.2* Hct-32.5*
MCV-93 MCH-32.1* MCHC-34.5 RDW-12.5 Plt ___
___ 11:00PM BLOOD WBC-17.5* RBC-3.65* Hgb-11.4* Hct-33.5*
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.6 Plt ___
___ 11:58AM BLOOD WBC-19.7* RBC-3.74* Hgb-11.8* Hct-33.9*
MCV-91 MCH-31.5 MCHC-34.7 RDW-12.5 Plt ___
___ 09:30AM BLOOD WBC-17.5*# RBC-3.78* Hgb-11.7* Hct-35.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-12.5 Plt ___
___ 06:50AM BLOOD Neuts-92.9* Lymphs-3.7* Monos-3.1 Eos-0.2
Baso-0.1
___ 09:59PM BLOOD Neuts-91.4* Lymphs-5.3* Monos-3.0 Eos-0.2
Baso-0.1
___ 06:55AM BLOOD Neuts-90.0* Lymphs-5.9* Monos-3.5 Eos-0.4
Baso-0.2
___ 11:00PM BLOOD Neuts-87.8* Lymphs-9.7* Monos-2.0 Eos-0.3
Baso-0.1
___ 11:58AM BLOOD Neuts-90.3* Lymphs-7.7* Monos-1.8*
Eos-0.1 Baso-0.2
___ 09:30AM BLOOD Neuts-91.3* Lymphs-5.0* Monos-3.3 Eos-0.2
Baso-0.2
___ 09:20AM BLOOD ___ PTT-26.5 ___
___ 09:59PM BLOOD ___ PTT-28.3 ___
___ 09:20AM BLOOD ___
___ 09:59PM BLOOD ___
___ 11:58AM BLOOD ESR-25*
___ 09:30AM BLOOD ___
___ 06:50AM BLOOD Glucose-146* UreaN-6 Creat-0.4 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
___ 09:59PM BLOOD Glucose-131* UreaN-7 Creat-0.6 Na-136
K-3.5 Cl-101 HCO3-29 AnGap-10
___ 06:55AM BLOOD Glucose-121* UreaN-10 Creat-0.4 Na-135
K-3.6 Cl-101 HCO3-27 AnGap-11
___ 11:00PM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
___ 11:58AM BLOOD Glucose-116* UreaN-10 Creat-0.5 Na-136
K-3.8 Cl-100 HCO3-26 AnGap-14
___ 09:30AM BLOOD UreaN-11 Creat-0.6 Na-136 K-3.9 Cl-99
HCO3-30 AnGap-11
___ 06:50AM BLOOD ALT-8 AST-11 TotBili-0.4
___ 09:30AM BLOOD ALT-11 AST-14 LD(LDH)-176 AlkPhos-62
TotBili-0.7
___ 06:50AM BLOOD Albumin-3.8 Calcium-8.7 Phos-1.9* Mg-1.8
___ 09:59PM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
___ 06:55AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9
___ 09:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
___ 09:30AM BLOOD HCG-<5
___ 11:58AM BLOOD CRP-89.7*
___ 12:13PM BLOOD Lactate-2.1*
___ 05:32PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:58AM URINE Color-Straw Appear-Clear Sp ___
___ 05:32PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:32PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
GC/Ch cultures negative (final)
Urine culture ___ and ___ no growth (final)
blood culture ___ no growth (final)
blood cultures ___, and ___ no growth to date
Pelvic US ___: The ultrasound shows a dilated tube on the left
with a slightly thick
wall and debris. The ovary is seen adjacent to this. This is not
a classic
___ since the ovary is seen separate from the tube, and but the
amount of
debris in the tube is compatible with a pyosalpinx. This tube
measures 5.2 x
2.3 cm on the images where it appears the largest. This change
in diagnosis
from hydrosalpinx to pyosalpinx is compatible with the patient's
clinical
history of PID.
CT A/P ___: 1. Bilateral fluid-filled tubular structures within
the pelvis most likely
represent bilateral hydrosalpinges including suggestion of
bilateral
inflammatory changes. Although an inflamed appendix intermingled
with the
right adnexa is hard to exclude, a small inflammed tube seems
much more
likely. Active pelvic inflammatory disease is a likely etiology
and further
evaluation with ultrasound is suggested.
2. Cholelithiasis without evidence of cholecystitis.
CT A/P ___:
1. Fluid-filled rim-enhancing tubular structures in both adnexa
are most
consistent with pyosalpinx as noted on the recent ultrasound.
2. 9 mm fluid filled appendix without ___ stranding
to suggest appendicitis.
Medications on Admission:
acyclovir
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 7 days: do not consume alcohol while on this
medication.
Disp:*21 Tablet(s)* Refills:*0*
3. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral pyosalpinx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with marked bilateral abdominal pain and
rebound tenderness.
COMPARISON: ___ examination.
TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was
obtained after administration of 130 cc of Omnipaque intravenous contrast.
Axial, coronal, and sagittal reformats were prepared.
FINDINGS: Within the lung bases, no concerning lesions or pleural effusions
are seen. The mediastinum is unremarkable.
CT OF THE ABDOMEN: A hypodense lesion in the right lobe of the liver measures
16 x 12 mm in axial ___ (2:17), similar to decreased; although
indeterminant stability suggests benignity. The spleen, pancreas, bilateral
kidneys, and bilateral adrenal glands are unremarkable. The gallbladder shows
several dependent calcified gallstones. The stomach, duodenum, and small
bowel loops within the abdomen are unremarkable. Portions of the colon within
the abdomen are unremarkable.
CT OF THE PELVIS: Within the pelvis, the adnexa show evidence of
calcifications followed by a fluid-filled tubular structures on the right as
well as the left (image 2:64 and image 2:65 as well as image 601B:17 and image
601B:18). On the right the tubular structure is small but with mural
enhancement. Although the cecum closely approaches it, it appears more likely
adnexal suggesting a small probably inflammed fallopian tube. On the left
there is clearly a moderate convoluted tube consistent with a hydrosalpinx and
its fluid content is perhaps slightly hyperdense.
The appendix is not clearly visualized as a separate entity (although it is
also not clearly seen on earlier examinations) so it is difficult to
completely exclude that the right-sided structure could potentially represent
an inflammed appendix, although doubted. The loops of small bowel within the
pelvis as well as the rectum and uterus are unremarkable. The bladder is
distended and unremarkable. No pelvic lymphadenopathy is seen.
OSSEOUS STRUCTURES: The osseous structures show no concerning sclerotic or
lytic bone lesions.
IMPRESSION:
1. Bilateral fluid-filled tubular structures within the pelvis most likely
represent bilateral hydrosalpinges including suggestion of bilateral
inflammatory changes. Although an inflamed appendix intermingled with the
right adnexa is hard to exclude, a small inflammed tube seems much more
likely. Active pelvic inflammatory disease is a likely etiology and further
evaluation with ultrasound is suggested.
2. Cholelithiasis without evidence of cholecystitis.
Radiology Report
INDICATION: ___ woman with clinical PID, evaluate for tubo-ovarian
abscess.
COMPARISON: CT abdomen and pelvis with contrast ___.
PELVIC ULTRASOUND:
LMP: ___.
Transabdominal and transvaginal ultrasound examinations were performed, the
latter for better visualization of the endometrium and adnexa.
The uterus measures 9.3 x 5.4 x 7.5 cm. The endometrium measures 6 mm and is
within normal limits. The right ovary measures 4.4 x 2.5 x 3.3 cm. A
follicle is noted within the right ovary. The left ovary measures 3.5 x 2.8 x
2.4 cm. A predominantly anechoic tubular structure within the left adnexa
appears consistent with hydrosalpinx. C-section scar with possible fibroid
measuring 1.1 x 1.4 x 1.4 cm within the C-section scar is noted in the lower
uterine segment. There is fluid in the cervix.
IMPRESSION:
1. C-section scar with possible small fibroid at the C-section scar.
2. Fluid within the cervix.
3. Left hydrosalpinx.
Addendum: This study was discussed with Dr. ___ at 845 AM on ___ by Dr.
___. The ultrasound shows a dilated tube on the left with a slightly thick
wall and debris. The ovary is seen adjacent to this. This is not a classic
___ since the ovary is seen separate from the tube, and but the amount of
debris in the tube is compatible with a pyosalpinx. This tube measures 5.2 x
2.3 cm on the images where it appears the largest. This change in diagnosis
from hydrosalpinx to pyosalpinx is compatible with the patient's clinical
history of PID.
Radiology Report
INDICATION: ___ woman with likely PID versus appe, now with worsening
pain and continued to be febrile.
COMPARISON: Pelvic ultrasound from ___, CT of the abdomen and
pelvis from ___.
TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV
and oral contrast. Multiplanar reformations were obtained and reviewed. DLP:
503.24 mGy-cm.
FINDINGS: The partially imaged lungs show minimal bibasilar atelectasis. The
partially imaged heart is unremarkable. The topmost dome of the right lobe of
the liver is not imaged on the current exam.
CT OF THE ABDOMEN WITH IV CONTRAST:
The liver shows a focal hypodensity adjacent to the IVC, likely representing a
simple cyst. The portal vein is patent. The spleen, both adrenals, both
kidneys, pancreas are unremarkable. The gallbladder contains vicariously
excreted contrast. A stone is noted in the neck of the gallbladder measuring
12 x 15 mm. No abdominal free fluid or free air is present. No abdominal,
retroperitoneal or mesenteric lymphadenopathy by CT size criteria is present.
The small bowel loops are unremarkable. The appendix measures up to 9 mm and
is fluid filled, although no significant periappendiceal stranding is noted.
CT OF THE PELVIS WITH IV CONTRAST:
The rectum, sigmoid colon, bladder, and uterus are unremarkable. Both adnexa
show tubular rim-enhancing structures which are most consistent with
pyosalpinx as noted on the recent pelvic ultrasound. There is a small amount
of pelvic free fluid. A Foley catheter terminates within the bladder. No
pelvic or inguinal lymphadenopathy is present.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or blastic lesions or
fractures.
IMPRESSION:
1. Fluid-filled rim-enhancing tubular structures in both adnexa are most
consistent with pyosalpinx as noted on the recent ultrasound.
2. 9 mm fluid filled appendix without ___ stranding to suggest
appendicitis.
Gender: F
Race: HISPANIC OR LATINO
Arrive by AMBULANCE
Chief complaint: RLQ ABD PAIN
Diagnosed with ABDOMINAL PAIN RLQ, ACUTE MYELOID LEUK-IN REMISS
temperature: 99.6
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 111.0
dbp: 65.0
level of pain: 10
level of acuity: 3.0 | On ___, Ms. ___ was made NPO and admitted from the
emergency department for serial abdominal exams and IV
gentamicin and clindamycin for presumed pelvic inflammatory
disease in the setting of leukocytosis to 19.7 with left shift,
elevated ESR and CRP, and a final pelvic ultrasound consistent
with 5.2cm left pyosalpinx that was not amenable to ___ guided
drainage. General surgery was consulted as appendicitis could
not be ruled out and recommended the addition of IV flagyl.
Since she had significant RLQ tenderness and the initial CT scan
was not able to visualize the appendix, a repeat CT with IV and
oral contrast was ordered to rule-out appendicitis. She refused
to drink oral contrast throughout the day, saying that she would
have emesis with it although she continued to ask for coffee and
food. Her abdominal exam throughout hospital day 1 was unchanged
with significant RLQ tenderness and some voluntary guarding but
no rebound tenderness. She was afebrile and her vital signs were
stable.
On hospital day 2, Ms. ___ continued to refused to drink the
oral contrast through the day, ultimately throwing the oral
contrast on the floor. In the afternoon, she was unable to void
despite several attempts, and a foley was placed for urine
output monitoring. She had two brief episodes of anxiety marked
by crying, hyperventilation, tachycardia to 120 and elevated
blood pressure (140/70). The first was related to her aversion
to drinking oral contrast, and the second was related to placing
the foley catheter. She continued to report no change in her
abdominal pain, and her abdominal exams during both episodes was
unchanged with continued tenderness on the right side but no
rebound. Both episodes resolved with IV ativan. Social work was
consulted for support as the patient repeatedly threatened to go
home during these episodes. In the afternoon, she spiked her
first fever to 102.7 at 5pm. She initially refused to have labs
drawn but eventually consented to labs. Her WBC remained
elevated. As she had not received a full 24 hours of intravenous
antibiotics and her exam continued to have no evidence of
peritoneal signs, she was monitored with serial exams overnight.
Early in the morning on hospital day 3, Ms. ___ had increased
abdominal pain, continued fever to 101.5 at 3am and new
development of rebound tenderness on exam. She was again
counseled on the importance of a repeat CT scan with oral
contrast. She then agreed to drink some oral contrast in order
to proceed with a repeat CT scan, which revealed bilateral
pyosalpinx and normal appendix. Infectious disease was consulted
for persistent fever despite IV antibiotics, and they
recommended intravenous levofloxacin and flagyl for 24 hours
afebrile, which could then be transitioned to a 7 days oral
outpatient antibioitic course. At this point, she had been
afebrile since 7am, her WBC count was trending down, and her
abdominal pain was improved with less tenderness on exam and no
peritoneal signs. Throughout the day she continued to express
her desire to stop intravenous antibiotics, to eat, and to go
home. Multiple efforts were made to explain the importance of
continued inpatient hospitalization for intravenous antibiotics,
labs, and monitoring for her pelvic infection. Later in the
evening, Ms. ___ ultimately signed out against medical advice
with the knowledge that improper treatment of her infection
could result in her death. Her foley catheter and IVs were
removed prior to her departure. She was counseled on the
importance of continuing outpatient antibiotics and to return to
the emergency room if she had any change in symptoms including
continued fever, worsened abdominal pain, nausea/vomiting, or
any other concerns. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion, early satiety
Major Surgical or Invasive Procedure:
Upper and lower endoscopy, ___
History of Present Illness:
___ with a PMH of non-ischemic cardiomyopathy with EF 35-40% p/w
several weeks of DOE which worsened yesterday. He states his
symptoms started around 2 weeks ago while he was in ___ and
were stable to mildly worsening until yesterday he had
significant worsening of his SOB. He notes the SOB is present
mainly with exertion and has been limiting his activity but
resolves with rest. He has no accompanied wheezing. He has not
any symptoms like this before. He denies any chest pain or
pressure, PND, and orthopnea. He notes intermittent ankle
swelling which he attributed to gout and which has currently
resolved. He flew in to ___ where he recieves his medical
care on ___ and underwent prostate biopsy on ___ which was
uncomplicated. He has noted no changes in his urination since
the biopsy including hematuria, dysuria, frequency, or changes
in his stream. He had an associated occasionally productive
cough but denies fevers and chills.
In the ED initial vitals were: 99.5 108 141/87 20 96% RA
- Labs were significant for BNP 7500, Cr 1.9 (baseline 1.0),
Trop negative x1, VGB 7.38/40 with lactate of 3.4. CXR without
infiltrate or edema and bedside u/s without pericardial
effusion.
- Patient was given:
___ 18:04 PO Acetaminophen 650 mg
___ 18:04 PO Acetaminophen 650 mg
___ 18:04 IVF 1000 mL NS
___ 20:42 IV Heparin 5000 UNIT
___ 20:42 IV Heparin gtt
This AM he denies CP, PND, orthopnea. He feels that his
breathing is improved. He does note red urine. No other
complaints.
Review of Systems:
(+) per HPI
Past Medical History:
HTN
DM2
Cardiomyopathy CHF EF 35-40%
Sickle cell disease
Hyperlipidemia
h/o osteomyelitis in right femur
h/o elevated PSA
h/o iron deficiency anemia
Social History:
___
Family History:
No family history of colon cancer or IBD. Mother died of old
age, father passed away when he was young. Unremarkable,
specifically no history of prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.9 ___ on 2L. 93 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, moderately elevated JVP
CARDIAC: Tachycardic, regular, S1, split S2,
LUNG: Bibasilar crackles R>L, no increased work of breathing
ABDOMEN: Mild distention, no detectable ascites, +BS, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused with good cap refill, no
excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
Vitals - 97.7 ___ 20 100RA
Weight: 85.5kg from 88 admission.
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, JVP 1cm above the clavicle at 90
deg.
CARDIAC: regular rhythm, normal rhythm, S1, S2 split, no rubs or
murmurs. LUNG: CTAB nonlabored. + expiratory wheeze. No
appreciable RV heave or PA tap. Good air movement.
ABDOMEN: Mild distention, no detectable ascites, +BS, nontender
in all quadrants, no rebound/guarding,
EXTREMITIES: no cyanosis, clubbing. No sacral or lower extremity
edema.
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused with good cap refill, no
excoriations or lesions, no rashes
Pertinent Results:
================================================================
LABS
7.7 > 10.2 (MCV 85) < 247 ___ Hb baseline ~12, retics 5%, hx
Sickle Cell, Fe studies pending
BUN/Cr: ___ -> ___
BNP 7,500 (___)
D-Dimer: 5,045 (nl < 500) (___)
PSA: 7.6 (___)
VBG: 7.38/42; lactate 3.3 (___)
UA: 106 RBCs, 17 WBCs, otherwise neg
FeNa: 6.84%; FeUrea: 48%
================================================================
MICRO:
UCx: ___ pending (UA w/ 17 WBCs)
BCx: ___ - pending x 2
RPR: ___ - pending
Lyme serology: ___ - pending
================================================================
STUDIES:
C-SCOPE (___): Normal colon to cecum, good prep.
EGD (___):
Normal esophagus.
Irregular Z-line (path pending)
Erythema and friability with few superficial erosions in the
duodenum compatible w/ duodenitis (path pending)
Otherwise nl EGD to ___ part of duodenum.
Recommend PPI BID for at least 8 weeks, then daily.
V/Q Scan (___): Definite, unmatched segmental perfusion defects
involving the right apex and RML, with a possible lingular
subsegmental defect. These findings are consistent with a high
likelihood for pulmonary embolism
CT A/P (non-con) (___):
- Liver, pancreas unremarkable
- Auto-infarction of the spleen with residual calcified soft
tissue mass
- Assesment of the gastric lumen precluded by PO intake
- Markedly enlarged prostate (unchanged); no pathologic lymph
nodes
- Bones demonstrate appearance classic for sickle cell w/
endplate infarction
- Fullness of L. adrenal gland (chronic, unchanged)
CT Chest (non-con) ___:
No suspicious pulmonary nodules. Non-characteristic scarrning at
the bases of the lingula. Old left rib fracture. No evidence
of malignancy on the current examination.
CXR (PA/Lat): ___ - mild cardiomegaly, otherwise clear
TTE (___): 35-40%; non-dilated. Moderate LV hypokinesis. Nl
RV. No significant valvular disease.
================================================================
PRIOR STUDIES:
EGD (___): Inflammation at GE junction, chronic active
gastritis (H. pylori +ve).
C-scope (___): 3 x <5mm sessile polyps; serrated adenomas
================================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Simvastatin 40 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 100 mg PO BID
2. Simvastatin 40 mg PO DAILY
3. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
4. TraZODone 100 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Unprovoked, pulmonary embolism. Duodenitis,
hematuria
SECONDARY DIAGNOSIS: Sickle Cell. Hypertension, Diabetes,
Systolic Heart Failure,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with several weeks of dyspnea with recent worsening,
productive cough.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph and ___ chest CTA
FINDINGS:
The heart size remains mildly enlarged. The mediastinal and hilar contours are
within normal limits. Pulmonary vasculature is normal. Linear opacities in the
left lung base likely reflect atelectasis or scarring. No focal consolidation,
pleural effusion or pneumothorax is present. Remote left-sided rib fractures
are demonstrated.
IMPRESSION:
No radiographic evidence for pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dyspnea. // interval change, pulmonary
vascular congestion interval change, pulmonary vascular congestion
IMPRESSION:
In comparison with the study of ___, there is little interval change.
The cardiac silhouette is at the upper limits of normal in size and there is
no evidence of acute pneumonia, vascular congestion, or pleural effusion.
Streak of atelectasis is seen at the left base.
Radiology Report
INDICATION: ___ year old man with unprovoked PE and history of early satiety.
ORAL CONTRAST ONLY. MARGINAL RENAL FUNCTION // malignancy, specifically
gastric or pancreatic
TECHNIQUE: CT of the Abdomen and Pelvis WITHOUT IV contrast and with oral
contrast
DOSE: DLP: 876.
COMPARISON: ABDOMINAL CT FROM ___
FINDINGS:
LOWER CHEST: Please see the CT chest report from the same day for full details
CT OF THE ABDOMEN WITHOUT CONTRAST: LIVER SHOWS NO DEFINITE MASS LESIONS,
PORTAL VASCULATURE CANNOT BE ASSESSED, GALLBLADDER IS UNREMARKABLE OTHER THAN
SIMPLE AND UNCHANGED CHOLELITHIASIS. MILD PROMINENCE OF THE LEFT ADRENAL GLAND
UNCHANGED, THE RIGHT ADRENAL GLAND IS UNREMARKABLE AS ARE BOTH KIDNEYS OTHER
THAN SIMPLE CYSTS INVOLVING THE LEFT KIDNEY. THERE IS NO FREE FLUID, NO
PATHOLOGICALLY ENLARGED ADENOPATHY, THE PANCREAS APPEARS UNREMARKABLE. THERE
IS AUTO INFARCTION OF THE SPLEEN WITH A RESIDUAL CALCIFIED SOFT TISSUE MASS,
UNCHANGED. THERE IS MARKED A P.O. INTAKE WITHIN THE GASTRIC LUMEN, EXCLUDING
ANY ASSESSMENT OF THE AND GASTRIC LUMEN. MILD ATHEROSCLEROTIC DISEASE AT THE
ORIGIN OF THE CELIAC AXIS.
CT OF THE PELVIS WITHOUT CONTRAST: VISUALIZED LOOPS OF LARGE SMALL BOWEL
APPEAR UNREMARKABLE, SIMPLE MIDLINE FAT CONTAINING UMBILICAL HERNIA, MARKEDLY
ENLARGED BUT UNCHANGED PROSTATE, NO FREE FLUID, NO PATHOLOGICALLY ENLARGED
NODES.
BONES DEMONSTRATE APPEARANCE CLASSIC FOR SICKLE CELL WITH ENDPLATE INFARCTION
IMPRESSION:
1. No specific evidence of malignancy on this non contrast CT
2. FINDINGS CONSISTENT WITH SICKLE CELL DISEASE INCLUDING AUTO INFARCTION OF
THE SPLEEN, VERTEBRAL ENDPLATE INFARCTION.
3. CHRONIC FINDINGS INCLUDING A FULLNESS OF THE LEFT ADRENAL GLAND, SIMPLE
CHOLELITHIASIS.
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Search for malignancy.
COMPARISON: ___.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material.
FINDINGS: 12 mm hypodense right thyroid nodule. No supraclavicular,
infraclavicular or axillary lymphadenopathy. No lymphadenopathy in the
mediastinum. No substantial coronary calcifications. Mild mitral valve
calcifications. No pericardial effusion. The abdominal findings are reported
in detail in the abdominal CT examination performed today.
Diffuse bony changes, not different from previous examination from ___.
Minimal subpleural bulla on the left. Non-characteristic subpleural
micronodules, none of which is suspicious for malignancy. No suspicious
pulmonary nodules. No pleural effusions. No pneumonia. Non-characteristic
scarring at the bases of the lingula. Pleural thickening and scarring at the
right lung base (4, 258). Old left rib fracture.
IMPRESSION: No evidence of malignancy on the current examination.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 99.5
heartrate: 108.0
resprate: 20.0
o2sat: 96.0
sbp: 141.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | ___ with a PMH of non-ischemic cardiomyopathy with last EF 35%
p/w several weeks of DOE with significant worsening over the
past day.
# Pulmonary embolism: Dyspnea, likely secondary to PE. His
presentation was initially concerning for a systolic CHF
exacerbation given the gradual onset and known cardiomyopathy.
However, he has not had prior CHF episodes in the past but he
only has mild bibasilar crackles, no ___ edema, no history of
PND/orthopnea. No evidence of acute ischemia with negative
biomarkers in ED. Alternatively, give his acute worsening on the
day PTA and presentation with tachycardia/hypoxia in the setting
of potential malignancy and recent plane flight a PE could be
considered. Wells score indicates moderate probability and
D-dimer was elevated. Cr too elevated for CTA so patient
recieved a VQ scan was ordered which shoed In terms of other
potential diagnoses, no evidence of pneumonia or infection.
Patient has sickle cell but does not appear to be in a crisis
and is without significant anemia.
- Was up to date on age appropriate cancer screening. However
early satiety prompted up to rule out a GI maligancy, discussed
below.
- Rivaroxaban 15mg BID for 21 days then 20mg daily for at least
6 months of anti-coagulation.
# EARLY SATIETY: Weight stable since ___ but reports subacute
onset of poor appetite and early satiety. No night sweats. Hct
is slightly down. Given recent possibly unprovoked PE, occult
malignancy should be excluded. CT Torso and ___ without
concerning findings for malignancy.
# ACUTE KIDNEY INJURY: Presented with Cr of 1.9. Patient with
diabetic nephropathy based on past labs but no evidence of CKD
and recent Cr measurement of 1.0 within 1 week. Suspect a
pre-renal etiology potentially related to decreased cardiac
output related to his above dyspnea. No evidence of poor PO or
increased volume losses. Could consider a post-renal etiology
given his suspected prostate cancer and recent urologic
procedure although he does not endorse any obstructive symptoms.
Urine lytes with FeUrea of 47%. Creatinine was 1.2 by time of
discharge.
# HEMATURIA: Likely ___ recent prostate biopsy procedure +
heparin gtt. However does have history of bladder cancer, but
most recent cystoscopy was normal. Unlikely from renal course
given presence of small clots.
# LACTIC ACIDOSIS: Most likely reflects a type B lactic acidosis
related to metformin use in the setting of renal failure. Could
consider a type A acidosis although his vitals and exam are not
c/w shock. LFTs within normal limits.
# DM2: Held home metformin given lactic acidosis above. Please
restart as an outpatient.
# HTN: Cont metoprolol, HCTZ, simvastatin
# Code: FULL (confirmed)
# Emergency Contact: ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim DS
Attending: ___
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
DC Cardioversion ___
History of Present Illness:
Mr. ___ is a ___ year old M with newly diagnosed HFrEF (EF 28%
___, persistent Afib, HTN, HLD, recently admitted for CHF
exacerbation and rapid AF, now re-presenting with one day of
profound fatigue as well as transient disequilibrium and garbled
speech.
Patient was very recently admitted to the ___ Cardiology
service for CHF exacerbation and rapid AFib. He was diuresed to
euvolemia, started on amiodarone, and successfully electrically
cardioverted on ___. He discharged home the following day in
sinus rhythm. He felt well for the two days and was able to go
to
work and go out to dinner. However, ___ evening he began
feeling fatigued. He attributed this initially to a cold.
However, his fatigue persisted despite his runny nose and chills
resolving. Yesterday evening (___) he nearly fell asleep
sitting
at the dinner table. When he awoke he felt transiently off
balance; no dizziness or unilateral weakness, just
disequilibrium; this resolved quickly. His wife also reported
his
speech was transiently garbled. He thought this was due to being
half asleep, but she was worried and insisted he seek medical
attention so they drove to the ED.
In the ED:
- Initial VS: 99.9 107 177/97 18 RA
- Labs notable for:
WBC 6.4
Cr 1.1 (at baseline), K 4.5, Mg 1.9
Trop <0.01
proBNP 904 (___ last admission)
- EKG: AF at 114, normal axis, QTc 457/501, TWI.
- CXR: stable cardiomegaly, no edema or pneumonia.
- CT head found subacute/chronic bilateral infarcts.
- CTA head/neck negative.
- Neuro was consulted and believed his symptoms were more
related
to his rapid AF rather than his strokes and recommended
admission
to Medicine vs. Cardiology for further management, as well as
non-urgent MRI.
On the floor, patient reports ongoing fatigue and palpitations.
No chest pain, dyspnea, or dizziness. No recurrence of
neurologic
symptoms since
Of note, patient reports good adherence to apixiban, amiodarone,
lasix, and all other medications. He weighs himself daily and
his
weight has been stable since discharge. He follows a low-salt
diet. He denies any exertional dyspnea (just fatigue),
orthopnea,
PND, or recurrent edema.
Regarding his neuro symptoms, he denies any headache, vision
changes, unilateral weakness, paresthesias, or dysarthria. No
convulsions, urinary incontinence, or confusion.
His cold symptoms were limited to rhinorrhea and chills. He has
not had any fevers, sinus pain, cough, N/V/D/abdominal pain,
dysuria, or rashes.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY
- A-fib
3. OTHER PAST MEDICAL HISTORY
Motor vehicle crash ___: Whiplash, low back and knee
injuries
History of recurrent MRSA infections: Sees dermatology p.r.n.
Hypertension
Hyperlipidemia
Hearing loss b/l wears hearing aids f/up by ENT,
Erectile Dysfunction on viagra
Ca Prostate followed by ___, s/p radiation and hormonal
therapy
colonosocpy done ___ rec repeat in ___ yrs ___
persistant rash: face/neck abscess ___
Social History:
___
Family History:
Negative for premature CAD, arrhythmias, heart failure,
cardiomyopathy, sudden or unexpected death. No family history of
HTN, DM, or cancers.
Physical Exam:
ADMISSION EXAM:
===============
VS: 97.6 129/94 124 18 95%RA
GEN: Lying comfortably flat in bed.
HEENT: NC/AT. No icterus or injection. MMM.
CV: JVP ~7cm. Tachycardic, irregularly irregular, no murmurs.
Normal distal pulses.
RESP: Normal work of breathing. Transmitted coarse upper airway
sounds but no crackles or wheezes.
ABD: Soft, NDNT. No HSM.
EXTR: Warm, trace edema beneath compression stockings.
NEURO: Alert, oriented, normal attention, memory, and speech.
PERRL, EOMI, CN ___ intact. Strength ___ throughout. No
dysmetria.
DISCHARGE EXAM:
===============
Temp: 97.2 (Tm 98.9), BP: 127/57 (107-144/57-80), HR: 62
(62-86), RR: 18 (___), O2 sat: 100% (94-100), O2 delivery: Ra,
Wt: 140.43 lb/63.7 kg
GEN: Lying comfortably flat in bed.
HEENT: NC/AT. No icterus or injection. MMM.
CV: JVP not visible. RRR, no murmurs. Normal distal pulses.
RESP: Normal work of breathing. Minimal wheeze throughout.
ABD: Soft, NDNT. No HSM.
EXTR: Warm, no edema.
NEURO: Alert, oriented, normal attention, memory, and speech.
PERRL, EOMI, CN ___ intact. Strength ___ throughout. No
dysmetria. Sensation grossly intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 10:55AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:16AM GLUCOSE-60* UREA N-13 CREAT-0.8 SODIUM-137
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16
___ 07:16AM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9
___:16AM WBC-7.1 RBC-5.52 HGB-17.5 HCT-51.5* MCV-93
MCH-31.7 MCHC-34.0 RDW-13.7 RDWSD-47.5*
___ 07:16AM PLT COUNT-150
___ 07:16AM ___ PTT-31.0 ___
___ 08:40PM GLUCOSE-88 UREA N-17 CREAT-1.1 SODIUM-140
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10
___ 08:40PM ALT(SGPT)-73* AST(SGOT)-58* ALK PHOS-119 TOT
BILI-0.8
___ 08:40PM cTropnT-<0.01
___ 08:40PM proBNP-904*
___ 08:40PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.5*
MAGNESIUM-1.9 CHOLEST-210*
___ 08:40PM %HbA1c-6.0 eAG-126
___ 08:40PM TRIGLYCER-162* HDL CHOL-47 CHOL/HDL-4.5
LDL(CALC)-131*
___ 08:40PM TSH-2.1
___ 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:40PM WBC-6.4 RBC-5.35 HGB-16.7 HCT-49.7 MCV-93
MCH-31.2 MCHC-33.6 RDW-13.6 RDWSD-47.1*
___ 08:40PM NEUTS-78.2* LYMPHS-6.7* MONOS-12.9 EOS-1.4
BASOS-0.5 IM ___ AbsNeut-5.01 AbsLymp-0.43* AbsMono-0.83*
AbsEos-0.09 AbsBaso-0.03
___ 08:40PM PLT COUNT-153
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-6.7 RBC-4.86 Hgb-15.0 Hct-45.0 MCV-93
MCH-30.9 MCHC-33.3 RDW-13.6 RDWSD-46.7* Plt ___
___ 07:10AM BLOOD Glucose-105* UreaN-15 Creat-0.9 Na-143
K-4.5 Cl-101 HCO3-26 AnGap-16
___ 07:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
CXR ___:
==============
FINDINGS:
Cardiac silhouette size remains moderately enlarged. The aorta
is tortuous with atherosclerotic calcifications noted at the
aortic knob. Pulmonary vasculature is not engorged. Lungs are
clear. No pleural effusion or pneumothorax is demonstrated.
Mild degenerative changes are seen in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
CT HEAD WITHOUT CONTRAST ___:
===================================
IMPRESSION:
Findings suggestive of subacute/chronic infarctions within the
left occipital lobe, right posterior parietal lobe, and right
cerebellum. If clinical concern remains high for an acute
infarction, MRI would be more sensitive for evaluation. No
evidence of intracranial hemorrhage.
RECOMMENDATION(S): If clinical concern remains high for an
acute infarction, MRI would be more sensitive for evaluation.
CTA HEAD AND CTA NECK ___:
================================
FINDINGS:
CTA HEAD:
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.
There are small bilateral mucous retention cysts, otherwise
remaining paranasal sinuses middle ear canals and mastoid air
cells are clear. Left occipital, right parietal and right
cerebellar chronic infarcts are better assessed on noncontrast
head CT from ___.
CTA NECK:
There is a predominantly noncalcified atherosclerotic plaque at
the origin of the right internal carotid artery. This mildly
encroaches on the carotid bulb. Otherwise the carotid and
vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
Partially imaged portions of the lung apices demonstrate stable
pleural
scarring with a stable 5 mm left apical subpleural nodule,
unchanged since
___. There are 2 potential hypodensities in the right thyroid
lobe measuring up to 8 mm, however may be artifactual (2:107,
2:112). Otherwise, the visualized portion of the thyroid gland
is within normal limits. There is no lymphadenopathy by CT size
criteria. There is moderate calcification of the aortic arch.
IMPRESSION:
1. Noncalcified plaque at the origin of the right internal
carotid artery with no evidence of stenosis.
2. The remainder of the vessels appear normal
3. Possible subcentimeter right thyroid lobe nodules, however
not definitive and may be artifactual.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
MRI HEAD ___:
==============
FINDINGS:
There is no acute infarction. There are small chronic infarcts
involving the left occipital lobe, right posterior parietal lobe
and right posterior
cerebellar hemisphere. Moderately extensive subcortical, deep
and
periventricular white matter T2/FLAIR hyperintensities are
nonspecific but
compatible with chronic small vessel ischemic disease given the
patient's age. No evidence for edema, mass effect, or blood
products. There is mild global parenchymal volume loss with
prominent ventricles and sulci.
The major intracranial vascular flow voids are maintained.
There are mucous retention cysts in the maxillary sinuses and
mild mucosal thickening in the ethmoid air cells. There is
trace fluid signal in bilateral mastoid tip air cells.
There are degenerative changes in the included upper cervical
spine, including mild retrolisthesis of C3 on C4 with posterior
endplate osteophytes, previously seen on the ___
cervical spine MRI.
IMPRESSION:
1. No acute infarction.
2. Small chronic infarcts involving the left occipital lobe,
right posterior parietal lobe and right posterior cerebellar
hemisphere.
3. Moderately extensive supratentorial white matter signal
abnormality
nonspecific, but likely sequela of chronic small vessel ischemic
disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Lisinopril 20 mg PO DAILY
3. TraZODone 50 mg PO QHS:PRN Insomnia
4. Sildenafil 100 mg PO ONCE:PRN Erectile Dysfunction
5. Amiodarone 200 mg PO BID
6. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Apixaban 5 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Sildenafil 100 mg PO ONCE:PRN Erectile Dysfunction
6. TraZODone 50 mg PO QHS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
Atrial fibrillation
Hypertension
CHF exacerbation
Subacute/Chronic CVAs
SECONDARY:
==========
Hyperlipidemia
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with AF, found to have sub-acute to chronic ischemic
changes// Aneurysms, carotid artery stenosis?
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain with
contrast material. Helically acquired rapid axial imaging was performed from
the aortic arch through the brain during the infusion of 70 mL of Omnipaque350
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) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
2) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,319.1 mGy-cm.
Total DLP (Head) = 1,349 mGy-cm.
COMPARISON: Noncontrast head CT ___. CT neck ___
FINDINGS:
CTA HEAD:
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. There are small bilateral mucous retention cysts,
otherwise remaining paranasal sinuses middle ear canals and mastoid air cells
are clear. Left occipital, right parietal and right cerebellar chronic
infarcts are better assessed on noncontrast head CT from ___.
CTA NECK:
There is a predominantly noncalcified atherosclerotic plaque at the origin of
the right internal carotid artery. This mildly encroaches on the carotid
bulb. Otherwise the carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. There is no evidence
of internal carotid stenosis by NASCET criteria.
OTHER:
Partially imaged portions of the lung apices demonstrate stable pleural
scarring with a stable 5 mm left apical subpleural nodule, unchanged since
___. There are 2 potential hypodensities in the right thyroid lobe measuring
up to 8 mm, however may be artifactual (2:107, 2:112). Otherwise, the
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. There is moderate calcification of the
aortic arch.
IMPRESSION:
1. Noncalcified plaque at the origin of the right internal carotid artery with
no evidence of stenosis.
2. The remainder of the vessels appear normal
3. Possible subcentimeter right thyroid lobe nodules, however not definitive
and may be artifactual.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with subacute/chronic strokes on CT. Evaluate
location and chronicity of strokes.
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 ___ at 21:53 (approximately
12 hours earlier).
FINDINGS:
There is no acute infarction. There are small chronic infarcts involving the
left occipital lobe, right posterior parietal lobe and right posterior
cerebellar hemisphere. Moderately extensive subcortical, deep and
periventricular white matter T2/FLAIR hyperintensities are nonspecific but
compatible with chronic small vessel ischemic disease given the patient's age.
No evidence for edema, mass effect, or blood products. There is mild global
parenchymal volume loss with prominent ventricles and sulci.
The major intracranial vascular flow voids are maintained. There are mucous
retention cysts in the maxillary sinuses and mild mucosal thickening in the
ethmoid air cells. There is trace fluid signal in bilateral mastoid tip air
cells.
There are degenerative changes in the included upper cervical spine, including
mild retrolisthesis of C3 on C4 with posterior endplate osteophytes,
previously seen on the ___ cervical spine MRI.
IMPRESSION:
1. No acute infarction.
2. Small chronic infarcts involving the left occipital lobe, right posterior
parietal lobe and right posterior cerebellar hemisphere.
3. Moderately extensive supratentorial white matter signal abnormality
nonspecific, but likely sequela of chronic small vessel ischemic disease.
Radiology Report
INDICATION: ___ year old man with new fevers, cough// Assess for pneumonia,
cause of fevers/cough
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Altered mental status, Weakness
Diagnosed with Dizziness and giddiness, Other fatigue, Altered mental status, unspecified, Unspecified atrial fibrillation
temperature: 99.9
heartrate: 107.0
resprate: 18.0
o2sat: nan
sbp: 177.0
dbp: 97.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
====================
___ with HFrEF, persistent AF despite multiple cardioversions,
recently admitted at ___ from ___ for CHF exacerbation
in the setting of AF with RVR s/p successful cardioversion, now
readmitted with profound fatigue and transient neurologic
symptoms, found to have recurrent atrial tachycardia and
subacute/chronic CVAs with no residual deficits. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toprol XL / Univasc / Sulfa (Sulfonamide Antibiotics) /
nitrofurantoin
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o dementia, bipolar
disorder,
T2DM, hypothyroidism, CVA, recurrent UTIs, and recent admission
from ___ for confusion and worsening tardive dyskinesia
attributed to E coli UTI, who re-presents to the ED with
worsening mental status, agitation, and tardive dyskinesia.
Briefly, the patient was admitted from ___ for altered
mental
status and worsening tardive dyskinesia ultimately attributed to
E coli UTI, with improvement of her symptoms following treatment
of her infection. She was initially treated with linezolid given
history of MDR enterococcus UTI and was subsequently narrowed to
ceftriaxone and was discharged on a course of augmentin to be
completed on ___. Hospital course was complicated by
hypernatremia attributed to decreased free water intake,
underlying partial nephrogenic DI in the setting of chronic
lithium, and multiple falls.
She was discharged from the hospital on ___ to home with her
daughters, who are with her ___. Of note there was discussion
about rehab at the time of discharge per ___ recommendations,
however the family at that time felt their ultimate goal was to
get the patient home and decision was made with medical team
that
patient may be safer at home under ___ care. On arrival to the
ED on admission her daughters report that the patient has not
returned to her baseline mobility (still using a wheelchair),
and
over the past few days has become increasingly agitated and
frequently tries to get out of her chair or bed without
assistance. Unfortunately there seems to have been inadequate
support from ___ and ___. In this setting they are concerned that
she is not safe at home. Her daughters additionally note that
she
has had worsening symptoms of insomnia, paranoia, visual
hallucinations after recent discharge from the hospital for
treatment of recurrent UTIs. They deny any fevers, falls at
home.
Per discussion with outpatient psychiatrist Dr. ___ by the ED: Pt's baseline is some irritability, but
family has able to care for her adequately in the past. In
recent
weeks-months, she has been intermittently far form her baseline
in the setting of frequent UTI.
In the ED:
- Initial vital signs were notable for:
T97.3 HR77 BP127/95 RR17 O2-96 on RA
- Exam notable for:
- Labs were notable for:
H/H 9.1/30.6
Troponin-T 0.06
UA: >183 WBC, few bacteria, neg nitrites
- Patient was given:
___ 15:20 IM OLANZapine 5 mg
- Consults: Psychiatry
Upon arrival to the floor, she is lying peacefully in bed but
becomes agitated with interaction. She is unable to provide any
history or reliably answer questions but denies pain.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Schizoaffective disorder, bipolar type
Hypothyroidism
Type 2 diabetes
Tardive dyskinesia
Recurrent UTIs
Recurrent falls of unclear etiology
Status post CVA
History of C1 fracture/cervical spondylolysis
Vitamin B12 deficiency
Anemia
Osteoarthritis
Osteoporosis
Constipation
Seizures - undetermined type, with aura, ?every month
Social History:
___
Family History:
Mother - died from MI in ___
Father - died from MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T97.9 BP112/66 HR72 RR17 O2-95
GENERAL: Agitated, cachectic.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Frequent repetitive mouth and tongue movements.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. Normal work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No palpable organomegaly. No
suprapubic tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: Oriented to self and to hospital in ___.
Agitated,
crying out intermittently. Difficult to understand speech in
setting of tardive dyskinesa. Squeezes finger on command.
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 815)
Temp: 98.1 (Tm 98.1), BP: 103/45 (103-146/45-92), HR: 76
(67-76), RR: 18, O2 sat: 95% (94-95), O2 delivery: RA
GENERAL: lying on her side in bed, awake and alert, speaking
clearly
HEENT: Very dry lips and tongue, frequent repetitive mouth and
tongue movements.
LUNGS: no respiratory distress
ABDOMEN: non distended
NEUROLOGIC: Frequent limb movement without purpose
Pertinent Results:
ADMISSION LABS:
================
___ 01:29PM BLOOD WBC-7.9 RBC-2.81* Hgb-9.1* Hct-30.6*
MCV-109* MCH-32.4* MCHC-29.7* RDW-16.8* RDWSD-67.2* Plt ___
___ 01:29PM BLOOD Glucose-107* UreaN-28* Creat-0.9 Na-145
K-4.4 Cl-109* HCO3-23 AnGap-13
___ 01:29PM BLOOD ALT-22 AST-43* CK(CPK)-128 AlkPhos-64
TotBili-0.4
___ 01:29PM BLOOD cTropnT-0.06*
___ 07:50PM BLOOD CK-MB-3 cTropnT-0.06*
___ 04:47AM BLOOD cTropnT-0.05*
___ 01:29PM BLOOD Albumin-4.2 Calcium-10.5* Phos-3.4 Mg-2.4
___ 04:47AM BLOOD Folate-12
___ 06:03AM BLOOD %HbA1c-4.6 eAG-85
___ 06:03AM BLOOD Triglyc-140 HDL-54 CHOL/HD-2.4 LDLcalc-46
___ 06:10AM BLOOD TSH-2.0
LATEST LABS PRIOR TO DISCHARGE:
___ 11:03AM BLOOD WBC-10.2* RBC-2.66* Hgb-8.9* Hct-32.6*
MCV-123* MCH-33.5* MCHC-27.3* RDW-17.1* RDWSD-77.2* Plt ___
___ 05:52AM BLOOD Glucose-88 UreaN-21* Creat-0.6 Na-156*
K-3.8 Cl-124* HCO3-24 AnGap-8*
___ 05:52AM BLOOD LD(LDH)-308*
___ 09:01AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2
MICROBIOLOGY:
================
___ 6:29 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
IDENTIFICATION AND Susceptibility testing requested per
___
ON ___ AT 11:52.
___ ALBICANS. >100,000 CFU/mL.
Yeast Susceptibility:.
Fluconazole MIC OF 0.5 MCG/ML SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
___ - STOOL CDIFF PCR POSITIVE, TOXIN NEGATIVE
IMAGING:
==========
___ MRI head without contrast IMPRESSION:
1. Please note the study is suboptimal due to extensive motion
artifact which limits evaluation of intracranial structures.
2. Within these limitations, several areas of high signal on the
diffusion weighted images are seen in the left cerebellum are
seen without definite correlate on the ADC sequences. While
these lesions could represent subacute infarcts, other lesions
are not excluded given degree of motion and a repeat study may
be helpful for further characterization.
RECOMMENDATION(S): A repeat study when patient is more
cooperative would be helpful to better characterize the left
cerebellar lesions.
___ ECHO:
The left atrial volume index is normal. The interatrial septum
is dynamic, but not frankly aneurysmal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is
hyperdynamic. The visually estimated left ventricular ejection
fraction is 75%. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic 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.
There is trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened with systolic prolapse. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. Compared with the prior TTE (images not available for
review) of ___, the findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ClonazePAM 0.25 mg PO AM
3. ClonazePAM 0.5 mg PO QHS
4. ClonazePAM 0.25 mg PO AFTERNOON:PRN agitation
5. Cyanocobalamin ___ mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lithium Carbonate 150 mg PO QHS
9. Omeprazole 20 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY
11. Pyridoxine 100 mg PO DAILY
12. QUEtiapine Fumarate 100 mg PO QHS
13. Senna 8.6 mg PO BID:PRN Constipation
14. Simvastatin 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Multivitamins W/minerals 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
18. QUEtiapine Fumarate 25 mg PO DAILY PRN paranoia
19. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
20. Dipyridamole-Aspirin 1 CAP PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
2. Fluconazole 100 mg PO Q24H Duration: 14 Days
RX *fluconazole 40 mg/mL 2.5 mL(s) by mouth daily Refills:*0
3. ClonazePAM 0.25 mg PO BID
RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice daily at 8AM
and noon Disp #*14 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*14 Packet Refills:*0
5. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
6. QUEtiapine Fumarate 25 mg PO BID:PRN agitation
RX *quetiapine 25 mg 1 tablet(s) by mouth twice daily Disp #*14
Tablet Refills:*0
7. ClonazePAM 0.5 mg PO QHS
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
8. Dipyridamole-Aspirin 1 CAP PO BID
RX *aspirin-dipyridamole 25 mg-200 mg 1 capsule(s) by mouth
twice daily Disp #*14 Capsule Refills:*0
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
10. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine 50 mcg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
11. Lithium Carbonate 150 mg PO QHS
RX *lithium carbonate 150 mg 1 capsule(s) by mouth at bedtime
Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
==================
Subacute encephalopathy in the setting of dementia
Cerebral vascular accident
Failure to thrive
Severe malnutrition
SECONDARY:
==================
Tardive dyskinesia
Schizophrenia vs bipolar disorder
Hypernatremia
Recurrent urinary tract infection, ___
Oropharyngeal dysphagia
GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with unequal pupils concern for intracranial
process, stroke// unequal pupils concern for intracranial process, stroke
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.6 s, 22.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
1,166.0 mGy-cm.
2) Sequenced Acquisition 6.6 s, 22.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
1,166.0 mGy-cm.
Total DLP (Head) = 2,332 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Examination is significantly limited by patient positioning, motion and beam
hardening artifact. Evaluation of the skull brain interfaces particularly
suboptimal. Within these confines: There is an approximately 3.2 cm
hypodensity in the left cerebellum demonstrating mass effect, not previously
seen on CT head ___, consistent with an late acute to subacute
infarct. There is no large hemorrhage, however, small hemorrhage cannot be
excluded on this limited study. There is no midline shift. The ventricles
and sulci are prominent, consistent with age related atrophy.
The known bilateral C1 anterior and posterior arch fractures are partially
imaged. There is mild mucosal thickening of the sphenoid and ethmoid sinuses.
Patient is status post bilateral lens replacement; the visualized portion of
the orbits are otherwise unremarkable.
IMPRESSION:
1. Findings compatible with late acute to subacute left cerebellar infarct.
2. No large hemorrhage or midline shift. Examination is significantly limited
by patient positioning, motion and beam hardening artifact.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:06 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with history of dementia,
bipolardisorder/schizoaffective disorder, tardive dyskinesia (thoughtto be
due to olanzapine, stelazine) that presented to the hospital for change in
mental status found to have late acute to subacute cerebellar stroke//
evaluate 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 CT head without contrast from ___
FINDINGS:
Please note that the study is suboptimal due to extensive motion artifact
which limits evaluation of intracranial structures. Within these limitations,
there are several areas of high signal on the diffusion-weighted images in the
left cerebellar hemisphere corresponding to the abnormalities seen on the CT
head study from ___. However, the apparent diffusion coefficient
images are so degraded by motion artifact that it is not clear whether there
are corresponding regions of slow diffusion. Prominence of ventricles and
sulci are compatible with age related involutional changes. Ill-defined
T2/FLAIR hyperintensities are nonspecific but likely due to chronic sequela of
small-vessel ischemic disease.
The paranasal sinuses are grossly clear without obvious opacification. The
orbits are unremarkable.
IMPRESSION:
1. Please note the study is suboptimal due to extensive motion artifact which
limits evaluation of intracranial structures.
2. Within these limitations, several areas of high signal on the diffusion
weighted images are seen in the left cerebral hemisphere are seen without
definite correlate on the ADC sequences. While these lesions could represent
subacute infarcts, other lesions are not excluded given degree of motion and a
repeat study may be helpful for further characterization.
RECOMMENDATION(S): A repeat study when patient is more cooperative would be
helpful to better characterize the left cerebellar lesions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:21 pm, 1 minutes after discovery
of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status, Dehydration
Diagnosed with Altered mental status, unspecified
temperature: 97.3
heartrate: 88.0
resprate: 17.0
o2sat: nan
sbp: 127.0
dbp: 95.0
level of pain: u
level of acuity: 2.0 | PATIENT SUMMARY FOR ADMISSION:
================================
___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism,
CVA, recurrent UTIs, and recent admission from ___
forconfusion and worsening tardive dyskinesia attributed to E
coli UTI, who represents to the ED with worsening mental status,
agitation, and tardive dyskinesia found to have
subacutecerebellar stroke.
Ultimately, due to a persistent decline in mental status and
failure to thrive, especially with regard to severe malnutrition
and cachexia, the medical team, psychiatry team, and geriatric
service met with the family and it was determined that the
patient would benefit most from home hospice. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C. Diff Colitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo man w PMHx significant for DMII, HTN, HLD, GERD
presents with 5 weeks of watery diarrhea (24x/day) associated
with abdominal cramps. Patient reports significant decreased
appetite, with 25lb weight loss in the past two weeks. The
patient had planned a 2 week trip to ___, and
prior to leaving had started experiencing symptoms of bloating,
loose stools, and abdominal pain. While on vacation, the
diarrhea worsened, increasing in frequency and becoming watery.
Patient visited PCP ___ ___ (one day after returning from ___
when her returned from the ___ ___ stool analysis and lab
tests that were unremarkable. Patient presented to the ED (___
___ on ___ where he had a an abdominal CT that
showed pancolitis, but both stool and blood samples were
unrevealing. Patient was discharged on ciprofloxacin. Patient
was then seen by outpatient GI on ___ who ordered a new stool
analysis, added flagyl to his treatment, and scheduled him for a
colonoscopy. Once the stool came back positive for C. diff
(___), the patient was started on PO vancomycin. His GI
physician suggested the patient should visit the ED given his
dehydration and weight loss. Patient denies recent antibiotic
use or hospitalization.
In the ED, initial vital signs were:
T=97.8 HR=100 BP=142/80 RR=20 SpO2=98% RA
Labs were notable for Na of 132, glucose of 302.
KUB showed normal bowel gas pattern without evidence of
obstruction or free intraperitoneal air.
Patient was given 2L of NS and Vancomycin Oral Liquid ___ mg PO
On transfer the patient's vitals were: T=98.2, HR=83, BP=122/84,
RR=20, and SpO2=97%RA
Past Medical History:
Poorly Controlled DMII
HTN
HLD
Asthma
GERD
Left Hip Replacement in ___
Facial reconstructive surgery after MVA at age ___
Hernia repair
Vasectomy
Social History:
___
Family History:
Father has DM2, HTN, HLD
Mother died of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T=98.2, HR=83, BP=122/84, RR=20, and SpO2=97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T=98.0 BP=138/75 HR=94 RR=18 SpO2=100% on RA
General: Well appearing, comfortable
HEENT: NC/AT, EOMI, MMM
Lungs: CTAB, no r/r/w
CV: RR, +S1/S2, no m/r/g
Abdomen: Soft, ND, non-tender, no rebound or guarding
Ext: WWP, no edema
Neuro: AAO x3, non-focal
Pertinent Results:
ADMISSION LABS:
===============
___ 04:15PM WBC-9.3 RBC-4.85 HGB-13.8 HCT-40.5 MCV-84
MCH-28.5 MCHC-34.1 RDW-13.2 RDWSD-40.0
___ 04:15PM NEUTS-66.7 LYMPHS-17.6* MONOS-9.2 EOS-4.5
BASOS-0.6 IM ___ AbsNeut-6.19* AbsLymp-1.63 AbsMono-0.85*
AbsEos-0.42 AbsBaso-0.06
___ 04:15PM PLT COUNT-396
___ 04:15PM GLUCOSE-302* UREA N-13 CREAT-1.0 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
___ 04:16PM LACTATE-1.5
DISCHARGE LABS:
===============
___ 06:09AM BLOOD WBC-7.9 RBC-4.17* Hgb-11.8* Hct-36.0*
MCV-86 MCH-28.3 MCHC-32.8 RDW-13.5 RDWSD-42.1 Plt ___
___ 06:09AM BLOOD Plt ___
___ 06:09AM BLOOD Glucose-296* UreaN-9 Creat-0.9 Na-132*
K-4.7 Cl-96 HCO3-24 AnGap-17
___ 06:09AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
PERTINENT IMAGING:
==================
ABD XRAY SUPINE/ERECT (___)
Nonobstructive bowel gas pattern is demonstrated. No free
intraperitoneal air, pneumatosis, or differential air-fluid
levels are seen. There are no concerning soft tissue
calcifications. Mild degenerative changes are noted in the lower
thoracic and lower lumbar spine. Patient is status post left hip
arthroplasty. Marked degenerative changes are noted in the right
femoral acetabular joint.
Radiology Report
INDICATION: ___ yoM with DMII, HTN,HLD presenting with 5 weeks of watery
diarrhea, C Diff positive.
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: None.
FINDINGS:
Nonobstructive bowel gas pattern is demonstrated. No free intraperitoneal
air, pneumatosis, or differential air-fluid levels are seen. There are no
concerning soft tissue calcifications. Mild degenerative changes are noted in
the lower thoracic and lower lumbar spine. Patient is status post left hip
arthroplasty. Marked degenerative changes are noted in the right femoral
acetabular joint.
IMPRESSION:
Normal bowel gas pattern without evidence for obstruction or free
intraperitoneal air.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Diarrhea
Diagnosed with Enterocolitis due to Clostridium difficile
temperature: 97.8
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 142.0
dbp: 80.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ yo man w PMHx significant for DMII, HTN,
HLD, GERD
presents with 5 weeks of watery diarrhea (24x/day) associated
with abdominal cramps and 25lb weight loss. Prior to admission,
he was found to have a stool sample positive for C. difficile
and an abdominal CT that showed pancolitis.
# C.Difficile Colitis: Prior to admission, the patient was
started on PO vancomycin 24h per GI recommendation. Because the
patient he was reporting >24 BMs per day, he was instructed to
go to the ED, given concern for dehydration and electrolyte
abnormalities. On admission, the patient was HD stable, afebrile
with WBC 9.3. Exam notable for generalized weakness and dry
mucous membranes. Labs were notable for Na of 132, glucose of
302. KUB showed normal bowel gas pattern without evidence of
obstruction or free intraperitoneal air. He received a bolus of
2L NS and was continued on his vancomycin 125 mg PO Q6h. Over
the course of his hospital stay, the patient's symptoms improved
with decreased frequency of BMs to approximately 10/day,
improved appetite, and significant improvement in his abdominal
pain. He was discharged with instructions to complete a 14-day
regimen of vancomycin (First day: ___ - Last day: ___.
# Anemia/BRBPR: Patient's HgB dropped from 13.8 on admission to
11.9 on ___ but did not continue to downtrend. Likely
multifactorial including initial hemoconcentration with dilution
following IVF as well as GI losses as patient reported
occasional blood on the toilet paper that started in the setting
of his very frequent BMs. On discharge, his Hgb was 11.8.
Requires outpatient follow with GI after resolution of colitis
for colonoscopy.
# DM2: Patient with known DM2, recent HbA1C=10.1. On admission,
blood sugar >300. Despite standard HISS, an diabetic diet
in-hospital, blood sugar remained high. Requires follow-up and
adjustment of oral antidiabetics with possible addition of
insulin.
#Hyponatremia: Likely hypovolemic hyponatremia in the setting
above c. diff infection.
***TRANSITIONAL ISSUES***
# Continue Vancomycin 125 mg PO QID for a total of 14 days (Last
day: ___.
# To follow-up with PCP, ___ (___) within
___ days of discharge.
# To follow-up with GI specialist, Dr. ___
(___) as an out-patient within 2 weeks of discharge.
# Patient had reported a little bright red blood per rectum
without hematochezia, likely from hemorrhoids. Will require
follow-up.
# Patient is diabetic with last HbA1c of 10.1. Blood sugar in
the hospital >300. Patient may require increasing oral
antidiabetics or adding on insulin. Will require follow-up with
PCP for proper management of diabetes.
#CODE: Full
#Contact: Girlfriend (___) - ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
ACE Inhibitors / adhesive tape / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Cardiac cath with Impella insertion and 2 DES
___ Impella repositioning, unsuccessful impella removal
___ 1. Coronary artery bypass grafting x1 with left internal
mammary artery to the left anterior descending artery. 2.
Removal of Impella device with aortotomy.
History of Present Illness:
___ with hx of HTN and high cholesterol who is presenting as a
transfer from ___ with NSTEMI on heparin and nitro.
She started having exertional chest pain for 2 days. Pain
progressed to severe rest pain on morning (___). Pain was
described as constant, heavy, and in the ___ her chest
that radiated up to her neck. She presented to ___ ED and was
transferred to BI ED.
She has no cardiac history and has never had this chest pain
before. She denies shortness of breath, fever, chills, abdominal
pain, nausea, vomiting, diarrhea or other symptoms.
In the ED initial vitals were: 98.8, 75, 136/70, 14, 97% Nasal
Cannula
EKG:STE in II, III, aVF, STD in V1-V3 with T wave inversions
Labs/studies notable for:
CBC: 9.3/12.7/39.5/280
BMP: ___
Trop: 0.11
CK-MB: 21
CK:211
Patient was given:
___ 18:55 IV Heparin Started 12 units/hr
___ 18:55 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min
ordered)Started 0.4 mcg/kg/min
___ 18:55 PO/NG TiCAGRELOR 180 mg
She was taken to the cath lab found 90% occlusion of proximal
LAD which was not thought to be culprit lesion so was not
revascularized. Proximal RCA was totally occluded and was
revascularized with DES x2.
Patient became hypotensive and dopamine was started, she went
into complete heart block with bradycardia and a RV temp wire
was placed. Temp wire was subsequently pulled.
She remained hypotensive (SBP 85 mmHg) so IABP was inserted. She
then developed polymorphic VT requiring Lidocaine, Amiodarone, 3
shocks, and ~5min CPR. Hemodynamic support was escalated to
Impella. Was in SVT, and then a fib with RVR (rates in 120s).
On arrival to the CCU patient on levo 0.03 and heparin drip,
alert and oriented breathing comfortably on NC. Initially
patient was in a fib but converted to NSR with rates in ___.
Right sided cordis, swan, and a line were placed.
Per family, patient has no cardiac history and only takes
medication for hypertension and hyperlipidemia. They do not
remember the names of her medications.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries CAD: unknown
- Pump ECHO CHF: unknown
- Rhythm: LBBB (new)
3. OTHER PAST MEDICAL HISTORY
- Osteoporosis
- Basal cell carcinoma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
VS: T HR 59 BP 108/77 RR 12 O2 SAT 99% on NC
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma. Cordis in place on right side, dressing in place
is clean.
NECK: Supple. JVP of ____ cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
Vital Signs and Intake/Output:
Tmax: 98.9 Tcurrent: 98.3 B/P: 112/63 HR/Rhythm: 86
RR:
18
SaO2:92 Oxygen: RA FSBG: n/a
Date: 73.1 (74 kg)
In Out: ___
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 [x]
Lungs: CTA [x] No resp distress [x]
Abd: NBS [x]Soft [x] ND [x] NT [x]
Extremities: 1+ CCE[x] Pulses doppler [x] palpable [], r foot
paresthesias continue
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena [x]
R groin: Staples intact
Pertinent Results:
___ 04:50AM BLOOD WBC-8.3 RBC-3.23* Hgb-9.6* Hct-28.6*
MCV-89 MCH-29.7 MCHC-33.6 RDW-15.5 RDWSD-49.5* Plt ___
___ 04:50AM BLOOD Glucose-98 UreaN-26* Creat-0.7 Na-141
K-3.7 Cl-101 HCO3-27 AnGap-13
TTE ___
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is mildly depressed (LVEF= 50
%). Right ventricular chamber size and free wall motion are
normal. There is abnormal septal motion/position. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly reduced left
ventricular systolic function. Unable to assess for regional
dysfunction. Mild aortic and tricuspid regurgitation. Borderline
pulmonary hypertension.
PA and Lateral ___
-Trace bilateral pleural effusions, otherwise good aeration
Medications on Admission:
Asa 81'
Losartan 50'
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 40 mg PO DAILY Duration: 10 Days
5. Metoprolol Tartrate 25 mg PO BID
6. Pantoprazole 40 mg PO Q24H Duration: 30 Days
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
9. Tamsulosin 0.4 mg PO QHS
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. Aspirin EC 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Myocardial infarction, coronary artery disease s/p Coronary
artery bypass graft x 1, drug-eluting stent placement x 2
Past medical history:
Hypertension
LBBB
Osteoporosis
Hyperlipidemia
Basal cell carcinoma of skin
b/l total knee replacement
Cataract extraction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with impella, and swan placed// interval
changes
IMPRESSION:
Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. Please
note that the superior portion of the catheter tip is not included on the
field of view. Please refer to the operative note for additional
details.There is gaseous distention of the stomach.
Radiology Report
INDICATION: ___ year old woman with impella and Swan// need stat CXR to
confirm impella placement
COMPARISON: Intra procedural study from 1 hour earlier.
IMPRESSION:
There is a Swan-Ganz catheter with the distal tip projecting over the main
pulmonary artery in good position. Impella catheter is seen within the aorta.
Heart size is within normal limits. There is no focal consolidation, large
pleural effusions, pulmonary edema, or pneumothoraces.
Radiology Report
INDICATION: Adjustment of Impella catheter.
COMPARISON: Compared to radiographs from ___
IMPRESSION:
Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. On the
last image, the distal tip appears to terminate within a distal right main
pulmonary arterial branch. This could be pulled back 4-5 cm for more optimal
placement. Please refer to the procedure note for additional details.
Radiology Report
INDICATION: ___ year old woman with Impella removal; CABG// eval tube position
COMPARISON: Radiographs from ___
IMPRESSION:
The Impella device has been removed. There is a Swan-Ganz catheter,
endotracheal tube, feeding tube, and chest tubes which are in standard
position. Heart size is upper limits of normal. There remains some
prominence of the upper left mediastinum, unchanged. There is minimal
blunting of the right CP angle. Lungs are relatively clear. There is no
pneumothoraces.
Radiology Report
EXAMINATION: Lower extremity arterial duplex US.
INDICATION: ___ year old woman s/p cabg/impella pre-op, right side
cannulation// assess flow right leg
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the right lower extremity arteries was obtained.
FINDINGS:
On the right, the common femoral artery is patent with a peak velocity of 0
with impella device in place.
The SFA is patent with velocities of 37, 18, and 17 cm/sec. There is no
velocity elevation to suggest stenosis.
The popliteal artery is patent with a velocity of 11 cm/sec.
The and anterior tibial artery is patent with a velocity of 15 cm/sec but the
peronal, poterior tibial and dorsalis pedis arteries do not have flow.
IMPRPRESSION: Patent right femoral and popliteal arteries with severely
decreased flows. No flow seen in distal tibial arteries.
Radiology Report
INDICATION: ___ year old woman s/p CABG-had Impella pre-op with in right side
cannulation// assess right ___
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
FINDINGS:
On the right side, no Doppler waveforms are seen at the ankle. The toe PPG
waveform is flat.
On the left side, triphasic Doppler waveforms are seen at the posterior tibial
and dorsalis pedis arteries.
The left ABI was 1.19. The digit PPG waveform is barely pulsatile.
Pulse volume recordings are severely dampened on the right. They are normally
pulsatile at the left calf, ankle, and metatarsal levels.
IMPRESSION:
Evidence of severe right lower extremity ischemia. No evidence ischemia on
the left.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with knee pain/after impella removal// assess
for mass/trauma/ assess for mass/trauma/
TECHNIQUE: Right knee, three views.
COMPARISON: None.
FINDINGS:
Right total knee arthroplasty hardware is in place without periprosthetic
fracture, or hardware complication. Alignment is preserved. There is a
moderate joint effusion. There is no fracture or dislocation.
IMPRESSION:
Moderate joint effusion. Right TKR without fracture or dislocation.
Radiology Report
EXAMINATION: Portable chest
INDICATION: ___ year old woman with POD 2 from Impella removal and CABGx1.//
Post chest tube removal
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
There is a large right-sided pneumothorax. There is increased opacification
of the right lower lung which is likely due to layering pleural effusion. In
the left midlung there is a focal area of opacification which may be due to
central pulmonary vascular congestion or aspiration/pneumonia in the
appropriate clinical setting. The cardiomediastinal silhouette is mildly
enlarged and appears stable. There are medial sternotomy wires which appear
intact and aligned. There has been interval removal of a left-sided chest
tube, a Swan-Ganz catheter, endotracheal tube, and nasogastric tube. A right
central venous catheter is seen with its tip in the mid SVC.
IMPRESSION:
There is a new large right-sided pneumothorax and right-sided pleural
effusion. New area of focal opacification in the left midlung which may be
due to pulmonary vascular congestion or aspiration/pneumonia in the
appropriate clinical setting.
NOTIFICATION: The findings were discussed with Dr. ___. by
___, M.D. on the telephone on ___ at 5:10 pm, 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman post pigtail placement.// Expansion of right
lung.
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 16:09
IMPRESSION:
Compared to the examination from 2 hours prior, a right upper pleural pigtail
catheter has been placed, with decrease of the right apical lateral
pneumothorax, though with small residual apical component and residual partial
collapse of the right upper lobe. No other interval changes seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PTX// ___ year old woman with PTX ___
year old woman with PTX
IMPRESSION:
Comparison to ___. The right internal jugular vein catheter and
the right chest tube are in stable position. On the current radiograph, there
is no evidence of pneumothorax. Moderate cardiomegaly. Mild retrocardiac
atelectasis. No larger pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p cabg// chest tube on water seal-
please do xray around 1200 thank you
IMPRESSION:
In comparison with the earlier study of this date, with the right chest tube
on water seal, there is no evidence of appreciable pneumothorax.
Otherwise no change.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p Line exchange// ___ year old woman s/p Line
exchange Contact name: ___: ___
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 12:06
IMPRESSION:
Compared to the earlier same day examination, there has been exchange of the
right internal jugular central venous catheter with the tip now terminating at
the cavoatrial junction, satisfactory. There is no associated pneumothorax.
There is otherwise no significant change compared to the earlier same day
examination. The right pigtail pleural catheter remains in place and there is
no gross pneumothorax. There are likely small bilateral pleural effusions
with bibasilar atelectasis and linear lingular atelectasis. There is no
worsening or new consolidation.
Radiology Report
EXAMINATION: Chest AP view.
INDICATION: ___ year old woman s/p clamp trial, perform at 1130// ___ year old
woman s/p clamp trial, perform at 1130
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Chest AP view is compared to a prior done ___. Right-sided pigtail
catheter and right IJ line are unchanged in position. Small bilateral
effusions right greater than left have slightly increased in volume.
Cardiomediastinal silhouette is stable. No pneumothorax is seen. Lungs are
low volume.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p chest tube removal// ___ year old woman s/p
chest tube removal ___ year old woman s/p chest tube removal
IMPRESSION:
Compared to chest radiographs ___, through 11:33.
Small right pleural effusion stable, no detectable right pneumothorax,
following removal of the right pigtail pleural drainage catheter. Previous
mild cardiomegaly has resolved and small pleural effusions are smaller.
Moderate left lower lobe atelectasis unchanged. No pulmonary edema.
Right jugular line ends in the low SVC.
Radiology Report
EXAMINATION: Chest radiograph PA and lateral
INDICATION: ___ year old woman s/p CABG// ___ year old woman s/p CABG
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Small bilateral pleural effusions. There is left basilar atelectasis. There
is no focal consolidation or definite evidence of pneumothorax. The cardiac
silhouette is mildly enlarged. There has been interval removal of right-sided
chest tube and a right central venous catheter. There are medial sternotomy
wires which appear aligned and intact.
IMPRESSION:
No definite evidence of pneumothorax. Stable small pleural effusions.
Gender: F
Race: PATIENT DECLINED TO ANSWER
Arrive by UNKNOWN
Chief complaint: NSTEMI, Transfer
Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site
temperature: 98.8
heartrate: 75.0
resprate: 14.0
o2sat: 97.0
sbp: 136.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with history of HTN and high cholesterol who is presenting
as a transfer from ___ with NSTEMI on heparin and
nitro found to have inferior STEMI successfully
revascularization of RCA, remaining 90% LAD occlusion
complicated by reperfusion VT and cardiogenic shock requiring
mechanical support with Impella.
In CCU, ___ catheter placed. Attempted echo verification
of placement of impella, however this appeared somewhat shallow
so bedside advancement was attempted. This was complicated by
coiling of impella in LV. Attempted to withdraw the impella
unsuccessfully, and so CSurg was consulted. Patient was taken to
the the OR on ___ for impella removal and concomitant coronary
artery bypass graft x 1. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring. Arrived from OR intubated and sedated on on
Epi infusion for hramodynamic support. On POD#1 was noted to
have a cold right foot and loss of pedal pulses. Vascular
surgery was consulted and the patient was taken tot he operating
room for a Right femoral exploration and thrombectomy. She
underwent a thrombectomy on ___ and pedal pulses returned and
systemic anticoagulation with heparin was maintained for
profusion. The patient will not require anticoagulation and will
be discharged on Plavix and aspirin. She will follow up with the
vascular surgery team as an outpatient. She has groin staples in
place which should be removed 2 weeks after placement (___).
Her perfusion returned after surgery, however she has moderate
right foot sensation loss. She will be discharged with a
multi-podus boot and will need follow up with physical therapy.
CT's were removed and patient developed a right PTX-a pigtail as
placed with lung re-expansion. Water seal trial was successful
and Pigtail was removed without incident on ___. Her discharge
CXR shows no residual PTX. She was started on Lopressor prior to
discharge but was not started on a statin due to allergy. A
foley was replaced on ___ due to acute urinary retention. She
was started on Flomax and will be discharged with a foley
catheter in place. A UA was obtained and was negative. A voiding
trial should be attempted at rehab. The patient was evaluated by
physical therapy and was deemed appropriate for rehab. The
patient should have aggressive physical and occupational therapy
at rehab to help facilitate recovery of strength in her right
foot. She will be discharged to ___ at
___ on ___ on POD 5. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of A. fib on
apixaban, type 2 diabetes, MVR, mental disability with
developmental delay who presented after an unwitnessed fall.
Patient was found at his assisted living facility wedged between
the door and toilet. Patiend denies remembering a fall. When
EMS arrived, patient's blood glucose was 23. Had no complaints
per report.
Reported takes his medications. ___ recently made adjustments
to diabetes medications in ___, and it appears that he may be
being prescribed glimerpide from 2 different prescribers.
Patient also had recent ED visit at ___ ___ for slurred
speech and confusion found to be hypoglycemic to 63, improved
with food. Also, sister reports an episode of symptomatic
hypoglycemia on ___ for which he did not go to the hospital.
On arrival to the ED, patient was seen by ortho spine and ACS,
and had a CT cervical spine was notable for teardrop fracture.
Ortho spine team and ACS recommending non-surgical management.
On ___, patient transferred to medicine through the ___
pathway.
At time of transfer, patient feeling rather well. Denies pain
anywhere including his neck. No neuro symptoms. No chest pain or
dyspnea.
A 10 point ROS [was] obtained and negative except for HPI.
Past Medical History:
Atrial fibrillation
Type 2 diabetes mellitus, on insulin
Essential hypertension
Hyperlipidemia
Intellectual functioning disability
Mitral regurgitation
Bladder Mass
Social History:
___
Family History:
- Mother alive
- Father deceased, COPD (age ___
Physical Exam:
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 24 HR Data (last updated ___ @ 819)
Temp: 97.6 (Tm 99.7), BP: 120/75 (86-138/50 Manual-85), HR:
107 (80-117), RR: 16 (___), O2 sat: 93% (92-94), O2 delivery:
Ra, Wt: 145.94 lb/66.2 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: MMM, no obvious trauma.
NECK: C-collar in place
CARDIAC: Irregularly irregular rate, tachycardic, II/VI
holosystolic murmur best heard at apex
LUNGS: CTAB, non-labored breathing
ABDOMEN: Normal bowels sounds, non distended
EXTREMITIES: No ___ edema, warm
SKIN: Warm. No rash.
NEUROLOGIC: AOx3, facial symmetry
Pertinent Results:
ADMISSION LABS
==============
___ 01:10PM BLOOD ___ PTT-24.3* ___
___ 11:00AM BLOOD Glucose-105* UreaN-22* Creat-0.8 Na-141
K-4.6 Cl-103 HCO3-23 AnGap-15
___ 06:13AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.7
DISCHARGE LABS
==============
___ 04:17AM BLOOD WBC-12.7* RBC-4.96 Hgb-14.7 Hct-44.5
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.2 RDWSD-43.7 Plt ___
___ 04:17AM BLOOD Plt ___
___ 04:17AM BLOOD Glucose-149* UreaN-19 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-28 AnGap-10
NOTABLE IMAGING
===============
___ NCHCT
IMPRESSION:
1. No intracranial hemorrhage or calvarial fracture.
2. Global age-related involutional changes.
3. Mild paranasal sinus disease.
___ C-SPINE XR
IMPRESSION:
Acute avulsion fracture of the anteroinferior corner of the C3
vertebra,
likely due to hyperextension.
___ C-SPINE XR
FINDINGS:
C1-C6 visualized on the lateral projection. There is
straightening of the
normal cervical lordosis, likely positional as the patient was
imaged in a
hard collar. There is persistent visualization of a C3 fracture
involving the
anterior inferior endplate. This is minimally displaced but
unchanged in
appearance when compared to the prior study. Severe
degenerative disc disease
at C5-6. No prevertebral soft tissue swelling seen.
IMPRESSION:
Unchanged appearances of the known C3 fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. glimepiride 4 mg oral BID
4. Glargine 34 Units Breakfast
5. Atorvastatin 80 mg PO QPM
6. amLODIPine 10 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Glargine 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis
- C3 fractures
Secondary diagnoses
- Atrial fibrillation
- Type II diabetes
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypoglycemia// pna
COMPARISON: Prior chest radiograph is dated ___ and CT of the
chest dated ___
FINDINGS:
AP portable upright view of the chest. Lung volumes remain low though the
lungs are clear. An unfolded thoracic aorta accounts for prominence of the
mediastinum. The heart size is normal. No large effusion or pneumothorax.
Imaged bony structures are intact.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall on apixaban// eval for hemorrhage or 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: Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of large territory infarction,hemorrhage,edema,or
discrete mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Asymmetry of the lateral ventricles is unchanged since
___. There are dense atherosclerotic calcifications within the
bilateral carotid siphons and proximal intracranial vertebral arteries.
There is no evidence of fracture. Other than a small mucous retention cyst in
the right maxillary sinus, the visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or calvarial fracture.
2. Global age-related involutional changes.
3. Mild paranasal sinus disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall on apixaban// eval for hemorrhage or bleed
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) = 566 mGy-cm.
COMPARISON: CT C-spine ___
FINDINGS:
There is an acute avulsion fracture at the anterior-inferior corner of C3
vertebral body, likely due to hyperextension. No significant prevertebral
soft tissue swelling. Alignment is unchanged. Multilevel degenerative changes
most notable at the C3-4 and C5-6 with intervertebral disc height loss,
anterior and posterior osteophytosis, and uncovertebral joint hypertrophy
appear grossly similar. As with the prior study, there is mild-to-moderate
spinal canal narrowing at these levels. There is moderate right and
mild-to-moderate left foraminal narrowing at the C5-6 level.
IMPRESSION:
Acute avulsion fracture of the anteroinferior corner of the C3 vertebra,
likely due to hyperextension.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:08 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man with cervical fracture// Position to compare w/
follow up radiographs. In collar
TECHNIQUE: AP and lateral views of the cervical spine
COMPARISON: CT cervical spine ___
FINDINGS:
C1-C6 visualized on the lateral projection. There is straightening of the
normal cervical lordosis, likely positional as the patient was imaged in a
hard collar. There is persistent visualization of a C3 fracture involving the
anterior inferior endplate. This is minimally displaced but unchanged in
appearance when compared to the prior study. Severe degenerative disc disease
at C5-6. No prevertebral soft tissue swelling seen.
IMPRESSION:
Unchanged appearances of the known C3 fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoglycemia, s/p Fall
Diagnosed with Type 2 diabetes mellitus with hypoglycemia without coma, Long term (current) use of insulin
temperature: 98.6
heartrate: 104.0
resprate: 16.0
o2sat: 97.0
sbp: 164.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | HOSPITAL COURSE
===============
Mr. ___ is a ___ man with a history of A. fib on
apixaban, type 2 diabetes, MVR, mental disability with
developmental delay who presented after an unwitnessed fall,
found to be severely hypoglycemic likely in the setting of
medication errors and had C3 fracture with plan for non-surgical
management.
ACTIVE ISSUES
=============
# Hypoglcyemia
# DMII: Likely ___ to missed meal and incorrect medication
administration. Per most recent PCP ___ (in external reports),
on glimepiride 2mg daily and 34 u lantus. Per ___ is on 40 U
lantus, 4mg BID glimepiride, and metformin 500mg BID. Based on
his pill bottles from home, it appeared he was taking
glimepiride 4mg BID and lantus without any metformin. ___
consulted and decreased his Lantus significantly with good
results.
# A-fib: Failed cardioversion ___. Initial heart rates are
not well
controlled in the 120's, started metop tatrate 12.5mg q6h,
titrated to 25mg q6 for goal HR < 110. Continued apixiban 5mg
BID.
# Fall
# C3 spine fracture: C3 avulsion fracture: Non-operative per
orthopedics. Cervical collar in place at all times. Activity as
tolerated. Follow-up in spine clinic in 2 weeks.
# Home safety
# Medication errors: Multiple falls recently. Likely both
hypoglycemia and excess amlodipine dosing could be contributing.
___ recommended acute rehab, and on discharge will need higher
level of care to assist with medication and insulin
administration.
CHRONC ISSUES
=============
# Prostatomegaly
# Hematuria
# Flexible cystoscopy: Follows with urology. No current change
in
management, follow up in 6 months for possible procedure. Stable
inpatient.
# PE: Subsegmental, found in syncopal work up last admission. On
apixiban for afib. Unclear if significant or incidental finding.
Continued apixiban.
TRANSITIONAL ISSUES
===================
[] Medication changes
- Reduced dose of insulin Lantus to 18U QHS
- Increased Metoprolol Succinate XL from 50mg to 100 mg PO DAILY
- Stopped amLODIPine 10 mg PO BID (normal blood pressure)
- Stopped glimepiride 4 mg oral BID
[] Check morning blood sugars, if < 120 would decreased his
Lantus by at least 2 units
[] Follow up scheduled with ___ Diabetes and Spine Clinic
# CONTACT: ___
___: sister
Phone number: ___
Cell phone: ___
>30 minutes spent on complex 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:
shortness of breath
Major Surgical or Invasive Procedure:
___ - Cardiac catheterization with right coronary artery
stenting
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a PMH of atrial
fibrillation on warfarin, CAD s/p CABGx2, systolic heart failure
with an LVEF of 25%, carotid stenosis s/p CEA, and recent
admission for mechanical fall c/b multiple bruises and liver
laceration (___), now being readmitted with increased
dyspnea on exertion, a few episodes of acute SOB and continued
right-sided abomdinal pain. Patient is being admitted for
observation, pain control and serial hematocrit monitoring.
Patient notes that he felt fine when he left the hospital on
___. The next day, "things went South," and the following day
"things went farther South." The patient developed increasing
dyspnea on exertion, just after walking 2 steps up the stairs,
so that he had to go up the stairs on his bottom one step at a
time. Additionally, he had 9 episodes of right-sided, lower
chest pain over the past three days; these episodes responded to
nitroglycerin. These episodes were accompanied by shortness of
breath. He has a dry cough at baseline, as this cough increased
in frequency, but is not productive. He denies any orthopnea,
PND, weight gain, central chest pain or peripheral edema. He
also notes more anxiety than usual.
.
In the ED, initial vs were: T 98.4 BP 133/76 HR 108 RR 16 SaO2
98%RA. Physical exam with ecchmosis around R eye stable; AOx3,
although slightly more confused; lungs CTAB no crackles; heart
irregular no S3, no elevation of JVD, abd firm, slightly
distended and tympanitic, no chest wall tenderness, no ___ edema.
Labs were remarkable for BNP 2485, differential with
neutrophilic predominance of 77.8%, INR 2.7. Troponin <0.01. CT
abdomen and pelvis with contrast showed no evidence of liver
laceration or evolution of ascites, with a decrease in the
amount of ascites since imaging on ___. Vitals on Transfer:
Temp: 97.8 °F (36.6 °C), Pulse: 82, RR: 24, BP: 152/68, O2Sat:
96 on RA.
.
On arrival to the floor, the patient developed an acute episode
of chest pain and shortness of breath on transfer from the
stretcher to his bed. His vitals on arrival were 97.3 184/109 58
98%RA. He received one nitroglycerin 0.4 mg SL, which resulted
in decrease in BP to 140/80.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies 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
- Dyslipidemia
- Hypertension
- CAD s/p anterior and inferior MIs s/p CABG ___
- Ischemic Cardiomyopathy and CHF ___ EF 28%) s/p ICD in
___
- Afib on warfarin
- PACING/ICD: dual chamber ICD ___
- s/p bilateral carotid endarterectomy
- Restrictive lung disease (asbestos exposure)
- h/o Frontal lobe CVA
- CKD (baseline Cr 1.1-1.4)
- h/o PUD
- Benign abdominal tumor s/p resection
- Restless leg syndrome
- Obstructive sleep apnea on CPAP
- Depression on lamotrigine and lithium
- Prostate cancer, s/p radiation, c/b radiation proctitis
- Gout
- Arthritis
Social History:
___
Family History:
Maternal aunt may have had Alzheimer's disease. Father died of
complications related to a football injury at a young age.
Mother lived to be ___ and died following a rapidly progressive
course of pancreatic cancer. One sister died in early ___
possibly related to malnutrition. 4 adult siblings are all in
good health. Brother with HTN.
Physical Exam:
ADMISSION EXAM:
VS 97.3 184/109 (-> 140/80) 58 20 98%RA
General: Alert, oriented, initially in distress with chest pain
and SOB, but lwess anxious after getting nitroglycerin
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Very good air movement. Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Irregular rhythm, controlled rate, normal S1 + S2, I/VI
holosystolic murmur at LLSB with radiation to apex
Abdomen: soft, non-tender, slightly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back: No CVA tenderness, +TTP over right lower flank
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: alert, awake and oriented x3, no asterixis. CNs II-XII
intact and symmetric. Moving all extremities.
DISCHARGE EXAM:
VS- 97.7 ___ 74 20 97% RA
Lungs clear to auscultation
CV- irregularly irregular HR, normal S1/S2, I/VI holosystolic
murmur unchanged
Abd- +BS, soft, nontender, nondistended
Neuro- alert, agitated, oriented x 1 (person), unable to attend,
nonlinear thought process
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-6.9 RBC-3.40* Hgb-8.2* Hct-27.4*
MCV-80* MCH-24.2* MCHC-30.0* RDW-19.6* Plt ___
___ 01:00PM BLOOD Neuts-77.8* Lymphs-15.8* Monos-5.0
Eos-1.1 Baso-0.2
___ 01:00PM BLOOD ___ PTT-41.1* ___
___ 05:40AM BLOOD Ret Aut-2.8
___ 01:00PM BLOOD Glucose-334* UreaN-24* Creat-1.2 Na-137
K-4.5 Cl-107 HCO3-17* AnGap-18
___ 01:00PM BLOOD proBNP-2485*
___ 01:00PM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:05PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:49PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.3
___ 05:40AM BLOOD calTIBC-520* Ferritn-35 TRF-400*
___ 05:40AM BLOOD %HbA1c-7.4* eAG-166*
DISCHARGE LABS:
Hct 30.1 WBC 7.7
Creatinine 1.5
MICROBIOLOGY DATA:
___ Urine culture - mixed bacterial flora
___ Blood culture - no growth
___ Stool culture- c.difficile DNA amplification assay
negative
___ Urine culture- <10,000 org/ul
IMAGING:
___ CT ABDOMEN & PELVIS - No evidence of acute
intra-abdominal pathology. Amount of ascites since the
examination of ___ has decreased.
___ CHEST (PORTABLE AP) - Again seen is a dual-lead
pacemaker, moderate cardiomegaly, sternal wires, mediastinal
clips, patchy areas of volume loss and bilateral small
effusions, small pulmonary vascular redistribution. Compared to
the study from five days prior, the effusions are slightly
smaller and the aeration of the right lower lung is slightly
larger, but the vascular plethora is more
pronounced. The overall impression is that of persistent CHF.
___ CHEST (PORTABLE AP) - Lower lung volumes with persistent
bilateral pleural effusions and bibasilar atelectasis.
Retrocardiac air-bronchograms and hazy right lower lung field
could be secondary to atelectasis, but infection cannot be
excluded.
___ Cardiac cath-
1. Severe native 3 vessel CAD.
2. Patent LIMA-LAD, SVG-RPDA, and SVG-D.
3. Totally occluded SVG-OM.
4. Elevated right and left-sided filling pressures.
5. Moderate-severe pulmonary arterial hypertension.
6. Successful PCI of 99% stenosis of SVG-PDA with excellent
result.
7. Bare metal stent (Integrity 2.5 x 12 mm BMS) used given
Warfarin use.
8. Angioseal closure of RFA.
___ CT head w/o contrast - No CT evidence for acute
intracranial hemorrhage. Bifrontal areas of encephalomalacia
unchanged from ___.
Medications on Admission:
Acetaminophen 1000 mg PO/NG TID
Aspirin 81 mg PO/NG DAILY
ALPRAZolam 0.25 mg PO/NG TID:PRN anxiety
Citalopram 20 mg PO/NG DAILY
Docusate Sodium 100 mg PO/NG BID
Donepezil 10 mg PO/NG HS
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Furosemide 40 mg PO/NG DAILY Start: In am hold for SBP < 90
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Insulin SC (per Insulin Flowsheet) Sliding Scale
Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY hold
for SBP < 90
LaMOTrigine 400 mg PO/NG HS
Lisinopril 2.5 mg PO/NG DAILY Start: In am hold for SBP < 90
Lidocaine 5% Patch 1 PTCH TD DAILY
Metoprolol Tartrate 50 mg PO/NG BID hold for SBP < 90 or HR < 60
Morphine Sulfate ___ mg IV ONCE Duration: 1 Doses
Morphine Sulfate ___ mg IV Q4H:PRN breakthrough pain
Nitroglycerin SL 0.4 mg SL PRN chest pain
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN breakthrough
pain hold for AMS, sedation or RR < 12
Simvastatin 20 mg PO/NG HS
Spironolactone 25 mg PO/NG DAILY Start: In am hold for SBP < 90,
or K > 5
Warfarin 4 mg PO/NG 5X/WEEK (___)
Warfarin 2 mg PO/NG 2X/WEEK (WE,SA)
ranolazine *NF* 500 mg Oral BID Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
traZODONE 200 mg PO/NG HS
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. insulin lispro 100 unit/mL Solution Sig: Sliding scale unit
Subcutaneous ASDIR (AS DIRECTED).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
take 1 for chest pain, wait 5 min, take another, if call
ambulance.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
5. warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
please discuss with Dr. ___ prior to taking dose.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain: do not drink alcohol while
taking.
7. lamotrigine 200 mg Tablet Sig: Two (2) Tablet PO once a day.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranolazine 1,000 mg Tablet Extended Release 12 hr Sig: One
(1) Tablet Extended Release 12 hr PO twice a day.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas, bloating.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
17. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*0*
18. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation.
19. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis-
# CHF exacerbation
# Right PDA stenting with bare metal stent
# Acute delerium
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
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: DOE, question pulmonary edema.
FINDINGS: PA and lateral views of the chest obtained. AICD is again seen
with lead tips extending into the right atrium and right ventricle. Midline
sternotomy wires and mediastinal clips are again noted. There are bilateral
small pleural effusions with fluid tracking along the minor fissure. Mild
pulmonary interstitial edema is likely present. Cardiomediastinal silhouette
is stable. Bony structures are intact.
IMPRESSION: Mild interstitial edema with bilateral small pleural effusions.
Radiology Report
HISTORY: ___ man with questionable liver laceration now with
worsening abdominal pain and decreased hematocrit. Question worsening
abdominal pathology.
COMPARISON: ___ as well as ___ CT of the abdomen and
pelvis.
TECHNIQUE: CT of the abdomen and pelvis was performed with the administration
of IV contrast. No oral contrast was administered.
FINDINGS:
LUNG BASES: There is a stable appearing rounded consolidation in the right
lower lobe most consistent with rounded atelectasis. There is calcified
pleural plaques consistent with prior asbestos exposure. Apex of the heart is
unremarkable with ventricular lead terminating in the right ventricle.
ABDOMEN: Liver is of normal contour with no focal masses or evidence of
laceration. Gallbladder is unremarkable. Spleen and pancreas are
unremarkable. Bilateral kidneys are unremarkable; they enhance and excrete
contrast symmetrically. There is trace perihepatic ascites (2:23); however,
this is decreased since the prior examination. Other areas of ascites from
the prior examination such as the left paracolic gutter as well as pelvic free
fluid has mostly resolved with the exception of trace amounts of pelvic free
fluid (2:69). Overall, the amount of fluid has decreased. Loops of small and
large bowel are unremarkable. Aortic calcifications are once again noted.
These extend through the iliacs.
PELVIS: Large bowel is unremarkable. Bladder is normal. Prostate is
enlarged with multiple prostatic seeds. No pelvic lymphadenopathy. Trace
ascites in the pelvis again is mildly decreased since the prior examination.
OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions. No fracture is
identified. Significant degenerative changes within the thoracolumbar spine
are again noted and unchanged.
IMPRESSION:
1. No evidence of acute intra-abdominal pathology.
2. Amount of ascites since the examination of ___ has decreased.
Radiology Report
CHEST ON ___
HISTORY: Chest pain.
REFERENCE EXAM: ___.
FINDINGS: Again seen is a dual-lead pacemaker, moderate cardiomegaly, sternal
wires, mediastinal clips, patchy areas of volume loss and bilateral small
effusions, small pulmonary vascular redistribution. Compared to the study
from five days prior, the effusions are slightly smaller and the aeration of
the right lower lung is slightly larger, but the vascular plethora is more
pronounced. The overall impression is that of persistent CHF.
Radiology Report
HISTORY: CHF with acute delirium.
FINDINGS: In comparison with study of ___, there are continued low lung
volumes with enlargement of the cardiac silhouette and blunting of the
costophrenic angles consistent with pleural effusions and bibasilar
atelectasis. Pacemaker device remains in place. No convincing evidence of
pulmonary vascular congestion.
Radiology Report
INDICATION: Abdominal pain and distention. Concern for obstruction or
megacolon.
COMPARISON: CT abdomen and pelvis, ___.
FINDINGS: There is bibasilar atelectasis. Median sternotomy wires and pacer
leads are partially visualized. There is a large amount of gas within the
stomach. The bowel gas pattern is otherwise within normal limits. Radiopaque
brachytherapy seeds are visualized in the region of the prostate. There is no
evidence of free intraperitoneal air. The osseous structures are
unremarkable.
Radiology Report
INDICATION: ___ male with confusion status post fall with head
strike.
COMPARISON: ___.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
created and reviewed.
FINDINGS: Images of the skull base are degraded by motion artifact, limiting
evaluation. Within this limitation, there is no evidence for acute
intracranial hemorrhage, large mass, mass effect, or hydrocephalus. Bifrontal
encephalomalacia appears similar compared to prior. Arterial calcifications
are noted. Prominent ventricles and sulci suggest age-related involutional
changes. White matter hypodensity is likely secondary to sequela of chronic
small vessel ischemic disease. The basal cisterns appear patent.
Muscosal thickening is seen in the ethmoid air cells.
IMPRESSION: No CT evidence for acute intracranial hemorrhage. Bifrontal areas
of encephalomalacia unchanged from ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DOE
Diagnosed with SHORTNESS OF BREATH, ATRIAL FIBRILLATION
temperature: 98.4
heartrate: 108.0
resprate: 16.0
o2sat: 98.0
sbp: 133.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | IMPRESSION: ___ M with a PMH significant for A.fib (on
Coumadin), carotid stenosis, presumed ILD, severe coronary
artery disease (s/p 4V CABG), ischemic cardiomyopathy with an
LVEF of 25% with recent admission for mechanical fall and
conservatively managed liver laceration, who presented with
refractory shortness of breath now with hospital course
complicated by delirium now status-post cardiac catheterization
(___) with right coronary artery stenting.
# ACUTE ON CHRONIC DYSPNEA - Patient presented with increasing
dyspnea since discharge and evidence of persistent mild
pulmonary edema on CXR. Thought to be acute on chronic CHF
exacberation (LVEF 28%) but not much improvement with diuresis.
No evidence of consolidation or obvious infection on admission.
His BNP was mildly elevated. Cardiac enzymes on admission were
negative and his EKGs were reassuring. Received Lasix 40 mg IV x
1 on ___. Pulmonary embolism seemed less likely given his
anticoagulation needs. Given these findings, a chronic etiology
was considered most likely (deconditioning, pulmonary disease or
natural evolution of CHF). Cardiology was consulted and decided
a cardiac catheterization was necessary given his long-term
ischemic cardiomyopathy and concern for a reversible lesion. He
underwent cardiac catheteriztion on ___ with stenting of the
right coronary artery. Following the procedure, he was
maintained on Aspirin and started on Plavix 75 mg PO daily. He
was diuresed following catheterization, and was euvolemic for
several days prior to discharge. He was discharged on home dose
of lasix 40mg po daily.
# ACUTE DELIRIUM - Concern for delirium following admission with
inattentiveness and combativeness. Sleep patterns had been
erratic. Has occurred with prior hospitalizations. No infectious
cause was identified. Cardiac etiologies were treated as above,
but did not appear to be acute in nature, so unlikely to
precipitate acute change in mental status. Hematocrit was
stable, as was CT abd/pelvis, so unlikely to be related to
recent fall and liver laceration. in addition, CT head was
unchanged. Patient has underlying dementia predisposing him to
delerium.
Geripsych was consulted and followed patient closely. Optimal
regimen for controlled agitation was seroquel 25mg qHS with prn
dose. Patient was still confused at the time of discharge, and
___, primary team and geripsych recommended ___
___ facility to family. Family refused rehab, and
insisted on taking patient home. Family was encouraged to avoid
alprazolam and trazodone, and to continue seroquel as dosed
in-house.
# ACUTE DIARRHEA - Overnight on ___ developed episodic, watery
diarrhea that remained non-bloody. No abdominal pain or
cramping. Afebrile and without leukocytosis. C.diff toxin was
negative. Patient had been receiving large amount of
medications to prevent constipation which likely precipitated
diarrhea. It resolved spontaneously and did not return.
Abdominal exam was reassuring. Patient had stable hematocrit.
# CORONARY ARTERY DISEASE - Patient presented with strong
history of CAD and known 4-vessel disease with two prior CABG
surgeries. EKG reassuring on admission and cardiac enzymes flat
despite subjective dyspnea complaints. BNP slightly elevated on
admission. No history of chronic stable angina symptoms
recently. P-MIBI in ___ showing fixed RCA and LAD lesions.
Despite these findings, cardiology opted for cardiac
catheterization on ___ and stented his right coronary artery.
He was continued on Aspirin 325 mg PO daily, Simvastatin 20 mg
PO QHS, Imdur 90 mg PO daily and his Ranolazine. Plavix 75 mg PO
daily was added given his stent placement.
# CHRONIC SYSTOLIC HEART FAILURE WITH PRESUMED ACUTE
EXACERBATION - Presented with chronic systolic failure and LVEF
of 25% (since ___. Secondary to chronic graft occlusions with
WMA and fixed deficits in RCA, LAD remaining (ischemic
cardiomyopathy). Admitted with concern for volume overload,
requiring IV Lasix. His supplemental oxygen was weaned. His ACEI
was held on admission given concern for renal insufficiency, but
was restarted prior to discharge given improving renal function.
Metoprolol was increased to 100mg po BID and home sasix dosing
was continued. His aldosterone antagonist was held throughout
admission and at discharge. His daily weight was monitored and
he was maintained on strict I/O monitoring with a goal fluid
balance of even to 0.5L negative daily.
# ATRIAL FIBRILLATION - CHADs-2 score of 5 (CHF, HTN, DMII, h/o
TIA). Increased metoprolol to 100mg BID for improved rate
control. Coumadin was held on the two days prior to discharge
and patient was instructed to have INR checked by ___ on ___
with results sent to cardiologist Dr. ___ further
instructions on dosing.
# OSA/RLD - Likely contributing to chronic dyspnea complaints.
Patient has underlying ILD per report, without CT imaging
suggestive of interstitial process. FEV1 is 60% of predicted
value. No prior smoking history. CT chest showing pleural
plaques only with possible prior asbestos exposure. Consider
repeat PFTs and possible thin-cut CT scan of chest to evaluate
chronic dyspnea.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY - Baseline CR 1.2-1.7,
elevated on admission. Attributed to systolic failure
exacerbation vs. worsening baseline renal insufficiency. This
improved with improvement in his cardiac function and decreased
diuresis.
# TRANSITIONAL ISSUES -
- INR to be checked on ___ and sent to Dr. ___,
___ warfarin on discharge until further instructions
- electrolytes to be checked on ___ and sent to Dr.
___
- spironolactone held on discharge
- for delerium, trazodone, alprazolam, and donepezil were
discontinued. Patient should be given 25mg seroquel qHS with
additional 25mg as needed for agitation. Follow-up scheduled
with cognitive neurologist Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Lipitor / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
___ - Left calf fasciotomies and tibial plateau ex-fix
History of Present Illness:
___ mechanical fall down three stairs, landed on her left
side. Did not hit her head, denies LOC. No preceding light
headedness, SOB, CXP, dizziness. C/O left shoulder and left
knee/calf pain. Specifically denies left hip or groin pain.
Denies numbness or tingling. No neck or back pain. Fall occured
at 18:00. NPO since ___.
Patient is currently under treatment for bilateral lower
extremity cellulitis and is on day ___ of doxycycline. The
doxycycline resulted in oral thrush and she is currently on
nystatin swish and spit. Has also had diarrhea on doxycycline.
Past Medical History:
Hypothyroid, Alcoholism (Denies and gets angry when discussed),
osteopenia (denies and says it is improving), depression,
cellulitis BLE
PSH: Left intertrochanteric femur fracture ___ s/p TFN, removal
of TFN ___ for back pain
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is a somewhat confused female who
appears uncomfortable. She is AAOx3.
Vitals: BP 164/82
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
TTP at shoulder and pain with ROM there
Full, painless AROM/PROM of elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact, erythema over foot, reportedly improved
Shiny skin from knee down
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact, erythema over foot, reportedly improved
Edema of leg and foot
TTP in calf and firm compartments
TTP at knee and will not allow ROM
No pain with ___ at hip
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
+DP pulse, foot warm and well-perfused
COMPARTMENT PRESSURE:
After discussion of risks and benefit of compartment
interrogation the patient agreed to proceed.
DBP - 82
Deep posterior - 80
Superficial posterior - 88
Lateral - 85
Anterior - 79
Pertinent Results:
___ 10:00AM BLOOD WBC-12.7* RBC-2.40*# Hgb-6.2*# Hct-20.3*#
MCV-85 MCH-25.9* MCHC-30.6* RDW-14.6 Plt ___
___ 12:50AM BLOOD Glucose-123* UreaN-14 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-23 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Pravastatin 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. LaMOTrigine 50 mg PO BID
8. ClonazePAM 0.5 mg PO QHS:PRN insomnia
9. Doxycycline Hyclate 100 mg PO Q12H
10. Nystatin Oral Suspension 5 mL PO QID thrush
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. ClonazePAM 0.5 mg PO QAM
3. ClonazePAM 1 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. LaMOTrigine 50 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID thrush
9. Omeprazole 20 mg PO DAILY
10. Pravastatin 10 mg PO DAILY
11. Cyclobenzaprine 5 mg PO BID:PRN spasm
12. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC Daily Disp #*14 Syringe
Refills:*0
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Senna 8.6 mg PO BID
15. TraZODone 25 mg PO HS:PRN insomnia
16. Vitamin D 400 UNIT PO DAILY
17. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Tibial plateau fracture and compartment syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ with s/p fall, pain, headache.
TECHNIQUE: Multi detector CT scan of the head without IV contrast.
Reformatted images were provided.
DLP: 891.93 mGy-cm. CTDIvol: 55.75 mGy.
COMPARISON: None.
FINDINGS: There is no acute hemorrhage, edema, mass, mass effect or acute
large vascular territorial infarction. The ventricles and sulci are normal in
size and configuration. There is preservation of gray-white matter
differentiation. The basal cisterns are patent. Periventricular white matter
hypodensities likely represent the sequela of chronic small vessel ischemic
disease.
No fracture is identified. The globes appear normal. The paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: ___ with s/p fall, pain, headache.
TECHNIQUE: Multi detector CT scan of the cervical spine without IV contrast.
Reformatted images were provided.
DLP: 1,537.19 mGy-cm. CTDIvol: 36.89 mGy.
COMPARISON: None.
FINDINGS: No acute fracture or traumatic malalignment is seen. There is
multilevel degenerative changes from the C3 to the C7 level including disc
space narrowing and tiny anterior osteophytes. There is no prevertebral soft
tissue swelling. The aerodigestive tract is clear. The thyroid appears
normal. The lung apices are scarred. There is no pathologic lymphadenopathy
by CT size criteria.
IMPRESSION: No acute fracture or traumatic malalignment.
Radiology Report
CLINICAL INDICATION: Fasciotomy. Left tib/fib fractures.
COMPARISON: Outside hospital knee and hip radiographs.
17 intraoperative fluoroscopic spot images show placement of external fixation
pins in the distal femur and proximal tibia.
Radiology Report
INDICATION: Left tibial plateau fracture, status post fasciotomy and ex-fix
placement.
TECHNIQUE: Axial MDCT images were acquired through the left knee without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
COMPARISON: Left knee radiographs, ___ and intraoperative
images, ___.
FINDINGS:
There has been placement of an external fixator device with proximal fixation
through the distal femur and distal fixation through the distal tibia. There
has also been fasciotomy with skin defects evident along the medial and
lateral aspects of the calf. There is a small amount of subcutaneous air,
some of which tracks into the fascial planes (3:277). This is presumed to be
related to the recent surgery. There is also a small amount of air in the
medullary cavity of the tibia (3:223).
There is a split and depressed fracture of the lateral tibial plateau
(401B:40) with depression of the articular surface by approximately 1.1 cm.
There is a spiral component of this fracture which extends down to the mid
tibial diaphysis (401B:35). There is minimal displacement of this fracture
line. There is an additional comminuted fracture of the proximal fibula
(401B:44). This is angulated but not displaced.
A moderate-sized lipohemarthrosis is seen. There is mild diffuse subcutaneous
edema throughout the visualized lower extremity. Assessment of the soft
tissue structures of the knee is limited; nonetheless, the anterior and
posterior cruciate ligaments appear to be intact. The extensor mechanism is
intact. Multifocal areas of increased attenuation within the medulla of both
the femur and the proximal tibia are presumed to be blood related to the
fracture at the placement of the ex-fix device (3:100). No ___ cyst is
seen.
IMPRESSION:
1. Split and depressed-type fracture of the lateral tibial plateau, Schatzker
type 2, with 1.1 cm depression of the articular surface. A spiral component
to the fracture extends down to the mid tibial diaphysis.
2. Moderate lipohemarthrosis.
3. Status post fasciotomy.
Radiology Report
HISTORY: Three intraoperative radiographs of the left leg.
Since preoperative exam ___ (5 days ago) the lateral tibial plateau
fracture has been fixated by a lateral plate extending to the mid portion of
the tibia with multiple associated horizontal screws. There is poorly
visualized associated fracture of the proximal fibula.
Radiology Report
HISTORY: Status post multiple surgeries now with increasing white blood cell
count and platelet count. Evaluate for pneumonia or consolidation.
COMPARISON: Chest radiograph ___.
FRONTAL SUPINE CHEST RADIOGRAPH: The lungs are hyperinflated. There is no
pleural effusion, pneumothorax or focal airspace consolidation worrisome for
pneumonia. A right nipple shadow is noted and should not be mistaken for an
intraparenchymal lesion. The heart is normal in size. Mediastinal structures
are unremarkable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX UPPER END TIBIA-CLOSE, TRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY, FALL ON STAIR/STEP NEC
temperature: 98.2
heartrate: 76.0
resprate: 18.0
o2sat: 96.0
sbp: 176.0
dbp: 93.0
level of pain: 10
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left calf compartment syndrome and tibial plateau
fracture and was taken emergently to the operating room on
___ for left calf fasciotomy and external fixation of tibial
plateau fracture. Postoperatively she was admitted to the
orthopedic surgery service. She subsequently underwent several
operations including repeat I&D and vac change on ___,
ex-fix removal, ORIF left tibial plateau fracture, and vac
placement on ___, and left lower extremity lateral wound
split thickness skin graft and medial primary closure with vav
placement over skin graft and incisional vac placement over
medial primary closure.
The patient tolerated the procedure well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. She was transfused
2 units of pRBCs for a HCT of 20.3 on POD2. The patients home
medications were continued throughout this hospitalization. She
was evaluated by psychiatry for medication management with mild
agitation while an inpatient. They recommended limiting
benzodiazepine use in addition to continuing her home
medications. Her platelet count increased to greater than ___ on
___ and hematology was consulted for further evaluation.
Given her lack of signs of an infection this was thought to be
reactive in nature and they recommended following her CBC and
monitoring her clinical status. Her platelets began to trend
down on ___ and she remained afebrile with stable vital
signs and no signs of an infectious process. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
epinephrine
Attending: ___
___ Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy ___
Endoscopy ___
History of Present Illness:
Ms. ___ is an ___ year female with history significant for
hemorrhoids, diverticulitis, and polyps who presents with 2 day
history of colicky abdominal pain, constipation, followed by 2
loose stools with "mucousy" blood in the toilet.
In the ED, initial vitals were:
Temp. 97.9, HR 66, BP 136/93, RR 18, 100% RA
Labs in the ED were notable for elevated lactate 2.5, Hg/Hct
15.8/45.4, and WBC of 11.7. UA negative for nitrites and
leukocytes.
CTA was significant for no evidence of mesenteric ischemia,
hyperenhancing 5mm focus along the wall of the jejunum that may
represent polyp or extravasation and hiatal hernia. The patient
was given 1L NS. She was noted to be anxious in the ED and
received her AM dose of ativan at that time.
On the floor, the patient notes that starting last night she
noted diffuse colickly abdominal pain. She notes that she is
constipated at baseline and that she noted feeling constipated
in the setting of her abdominal discomfort. She denies any
correlation of her colicky abdominal pain to food. She had 2
hard bowel movements both of which were associated with
straining and bright red blood per rectum. Her abdominal pain
did not resolve however and continued this morning at which time
she came to the ED. She denies any associated nausea, vomiting,
fever, or chills. She does endorse previous mid-epigastric
discomfort that has resolved with prilosec.
She does endorse a recent fall last while tripping over a rug
and fell on her tail bone. In addition she notes "blurred, half
vision" currently in the setting of resolving migraine on
___. She notes that this is usually how she feels prior
getting a migraine. She denies any splurred speech, facial
droop, or weakness in her arms or legs.
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, or diahrea.
She denies any dysuria or frequency. Denies arthralgias or
myalgias.
Past Medical History:
Anxiety
Skin cancer s/p Mohs
Cataracts
Constipation
GERD
Migraine headaches
GERD
Hypercholesterolemia
Hypertension
Hypothyroidism
Neck pain
Osteopenia
Recurrent urinary tract infections
Pedal Edema
Hemorrhoids
Social History:
___
Family History:
History of colon cancer on father's side predominately. Notes
she has paternal grandmother, aunt, and uncle all with colon
cancer she believes at ages over ___ years old. She notes her
father had "heart disease." Mother with uterine cancer
Physical Exam:
EXAM ON ADMISSION:
====================
Vitals: T: 99.2 BP: 150/70 P: 61 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
though hypoactive, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rash
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities
EXAM ON DISCHARGE:
==================
VItals: Temp. 99.2 BP 124/68 53 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
though hypoactive, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rash
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities
Pertinent Results:
PERTINENT LABS:
==================
___ 07:00AM BLOOD WBC-11.7*# RBC-5.37 Hgb-15.8 Hct-45.4
MCV-85 MCH-29.4 MCHC-34.8 RDW-14.5 Plt ___
___ 12:58PM BLOOD Hgb-14.9 Hct-44.9
___ 07:00AM BLOOD Glucose-116* UreaN-16 Creat-1.0 Na-139
K-5.9* Cl-107 HCO3-19* AnGap-19
___ 10:12AM BLOOD K-4.7
PERTINENT STUDIES:
==================
CTA Abdomen ___:
IMPRESSION:
1. No evidence of mesenteric ischemia.
2. Hyperenhancing 5 mm focus along the wall of the jejunum seen
only on portal venous phase may represent a polyp or venous
extravasation. No arterial extravasation identified.
3. Hiatal hernia.
4. Trace pleural effusions.
Flex sigmoidoscopy ___:
Mucosa: Localized erythema and ulceration were noted in the
proximal descending colon. These findings are compatible with
mild colitis (? ischemic). Cold forceps biopsies were performed
for histology at the sigmoid erythema.
Protruding Lesions Small internal hemorrhoids were noted.
Excavated Lesions A few diverticula with small openings were
seen.Diverticulosis appeared to be of mild severity.
Impression: Diverticulosis of the colon
Internal hemorrhoids
Erythema and ulceration in the proximal descending colon
compatible with mild colitis (? ischemic) (biopsy)
Otherwise normal sigmoidoscopy to descending colon
Recommendations: We will contact you with the results of the
biopsy
Stay hydrated
Prevent constipation by taking daily colace and miralax if you
have not had a bowel movement after 2 days
Endoscopy ___:
Esophagus: Normal esophagus.
Stomach:
Lumen: A large size hiatal hernia was seen.
Mucosa: Normal mucosa was noted.
Duodenum/Jejunum: Normal.
Other
findings: Nothing seen in the proximal jejunum to explain the
CTA findings.
Impression: Large hiatal hernia
Normal mucosa in the stomach
Nothing seen in the proximal jejunum to explain the CTA
findings.
Otherwise normal EGD to mid jejunum
Recommendations: Nothing on this exam to explain the CTA
findings
Hiatal hernia is the likely cause of acid reflux
Daily PPI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. isometh-dichloral-acetaminophn 65-100-325 mg oral PRN
headache
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lovastatin 40 mg oral QHS
5. Mirtazapine 15 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Lorazepam 0.5 mg PO QHS
10. Lorazepam 0.25 mg PO QAM
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. isometh-dichloral-acetaminophn 65-100-325 mg oral PRN
headache
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lorazepam 0.5 mg PO QHS
5. Lorazepam 0.25 mg PO QAM
6. Lovastatin 40 mg oral QHS
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17
powder(s) by mouth once a day Disp #*510 Gram Gram Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestinal bleeding
Colitis
Hiatal Hernia
Secondary:
Anxiety
Skin cancer s/p Mohs
Cataracts
Constipation
GERD
Migraine headaches
GERD
Hypercholesterolemia
Hypertension
Hypothyroidism
Neck pain
Osteopenia
Recurrent urinary tract infections
Pedal Edema
Hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ woman with bright red blood per rectum, intermittent
abdominal pain, question mesenteric ischemia.
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed utilizing
mesenteric CTA protocol. IV contrast was administered. Multiplanar
reformations were provided.
DOSE: DLP: 2495.2mGy-cm
COMPARISON: Chest CT from ___.
FINDINGS:
Lung Bases: Emphysema is noted at the imaged lung bases with areas of
scarring and mild atelectasis. There is a moderate in size hiatal hernia.
Trace pleural effusions noted bilaterally.
CTA: The abdominal aorta is normal in course and caliber with mild
atherosclerotic calcifications. The major aortic branches appearing patent
with a normal branching pattern. No dissection is identified.
Abdomen: A tiny hypodensity within segment 7 of the liver near the dome is
seen on series 4b, image 207, too small to characterize. Otherwise, the liver
appears normal. Main portal vein is patent. The gallbladder is not fully
distended. The pancreas appears normal. This spleen is unremarkable. Mild
nodular thickening is seen at the apex of the left adrenal gland measuring
approximately 11 mm, stable from the prior noncontrast CT chest from ___, suggesting a benign entity. The right adrenal gland appears
normal. There is a cortical hypodense lesion measuring approximately 1 cm in
diameter arising from the interpolar left kidney on series 4b, image 236
without significant difference in central attenuation on arterial and portal
venous phase suggesting a hemorrhagic cyst. No hydronephrosis or definite
renal lesion of concern. The distal aspect of the stomach and duodenum appear
normal.
Pelvis: There is abnormal hyperdensity along the wall of the proximal jejunum
on series 4b image 259 which matches blood pool and may represent a polyp or
venous extravasation. Loops of small bowel demonstrate no signs of ileus or
obstruction. The appendix is not visualized though there are no secondary
signs of appendicitis. Scattered colonic diverticulosis without diverticulitis
is noted. The colon is not fully distended though there is no evidence of
active arterial extravasation or bowel wall thickening. The sigmoid colon is
decompressed limiting assessment for mild colitis. The urinary bladder is
decompressed. The uterus and adnexal regions appear unremarkable. No free
pelvic fluid is seen.
Bones: No worrisome lytic or blastic osseous lesion is seen. Degenerative
changes are noted in the lumbar spine with loss of disc space most pronounced
at L3-4 and L4-5.
IMPRESSION:
1. No evidence of mesenteric ischemia.
2. Hyperenhancing 5 mm focus along the wall of the jejunum seen only on portal
venous phase may represent a polyp or venous extravasation. No arterial
extravasation identified.
3. Hiatal hernia.
4. Trace pleural effusions.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with RECTAL & ANAL HEMORRHAGE
temperature: 97.9
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 93.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is an ___ year female with history significant for
hemorrhoids, diverticulitis, and polyps who presents with 2 day
history of colicky abdominal pain, constipation, followed by 2
loose stools with "mucousy" blood in the toilet noted to be
guiac positive in the ED with signs/symptoms concerning for
possible lower GI bleed.
# Bright red blood per rectum:
Ms. ___ was admitted to the hospital because she noted
bright red blood per rectum. She was noted to be guiac positive
in the Emergency room. She was admitted and evaluated with
sigmoidoscopy and endoscopy. She remained hemodynamically stable
throughout the course of her hospital stay. Her sigmoidoscopy
showed colitis that was thought to be most likely due to
constipation or ischemia though CTA was without evidence of
mesenteric ischemia. Endoscopy was also done that showed known
hiatal hernia but no active evidence of bleeding. A biopsy was
taken at time of sigmoidoscopy and the results will be mailed to
the patient. It was recommended that Ms. ___ continue
taking daily prilosec and also take daily colace and miralax for
constipation.
#Colicky abdominal pain
Ms. ___ endorsed symptoms of colicky abdominal pain prior
to admission in the setting of constipation. Given her history
of constipation, straining with stooling, and hard stools her
symptoms were thought to be most likely due to constipation.
Infection less likely given absence of fever and exam that was
non-focal, with no evidence of rebound or guarding. She was
discharged with stool regimen including colace and miralax.
# Hypertension
-continued atenolol 25 mg daily
# Hypercholesterolemia
-continued lovastatin
-Aspirin held intially in setting of possible GI bleed but
restarted prior to discharge
# GERD with large hiatal hernia also seen on EGD
It was recommended by gastroenterology that patient continue
prilosec daily.
#Hypothyroidism
-continued levothyroxine
#Depression/Anxiety
-continued mirtazapine
-continued AM and ___ lorazepam |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUE weakness
Major Surgical or Invasive Procedure:
tPA at ___ on ___
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 5 minutes
Time (and date) the patient was last known well: 0500 on
___ clock)
___ Stroke Scale Score: 2
t-PA given:
No Reason t-PA was not given or considered: already given at OSH
___ Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
HPI: Mr. ___ is a ___ RHM h/o HTN p/w sudden onset RUE
weakness at 5am today.
He has recently been in his USOH w/o med changes. Typically
wakes
early and woke today at 4:30 am. While tying shoes at 5am, noted
clumsiness of the hand. Was able to drive to his daughter's who
brought him to ___ where acute stroke identified (NIHSS
unclear but findings limited to RUE) and pt given tPA at 7:06am.
Transferred here for further care.
In the ED, NIHSS 2 for weakness and sensory in the RUE. CTA was
done to ensure that there was no need for further intervention;
demonstrated carotid atherosclerosis. Subjectively pt feels
slightly improved from prior.
ROS: Positive for weak/numb as above, no other weakness or
numbness. Denies any productive/receptive/articulation
difficulty. No clumsiness RUE aside. No incontinence. General
ROS
negative for F/C/sweats, head/neck/back pain, chest pain, SOB,
cough, abd pain, N/V/C/D, myalgias, arthralgias, rash.
Past Medical History:
- HTN on lisinopril and atenolol
- Cataract s/p surgery OS
- s/p b/l knee surgery
Social History:
___
Family History:
Negative for stroke in the young, recurrent miscarriage,
bleeding issues.
Physical Exam:
Admission Physical Examination
98 86 153/88 16 99% RA
General: NAD NT ND
Heent: NC/AT
Neck: No bruits
Card: Faint sounds, regular
Pulm: Clear
Abd:S oft normal sounds
Extrem: Thin
Neurologic
- MS: A&Ox3. DOWIR nl. Names normally with intact fluency,
repetition, comprehension. No dysarthria. No neglect.
- CN: 3.5 -> 3 OS (post surgical), 3 -> 2 OD. VFFTC without
neglect. Eyes ortho, EOMI. Face symmetric to pin and activates
equally. Symmetric audition, tongue, palate, shrug.
- Motor: Right delt 4, tric/bic 5-, no movement of right wrist
or intrinsic muscles of the hand. The EHLs are 4+ bilaterally
but
otherwise he is full strength. Cannot relax making tone
difficult
but no clonus at ankles; ? upgoing R toe (weakly). j
- Sensory: Diminished to pin glove-like distribution R hand
extending to forearm. R thumb proprioception impaired; halluces
normal. Otherwise sensitive to pin. Does not extinguish to
double. Romberg deferred.
- Reflexes: Difficult to relax; no apparent asymmetry between
arms. Surgical knees, present at ankles.
- Cerebellar: FNF abnl in RUE but not out of proportion to
weakness, L FNF and heel/shin b/l nl.
- Gait; Deferred
Discharge Physical Examination
Most significant for a right cortical hand with ___ delt, ___
tri/biceps, no movement of right wrist or intrinsic muscles of
the hand
Pertinent Results:
___ 08:35AM BLOOD WBC-12.1* RBC-4.62 Hgb-14.5 Hct-38.6*
MCV-84 MCH-31.3 MCHC-37.5* RDW-13.2 Plt ___
___ 02:40AM BLOOD WBC-7.6 RBC-4.28* Hgb-13.5* Hct-36.0*
MCV-84 MCH-31.4 MCHC-37.3* RDW-13.2 Plt ___
___ 06:30AM BLOOD WBC-8.5 RBC-4.53* Hgb-14.2 Hct-38.8*
MCV-86 MCH-31.4 MCHC-36.6* RDW-13.2 Plt ___
___ 02:40AM BLOOD Neuts-49.2* ___ Monos-8.8 Eos-2.8
Baso-0.9
___ 06:30AM BLOOD Neuts-64.6 ___ Monos-8.0 Eos-2.1
Baso-0.7
___ 08:35AM BLOOD ___ PTT-27.6 ___
___ 02:40AM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-134
K-3.8 Cl-99 HCO3-23 AnGap-16
___ 06:30AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-137
K-4.5 Cl-102 HCO3-26 AnGap-14
___ 08:35AM BLOOD ALT-15 AST-21 AlkPhos-35* TotBili-0.4
___ 08:35AM BLOOD Lipase-51
___ 08:35AM BLOOD cTropnT-<0.01
___ 02:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Cholest-147
___ 06:30AM BLOOD %HbA1c-5.6 eAG-114
___ 02:40AM BLOOD Triglyc-161* HDL-37 CHOL/HD-4.0
LDLcalc-78
___ 08:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:52AM BLOOD Glucose-124* Na-130* K-4.6 Cl-93*
calHCO3-27
___ 10:03AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:03AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ CTA Head/Neck
1. No acute intracranial hemorrhage or mass effect. Please see
MRI of the head performed subsequently regarding multiple small
acute infarcts in the left cerebral hemisphere.
2. Patent major intra and extracranial arteries as described
above.
Extensive atherosclerotic disease with calcified and
noncalcified plaques in the aortic arch, arch vessels, common
carotid arteries and the bifurcations and cervical internal
carotid arteries as described above.
Approximately 50% stenosis in the right common carotid artery,
less than 20% in the left common carotid artery and
approximately 55% stenosis at the left common carotid
bifurcation.
Left Cervical ICA: Prominent calcified and noncalcified plaques
in the left proximal cervical internal carotid artery extending
from the common carotid bifurcation, causing approximately
60-65% luminal narrowing, based on European criteria, though
30% based on NASCET criteria, over a length of approximately
2.1cm; the difference can be attributed to tortuous course and
expanded vessel contour. Tiny hypodense focus within-? thrombus
or volume averaging. Right cervical ICA: Less than 20% stenosis
Intracranial ICA: Mild-moderate narrowing of the cavernous
carotid segments on both sides.
3. Multilevel, multifactorial degenerative changes are noted,
with mild canal moderate to severe foraminal narrowing with
deformity on the nerves from C3-C7 levels.
A small sclerotic focus in the T4 vertebral body question bone
island or a sclerotic neoplastic lesion. Correlate clinically to
decide on the need for further workup or followup.
4. Periapical lucencies noted around the left mandibular third
molar-
correlate with dental examination.
___ MRI Head w/o
1. Several foci of acute-subacute infarction in primarily the
left MCA
territory as detailed above, likely embolic; no evidence of
hemorrhagic
transformation, significant edema or mass effect.
2. T2/FLAIR signal hyperintensity in the periventricular,
subcortical, and deep white matter which is nonspecific but
likely on the basis of chronic small vessel ischemic disease.
___ CT head w/o
1. No evidence of acute hemorrhage.
2. Unchanged appearance of left frontal lobe subcortical
hypodensity.
3. Age-related involutional changes and likely sequela of
chronic small vessel ischemic disease.
___ ECHO
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 mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
___ Carotid Dopplers
Less than 40% stenosis of the bilateral internal carotid
arteries. Doppler suggests that the left ICA stenosis is less
severe than suggested by CTA ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
4. Lisinopril 20 mg PO DAILY
5. Outpatient Occupational Therapy
Dx: Stroke
To Evaluate and Treat
Discharge Disposition:
Home
Discharge Diagnosis:
Left MCA Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with RUE weakness, numbness // Eval for clot/lesion
TECHNIQUE: CT of the head without IV contrast; CT angiogram of the head and
neck with IV contrast; 2D and 3D reformations of the intra and extracranial
arteries. Report based on all the images provided.
COMPARISON: CT head from ___, on ___.
FINDINGS:
CT HEAD:
No acute intracranial hemorrhage or mass effect.
Dense calcifications in the basal ganglia and cerebellar hemispheres, similar
to the prior study.
Scattered hypodense foci in the cerebral white matter in the frontal and the
parietal lobes on both sides.
Limited assessment for small acute infarcts.
Moderately prominent ventricles, mildly prominent extra-axial CSF spaces and
sulci, likely relates to volume loss.
No suspicious osseous lytic or sclerotic lesions are noted.
Mild ethmoidal mucosal thickening.
The mastoid air cells are clear.
CT ANGIOGRAM HEAD:
The major intracranial arteries of the anterior and the posterior circulation
are patent, without focal flow-limiting stenosis or occlusion.
There is fetal PCA pattern on the left side, with diminutive or absent P1
segment and posterior communicating artery continuing as the posterior
cerebral artery.
Vascular calcifications are noted in the cavernous carotid segments on both
sides, with mild to moderate narrowing.
The anterior and the middle cerebral arteries are patent.
CT ANGIOGRAM NECK:
The origins of the arch vessels are patent. Calcifications are noted at the
aortic arch and the arch vessels.
The included portions of the subclavian arteries on patent, the left not well
seen distally-? Artifactual.
Calcified and noncalcified plaques are noted in right common carotid artery
proximally, causing approximately 50% stenosis series 3, image 132 and less
than 20% in the left common carotid artery- se 3, im 124.
Calcified and noncalcified plaques are noted at the common carotid
bifurcations, extending into the proximal cervical internal carotid arteries
on both sides, more on the left. In the left common carotid bifurcation, there
is approximately 55% stenosis series 3, image 157 by calcified and
noncalcified plaques.
In the left proximal cervical internal carotid artery, though there is
approximately 30% stenosis by NASCET criteria, there is mild expansion of the
vessel contour, with peripheral calcifications and noncalcified plaques
laterally, over a length of approximately 2.1 cm series 602b, image 47,
resulting in approximately atleast 60-65% stenosis by European criteria-
series 3, image 167. Accurate assessment is somewhat limited due to the
tortuous course and eccentric location of the plaques.
There is also likely tiny hypodense focus, that can relate to filling defect
within or volume averaging -series 3, image 173.
The vertebral arteries are patent throughout their course, without focal
flow-limiting stenosis or occlusion.
Calcifications are noted at the vertebral artery origins right more than left
and in the left V2 and V4 segments.
CT NECK:
A few small nodes are noted in both sides of the neck, not abnormally enlarged
by size criteria.
Prominent adenoids and palatine tonsils with punctate calcifications in the
palatine tonsils likely from prior inflammation.
Thyroid is normal.
Periapical lucencies noted around the left mandibular third molar, series 3,
image 179-193.
Multilevel, multifactorial degenerative changes are noted, with mild canal
moderate to severe foraminal narrowing with deformity on the nerves from C3-C7
levels.
A small sclerotic focus in the T4 vertebral body question bone island or a
sclerotic neoplastic lesion.
The included lung the pieces are clear.
Scattered emphysematous changes are noted.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. Please see MRI of the
head performed subsequently regarding multiple small acute infarcts in the
left cerebral hemisphere.
2. Patent major intra and extracranial arteries as described above.
Extensive atherosclerotic disease with calcified and noncalcified plaques in
the aortic arch, arch vessels, common carotid arteries and the bifurcations
and cervical internal carotid arteries as described above.
Approximately 50% stenosis in the right common carotid artery, less than 20%
in the left common carotid artery and approximately 55% stenosis at the left
common carotid bifurcation.
Left Cervical ICA: Prominent calcified and noncalcified plaques in the left
proximal cervical internal carotid artery extending from the common carotid
bifurcation, causing approximately 60-65% luminal narrowing, based on European
criteria, though 30% based on NASCET criteria, over a length of approximately
2.1cm; the difference can be attributed to tortuous course and expanded vessel
contour. Tiny hypodense focus within-? thrombus or volume averaging.
Right cervical ICA: Less than 20% stenosis
Intracranial ICA: Mild-moderate narrowing of the cavernous carotid segments
on both sides.
3. Multilevel, multifactorial degenerative changes are noted, with mild canal
moderate to severe foraminal narrowing with deformity on the nerves from C3-C7
levels.
A small sclerotic focus in the T4 vertebral body question bone island or a
sclerotic neoplastic lesion. Correlate clinically to decide on the need for
further workup or followup.
4. Periapical lucencies noted around the left mandibular third molar-
correlate with dental examination.
Radiology Report
INDICATION: ___ year old man with stroke // ? Intrathoracic process
COMPARISON: Outside hospital radiograph from ___ at 06:10.
IMPRESSION:
Heart size is within normal limits. There is mild tortuosity of the thoracic
aorta. There are no focal consolidations, pleural effusion, or pulmonary
edema. There are no pneumothoraces.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with right cortical hand // define stroke
characteristics
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique.
COMPARISON: No prior MRI. Prior CT and CTA study dated ___
FINDINGS:
There are several small scattered regions of slow diffusion in the left
frontal lobe, left parietal lobe, and a few in the inferior left temporal lobe
and left occipital lobe. This diffusion abnormality is particularly evident in
the left pre and postcentral gyri. T2/FLAIR signal abnormality is seen within
these regions. Findings are consistent with acute-subacute infarction in
primarily MCA territory. There is no evidence of hemorrhagic transformation.
The ventricles and sulci are prominent likely reflecting age-related
parenchymal volume loss.
There is additional periventricular, subcortical, and deep white matter
T2/FLAIR signal hyperintensity likely reflecting chronic small vessel ischemic
disease. Susceptibility artifact noted in the bilateral cerebellar hemispheres
corresponds to calcification as seen on prior CT scan.
Major vascular flow voids are patent.
Patient is status post bilateral lens replacement.
There is mucosal thickening within the ethmoid air cells.
The remaining paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Several foci of acute-subacute infarction in primarily the left MCA
territory as detailed above, likely embolic; no evidence of hemorrhagic
transformation, significant edema or mass effect.
2. T2/FLAIR signal hyperintensity in the periventricular, subcortical, and
deep white matter which is nonspecific but likely on the basis of chronic
small vessel ischemic disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: 24 hour followup in a patient with a left MCA stroke, status post
TPA at 07:00 on ___.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 897.1 mGy-cm
CTDI: 53.8 mGy
COMPARISON: CTA head and neck from ___.
FINDINGS:
The patient is status post administration of tPA 24 hours prior, without
evidence of acute hemorrhage. Again seen is a prominent area of subcortical
hypodensity in the left frontal lobe, similar in appearance compared to the
most recent CT head. Additional foci of hypodensity in the left thalamus and
periventricular regions are consistent with sequela of chronic small vessel
ischemic disease. There is no evidence of mass. The ventricles sulci and
extra-axial CSF spaces are mildly prominent, consistent with age-related
involutional changes. Calcifications of the bilateral basal ganglia and
cerebellum are unchanged.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
1. No evidence of acute hemorrhage.
2. Unchanged appearance of left frontal lobe subcortical hypodensity.
3. Age-related involutional changes and likely sequela of chronic small vessel
ischemic disease.
Radiology Report
EXAMINATION: CAROTID DOPPLER ULTRASOUND
INDICATION: ___ year old man with L MCA stroke, L ICA 60% stenosis on CTA -
further evaluation with carotid U/S // degreee of L ICA stenosis - do
bilateral carotid US with dopplers
TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: Head and neck CTA ___
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque.
The right internal carotid artery has peak systolic/diastolic velocities of
47/12 cm/sec in its proximal portion, 56/21 cm/sec in its mid portion, and
42/12 cm/sec in its distal portion.
The right common carotid artery has peak systolic/diastolic velocities of 71/9
cm/sec.
The external carotid artery has peak systolic velocity of 34 cm/sec.
The vertebral artery has peak systolic velocity of 39 cm/sec with normal
antegrade flow.
The right ICA/CCA ratio is 0.79.
LEFT:
The left carotid vasculature has mild heterogeneous atherosclerotic plaque.
The left internal carotid artery has peak systolic/diastolic velocities of
78/27 cm/sec in its proximal portion, 53/17 cm/sec in its mid portion, and
41/15 cm/sec in its distal portion.
The left common carotid artery has peak systolic/diastolic velocities of 65/11
cm/sec.
The external carotid artery has peak systolic velocity of 65 cm/sec.
The vertebral artery has peak systolic velocity of 62 cm/sec with normal
antegrade flow.
The left ICA/CCA ratio is 1.2.
IMPRESSION:
Less than 40% stenosis of the bilateral internal carotid arteries. Doppler
suggests that the left ICA stenosis is less severe than suggested by CTA ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS
temperature: 98.0
heartrate: 86.0
resprate: 16.0
o2sat: 99.0
sbp: 153.0
dbp: 88.0
level of pain: 0
level of acuity: 1.0 | ___ presenting with stroke causing sensorimotor deficits of RUE
s/p tPA at 7:06am ___ (___ and some subjective
improvement in signs and symptoms. Etiology likely large vessel
to vessel embolus. His HA1c=5.6, and LDL=78.
CTA Head/Neck no acute intracranial hemorrhage or mass effect
but did reveal extensive atherosclerotic disease with calcified
and noncalcified plaques in the aortic arch, arch vessels,
common carotid arteries and the bifurcations and cervical
internal carotid arteries. MRI Head w/o showed several foci of
acute-subacute infarction in primarily the left MCA territory as
well as chronic small vessel ischemic disease. ECHO (TTE) showed
LVEF>55% and a normal left atrium with no trombus/mass. Carotid
dopplers showed less than 40% stenosis of the bilateral internal
carotid arteries. The patient was started on aspirin 81 and
atorvastatin 80. He was also evaluated by occupational therapy
who recommended outpatient OT. He was provided a prescription
for these services. He was discharged in stable condition with
close neurology follow up.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 78) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol-Codeine #3
Attending: ___.
Chief Complaint:
L wrist fracture
Major Surgical or Invasive Procedure:
external fixation and splinting of L wrist fracture
History of Present Illness:
This is a ___ year-old Female with PMH significant for
hypertension, atrial fibrillation (not on anticoagulation),
adjustment disorder, anxiety, prior left breast cancer (invasive
lobular adenocarcinoma, s/p XRT and tamoxifen), osteopenia,
presenting to the ED with a L wrist fracture (comminuted
displaced left distal radius fx with ulnar styloid fx). The
patient fractured her wrist on ___, when she was walking
into a casino and lost her footing on an uneven entryway. Denies
fever, chills, weight loss, nausea, vomiting, diarrhea, dysuria.
On ___ she went to a Dr ___, who wrapped her
hand and only let her leave when she promised to see her Dr ___
___ soon. On ___ she saw her PCP in ___, who "did not
like the color of the hand" and sent her to the ___ ED. Per
the patient the hand has felt numb and been dusky in color ever
since the fall. She is no able to move her ___ finger, she can
wiggle her other fingers.
In the ED, initial VS 98.8 70 154/49 18 96% RA. Seen by
hand-palstic surgery in the ED. They attempted closed reduction
in the ED. She was requiring escalating doses of pain
medications and required admission to medicine. She received
Morphine 5 mg IV x 3, then Oxycodone 5 mg PO x 1. Following this
she became somnolent and had oxygen desaturations to 78% on RA
and recieved Naloxone 0.4 mg IV x 2 with improvement. She then
recieved Ibuprofen 800 mg PO x 1, Oxycodone 5 mg PO x 1, Toradol
30 mg IV x 1 and Dilaudid 1 mg IV x 1. She was then transferred
to the medicine floor.
Past Medical History:
1. adjustment disorder
2. atrial fibrillation (cardiologist - Dr. ___,
___
3. anxiety and depression
4. vitamin B12 deficiency
5. breast cancer (T1N0M0 invasive lobular adenocarcinoma
s/p RTX/implant/tamoxifen for ___ years)
6. colonic polyps (___)
7. constipation
8. hypertension
9. osteopenia
10. seasonal affective disorder
11. gastric bypass ___
Social History:
___
Family History:
Mother deceased from recurrent non-Hodgkin's lymphoma. Multiple
family members with ovarian and breast ca at early ages (mother
with ovarian ca in her ___, 2 aunts with breast ca)
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.0 123/47 85 16 93%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: L arm braced and wrapped. L fingers dusky in color with cap
refill ~ 3 seconds. Sensation decrased in L hand, feels "numb".
Not able to wiggle ___ finger.
Pertinent Results:
___ 01:20PM BLOOD WBC-5.7 RBC-3.69* Hgb-11.9* Hct-38.0
MCV-103* MCH-32.1* MCHC-31.2 RDW-13.6 Plt ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD ___ PTT-34.5 ___
EKG without ischemic changes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
hold for sedation, RR < 12
2. Cyanocobalamin Dose is Unknown PO DAILY
3. Lisinopril 20 mg PO HS
hold for SBP < 100
4. Meclizine 12.5 mg PO TID:PRN dizziness
hold for sedation, RR < 12
5. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP < 100, HR < 60
6. Mirtazapine 15 mg PO HS
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
8. Paroxetine 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stool
11. Senna 1 TAB PO BID:PRN constipation
12. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO BID
4. Lisinopril 20 mg PO HS
5. Meclizine 12.5 mg PO TID:PRN dizziness
6. Metoprolol Tartrate 12.5 mg PO BID
7. Mirtazapine 15 mg PO HS
8. Paroxetine 40 mg PO DAILY
9. Senna 1 TAB PO BID
10. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours
(three times a day) Disp #*30 Tablet Refills:*0
11. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
12. Naproxen 250 mg PO Q12H
RX *naproxen 250 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*30 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 dose by
mouth daily Disp #*20 Packet Refills:*0
15. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
16. ALPRAZolam 0.5 mg PO BID:PRN anxiety
17. Cyanocobalamin 0 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. comminuted displaced left distal radius fx with ulnar styloid
fx
2. altered mental status from narcosis
Secondary Diagnosis
1. osteopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left wrist fracture with severe pain.
TECHNIQUE: Left wrist, 3 views.
COMPARISON: Reference wrist radiographs ___.
FINDINGS:
Overlying cast limits fine osseous detail. Comminuted fracture of the distal
radius is re- demonstrated with intra-articular extension, mild impaction, and
volar displacement of the dominant distal fracture fragments by approximately
1 shaft width. Displaced ulnar styloid fracture is also again seen and
similar in appearance. There is diffuse soft tissue swelling. The osseous
structures are diffusely demineralized.
IMPRESSION:
Comminuted distal radial fracture with intra-articular extension,
displacement, and slight impaction. Displaced ulnar styloid fracture,
unchanged.
Radiology Report
HISTORY: Distal radial fracture status post reduction.
TECHNIQUE: 3 views of the left wrist.
COMPARISON: ___ at 17:18.
FINDINGS:
Evaluation of the osseous structures is limited due to overlying splint.
Again seen is a comminuted, mildly impacted distal radial fracture with
intra-articular extension. The alignment of the fracture fragments appears
slightly improved with less volar displacement of the dominant distal fracture
fragment. Ulnar styloid fracture remains mildly displaced and unchanged. No
other fractures or dislocation is identified.
IMPRESSION:
Slight interval improvement in alignment of the comminuted distal radial
fracture. Persistent mildly displaced ulnar styloid fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT WRIST INJURY
Diagnosed with JOINT EFFUSION-L/LEG, POPLITEAL SYNOVIAL CYST
temperature: 98.8
heartrate: 70.0
resprate: 18.0
o2sat: 96.0
sbp: 154.0
dbp: 49.0
level of pain: 12
level of acuity: 3.0 | ___ with PMH significant for hypertension, atrial fibrillation
(not on anticoagulation), adjustment disorder, anxiety, prior
left breast cancer (invasive lobular adenocarcinoma, s/p XRT and
tamoxifen), osteopenia presenting to the ED with a comminuted
displaced left distal radius fx with ulnar styloid fx that
underwent closed reduction in the ED, admitted to medicine with
escalating pain requirements.
# COMMUNITED DISPLACED LEFT DISTAL RADIUS, ULNAR STYLOID
FRACTURE - Status post closed reduction by Hand surgery. Now in
a splint, the patinet continues to have severe pain. Is S/p a
large amount of pain medication in the ED for which she required
narcan. She was discharged on tylenol, naproxen, and oxycodone,
with some continued pain (she was counseled that she would
continue to have some pain until she had surgery). She will
follow up in hand clinic for surgery later this week. Pre-op
labs and EKG done.
# HYPERTENSION - BP well controlled in the 100-110 systolic
range. continued home ACEI and ___
# ATRIAL FIBRILLATION - CHADS-1. Currently in NSR on EKG with
adequate rate control on ___ and ___. cont beta blocker
and ___ 81
# OSTEOPENIA - started calcium and vitamin D supplementation.
# ANXIETY AND ADJUSTMENT DISORDERS - Stable mood. Continue
mirtazapine, paroxetine. Held alprazolam given concern for
sedation
# dizziness: cont meclizine
# CODE: FULL
# CONTACT: ___ (son) - ___
TRANSITIONAL ISSUES
- follow up outpatient with Hand Clinic for outpatient surgical
fixation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
EGD
Blood transfusion
History of Present Illness:
Mr. ___ is a ___ y/o gentleman without any significant
medical history who presented to the ED from his PCP's office
for a Hgb of 6.
He was in his normal state of health until five months ago when
he started to feel as if his 'stomach was bubbling'. He
attributed the sensation to excessive caffeine use, as he was
drinking several soft and energy drinks every day. As a result,
he stopped drinking caffeine and experienced severe caffeine
withdrawal headaches. To self-treat his withdrawal headaches he
was taking approximately 9 regular aspirin a day for about a
week, and then continued to take numerous aspirin after that
weeks.
In the setting of his excessive aspirin intake, he began to
notice dark tarry stools and increasing fatigue. He appoximates
that he's had about one melanic stool per day, although in the
past few days it has been more frequent. No other symptoms of
diarrhea or bright red blood in his stool. He had a couple
episodes of nonbilious, nonbloody vomiting approximately two
weeks ago.
As the month progressed, he noted increasing fatigue, especially
as his job as the ___ ___ requires a great deal of
energy. He notes increasing muscle weakness, a heart that 'was
working hard' and the sensation of 'seeing bright lights' with
exertion. A few weeks ago, he had a episode of left arm and
chest pain that resolved over the day, was not associated with
exertion, and changed with movement, which the patient
attributed to an uncomfortable sleeping position. He also noted
that his skin appeared more pale.
He initially attributed his symptoms to dehydration and thus,
drank a great deal of gatorade and water to compensate. When
this did not relieve his symptoms, he visited his PCP. Labs
done by his primary care physician ___ ___ were notable for
severe ___ deficiency anemia with Hg 6.0, Hct 19.9, MCV 68.3,
Plt 446, Serum Fe 27, TIBC 479, Tfn ___ 5.6 and Transferrin 342.
Due to his severe anemia and suggestive symptoms, his PCP
suggested he present to the ___ ED. At the advice of his PCP,
he presented to the ___ ED.
He does not report any fevers, chills, dyspnea, pain, chemical
exposures, travel history or trauma.
In the ED, initial vitals: 98.8 98 131/58 16 100% RA. He had
guiaic positive stools and GI was consulted. They suggested an
EGD tomorrow morning, and starting a PPI tonight.
Vitals prior to transfer: 98.1 79 93/61 18 100%RA
Currently, he feels slightly fatigued, but has no other
symptoms, including no pain, no dizziness, no lightheadedness
and no palpitations. He is comfortable laying in bed.
ROS:
No fevers, chills, night sweats. Has gained 3 lbs over the last
month.
No changes in hearing, no changes in balance.
No cough, no shortness of breath.
No chest pain.
No dysuria or hematuria.
No numbness or weakness, no focal deficits.
Past Medical History:
Oral surgery when a teenager.
Social History:
___
Family History:
Maternal grandmother- multiple brain aneurysms
Maternal grandfather- ___ disease
Paternal grandmother- throat cancer
___ grandfather- throat and stomach cancer
Mother- ___ deficiency anemia
Father- hyperlipidemia
Brother- ___ years old in good health
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.3 106/58 78 20 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric/pale, MMM, oropharynx clear
Neck- Supple, JVP at 8cm, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound
tenderness or guarding, no organomegaly, liver felt 1cm below
the rib cage.
GU- no foley
Ext- Warm, well perfused, 2+ radial and DP pulses, no clubbing,
cyanosis or edema, 2x 18G IVs, one in each arm.
Neuro- CNs2-12 intact, motor function grossly normal
Skin- Extremely pale.
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 99/51(80-100/40-60s) 77(50-80s) 20 100%RA
Exam:
General- Alert, oriented, no acute distress
HEENT- No conjunctiva pallor, MMM, oropharynx clear
Neck- Supple
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound
tenderness or guarding, no organomegaly.
GU- no foley
Ext- Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema, 2x 18G IVs, one in each arm.
Neuro- CNs2-12 intact, motor function grossly normal
Skin- pale.
Pertinent Results:
ADMISSION LABS:
___ 02:05PM BLOOD WBC-4.0 RBC-2.65* Hgb-5.1* Hct-20.1*
MCV-76* MCH-19.4* MCHC-25.5* RDW-18.5* Plt ___
___ 02:05PM BLOOD Neuts-68.6 ___ Monos-6.4 Eos-0.9
Baso-0.4
___ 02:05PM BLOOD Plt ___
___ 02:05PM BLOOD ___ PTT-30.0 ___
___ 02:05PM BLOOD Ret Man-5.2*
___ 12:25PM BLOOD Glucose-88 UreaN-16 Creat-1.1 Na-138
K-3.7 Cl-106 HCO3-24 AnGap-12
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-6.5 RBC-3.67* Hgb-8.7* Hct-28.7*
MCV-78* MCH-23.8* MCHC-30.4* RDW-19.2* Plt ___
RELEVANT INTERIM LABS:
H.pylori negative
EGD ___
Irregular z-line (biopsy)
Mild gastritis and erosion of the antrum. This does not
necessarily explain the patients severe anemia. (biopsy)
Normal mucosa in the whole duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
IMAGING:
CT A/P ___
IMPRESSION:
1. No imaging features to suggest small bowel lymphoma.
2. Multiple abnormal appearing segments of small bowel are
identified, some with apparent wall thickening and other with
fecalization as described above which may be related to
processes such as Crohn disease. Assessment is limited given the
static nature of CT enterography, and as the majority of enteric
contrast was in the colon. MR-Enterography is recommended for
further evaluation.
PATHOLOGY
-Upper GI biopsy pending at time of discharge
Medications on Admission:
None. Some aspirin use, as detailed in the HPI.
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg ___ 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ deficiency anemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Gastrointestinal bleeding. Rule out lymphoma.
COMPARISON: No prior studies available for comparison.
TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous and oral
contrast was performed (CT enterography). Multiplanar reformats were prepared
and reviewed.
DLP: 358 mGy-cm
FINDINGS:
ABDOMEN:
The liver is homogeneous in texture with no focal lesion. There is no intra-
or extra-hepatic biliary tree dilatation. The spleen, pancreas and adrenal
glands are normal. The gallbladder is unremarkable without any gallstones.
The aorta is of normal caliber. There are multiple small intra-mesenteric
lymph nodes which are not size significant. The stomach, duodenum and colon
are unremarkable. However, there is fecalization of a small bowel loop in the
right hemi-abdomen (5;36 and 6b; 17) which is slightly distended up to 3.2 cm.
Two additional segments of small bowel appear slightly circumferentially
thickened and enhancing in the mid abdomen (6b;13) measuring 7 cm and left
hemi-abdomen (6b;21) measuring 6 cm. The terminal ileum is difficult to
identify but appears unremarkable. No free fluid or fluid collection. The lung
bases are clear.
BONE WINDOWS: No focal lytic or sclerotic osseous lesions suspicious for
infection or malignancy is seen.
IMPRESSION:
1. No imaging features to suggest small bowel lymphoma.
2. Multiple abnormal appearing segments of small bowel are identified, some
with apparent wall thickening and other with fecalization as described above
which may be related to processes such as Crohn disease. Assessment is limited
given the static nature of CT enterography, and as the majority of enteric
contrast was in the colon. MR-Enterography is recommended for further
evaluation.
The findings were discussed with the treating team at 6:15 p.m. on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Anemia
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 100.0
sbp: 131.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ y/o gentleman with approximately one
month of melenic stools, excessive aspirin use and labs
suggestive of ___ deficiency anemia suggestive for upper
gastrointestinal bleeding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Traumatic brain injury
Major Surgical or Invasive Procedure:
___ - Right Neurovent placement
___ - Right decompressive hemicraniectomy, subdural
hematoma evacuation, removal of right Neurovent
___ - Trach and PEG
___ - Cranioplasty
___: Trach decannulated
History of Present Illness:
___ is a ___ year old male who presented to the
Emergency Department on ___ as a transfer from an outside
facility status post fall off the back of a moving pick-up truck
with a severe traumatic brain injury. The patient was
transferred to ___ for
escalation of care. The Neurosurgery Service was consulted for
evaluation and management recommendations.
Past Medical History:
- hyperlipidemia
- hypertension
- status post appendectomy as a child
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On Admission:
-------------
___
Physical Examination:
GCS at the Scene: 3
GCS on Neurosurgical Evaluation: 7T
Time of Neurosurgical Evaluation: ___ 11:15
Airway:
[x]Intubated
[ ]Not intubated
Eye Opening:
[x]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
Exam:
General: Well nourished adult male. Intubated. Sedation held for
5 minutes prior to examination.
HEENT: Normocephalic. Large, approximately 3cm, laceration to
left parietal scalp, poorly approximated.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Intubated. Sedation held prior to examination. No
eye opening. Does not follow commands.
Orientation: Unable to assess, patient intubated, unresponsive.
Language: Unable to assess, patient intubated, unresponsive.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 2.5-2mm,
bilaterally. Unable to test visual fields, patient intubated,
unresponsive.
III, IV, VI: Unable to test, patient intubated, unresponsive.
V, VII: Unable to test, patient intubated, unresponsive.
VIII: Unable to test, patient intubated, unresponsive.
IX, X: Unable to test, patient intubated, unresponsive.
XI: Unable to test, patient intubated, unresponsive.
XII: Unable to test, patient intubated, unresponsive.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Left upper extremity localizes to noxious, but
otherwise no movement in other extremities. Unable to test
drift, patient intubated, unresponsive.
Sensation: Unable to test, patient intubated, unresponsive.
On Discharge:
-------------
General:
Vital Signs:
___ 0551 Temp: 98.4 PO BP: 139/95 L Lying HR: 84 RR: 20 O2
sat: 93% O2 delivery: RA
Bowel Regimen: [x]Yes [ ]No BM: ___
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None
Follows Commands: [X]Simple [ ]Complex []None
Pupils: PERRL, 4-3mm, bilaterally
EOMs: [x]Crosses midline, tracks examiner
Face Symmetric: [x]No - right NL flattening at rest
Tongue Midline: [ ]Yes [ ]No [x]Unable to assess - Difficulty
with complex commands
Speech Fluent: [ ]Yes [x]No - Nonverbal
Comprehension Intact: [ ]Yes [x]No
Motor: MAEx4 spontaneously at least antigravity. Purposeful &
spontaneous.
Surgical Incisions:
[x]Clean, dry, intact
[x]Well healing
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Medications on Admission:
- amlodipine 10mg PO once daily
- hydrochlorothiazide unknown dose PO once daily
- metoprolol tartrate unknown dose PO BID
- pravastatin 10mg PO once daily
Discharge Medications:
***
1. Acetaminophen 1000 mg PO Q8H
2. BusPIRone 15 mg PO TID
3. Labetalol 200 mg PO Q8H
4. LACOSamide 200 mg PO BID
5. LamoTRIgine 150 mg PO BID
6. LevETIRAcetam Oral Solution 1000 mg PO BID Duration: 7 Days
7. LevETIRAcetam Oral Solution 500 mg PO BID
8. QUEtiapine Fumarate 12.5 mg PO DAILY
9. QUEtiapine Fumarate 25 mg PO QHS
10. Ramelteon 8 mg PO QHS
11. TraZODone 37.5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___ -
Discharge Diagnosis:
Traumatic brain injury
Epidural hematom
Subdural hematoma
Traumatic subarachnoid hemorrhage
Intraparenchymal hemorrhage
Brain compression/Mass effect
Nondisplaced fractures of left zygomatic, left sphenoid, left
temporal bones
Multiple rib fractures
Seizures
Pneumonia
Dysphagia
Hypertension
Tachycardia
Oral thrush
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 major trauma//ptx, rib fx
TECHNIQUE: Supine AP view of the chest
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Lung volumes are low. Endotracheal tube tip terminates approximately 3.8 cm
from the carina. Cardiac silhouette size is moderately enlarged, accentuated
by low lung volumes. There is pulmonary vascular congestion without frank
pulmonary edema. Patchy ill-defined opacities are seen within the upper lobes
bilaterally and to a lesser extent within the lower lobes, potentially areas
of atelectasis, with contusion not excluded. No large pleural effusion or
pneumothorax is seen on this supine exam. Fractures of the left third,
fourth, and fifth ribs are demonstrated. There is massive gastric distension.
IMPRESSION:
1. Endotracheal tube in standard position.
2. Low lung volumes with patchy ill-defined opacities in both upper lobes as
well as to a lesser extent in both lower lobes which could reflect atelectasis
and/or contusion.
3. Multiple left-sided rib fractures without large pneumothorax or pleural
effusion.
4. Marked gastric distension for which enteric tube placement is recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with trauma, fall from moving truck, +head strike
and injury, 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 18.0 s, 18.8 cm; CTDIvol = 48.1 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: No prior studies available for comparison.
FINDINGS:
Multiple acute intracranial hemorrhages are demonstrated including:
1. A 9 mm subdural hematoma along the right cerebral convexity and adjacent
subarachnoid hemorrhage seen within the sylvian fissure and right temporal
lobe sulci with mass effect resulting in effacement of the right lateral
ventricle and 5 mm of leftward midline shift. No subfalcine herniation.
2. A 2.7 x 1.7 x 5.2 cm left parietotemporal intraparenchymal hematoma with
adjacent diffuse subarachnoid hemorrhage extending the sylvian fissure and
inferiorly into the anterior temporal lobe. An overlying temporal bone
fracture noted as described below and thus an epidural component to this
hemorrhage cannot be excluded.
3. A 2.2 x 1.0 cm lentiform hematoma along the greater wing of the left
sphenoid (series 2, image 11), likely an epidural hematoma.
The basal cisterns are patent. No evidence of hydrocephalus or acute large
territorial infarction.
There are three nondisplaced hairline calvarial fractures involving the left
zygomatic bone (series 3, image 10), the greater wing of the left sphenoid
bone (series 3, image 20), and the squamous portion of the left temporal bone
(series 601, image 67) overlying the above-described intraparenchymal
hemorrhage.
Partial opacification of the bilateral maxillary sinuses and ethmoid air
cells, and complete opacification of the sphenoid sinus and nasopharynx may
represent sequelae of intubation. The mastoid air cells, and middle ear
cavities are clear. A small locule of air is noted in the extraconal left
orbit adjacent to the lateral rectus muscle, likely sequela of adjacent
sphenoid bone fracture. Otherwise, the visualized portion the orbits are
unremarkable.
IMPRESSION:
1. Extensive traumatic right-sided subdural, bilateral subarachnoid, left
parietotemporal intraparenchymal, and left-sided epidural hematomas as
described above.
2. Right-sided mass effect with effacement of the right lateral ventricle and
5 mm of right to left midline shift. No hydrocephalus, or subfalcine or uncal
herniation.
3. Nondisplaced fractures of the left zygomatic, greater wing of the left
sphenoid, and squamous portion of the left temporal bones as described above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with trauma, fall from moving truck, +head strike***
WARNING *** Multiple patients with same last name!// trauma 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 6.5 s, 25.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 585.7
mGy-cm.
Total DLP (Body) = 586 mGy-cm.
COMPARISON: No prior studies available for comparison.
FINDINGS:
Alignment is normal. No fractures are identified.Mild degenerative changes of
the cervical spine are most pronounced at C4-5 and C5-6 with intervertebral
disc space narrowing and posterior osteophyte formation resulting in mild
central canal narrowing. No evidence of high-grade spinal canal or neural
foraminal stenosis. There is no prevertebral soft tissue swelling, but
assessment is somewhat limited to the presence of enteric and endotracheal
tubes seen in the esophagus and trachea, respectively.There is no evidence of
infection or neoplasm.
Visualized aspect of the thyroid gland is unremarkable. Visualized lung
apices demonstrate atelectatic changes.
IMPRESSION:
1. No fracture or traumatic malalignment.
2. Mild degenerative change of the cervical spine.
Radiology Report
EXAMINATION: CT chest abdomen and pelvis
INDICATION: History: ___ with trauma, fall from moving truck, +head strike,
history of CP are//trauma
TECHNIQUE: MDCT axial images were acquired through the chest, 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 8.8 s, 69.6 cm; CTDIvol = 23.8 mGy (Body) DLP =
1,656.2 mGy-cm.
Total DLP (Body) = 1,656 mGy-cm.
COMPARISON: No similar prior studies available for comparison.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. Main pulmonary artery is dilated to 3.6 cm. No
central pulmonary embolism. The heart appears mildly enlarged. Pericardium
and great vessels are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: Trace left-sided hemothorax. No pneumothorax.
LUNGS/AIRWAYS: Mild to moderate atelectasis is seen in the upper and lower
lobes dependently. The airways are patent to the level of the segmental
bronchi bilaterally. Endotracheal tube terminates approximately 2.5 cm above
the carina.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 0.6
cm hypodense lesion within the hepatic dome is too small to characterize
(series 2, image 61). There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder contains gallstones without wall
thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal 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.
No evidence of hydronephrosis. Bilateral subcentimeter hypodense lesions are
too small to characterize, but likely represent renal cysts. There is no
perinephric abnormality.
GASTROINTESTINAL: Enteric tube terminates in the pylorus. Otherwise, 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 no evidence of mesenteric
injury.
There is no free fluid or free air in the abdomen.
PELVIS:
Foley catheter is visualized within the urinary bladder. 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: Acute bilateral rib fractures including the anterolateral second
through seventh ribs on the left, the anterolateral first through eighth ribs
on the right, and the posterior fourth through seventh ribs on the left. No
focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute bilateral rib fractures including the anterior left second through
seventh ribs, the posterior left fourth through seventh ribs, and the anterior
right first through eighth ribs. No pneumothorax.
2. Bilateral dependent atelectasis in the upper and lower lobes with trace
left-sided hemothorax.
3. No solid organ injury within the abdomen or pelvis.
Radiology Report
EXAMINATION: DX ELBOW AND FOREARM
INDICATION: ___ year old man with trauma// Fx
TECHNIQUE: Four portable views of the left elbow were obtained
COMPARISON: None
FINDINGS:
There is no acute fracture or dislocation identified. Fragmented
enthesophytes are noted along the olecranon at the attachment of the triceps
tendon. There is no evidence of a joint effusion however the lateral view
suboptimal. A peripheral intravenous catheter seen over the antecubital
fossa.
IMPRESSION:
No acute osseous injury of the left elbow.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with multiple rib Fx// interval changes
IMPRESSION:
In comparison with the study ___, the tip of the the subclavian base
central line of is about at the level of the cavoatrial junction.
Endotracheal tube has been somewhat withdrawn with the tip at the clavicular
level, approximately 6.5 cm above the carina.
Continued low lung volumes accentuates the enlargement of the cardiac
silhouette. Retrocardiac opacification has decreased and there is no evidence
of vascular congestion or acute focal pneumonia.
The left rib fractures are much better seen on the recent CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with head trauma. Evaluate for interval change.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain
window.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head ___ 12:28
FINDINGS:
There has been interval placement of a right frontal presumed ventriculostomy
drainage catheter which terminates in the deep white matter of the right
frontal lobe, outside of the ventricular system.
There is an acute subdural hematoma abutting the right cerebral convexity
measuring up to 1.0 cm across maximal width(2:20), mildly increased in size as
compared to most recent CT previously measuring up to 0.8 cm at the same
level. Subdural blood is also seen extending along the tentorium and falx.
There is a lenticular hyperdense collection abutting the right temporal lobe
measuring up to 1.3 cm across maximal width (2:12), which is new or increased
in size and could represent an epidural hematoma. Re-demonstrated is a
lenticular hyperdense extra-axial collection abutting the left temporal lobe
measuring up to 2.2 cm across maximal with (2:15), unchanged. There is
intraparenchymal hemorrhage in the left parietooccipital region measuring 3.9
x 2.7 cm (2:22), grossly unchanged. Diffuse subarachnoid hemorrhage, most
prominent along the bilateral sylvian fissures and tentorial leaflets, is
grossly unchanged.
There is mass effect with right to left midline shift of 5 mm (2:21), grossly
unchanged. Basal cisterns are patent. Nondisplaced left calvarial fractures
are better assessed on comparison CT. There is no evidence of a new or
worsening fracture.
There is partial opacification of the maxillary and bilateral ethmoid air
cells. Sphenoid sinuses are completely opacified.
IMPRESSION:
1. Right-sided acute subdural hematoma is mildly increased in size from most
recent head CT, now measuring 1.0 cm across maximal with, previously measuring
up to 0.8 cm, and extending to the tentorium and falx.
2. There is a lenticular shaped hyperdense extra-axial collection abutting the
right temporal lobe measuring up to 1.3 cm, which is new or increased in size
from most recent head CT and given the shape likely represents an epidural
hematoma.
3. There has been interval placement of a right-sided intraparenchymal
drainage catheter which terminates in the deep white matter of the right
frontal lobe. The presence of placement of a intraparenchymal drainage
catheter was confirmed by conversation with Dr. ___.
4. Diffuse subarachnoid hemorrhage, left parieto-occipital intraparenchymal
hemorrhage, and left temporal epidural hemorrhage with mass effect and right
to leftward midline shift of 5 mm are all unchanged.
5. Nondisplaced calvarial fractures are better assessed on recent head CT with
bone algorithm. There is no evidence of a new or worsening fracture.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr ___,
___ on the telephone on ___ at 5:45 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with trauma// line placemen t Contact name:
___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest from earlier today
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic trachea and a
feeding tube extends to the stomach. The tip of a left subclavian central
line projects over the upper right atrium, approximately 1 cm beyond the
cavoatrial junction.
There are low bilateral lung volumes. Opacities throughout the left
hemithorax likely reflect atelectasis. No pleural effusion or pneumothorax.
The size of the cardiac silhouette is mildly enlarged but is likely magnified
secondary to low lung volumes and AP technique. Multiple bilateral rib
fractures are again seen but were better evaluated on the CT chest from
earlier today.
IMPRESSION:
The tip of a left subclavian central line projects over the upper right
atrium, approximately 1 cm beyond the cavoatrial junction.
Opacities within the left hemithorax likely reflect atelectasis, better
evaluated on the CT chest from earlier today.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with TBI now s/p right craniectomy// interval
changes
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 =
934.5 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head with the same date.
FINDINGS:
Interval removal of the right frontal ICP monitor. The patient is status post
right hemi craniectomy and evacuation of an acute right subdural hematoma.
Surgical drain is seen within the right extra-axial space. There are multiple
small foci of pneumocephalus overlying the right frontal and temporal lobes,
expected.
The large left parietal intraparenchymal hemorrhage with surrounding edema is
unchanged measuring 3.9 x 2.7 cm in maximum axial ___ (series 2, image
23). The extent of subarachnoid hemorrhage throughout the left hemisphere is
unchanged. There is also an unchanged acute epidural hematoma along the left
temporal lobe measuring 10 mm. Small amount of remaining subarachnoid
hemorrhage overlying the right temporal lobe. Additional extra-axial
hemorrhage overlying the right temporal lobe has also decreased in size,
either subdural or epidural in location (series 2, image 13). Small subdural
along the tentorium and falx is unchanged.
There is no evidence of acute territorial infarction. No evidence of
significant mass, mass effect, or midline shift. The ventricles and sulci are
normal in size and configuration. Basal cisterns are patent.
There is a large subgaleal hematoma overlying the left parietal lobe. Known
calvarial fractures are better demonstrated on the prior head CT. Complete
opacification of the bilateral sphenoid sinuses. Air-fluid levels within the
posterior ethmoids and maxillary sinuses bilaterally. The visualized portion
of the mastoid air cells and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. Endotracheal and orogastric tubes are
partially imaged. Fluid filling the nasopharynx and oropharynx is likely due
to intubation.
IMPRESSION:
1. Interval right hemicraniectomy and evacuation of an acute right subdural
hematoma. Small residual right temporal extra-axial collection, either
epidural or subdural.
2. Unchanged large left parietal intraparenchymal, left temporal epidural, and
bilateral subarachnoid hemorrhage. Unchanged small subdural hemorrhage along
the tentorium and falx.
3. No evidence of new hemorrhage. Resolution of prior midline shift. The
basilar cisterns are patent.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT// eval PNA
TECHNIQUE: 2 frontal views of the chest
COMPARISON: None.
FINDINGS:
The ET tube is position below the thoracic inlet, approximately 6.1 cm above
the carina, within normal limits for position. The left-sided subclavian
central line is at the cavoatrial junction. Prominent cardiomegaly again
noted. Retrocardiac opacification is stable. Possible slight interval
increased hazy opacity left upper lobe.
No pneumothorax or effusion. The left rib fractures are better seen on prior
chest CT.
IMPRESSION:
Retrocardiac opacity, which may reflect pneumonia, stable. Mild increased
left upper lobe hazy opacity could reflect developing pneumonia in this
region.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ s/p fall from moving truck, w/ L IPH/SAH, L EDH, R SDH,
bilateral multiple rib fx// Left temporal bone fracture 1. involvement of otic
capsule2. course of facial nerve3. skull base4. involvement of carotid canal
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 12.3 cm; CTDIvol = 123.5 mGy (Head) DLP =
1,521.8 mGy-cm.
Total DLP (Head) = 1,522 mGy-cm.
COMPARISON: CTs head ___ and ___
FINDINGS:
Surgical changes from right hemi craniectomy are noted with a displaced bony
fragment(301:75) noted and overlying edema, hemorrhage, and foci of air.
There is overlying swelling, high-density fluid likely representing blood
products, and foci of air in the overlying soft tissues of the scalp.
There is no evidence of a right temporal bone fracture. There is no left
temporal bone fracture included in the field of view of this study. The
previously noted non-displaced fracture involving the squamous portion of the
left temporal bone, characterized on CT head ___, is not included
in the field of view of this study.
Re-demonstrated is diffuse subarachnoid hemorrhage, intraventricular
hemorrhage noted in the occipital horn of the left lateral ventricle, acute
temporal subdural hematoma, acute left temporal epidural hematoma, and
hemorrhage in both sphenoid and posterior ethmoid air cells are unchanged from
CT head ___. Basal cisterns are patent.
The ossicles are unremarkable. Minimal opacity in each right middle ear
canal, right greater than left, is doubtful in significance. Inner ear
structures are unremarkable.
Orogastric and endotracheal tube are partially visualized in the oropharynx.
IMPRESSION:
1. No evidence of a temporal bone fracture on the study. Please note that the
nondisplaced fracture involving the squamous portion of the left temporal
bone, characterized on CT head ___, is not included in the field
of view of this study (too cranial).
2. Partially visualized diffuse subarachnoid hemorrhage, intraventricular
hemorrhage, right temporal subdural hemorrhage, and left temporal epidural
hemorrhage are unchanged from CT head ___.
3. Postsurgical changes from right hemi-craniectomy with overlying swelling,
high-density fluid, likely representing blood products, and foci of air in the
scalp, all unchanged from ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with s/p fall from truck with subdural,
subarachnoid intraparenchymal hemorrhages. Evaluate for changes in
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: CT maxillofacial ___. Head CT ___.
FINDINGS:
The patient is status post right hemicraniectomy. A surgical drain is again
seen within the craniectomy site. There has been interval expansion of the
right cerebral hemisphere into the craniectomy site. While pneumocephalus
overlying the right frontal and temporal lobes has resolved, soft tissue
thickening near the craniectomy site has increased. A subgaleal hematoma
overlying left parietal lobe is again seen.
There has been expected evolution of the left parietal intraparenchymal
hemorrhage with surrounding edema, with interval mild decrease in size of the
hyperdense component. Subarachnoid blood within the left cerebral hemisphere
is not significantly changed. Epidural hematoma along the left temporal lobe
(03:12) measures 9 mm in greatest axial ___, previously 10 mm.
Extra-axial hemorrhage along the right temporal lobe measures 7 mm, decreased
in size from prior. Subarachnoid blood along the right temporal lobe has not
significantly changed. Subdural blood tracking along the falx and tentorium
is again seen. No definite areas of new hemorrhage identified.
There is mild effacement of the left lateral ventricle, with approximately 4
mm of rightward shift of normally midline structures. Question interval
increase in size of right lateral ventricle compared to ___ prior
exam. The basilar cisterns are grossly patent. Approximately 3 mm new
parafalcine hygroma is noted (see 03:32 on current study and 02:30 on ___ prior exam).
Partial opacification of the ethmoid air cells, with an air-fluid level in the
maxillary sinuses. Complete opacification of the bilateral sphenoid sinuses
is unchanged. Otherwise, the visualized portion of the mastoid air cells and
middle ear cavities are clear. The visualized portion of the orbits are
preserved.
IMPRESSION:
1. No evidence of new hemorrhage.
2. Interval expansion of the right cerebral hemisphere into craniectomy site,
with approximately 4 mm rightward shift of normally midline structures.
3. Question interval increase in size of right lateral ventricle compared to ___ prior exam. Recommend attention on follow-up imaging.
4. Approximately 3 mm new interhemispheric hygroma.
5. Grossly stable right temporal extra-axial hemorrhage, along with left
parietal intraparenchymal, left temporal epidural, and bilateral subarachnoid
hemorrhage.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:35 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with TBI with bleeds now intubated and having
thick secretions from his lungs// infiltrate in lungs?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided PICC line, ET and NG tube are unchanged. Cardiomediastinal
silhouette is stable. There is subsegmental atelectasis in the left lung
base. No pneumothorax is seen there is no pleural effusion
Radiology Report
EXAMINATION: CT of the temporal bones.
INDICATION: ___ year old man with multiple trauma. now s/p right craniectomy
with possible CSF leak// temporal bone CT with fine cuts to better delineate
the course of the fracture- On temporal bone CT, please evaluate specifically
involvementof: (1) otic capsule (2) facial nerve (3) skull base/tegmen (4)
carotid canal
TECHNIQUE: Multidetector CT images of the left of the temporal bones were
obtained without intravenous contrast. Sagittal and coronal reformations were
also performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.9 s, 18.3 cm; CTDIvol = 123.5 mGy (Head) DLP =
2,263.0 mGy-cm.
Total DLP (Head) = 2,263 mGy-cm.
COMPARISON: Recent prior studies from ___ and ___.
FINDINGS:
Multiple intracranial hemorrhages show no short-term change.
There is re-demonstration of subarachnoid hemorrhage overlying bilateral
hemispheres, not significantly changed in extent. An acute extra-axial
hematoma along the left temporal lobe measures 9 mm similar to prior. An acute
extra-axial hematoma along the right temporal lobe measures 7 mm, similar to
prior. There is a stable large intraparenchymal hemorrhage in the left
parietal lobe with evidence of a fluid-fluid level concerning for increased
risk of expansion. There is surrounding edema exerting mass effect on the left
lateral ventricle. There is 4 mm of rightward midline shift. The basal
cisterns are patent. Hemorrhage is seen within the occipital horn of the right
lateral ventricle.
There has been right hemicraniectomy and evacuation of a right subdural
hematoma. There has been interval removal of a surgical drain. There is
persistent hyperdense extra-axial hemorrhage seen layering along the falx and
tentorium and along the anterior right frontal lobe.
There is unchanged complete opacification of the sphenoid sinuses. There is
partial opacification of several ethmoid air cells with air-fluid level seen
in the maxillary sinuses.
Left zygomatic and left sphenoid fractures are again seen.
Similar to prior findings, there is hairline nondisplaced fracture which
begins superiorly along the left parietal bone, not fully imaged, and which
courses anteriorly and inferior ___ into the squamous part of the left
temporal bone. However, there is no evidence for involvement of the petrous
bone. There is trace opacity in the left middle ear cavity, similar to recent
prior findings, but no fluid. There are small quantities of new fluid within
the left mastoid air cells, however. However, there is no evidence for
fracture involving the petrous part of the temporal bone, and middle and inner
ear structures appear intact. On the right, there is similar to perhaps
mildly increased opacity within the right middle ear cavity as well as some
new fluid within the mastoid air cells. Again, however, middle and inner ear
structures appear intact without evidence for fracture involving the petrous
bone.
IMPRESSION:
1. Nondisplaced left parietal fracture extending into the left squamous
temporal bone. However, no evidence for fracture involving petrous temporal
bones on either side. No evidence for fracture small quantity of new fluid
within mastoid air cells bilaterally.
2. Unchanged findings associated with extensive intracranial hemorrhages.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with head trauma and brain bleeds// interval
changes.
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 =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Again, patient is status post right hemicraniectomy. Interval removal of
surgical drain is noted. There is increased expansion of the right cerebral
hemisphere into the craniotomy site with increased hypodense subdural fluid
collection measuring up to 6 mm in thickness. There is re-demonstration of
soft tissue thickening superficial to the craniectomy site, similar to prior.
Interval evolution of the left frontoparietal and temporal intraparenchymal
hemorrhage with surrounding edema, similar in extent compared to prior, with
increased effacement of the left occipital horn which demonstrates evolving
layering posterior intraventricular hemorrhage. There is also continued
evolution of the subarachnoid blood in the left cerebral hemisphere. Left
temporal epidural hematoma measures 6 mm in thickness, previously measuring 9
mm in thickness. Right temporal extra-axial hemorrhage measuring 8 mm in
thickness is similar to prior.
Left parafalcine subdural hematoma measures 4 mm in thickness, similar to
prior. Right parafalcine subdural hematoma measures 4 mm in greatest
thickness also similar to prior.
There is rightward midline shift measuring 5 mm, similar to prior. The size
the increased effacement of the left occipital horn, the size and
configuration of the ventricles and sulci are similar to prior. Again, the
basilar cisterns are grossly patent. Re-demonstration 3 mm right parafalcine
hygroma noted.
Small left parietal subgaleal hematoma has decreased in size compared to prior
with overlying skin staples. Partial opacification of bilateral mastoid air
cells have increased compared to prior. There is new fluid within bilateral
middle ear cavities. There is increased opacification of the ethmoid sinuses
and complete opacification of the sphenoid sinus with hyperdense material,
likely blood. Increased opacification of bilateral maxillary sinuses with
air-fluid levels are again demonstrated. Visualized bilateral orbits appear
unremarkable.
IMPRESSION:
1. Status post right hemi craniectomy with interval removal of surgical drain
with slightly increased expansion of the right cerebral hemisphere into the
craniotomy site and increased hemispheric hypodense subdural fluid collection
measuring up to 6 mm in thickness.
2. Interval evolution of left frontoparietal temporal intraparenchymal
hemorrhage, left frontal subarachnoid hemorrhage, left temporal epidural
hemorrhage, and right extra-axial hemorrhage. Re-demonstration of left and
right parafalcine subdural hematoma with right parafalcine subdural hygroma.
Right word 5 mm midline shift similar to prior. Increased effacement of the
left occipital horn.
3. Interval decrease in size of small left parietal scalp hematoma.
4. Increased opacification of the ethmoid sinuses, and bilateral maxillary
sinuses with complete opacification of the sphenoid sinus. Increased partial
opacification of bilateral mastoid air cells with new fluid in the bilateral
middle ear cavities. These findings do not necessarily imply an infectious
process in the setting of endotracheal intubation, however.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with suspected PNA// please eval for interval
changes please eval for interval changes
IMPRESSION:
Comparison to ___. The lung volumes have slightly decreased. As
a consequence, areas of basilar atelectasis are visualized. No pleural
effusions. No new focal parenchymal changes suggestive of pneumonia. No
pulmonary edema. The feeding tube and the endotracheal tube are in stable
correct position.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new picc// R picc 47cm Contact name: sal,
___: ___ R picc 47cm
IMPRESSION:
Comparison to ___. The patient has received a right-sided PICC
line. The course of the line is unremarkable, the tip projects over the lower
aspect of the right atrium, to be at the cavoatrial junction, the line needs
to be pulled back by approximately 9-10 cm. No complications, notably no
pneumothorax. Otherwise unchanged radiograph.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc repo// picc repo Contact name: sal,
___: ___
IMPRESSION:
In comparison with the earlier study of this date, the right subclavian PICC
line is been pulled back so that the tip is in the mid to lower SVC.
Otherwise, little change.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc line placement// ? picc line placement
Contact name: ___, Phone: 3 ? picc line placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
New tracheostomy tube is midline. No appreciable mediastinal widening. No
pneumothorax. Mild cardiomegaly stable. Lungs clear. No pleural effusion.
Right PIC line has been partially withdrawn and now ends in the upper SVC,
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with TBI s/p hemicraniectomy, assess for interval
change, not following commands.
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 =
747.6 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: Noncontrast head CTs between ___ and ___.
FINDINGS:
A left frontal intraparenchymal hematoma has decreased in size since 5 day
prior, now measuring approximately 4.5 x 3.3 cm, previously 6.5 x 3.5 cm.
Vasogenic edema is unchanged to minimally decreased. Midline shift is
minimally decreased, now measuring 3 mm toward the right. Previously seen
subarachnoid hemorrhage is less conspicuous. Right and left parafalcine
subdural hematomas are minimally decreased.
Patient is status-post right hemi craniectomy and subdural hematoma
evacuation. A large right subdural hygroma measuring approximately 1.5 cm
from the dura is unchanged. Right temporal lobe edema/encephalomalacia is
unchanged. A small amount of adjacent extra-axial blood products are less
conspicuous.
No evidence of new intracranial hemorrhage or acute, large territorial
infarction. The ventricles are not enlarged.
Interval decrease in paranasal sinus opacification. There is partial
opacification of the left sphenoid sinus and a posterior left ethmoid air
cell, though the sphenoid ostium is patent. mastoid air cells and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Continued evolution of a large left frontal intraparenchymal hemorrhage and
bilateral extra-axial hemorrhages as detailed in the findings. No evidence of
a new intracranial hemorrhage.
2. Status-post right hemi craniectomy with a persistent subdural hygroma.
3. Improved, partially imaged paranasal sinus disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever and leukocytosis// eval for pneumonia
eval for pneumonia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Pulmonary vasculature is more engorged and mediastinal veins are more
distended and moderate cardiomegaly has worsened, indicating interval
progression of cardiac decompensation.. Basal lung consolidation has
worsened, either atelectasis or pneumonia. No pneumothorax.
Right PIC line ends at the origin of the SVC. Tracheostomy tube midline.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with TBI s/p hemicraniectomy with tachycardia and
low grade fevers, r/o DVT// r/o DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT HEAD W/ CONTRAST Q1211 CT HEAD
INDICATION: ___ year old man febrile to 103, s/p decompressive
hemicraniectomy. Evaluate for empyema.
TECHNIQUE: Contiguous axial images of the brain were obtained after the
intravenous administration of 90 cc Omnipaque 350 contrast agent. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: Noncontrast head CT from ___ and multiple earlier
CTs dating back to ___.
FINDINGS:
Patient is status post right hemi-craniectomy. There is a stable hypodense
extra-axial fluid collection at the craniectomy site without rim enhancement.
Resolved left parietal parenchymal hematoma and surrounding edema are stable
compared to ___. Previously seen subarachnoid hemorrhage is not
well assessed on this exam due to intravascular contrast. Hypodensity in the
right temporal lobe is unchanged compared to ___, with decreased
mass effect compared to ___. No change in minimal parenchymal
herniation through right hemicraniectomy defect. The ventricles appear stable
in size and configuration compared to ___, though slightly larger
compared to ___, in part due to decreased compression of the left
atrium by the left parietal hematoma. Basal cisterns are preserved.
Dural venous sinuses are patent. There is expected opacification of the major
intracranial arteries, which are not assessed in angiographic detail. Carotid
and vertebral artery calcifications are again seen.
Nondisplaced left squamous temporal bone fracture is again seen.
Again seen is fluid in the left sphenoid sinus. There is fluid and mucosal
thickening and mucosal retention cyst in the left maxillary sinus, not
included in the field of view on ___, and with decreased overall
opacification compared to ___. There is trace fluid in the
bilateral mastoid air cells.
IMPRESSION:
1. No rim enhancement of the extra-axial fluid collection at the right
craniectomy site to suggest empyema. However, superimposed infection cannot
be definitively excluded on the basis of imaging.
2. Resolving left parietal parenchyma hematoma is stable compared to ___. Known subarachnoid hemorrhage is not adequately reassessed due
to the presence of intravascular contrast.
3. The ventricles are stable in size and configuration compared to ___, though slightly increased in size compared to ___.
4. Nondisplaced left squamous temporal bone fracture is again seen.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with consistent fevers. Chest xray with
congestion and atelectasis vs pna// eval for infectious process/
effusion/empyema
TECHNIQUE: Multidetector helical scanning of the chest was 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 2.2 s, 34.7 cm; CTDIvol = 20.3 mGy (Body) DLP = 702.2
mGy-cm.
Total DLP (Body) = 702 mGy-cm.
COMPARISON: Previous CT chest from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is a tracheostomy tube
present. The visualized portion of the thyroid is unremarkable. There is no
axillary adenopathy.
MEDIASTINUM: There is no mediastinal fluid, gas or lymphadenopathy. Right
upper extremity PICC line tip terminates in the mid SVC.
HILA: Unremarkable within the limits of unenhanced CT.
HEART and PERICARDIUM: Trace pericardial fluid.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
PARENCHYMA: There is segmental atelectasis in both lower lobes. This has
slightly improved overall from ___. There is a linear opacity in
the lateral basal right lower lobe associated with mild surrounding
ground-glass opacity. This is likely related to atelectasis although
superimposed inflammation or early infection is not excluded. Otherwise there
is no evidence of airspace consolidation to suggest pneumonia.
AIRWAYS: There is multifocal segmental/subsegmental bronchial plugging
associated with atelectasis in the lower lobes.
VESSELS: The pulmonary trunk is mildly dilated at 3.2 cm. This can be
associated with pulmonary hypertension.
MUSCULOSKELETAL: Bilateral posterior rib fractures are again demonstrated.
Notably these include segmental fractures of the left ___ to ___ and right ___
to 6th ribs.
UPPER ABDOMEN: There is a G-tube in the stomach. Limited images of the upper
abdomen are otherwise unremarkable.
IMPRESSION:
1. Mild improvement in the atelectasis of the bilateral lower lobes with
component of aspiration changes not excluded. Superimposed infection is
difficult to exclude radiographically and clinical correlation is recommended.
2. Multiple bilateral segmental rib fractures are again noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with PICC, partially withdrawn// check PICC
placement
TECHNIQUE: Portable supine frontal chest radiograph.
COMPARISON: ___ chest CT.
FINDINGS:
Distal tip of the right PICC now terminates in the confluence of the right
subclavian and right brachiocephalic vein. The endotracheal tube tip
terminates in the mid trachea. The lung volumes are low bilaterally. There
is no focal consolidation, large pleural effusion or pneumothorax. Prominence
of the cardiomediastinal silhouette is likely secondary to low lung volumes.
No acute osseous abnormality
IMPRESSION:
1. Distal tip of the right PICC now terminates in the confluence of the right
subclavian and right brachiocephalic vein.
2. No pneumothorax.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:11 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with TBI, s/p unwitnessed fall// Evaluate for
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 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.6 mGy-cm.
2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.8 mGy-cm.
Total DLP (Head) = 1,308 mGy-cm.
COMPARISON: ___
FINDINGS:
Status post right hemicraniectomy. Evolution of blood products at the right
hemi craniectomy site with a minimal interval increase in fluid volume.
Minimal herniation through the craniotomy site appears stable. No acute
intracranial hemorrhage is demonstrated. A intraparenchymal hematoma within
the left parietal lobe is decreased in prominence from prior without
high-density products identified. There is residual edema at the bleed site.
3 mm of rightward midline shift is unchanged. The ventricles are stable in
size and configuration compared to ___. The basal cisterns are
preserved.
The previously characterized left squamous temporal bone fracture is
nondisplaced and appears grossly unchanged from the prior study. No
significant thickening or abnormal findings within the paranasal sinuses. The
bilateral mastoid air cells demonstrate partial opacification on the right
which is unchanged from prior, otherwise unremarkable. The orbits are
unremarkable.
IMPRESSION:
1. Status post right hemi craniectomy with evolution of a right subdural
hygroma. No acute intracranial hemorrhage.
2. Resolving left parietal parenchymal hematoma without acute component,
minimally decreased associated edema.
3. Stable size and configuration of the ventricles compared to ___.
4. Nondisplaced left squamous temporal bone fracture which is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with severe TBI s/p right decompressive
craniectomy// Pre-op assessment for OR on ___ Surg: ___ (Right
cranioplasty)
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume. No new consolidations. Old healed posterior third rib
fracture on the right. There are no pleural effusions. No pneumothorax is
seen. Tracheostomy tube in place.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with severe TBI s/p decompressive craniotomy and
cranioplasty// S/p bone cranioplasty, eval for bleeding and hydrocephalus
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 =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
Since prior, right frontoparietal cranioplasty has been performed. Surgical
drain. Previously seen right hemispheric extra-axial fluid collection at the
cranioplasty level is no longer present. Trace extra-axial fluid overlies
posterior right occipital lobe, stable. Areas of encephalomalacia, volume
loss right temporal lobe, stable. Left MCA distribution subacute infarct
stable. No acute hemorrhage. Suggestion of trace low-density fluid
collection overlying left temporal lobe. No hydrocephalus.. Mild
opacification right mastoids, similar. Clear paranasal sinuses.
IMPRESSION:
1. Interval right cranioplasty, no acute hemorrhage.
2. Left MCA distribution subacute infarct, stable.
3. Suggestion of trace extra-axial fluid collection overlying left temporal
lobe.
4. Right temporal lobe encephalomalacia, volume loss.
5. Remainder as above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with severe TBI (day ___), s/p decompressive
hemicrani (___), now ___ s/p cranioplasty. Now with increased periorbital
edema.// please eval for fluid accumulation
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 =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Status post right hemicraniectomy. There is a right hemispheric extra-axial
collection representing a postoperative hygroma versus subacute/chronic blood
at the cranioplasty level measuring up to 0.9 cm in maximal thickness, new
from CT head ___. Trace extra-axial fluid overlies the posterior
right occipital lobe, decreased in size from prior. There is up to 0.3 cm of
leftward midline shift, previously up to 0.3 cm of rightward midline shift.
The basal cisterns are patent. The ventricles are stable in size.
Right temporal lobe encephalomalacia with ex vacuo dilation of the left
lateral ventricle temporal horn is unchanged. The left MCA distribution
subacute infarct/evolving intraparenchymal hemorrhage is grossly stable in
size without evidence of mass effect or hemorrhagic transformation.
There is a nondisplaced left zygomatic arch fracture is again noted,
unchanged. There is unchanged mild opacification of the right mastoid.
Visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavitiesare otherwise clear. The visualized portion of the orbits are
preserved.
IMPRESSION:
1. Interval development of right hemispheric extra-axial collection at the
cranioplasty level measuring up to 0.9 cm in maximal thickness. Differential
considerations include postoperative hygroma versus subacute/chronic subdural
blood products.
2. Grossly stable ventricle size as described.
3. Additional grossly stable findings as described.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with severe TBI// Assess interval changes.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.9 mGy-cm.
Total DLP (Head) = 1,309 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There are stable expected postoperative findings from large right craniotomy.
There is trace right subgaleal fluid just inferior and superficial to the
craniotomy, unchanged (02:12).
The 8 mm wide hypoattenuating right subdural collection is unchanged.
The hypodensity likely corresponding to subacute infarction in the left
frontoparietal region is unchanged.
Hypodensity in the right temporal pole is unchanged, and may reflect evolving
contusion/sequelae of recent trauma.
There is stable lateral and third ventriculomegaly the fourth ventricle is
also mildly prominent, unchanged. No obstructing mass.
Minimal leftward midline shift is unchanged. There is no evidence of new
hemorrhage, infarction, edema, or mass effect.
Right mastoid effusion is unchanged. Left mastoid is clear. The visualized
paranasal sinuses are clear. Globes are intact.
IMPRESSION:
1. Stable examination. No new acute infarction or new hemorrhage.
2. Unchanged 8 mm hypoattenuating right subdural collection.
3. Unchanged evolving left frontoparietal subacute infarction.
4. Unchanged ventriculomegaly.
5. Expected postoperative findings from large right craniotomy, unchanged.
6. Right mastoid effusion, unchanged.
Radiology Report
EXAMINATION: RF - GI TUBE CHECK
INDICATION: ___ year old man with severe TBI, PEG placement ___, pulled
out// With water soluble contrast- confirm placement of foley tip in stomach
(in tract of previous PEG)
TECHNIQUE: Two portable supine radiographs of the abdomen before and after
administration of contrast through Foley tube.
COMPARISON: CT chest, abdomen and pelvis ___.
FINDINGS:
There is a Foley tube projecting over the body of the stomach. Water-soluble
contrast was administered through the tube and appears within the body of the
stomach and proximal duodenum. There is no evidence of contrast leak,
although evaluation is limited by the small volume of contrast administered.
IMPRESSION:
The Foley tube is located within the body of the stomach. No definite
evidence of contrast leak.
Radiology Report
EXAMINATION: G tube placement check (optiray ordered)
INDICATION: ___ year old man with severe TBI, s/p PEG replacement// G tube
placement check (optiray ordered)
TECHNIQUE: Portable radiographs of the abdomen.
COMPARISON: None
FINDINGS:
Water-soluble contrast (Optiray) was administered through the gastrostomy
tube.
Injected contrast opacifies the stomach, indicating appropriate placement of
the gastrostomy tube. There is no evidence of extraluminal contrast.
Note is made of spina bifida occulta (a normal variant) involving S1.
IMPRESSION:
Gastrostomy tube appropriately positioned within the body of stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with TBI// evolutionary changes of TBI
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 =
934.8 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head without contrast from ___,
___
FINDINGS:
Patient is status post right frontotemporal craniotomy. Again seen are
hypodensities in the right temporal lobe and left frontoparietal region
compatible with evolving infarcts. There is persistent enlargement the
lateral ventricles, third ventricle, and fourth ventricle, which appears
increased in size since ___ although similar to ___.
There is no obvious midline shift. No evidence of intracranial hemorrhage or
new major acute infarct.
There is again partial opacification of the right mastoid air cells.
Otherwise, the visualized portion of the paranasal sinuses, left mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Postsurgical changes seen following right frontotemporal craniotomy. There
are evolving infarcts in the right temporal lobe and left frontoparietal
regions. No evidence of hemorrhagic transformation or new major acute
infarct.
2. Persistent enlargement of the lateral ventricles, third ventricle, and
fourth ventricle, which appears increased in size since ___
although similar to ___.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall, Transfer
Diagnosed with Multiple fractures of ribs, unsp side, init for clos fx, Prsn outsd pk-up/van inj in clsn w nonmtr veh in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UA
level of acuity: 1.0 | ___ year old male status post fall off the back of a moving
pick-up truck with a severe traumatic brain injury. CT of the
head in the Emergency Department revealed extensive traumatic
right sided subdural, bilateral subarachnoid, left sided
epidural, and left parietotemporal intraparenchymal hematomas
with mass effect and 5mm of leftward midline shift.
#Traumatic Brain Injury
The patient was admitted to the Neurosurgery Service for close
neurologic monitoring. He was started on Keppra for seizure
prophylaxis. He was started on 3% hypertonic saline. A right
Neurovent was placed for ICP monitoring. The procedure was
uncomplicated. Please see ___ Record for further
intraprocedural details. Repeat CT of the head showed proper
Neurovent placement, but worsening of the patient's multifocal
traumatic intracranial hemorrhage. Additionally, the patient's
ICPs were spiking to and sustaining in the ___. He was given a
bolus of mannitol, which brought his ICPs down to the ___,
however his ICPs remained consistently high despite medical
management. Given this, the patient was taken to the OR for a
right decompressive hemicraniectomy with subdural hematoma
evacuation and removal of right Neurovent. The operation was
uncomplicated. Please see ___ Record for further
intraoperative details. The patient was maintained on Keppra and
3% hypertonic saline postoperatively. His neurologic exam
remained stable. 3% was discontinued for hypernatremia. Patient
sodium was titrated to goal of >140. Overnight ___, the
patient had roving eyes on exam. STAT CT was stable. Patient was
placed on EEG, which was concerning for seizures. Keppra dose
was increased to 2g BID. He continued to have intermittent
seizures on EEG overnight and early morning on ___ and
Epilepsy recommended starting Vimpat 200mg BID as a second
agent. EEG remained negative for seizure thereafter and the EEG
was discontinued on ___. Repeat NCHCT on ___ showed expected
evolution of TBI but was otherwise stable. The patient's
neurological exam remained stable throughout the subsequent
period in the ___. He was then transferred to the floor ___.
On ___, he underwent cranioplasty with Dr. ___. Please see
operative report for further detail. Postoperatively, he was
closely monitored in the TSICU. VP shunt placement was offered
due to concern for hydrocephalus. This was discussed at length
with the patient's guardian (his brother) who ultimately decided
against pursuing a VP shunt or EVD placement. On ___ the
patient was made floor status. CT head on ___ demonstrated a
0.9cm extraaxial fluid collection on the right side, correlating
with mild swelling observed on exam. Cranioplasty staples were
removed on ___. Keppra was weaned off with last dose scheduled
___. Patient underwent a repeat CTH due to concerns for ongoing
right facial droop on ___. CTH with evolving infarcts in the
right temporal lobe and left frontoparietal regions, with no
evidence of hemorrhagic transformation or new major acute
infarct and persistent enlargement of the lateral ventricles,
third ventricle, and fourth ventricle.
#Agitation/Restlessness
Patient remained neurologically stable but with persistent
restlessness and agitation in bed requiring the use of
restraints to prevent patient injury to himself and pulling at
tubes/lines. Psych was consulted for medication recommendations.
Remelteon was added ___. Neurology was consulted to assist in
transitioning AEDs to include mood stabilization, and Lamictal
was added ___. They plan to uptitrate as outpatient prior to
weaning keppra. He was unable to wean from mitts and enclosure
bed, and buspirone was started on ___ per psych
recommendations for continuing agitation, and Trazodone was
increased. He was weaned from mitts on ___ and agitation
continued to improve. Lamictal was increased to 50mg BID on
___ per neurology recommendations. Buspirone was increased to
15mg TID and Seroquel PRN was added per psych recommendations on
___. Mitts were placed back on briefly on ___ due to
concern for pulling at PEG. Lamictal dose was slowly titrated up
to goal of 150mg BID on ___. He was starting on standing
Seroquel to help with agitation. Enclosure bed was discontinued
on ___ and patient was placed in a low bed with a 1:1 sitter.
#Left Temporal Bone Fracture
Otolaryngology was consulted for a left temporal bone fracture.
A dedicated CT of the temporal bones was obtained.
Otolaryngology recommended an outpatient audiogram and
outpatient follow-up.
#Concern For CSF Leak
Otolaryngology was consulted for concern for a CSF leak when the
patient began draining fluid from his nose. He was placed on CSF
leak precautions. The drainage self resolved.
#Respiratory Failure
The patient was intubated and was unable to wean from the
ventilator. Acute Care Surgery was consulted for a tracheostomy,
which was placed on ___. ACS removed the trach sutures ___.
First trach downsize was done by respiratory therapy on ___.
He was first seen by speech and swallow on ___ to assess PMV
use, they saw him again on ___ and noted that he could begin
to use PMV with supervision. On ___, a cap trial was started,
but the cap had to be discontinued after 1 hour following a
desaturation to 89% in the setting of agitation. Cap trials were
re-initiated on ___ with QID capping for ___ minutes. Trach
was changed to 6 CFS on ___. 24 hour cap trial started ___
was successful; the patient did not desaturate. His trach was
decannulated by respiratory therapy on ___. Patient was
without respiratory concerns throughout remainder of
hospitalization.
#Aspiration Pneumonia
The patient developed an aspiration pneumonia. He was initially
started on broad spectrum antibiotics, which were narrowed once
the cultures resulted. Patient developed leukocytosis and a low
grade fever ___, Tmax of 100.8. CXR was concerning for PNA.
Antibiotics were changed to Keflex based on the sensitivities.
On ___, he was noted to be febrile to 103, chest xray with
concern for worsening pneumonia. He was started on Nafcillin x 1
days. Infectious Disease weighed in, as patient was continually
febrile. He was changed to Vancomycin and Cefepime on ___.
He was given Tylenol Q6hr and started on a cooling blanket to
help with temperature control. A CT chest revealed improvement
in bilateral lower lobe atelectasis. Sputum culture was obtained
on ___ and grew out commensal respiratory flora. The patient
continued to experience low grade temperates and ID recommending
continuing vancomycin and cefepime, with the possibility of a
central component to these episodes. Vancomycin and cefepime
were discontinued on ___. Patient remained afebrile.
#Leukocytosis
In addition to a chest xray demonstrating pneumonia. On ___, a
urine culture was obtained which was negative. Bilateral ___
were negative. Blood cultures continued to be negative. CDiff
was sent on ___ and was negative. A head CT was obtained to
rule out intracranial infection, it was negative. WBC down
trended and was within normal range at time of discharge.
#Hypertension
Patient was started on labetalol for tachycardia/hypertension,
and it was titrated as tolerated.
#Dysphagia
Speech and Language Pathology was consulted and recommended the
patient be NPO. A NGT was placed. Nutrition was consulted for
tube feeding recommendations and adjusted tube feedings as
needed. Acute Care Surgery was consulted for a PEG, which was
placed on ___. Feeds were adjusted by nutrition, changed to
bolus feeds on ___. PEG was pulled out by patient on ___,
foley catheter placed in tract. ACS replaced PEG on ___ and
placement confirmed. Patient remained on bolus tube feeds.
#Family Coping
Social Work was consulted and followed for family coping. There
was a family meeting that took place on ___ with social work
to discuss steps for rehab once medically stable and prognosis.
Guardianship paperwork was obtained by his brother.
#Disposition
Physical Therapy and Occupational Therapy were both consulted
and recommended rehabilitation. Case management was contacted
and informed the team on ___ that the brother has outside
legal councel completing the guardianship. ___ legal is also
aware of the plan. CM looked for rehab facilities speciailizing
in TBI care at the request of the brother. ___ was
obtained. ___ guardianship was obtained. Patient was
discharged to rehab on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
bile duct stricture
Major Surgical or Invasive Procedure:
ERCP and biliary stent placement ___
Cholecystectomy, choledochojejunostomy and intraoperative
ultrasound of the pancreas ___
History of Present Illness:
___ with history of cholelithiasis & cholangitis ___ s/p
ERCP with stent placement and subsequent stent change x2 with
CBD
stricture thought to be inflammatory in nature. She had a CT
abdomen ___ which demonstrated a hypoenhancing area in the
head of the pancreas which was consistent with
pancreatitis/necrosis but could not rule out pancreatic head
mass. The plan was for her to f/u with West2a in clinic with a
repeat CT abdomen prior to operative intervention (likely
cholecystectomy with biliary bypass). She did not keep many
outpatient appointments and refused an outpatient CT scan
because
she had "personal issues" going on involving her apartment and
her kids. She presented to her PCP today complaining of
increasing right sided abdominal pain x 1 week. She reports
long
term poor appetite and nausea which has not changed recently.
She
reports that her eyes turned yellow 2 days ago and this is what
prompted her to go to her PCP. Also endorses darkened urine and
lighter color stools. No fevers, no emesis.
Past Medical History:
Past Medical History:
-asthma
-h/o seizures
Past Surgical History:
-C-section x ___
-s/p tonsillectomy
Social History:
___
Family History:
Mother with HTN, asthma, and arthritis.
Physical Exam:
At time of discharge:
99.9, 82, 90/52, 18. 96% on room air
no acute distress, ambulating independently
clear to auscultation bilaterally
regular rate and rhythm
abdomen soft, minimally distended, appropriately tender
periincisionally
incision with healing ridge, no erythema, no drainage, staples
in place, clean
no peripheral edema
Pertinent Results:
___ 06:15PM BLOOD ALT-234* AST-228* AlkPhos-1863*
TotBili-8.4*
___ 07:15AM BLOOD ALT-143* AST-67* AlkPhos-1361* Amylase-39
TotBili-2.9*
___ 07:00AM BLOOD ALT-115* AST-39 AlkPhos-1195*
TotBili-2.9*
___ 07:35AM BLOOD ALT-71* AST-32 AlkPhos-881* TotBili-2.1*
___ 04:55AM BLOOD ALT-127* AST-139* AlkPhos-692*
TotBili-2.1*
___ 09:14AM BLOOD ALT-93* AST-49* AlkPhos-514* TotBili-1.7*
___ 06:15PM BLOOD Lipase-11
___ 07:00AM BLOOD Lipase-13
Time Taken Not Noted Log-In Date/Time: ___ 3:14 pm
SWAB BILE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ERCP ___:
The ampulla was s/p previous sphincterotomy.
The old stent was partially migrated distally. It was removed
with a snare and sent for cytology.
Cannulation of the biliary duct was successful and deep with a
balloon catheter using a free-hand technique. Contrast medium
was injected resulting in complete opacification.
A straight tip .035in guidewire was placed.
A single stricture that was 1 cm long was seen at the distal
CBD. The proximal CBD was severely dilated to 2.5 cm. The left
intrahepatic ducts were mildly dilated.
Cytology samples were obtained for histology using a brush in
the stricture.
A 7cm by ___ Cotton ___ biliary stent was placed
successfully. The bile flow was good.
Otherwise normal ercp to third part of the duodenum.
Medications on Admission:
albuterol prn
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *Augmentin 500 mg-125 mg twice a day Disp #*9 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg twice a day Disp #*30 Capsule Refills:*1
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg q4-6 hours Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *Miralax 17 gram daily Disp #*30 Packet Refills:*1
5. Senna 1 TAB PO BID
RX *senna 8.6 mg twice a day Disp #*30 Tablet Refills:*1
6. ketorolac *NF* 10 mg Oral q6 Duration: 3 Days
RX *ketorolac 10 mg q6 Disp #*12 Tablet Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct stricture in the setting of chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ man with history of cholangitis and
pancreatitis and multiple ERCP stents, now with likely stent obstruction.
COMPARISON: ___ study.
TECHNIQUE: CTA of the abdomen was performed in multiple phases. IV contrast
was administered.
FINDINGS: The lung bases show dependent atelectasis; however, no nodules or
effusions are identified. Pericardium is unremarkable.
Within the abdomen, there is arterial enhancement of a portion of segment V of
the liver (3A:25) which is not seen on subsequent scans and likely a
perfusional abnormality. No focal liver lesions are noted. There is
extensive intra- and extra-hepatic ductal dilatation extending from the common
bile duct to intrahepatic ducts in both the left and right lobe (3A:23 through
3A:50). The cystic duct is also low inserting (3A:49) and is dilated. CBD
stent is seen at the distal aspect of the CBD, 3A:49, but does appear to be in
a backward configuration as compared to normal.
Within the pancreas, there is mild pancreatic ductal prominence, however,
decreased from the prior study. There is also again noted hypoattenuating
area in the head of the pancreas (3B:153). This is completely unchanged from
the prior study and perhaps which is due to the transversing common bile duct
stent. At the tail of the pancreas, a stable 2.6 x 2.5 cm cystic lesion is
noted indenting the stomach. The appearance is most likely a pancreatic tail
pseudocyst.
Bilateral kidneys enhance and excrete contrast symmetrically with no evidence
of hydronephrosis or masses. Spleen, aorta, and small and large bowel are
unremarkable. There are at least two enlarged portacaval lymph nodes (2:37 1.1
x 1.9 cm and 2:30, 1.2 x 1.4 cm) unchanged in size.
BONES: No suspicious bony lesions are noted.
IMPRESSION:
1. Intra- or extra-hepatic ductal dilatation with the common bile duct
measuring up to 3 cm. CBD stent appears to have migrated in a reverse
configuration.
2. Perfusional defects noted in segment V of the liver, but no focal lesions.
3. Stable hypodensity in the pancreatic head and stable pancreatic tail
pseudocyst. Stable portacaval lymph nodes.
Radiology Report
HISTORY: ___ female with cholangitis, pancreatitis, and biliary
obstruction, for preoperative evaluation.
COMPARISON: ___.
FINDINGS: AP and lateral chest radiographs demonstrate clear lungs without
effusion, or pneumothorax. The cardiac silhouette and mediastinal contours
are normal. The pulmonary vasculature is normal. A Silastic CBD stent is
unchanged in position in the right upper quadrant. A left IJ central venous
catheter has been removed in the interim.
IMPRESSION: No acute chest abnormality.
Radiology Report
INTRAOPERATIVE ULTRASOUND OF THE PANCREAS
INDICATION: ___ female with known chronic pancreatitis and
intermittent cholangitis and jaundice due to biliary obstruction. OR plan for
cholecystectomy and bile duct exploration and bypass.
Transgastric and retrogastric imaging of the pancreas was performed,
demonstrating extensive parenchymal calcifications throughout the somewhat
atrophic pancreas as well as multiple intraductal stones. The pancreatic duct
is dilated from the head to the tail with a maximum diameter of 5-6 mm. There
appears to be a structured narrowing of the pancreatic duct in the low head of
the pancreas within 1-2 cm of the ampulla. Markedly dilated common bile duct
is seen with an indwelling stent as well as sludge within the lumen of the
duct.
CONCLUSION: Findings indicate chronic pancreatitis with parenchymal atrophy
and calcifications and pancreatic duct dilatation up to 6 mm., with a short
stricture in the pancreatic head as described. Bile duct dilatation was also
noted with sludge in the duct and an indwelling ERCP-placed stent.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: RLQ PAIN
Diagnosed with ABDOMINAL PAIN RUQ, JAUNDICE NOS
temperature: 99.9
heartrate: 110.0
resprate: 16.0
o2sat: 99.0
sbp: 118.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | Patient was admitted with biliary obstruction. She underwent
ERCP on ___ with replacement of her common duct stent with
good drainage of bile. Her liver function tests improved
greatly, and she was tolerating a regular diet and passing
flatus and stool. Due to chronic cholecystitis and chronic
severe biliary stricture, she underwent cholecystectomy,
choledochojejunostomy and intraoperative ultrasound of the
pancreas on ___. She tolerated the procedure well. The rest
of her postoperative course was uncomplicated as follows:
Neuro: The patient had an epidural placed for pain control.
However it did not provide good pain relief. On POD #2 the
epidural dislodged inadvertently and was subsequently removed.
She was started on a PCA and was transitioned to oxycodone. She
was also given IV toradol on POD #4 as an adjunct and discharged
home with 3 days of PO toradol, and oxycodone prn.
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: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. She tolerated a
regular diet on POD #4 without nausea or vomiting. She also
received an aggressive bowel regimen which was successful in
producing multiple episodes of gas and a large stool.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She received unasyn from
___ through the am of ___. She was switched to augmentin which
she tolerated. She will take augmentin through ___ for a total
of 14 days of antibiotics.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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. She is passing gas and having bowel movements with
the help of a bowel regimen and is being encouraged to wean the
oxycodone and use toradol as a bridge for the next few days. 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:
Aspirin / Penicillins / Codeine / Inderal / Isordil Titradose /
Iodine-Iodine Containing / Celexa / Glucophage / Atorvastatin /
Dilaudid (PF) / Vioxx / Levofloxacin / Hydralazine And
Derivatives / Ondansetron / Carbapenem / Lidocaine /
Nortriptyline / Fosfomycin / Morphine / Trimethoprim / Latex /
Aloe ___
___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old female with history of CAD, DVT s/p IVC filter, HTN,
HLD and who presented to the ED complaining of worsening
frequency of presyncopal symptoms and chest pain. Describes pain
as burning x7 days and unrelieved with Maalox. Associated with
nausea but no vomiting. Has woken up with diaphoresis at night.
No relieving symptoms. Presyncopal symptoms worse on sitting up.
Has fainted at table before, but has not struck head or lost
consciousness (of note, family denies that patient has lost
consciousness). Patient is largely wheelchair dependent but can
use walker with seat for up to 3 minutes, does not say she is
dizzy while standing.
In the ED, initial vital signs were T 97.6 P 68 BP 164/79 R 18
O2 sat 96%. EKG was performed for chest pain, but no change from
prior EKGs noted. Patient was given 1g ceftriaxone for suspected
UTI. Foley was inserted which put out 1L clear urine.
Past Medical History:
Coronary artery disease (___ ___ with 50% lesion in mid LAD,
50% lesion in OM1).
Hypertension.
Hyperlipidemia.
Valvular heart disease ___ MR, 2+ TR).
?Symptomatic bradycardia.
Presyncope/?Syncope.
insulin-dependent diabetes
GERD
chronic kidney disease (Cr0.9-1.2)
recurrent UTIs
urinary retention
osteoporosis
status post CVA with residual left-sided weakness
status post DVT
status post IVC filter
L1-L2 discectomy, L5-S1 fusion
cervical stenosis and cervical spondylosis
arthritis
status post appendectomy
status post laparoscopic cholecystectomy
status post hysterectomy
cataract surgery x2
Social History:
___
Family History:
Parents both died of CAD in their ___. She had two brothers die
of CAD in their ___. One sister with ___ disease and
one with lung cancer.
Physical Exam:
ADMISSION EXAM
Vitals- T99 BP 157/64 P 89 R 18 SpO2 97 BS 214
General- Alert, oriented, anxious
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Pain produced on palpation, but not the same as
reported.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
GU- No CVA tenderness. foley to gravity.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM
Physical Exam:
Vitals- T97.8 BP 140/70 P 74 R 18 SpO2 97
Urine output 800cc
General- Alert, oriented, in no acute distress, mildly anxious
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
GU- No CVA tenderness. foley to gravity.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
CXR (___): The lungs are clear. No confluent
opacity is identified. There is no pulmonary edema or pleural
effusions. Cardiomediastinal and hilar contours are within
normal limits. Aortic knob calcifications are again noted.
Surgical clips are redemonstrated in the right upper quadrant.
IVC filter projects over the thoracolumbar spine.
STRESS ECHO (___): 3D echocardiographic evidence of prior
distal LAD-territory myocardial infarction without inducible
ischemia to achieved workload. Mild to moderate mitral
regurgitation at rest.
EKG: (___): Sinus rhythm. Left anterior fascicular block.
Atrio-ventricular conduction delay. Probable prior inferior
myocardial infarction. Possible prior
anteroseptal myocardial infarction. Left ventricular
hypertrophy. Low voltage in the limb leads. Compared to the
previous tracing of ___ the findings are similar.
CTA (___): Wet Read: ___ ___ 10:18 AM
No acute process of the chest including no evidence of acute
aortic syndrome or pulmonary embolism.
___ 07:10AM BLOOD WBC-6.2 RBC-3.70* Hgb-11.2* Hct-34.9*
MCV-94 MCH-30.2 MCHC-32.0 RDW-13.2 Plt ___
___ 07:10AM BLOOD Glucose-277* UreaN-22* Creat-1.2* Na-134
K-5.2* Cl-102 HCO3-23 AnGap-14
___ 02:00AM BLOOD Glucose-232* UreaN-25* Creat-1.5* Na-139
K-4.7 Cl-104 HCO3-25 AnGap-15
___ 02:00AM BLOOD cTropnT-<0.01
___ 07:10AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
___ 07:30AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.5* Hct-34.9*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.4 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-133* UreaN-22* Creat-1.1 Na-140
K-4.4 Cl-105 HCO3-26 AnGap-13
___ 07:30AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.1
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Ticlopidine HCl 250 mg PO BID
2. Gabapentin 300 mg PO DAILY
3. Gabapentin 100 mg PO HS
4. Simvastatin 40 mg PO DAILY
5. Glargine 15 Units Breakfast
Discharge Medications:
1. Gabapentin 100 mg PO HS
2. Gabapentin 300 mg PO DAILY
3. Glargine 15 Units Bedtime
4. Simvastatin 40 mg PO DAILY
5. Ticlopidine HCl 250 mg PO BID
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Nitrofurantoin (Macrodantin) 50 mg PO Q6H
RX *nitrofurantoin macrocrystal 50 mg 1 Capsule(s) by mouth
every 6 hours Disp #*36 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic atypical chest pain
Urinary retension
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
HISTORY: ___ female with chest pain.
COMPARISON: Chest radiograph from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPH: The lungs are clear. No confluent
opacity is identified. There is no pulmonary edema or pleural effusions.
Cardiomediastinal and hilar contours are within normal limits. Aortic knob
calcifications are again noted. Surgical clips are redemonstrated in the
right upper quadrant. IVC filter projects over the thoracolumbar spine.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Patient with elevated creatinine. Assess for hydronephrosis.
COMPARISONS: CTU of ___.
FINDINGS:
The right kidney measures 9.5 cm and the left kidney measures 9.7 cm. There
is no evidence of hydronephrosis, nephrolithiasis, or renal masses
bilaterally. Corticomedullary differentiation is well preserved. The bladder
is collapsed around the Foley catheter.
IMPRESSION:
No evidence of hydronephrosis.
Radiology Report
INDICATION: ___ woman with iodine allergy running with chest and back
pain.
Rule out aortic dissection.
TECHNIQUE: Contiguous MDCT images through the chest were obtained per CT
angiography protocol with initial non-enhanced and subsequently enhanced
imaging. Coronal and sagittal reformats were acquired. Reported iodine
allergy, pretreated with steroids. No complications.
COMPARISON: CTU from ___, the abdomen and pelvis from ___, chest radiograph from ___.
FINDINGS:
CTA OF THE CHEST: The thyroid gland is normal. There is no axillary, hilar
or mediastinal lymphadenopathy. There is no pneumomediastinum or mediastinal
hemorrhage. Normal heart size. No pericardial fluid.
No pleural fluid. The airways are patent to subsegmental level. Unchanged
right lower lobe basilar pulmonary nodule (2;36). Minimal bibasilar
atelectasis. Subsegmental atelectasis versus scar in the lower anterior right
upper lobe.
There are moderate-to-severe atherosclerotic calcifications of the aortic
arch, mild atherosclerotic calcifications of the descending and ascending
thoracic aorta. There are moderate atherosclerotic calcifications of the
coronary arteries and mild atherosclerotic calcifications of the mitral valve
and aortic valve.
There is no acute aortic syndrome including no evidence of aortic aneurysm or
aortic dissection. The origins of the supraaortic vessels are normal.There is
no pulmonary embolism. The main pulmoary artery is of normal caliber.
Partially visualized upper abdomen shows that the patient is status post
cholecystectomy. There is a small hiatal hernia and a large duodenal
diverticulum.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION: No acute process of the chest including no evidence of acute
aortic syndrome or pulmonary embolism.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NAUSEA ABD PAIN
Diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 68.0
resprate: 18.0
o2sat: 96.0
sbp: 164.0
dbp: 79.0
level of pain: 8
level of acuity: 2.0 | HOSPITAL COURSE: ___ year old female with a PMH of CAD, DVT s/p
IVC filter, HTN, HLD, and presyncope who presents with worsening
presyncopal symptoms and chest pain. She had a cardiac workup
including CTA to rule out microdissection which was negative.
She was found to be retaining urine and failed a voiding trial
so a foley to gravity placed. |
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, vomiting, anorexia, weight loss, jaundice
Major Surgical or Invasive Procedure:
(___): Percutaneous liver biopsy
History of Present Illness:
___ previously healthy who presented with a 2 week history of
nausea, anorexia, 10lb weight loss, tea-colored urine, and
pruritus. Patient's family told him that he was jaundiced.
Today, the patient denied abdominal pain or discomfort but did
note that recently he has been gassy and taking pepto-bismuth
for his symptoms. He has had an almost constant, dull, and
diffuse discomfort of his abdomen.
He reported no fever, chills, UTI symptoms or abnormal stool. He
has no recent travel or food poisoning. He denies taking any
medications or acetaminophen. He has been consuming dry beef
that his mother brought from ___, but many other family
members have been eating the same food and are asymptomatic.
In the ED, initial vitals:
ED physical exam: -- 134/78 79 17 100%RA
Physical exam: alert, not in distress
HEENT: scleral icterus, PERLA, EOM intact
Lung: cta
___: rrr, normal s1,s2
Abdomen: soft, lax, non tender, no ascites or fluid thrill,
normal bowel sounds
Skin: slightly jaundice
LL: no ankle edema or calf pain
Labs were significant for ___ 13.3, INR 1.2, ALT 1868, AST 939,
TBili 7.9, Dbili 5.5, lipase 102, cholesterol 225
Imaging showed hepatic steatosis
Patient was given 2L NS bolus.
Patient was seen by Hepatology/
Decision made to admit for further workup.
Vitals prior to transfer: ___ 115/68 79 18 99%RA
On arrival to the floor, the patient stated he was hungry with
some mild epigastric discomfort he believed was related to
hunger.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Hepatic steatosis (noted on U/S ___
Retinal detachment
Hemorrhoids
Social History:
___
Family History:
Father with type ___ diabetes, HTN
Coronary artery disease
No known history of liver disorders, blood disorders, or cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.8 146/79 61 18 96%RA
GEN: Alert, lying in bed, no acute distress, comfortable
appearing
HEENT: dry MM, icteric sclerae, no conjunctival pallor, palatal
jaundice
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: +BS, soft, non-tender, non-distended, no hepatomegaly
appreciated
EXTREM: Warm, well-perfused, no edema
NEURO: AAOx3, CN ___ grossly intact, motor function grossly
normal
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.7 108/67 60 20 94%RA
GEN: Alert, walking around room, no acute distress, comfortable
appearing
HEENT: dry MM, icteric sclerae, no conjunctival pallor, palatal
jaundice
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: +BS, soft, non-tender, non-distended, hepatomegaly
appreciated, no masses palpated
EXTREM: Warm, well-perfused, no edema
NEURO: AAOx3, CN ___ grossly intact, motor function grossly
normal
Pertinent Results:
ADMISSION LABS:
================
___ 08:58AM BLOOD WBC-3.1* RBC-4.94 Hgb-15.2 Hct-47.0
MCV-95 MCH-30.8 MCHC-32.3 RDW-14.0 RDWSD-49.5* Plt ___
___ 02:00PM BLOOD Neuts-39.5 ___ Monos-10.6 Eos-3.3
Baso-1.3* Im ___ AbsNeut-1.19* AbsLymp-1.36 AbsMono-0.32
AbsEos-0.10 AbsBaso-0.04
___ 02:00PM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-137
K-4.0 Cl-98 HCO3-27 AnGap-16
___ 02:22PM BLOOD Lactate-1.4
___ 08:58AM BLOOD ALT-1848* AST-903* AlkPhos-129
TotBili-7.3* DirBili-5.2* IndBili-2.1
___ 02:00PM BLOOD Lipase-102*
___ 08:58AM BLOOD Albumin-4.4 Cholest-225*
___ 08:58AM BLOOD Triglyc-243* HDL-18 CHOL/HD-12.5
LDLcalc-158*
___ 02:12PM BLOOD ___ PTT-36.3 ___
___ 08:58AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Positive IgM HAV-NEGATIVE
DISCHARGE LABS:
================
___ 06:35AM BLOOD WBC-2.8* RBC-4.47* Hgb-14.0 Hct-42.6
MCV-95 MCH-31.3 MCHC-32.9 RDW-14.6 RDWSD-52.0* Plt ___
___ 06:35AM BLOOD Neuts-38.8 ___ Monos-11.0 Eos-5.3
Baso-1.4* Im ___ AbsNeut-1.09* AbsLymp-1.21 AbsMono-0.31
AbsEos-0.15 AbsBaso-0.04
___ 06:35AM BLOOD ___ PTT-34.1 ___
___ 06:35AM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
___ 06:35AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-2.0
___ 06:35AM BLOOD ALT-1654* AST-895* LD(LDH)-361*
AlkPhos-103 TotBili-7.3*
OTHER PERTINENT LABS:
======================
___ 06:13AM BLOOD Lipase-110*
___ 06:13AM BLOOD Smooth-NEGATIVE
___ 06:13AM BLOOD ___
___ 06:13AM BLOOD HIV Ab-Negative
___ 02:00PM BLOOD Acetmnp-NEG
___ 08:58AM BLOOD HCV Ab-Negative
___ 06:13AM BLOOD HCV VL-NOT DETECT
___ 06:13AM BLOOD CMV VL-NOT DETECT
___ 06:13AM BLOOD HBV VL-NOT DETECT
___ 06:13AM BLOOD HIV1 VL-NOT DETECT
URINE STUDIES:
===============
___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-6.0 Leuks-NEG
MICROBIOLOGY:
==============
___ 2:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 2:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
================
___ LIVER/GB ULTRASOUND IMPRESSION:
1. 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.
2. Adenomyomatosis of the gallbladder.
3. No cholelithiasis or cholecystitis.
___
PATHOLOGIC DIAGNOSIS:
Liver, needle core biopsy:
- Portal areas with moderate, predominantly mononuclear
inflammation comprised of lymphocytes
and macrophages along with focally prominent eosinophils.
- Bile ducts with dystrophic change and intraductal lymphocytes.
-Lobules with moderate lymphohistiocytic inflammation, including
within sinusoids, and scattered
eosinophils along with prominent apoptotic hepatocytes and focal
canalicular cholestasis.
-No features of toxic/metabolic injury (steatosis, ballooning
degeneration) are seen prominently in
this biopsy.
-Trichrome stain demonstrates no increase in fibrosis.
-Iron stain shows no stainable iron.
-EBV in-situ and latent membrane protein immunostains are in
progress and will be reported in a
revised report.
Note: Overall, the features of those of a moderately active
hepatitis with associated cholestasis as
well as bile duct damage. The differential diagnosis includes an
acute viral hepatitis (negative
serologies thus far with few pending results), a
drug/supplement/toxin-related liver injury, or least
likely given lack of prominent plasma cells and negative
serologies, an autoimmune hepatitis.
Clinical correlation with special consideration to the patient's
medication (including herbals and OTC
drugs) and ingestion history is recommended.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with ___// eval for PVT, hepatic
architecture
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ abdominal ultrasound
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones. Focal mural thickening of the
gall bladder fundus is consistent with fundal adenomyomatosis.
PANCREAS: The pancreas is incompletely visualized and assessed due to
overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.8 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. 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.
2. Adenomyomatosis of the gallbladder.
3. No cholelithiasis or cholecystitis.
Radiology Report
EXAMINATION: Ultrasound-guided liver biopsy
INDICATION: ___ year old previously healthy man with sudden onset nausea,
anorexia, 10lb weight loss, jaundice, and pruritus. Labs notable to be stably
elevated: ALT 1848, AST 903, Tbili 7.3, lipase 102. Hepatic steatosis was seen
___. Workup so far has been negative.// Etiology for acute hepatitis
COMPARISON: Abdominal ultrasound from ___
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. The liver is diffusely echogenic.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 7 mL 1% lidocaine. Under real-time ultrasound
guidance, an 18 gauge core biopsy needle was then advanced into the liver and
a single core biopsy sample was obtained and placed in formalin. The skin was
then cleaned and a dry sterile dressing was applied. There was no immediate
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated non-targeted liver biopsy.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute viral hepatitis, unspecified
temperature: nan
heartrate: 79.0
resprate: 17.0
o2sat: 100.0
sbp: 134.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male without significant medical
history who presented with a 2-week history of nausea, anorexia,
10lb weight loss, tea-colored urine, and pruritus found to have
transaminitis with AST/ALT ___, Tbili 7.3, Dbili 5.2, IBil
2.1. Ultrasound revealed only hepatic steatosis. Laboratory
workup was unrevealing. He subsequently underwent liver biopsy
on ___. Tolerated the procedure well. Discharged home on ___
with follow-up with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Keflex / Penicillins / Dicloxacillin / Morphine / Compazine /
Reglan / Amicar / Verapamil / Ambien / Valtrex / Percocet /
Vibramycin / doxycycline / Demerol / adhesive / Creon / Geodon /
Amitiza / Neurontin / dronabinol / lactulose
Attending: ___
Chief Complaint:
Vertigo, diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old woman with a history of
antiphospholipid antibody syndrome on warfarin, epilepsy on
Lamictal, migraine headaches and end-stage renal disease on
hemodialysis who presents with gait unsteadiness, vertigo,
oscillopsia and diplopia.
Patient is followed very closely by Dr. ___ her history of
antiphospholipid antibody syndrome. She has multiple neurologic
complaints and has been seen in the emergency room numerous
times
for variants of the above symptoms.
Today, she reports waking up and feeling well at 6:30 AM.
Around
730, she noticed gradual onset unsteadiness when walking around
getting ready for work. She also noted vertiginous symptoms
like
things are moving around her. This has happened in the past so
she took meclizine which did not help her symptoms. Her eyes
"jumping around" and she felt confused, like she could not
complete tasks. For example, she tried turning off the computer
could not think of the steps in order to do it. She also felt
like she had problems with her memory. She felt like her right
hand was shaking and had difficulty typing, hitting a key she
wanted to hit multiple times. Her symptoms continued to
progress
over the course in the morning though she was able to go to
work.
At some point, she noticed horizontal double vision and closed
one eye and things improved. She did note that the vertiginous
symptoms continued throughout the day, would worsen with head
movement but still be present when standing still. Her last
episode of vertigo was a few months ago. She does note that she
tends to get vertiginous symptoms on days of dialysis. She was
supposed to go to dialysis this afternoon, but instead she
called
her nephrologist reporting that her symptoms are unmanageable
and
she had to go to the emergency department.
She was hospitalized last week for a vulvar infection, for which
she was started on initially vancomycin and then levofloxacin.
Otherwise there have been no new medications.
Regarding her neurologic history, she is seen by somebody from
neurology either inpatient or outpatient at least once every 2
months for various complaints. Most recently, she was evaluated
by Dr. ___ on ___ for visual disturbances,
headache and neck pain. The neck pain was felt to be
musculoskeletal in origin and she was advised to wear a soft
collar. It was thought that the neck pain was triggering her
migraines. Given the history of images jumping around, the
etiology of her visual disturbances was thought to be
oscillopsia
from an underlying vestibular disorder.
Currently, patient feels "way off my baseline."
On neuro ROS, the pt denies headache, loss of vision,
dysarthria,
dysphagia, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills.
Past Medical History:
- Migraine headaches
- SLE with antiphospholipid antibody syndrome
- history of DVT
- depression and anxiety
- seizure disorder
- Raynaud's phenomenon
- gastritis, GERD
- glaucoma
- Thrombotic microangiopathy s/p failed renal transplant in ___
- ___ deficiency
- OSA on CPAP (auto CPAP ___ with 50 mL EERS and 2L NC)
- bipolar disorder
- H/o malignant HTN c/b hypertensive encephalopathy and PRES
- Hyperlipidemia
- s/p TAH-BSO at 43 for heavy menses and bleeding ovarian cysts
- H/o tardive dyskinesia
Social History:
Per last ___ summary "No alcohol, tobacco or drug use. Works as
___ ___ 3 hr/day. Lives alone, has help with grocery
shopping, cleaning. Cooks for herself, self bathes, self
dresses. Sister, ___, is HCP."
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[x] 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:
Father with anti-phospholipid syndrome, HTN, DM.
Sister with MS.
___ siblings with asthma, HTN.
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam:
Vitals: T: 97.7 P: 68 R: 16 BP: 136/72 SaO2: 96%
General: Awake, cooperative, NAD, she has backed multiple bags
for the possibility of admission.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. 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.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus, though reports horizontal diplopia with near vision.
She also reports horizontal diplopia L > R extremes. The inside
image disappears when she closes her right eye. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Decreased hearing on the right ear
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, proprioception throughout.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was withdrawal bilaterally.
-Coordination: L > R end intention tremor versus mild dysmetria.
Normal finger-tap bilaterally.
-Gait: Needs assistance getting out of bed. Takes a few narrow
based steps, but very hesitant, will not walk without 1 person
assist.
==============
DISCHARGE EXAM
==============
-GEN: Awake in bed, NAD
-HEENT: NC/AT
-NECK: Supple
-CV: Well perfused.
-PULM: Breathing comfortably on room air.
-ABD: Soft, NT/ND.
-EXT: Warm, well-perfused. No clubbing, cyanosis, or edema.
Jaundiced.
-MS: A&Ox4. Language fluent. Able to recount entire history
without difficulty.
-CN: PERRL ___. EOMI. Complains of diplopia on left, right, and
upgaze. No diplopia in primary position, or downgaze. No
dysarthria. Face symmetric.
-MOT: No drift, no rebound. No asterexis.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-___: Symmetric on arms and legs.
-COORD: FNF intact and with good speed. Rapid finger tapping
with good speed bilaterally.
-GAIT: Narrow-based, small steps, stable. Able to walk
comfortably.
Pertinent Results:
====
LABS
====
___ 02:59PM BLOOD WBC-3.9* RBC-2.82* Hgb-8.9* Hct-29.3*
MCV-104* MCH-31.6 MCHC-30.4* RDW-17.1* RDWSD-62.8* Plt ___
___ 06:06AM BLOOD WBC-3.6* RBC-2.98* Hgb-9.2* Hct-30.4*
MCV-102* MCH-30.9 MCHC-30.3* RDW-17.0* RDWSD-61.8* Plt ___
___ 07:49AM BLOOD WBC-4.1 RBC-2.93* Hgb-9.5* Hct-29.6*
MCV-101* MCH-32.4* MCHC-32.1 RDW-16.9* RDWSD-62.2* Plt ___
___ 02:59PM BLOOD Neuts-69 Bands-0 Lymphs-14* Monos-8 Eos-6
Baso-0 ___ Metas-3* Myelos-0 AbsNeut-2.69 AbsLymp-0.55*
AbsMono-0.31 AbsEos-0.23 AbsBaso-0.00*
___ 07:49AM BLOOD Neuts-66 Bands-1 ___ Monos-5 Eos-4
Baso-1 ___ Myelos-1* AbsNeut-2.75 AbsLymp-0.90*
AbsMono-0.21 AbsEos-0.16 AbsBaso-0.04
___ 02:59PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
___ 07:49AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear
___
___ 10:25PM BLOOD ___ PTT-45.7* ___
___ 06:06AM BLOOD ___ PTT-44.8* ___
___ 07:49AM BLOOD ___ PTT-46.4* ___
___ 02:59PM BLOOD Glucose-85 UreaN-61* Creat-6.8*# Na-133
K-5.9* Cl-96 HCO3-19* AnGap-24*
___ 10:25PM BLOOD Glucose-68* UreaN-67* Creat-7.4* Na-131*
K-6.0* Cl-96 HCO3-19* AnGap-22*
___ 06:06AM BLOOD Glucose-68* UreaN-75* Creat-7.7* Na-131*
K-5.7* Cl-95* HCO3-18* AnGap-24*
___ 07:49AM BLOOD Glucose-80 UreaN-75* Creat-8.2* Na-131*
K-5.6* Cl-94* HCO3-20* AnGap-23*
___ 02:59PM BLOOD ALT-12 AST-26 AlkPhos-175* TotBili-0.3
___ 06:06AM BLOOD CK-MB-<1 cTropnT-0.02*
___ 02:59PM BLOOD Albumin-3.2* Calcium-9.0 Phos-4.3 Mg-3.6*
___ 06:06AM BLOOD Calcium-8.8 Phos-4.7* Mg-3.7* Cholest-86
___ 07:49AM BLOOD Calcium-8.7 Phos-4.9* Mg-3.6*
___ 06:06AM BLOOD %HbA1c-4.2 eAG-74
___ 06:06AM BLOOD Triglyc-184* HDL-25 CHOL/HD-3.4
LDLcalc-24
___ 02:59PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:00PM BLOOD K-5.5*
___ 10:42PM BLOOD K-5.9*
=======
IMAGING
=======
- ___ CTA Head & Neck
1. No evidence for acute intracranial abnormalities.
2. Chronic bilateral sphenoid sinusitis and chronic small mucous
retention cyst in the right posterior ethmoid. Chronic near
complete opacification of the right mastoid air cells and
partial opacification of the right middle ear cavity. Please
correlate with any associated active symptoms.
3. No evidence for flow-limiting stenosis in the cervical or
major
intracranial arteries.
4. Partially visualized small bilateral pleural effusions with
adjacent atelectasis. Partially visualized ground-glass
opacities with perihilar predominance in the upper lobes are
suggestive of pulmonary edema, but infectious etiology is not
excluded. Small peripheral ground-glass opacities in the
anterior right lower lobe are nonspecific. These abnormalities
are new compared to the ___. Extensive mediastinal and hilar lymphadenopathy is again
partially
visualized. Prominent supraclavicular and bilateral cervical
lymph nodes are not significantly changed compared to the
___tiology of lymphadenopathy cannot be
determined on this exam.
RECOMMENDATION(S):
1. MRI would be more sensitive for an acute infarction, if
clinically
warranted.
2. Consider follow-up chest CT in 3 months, if clinically
warranted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Calcitriol 1 mcg PO 3X/WEEK (___)
4. Docusate Sodium 300 mg PO BID
5. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
6. LamoTRIgine 200 mg PO BID
7. Levofloxacin 500 mg PO Q48H
8. macitentan 10 mg oral DAILY
9. Meclizine 12.5 mg PO Q12H:PRN dizziness
10. Mupirocin Ointment 2% 1 Appl TP QID:PRN rash
11. Ondansetron 8 mg PO BID nausea
12. Ranitidine 300 mg PO QHS
13. RESTASIS 1 drop ophthalmic BID
14. Senna 17.2 mg PO BID:PRN constipation
15. sevelamer CARBONATE 2400 mg PO TID W/MEALS
16. sevelamer CARBONATE 1600 mg PO ONCE DAILY W/ SNACK
17. Sildenafil 20 mg PO TID
18. Sucralfate 1 gm PO QID
19. TraZODone 200 mg PO 3X/WEEK (___)
20. TraZODone 100 mg PO 4X/WEEK (___)
21. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Calcitriol 1 mcg PO 3X/WEEK (___)
5. Docusate Sodium 300 mg PO BID
6. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
7. LamoTRIgine 200 mg PO BID
8. macitentan 10 mg oral DAILY
9. Meclizine 12.5 mg PO Q12H:PRN dizziness
10. Mupirocin Ointment 2% 1 Appl TP QID:PRN rash
11. Ondansetron 8 mg PO BID nausea
12. Ranitidine 300 mg PO QHS
13. RESTASIS 1 drop ophthalmic BID
14. Senna 17.2 mg PO BID:PRN constipation
15. sevelamer CARBONATE 2400 mg PO TID W/MEALS
16. sevelamer CARBONATE 1600 mg PO ONCE DAILY W/ SNACK
17. Sildenafil 20 mg PO TID
18. Sucralfate 1 gm PO QID
19. TraZODone 200 mg PO 3X/WEEK (___)
20. TraZODone 100 mg PO 4X/WEEK (___)
21. Warfarin 3 mg PO DAILY16
22.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Diplopia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with dizziness, vision changes. Evaluate for
stroke. The patient has chronic renal failure on hemodialysis.
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 Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 4.8 s, 37.8 cm; CTDIvol = 11.4 mGy (Body) DLP = 430.0
mGy-cm.
3) Spiral Acquisition 5.0 s, 39.0 cm; CTDIvol = 11.4 mGy (Body) DLP = 442.6
mGy-cm.
4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 33.0 mGy (Body) DLP =
16.5 mGy-cm.
Total DLP (Body) = 897 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: ___ brain MRI.
___ head CT.
___ brain MRI/brain MRA/neck MRA.
___ chest CT.
___ neck CT.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no acute hemorrhage, edema, mass effect, or CT evidence for an acute
major vascular territorial infarction. Mild to moderate periventricular and
deep white matter hypodensities are nonspecific but likely sequela of chronic
small vessel ischemic disease in this age group. There is mild global
parenchymal volume loss with associated prominence of the ventricles and
sulci.
There is an unchanged mucous retention cyst in the air right posterior ethmoid
air cell on image 3:230. There is dependent polypoid material an bilateral
sphenoid sinuses, which is unchanged on the left compared to ___,
suggesting combination of mucous retention cysts and secretions, but shifted
in location since ___ on the right, suggesting secretions.
Thickening of the sphenoid sinus walls and sphenoid septum indicates sequela
of chronic inflammation. There is near complete opacification of right
mastoid air cells, unchanged since ___. Partial opacification of
the right middle ear cavity was probably present previously, but is better
seen currently due to thinner slices. Left mastoid air cells and left middle
ear cavity appear well-aerated.
CTA NECK:
There is a 3 vessel aortic arch. There is calcified plaque in bilateral
proximal subclavian arteries without evidence for significant narrowing.
There is minimal calcified plaque in bilateral proximal internal carotid
arteries without stenosis by NASCET criteria. Streak artifact from dental
amalgam limits evaluation of mid to distal cervical internal carotid and
distal cervical vertebral arteries bilaterally. Vertebral arteries otherwise
demonstrate no evidence for flow-limiting stenosis.
CTA HEAD:
There is calcified plaque in bilateral carotid siphons without evidence for
flow-limiting stenosis. There is no evidence for flow-limiting stenosis or
aneurysm elsewhere in the major intracranial arteries. The dural venous
sinuses are patent.
OTHER:
Small bilateral pleural effusions are partially visualized, new since the ___ chest CT. There is mild dependent atelectasis, mostly in the
included superior segments of the lower lobes. Ground-glass opacities with
perihilar predominance in the included upper lobes are suggestive of pulmonary
edema, though infectious etiology is not excluded. Small peripheral
ground-glass opacities in the anterior right lower lobe, 9 mm on image 4:1 and
10 mm on image 4:8, are new compared to the ___ chest CT; they are
nonspecific and could be related to pulmonary edema or infection. 3.5 mm
nodule in the right minor fissure on image 4:12 is unchanged compared to the
prior chest CT.
There is extensive mediastinal and hilar lymphadenopathy, as seen on the prior
chest CT. Supraclavicular lymph nodes measure up to 8 mm in long axis on the
right and 7 mm on the left (images 4:132, 4:139), not dramatically changed
compared to the ___ neck CT. Cervical lymph nodes are prominent
bilaterally, up to 15 mm at level 2a on the left (top-normal, image 4:167),
10 mm at level 2b on the left (top-normal, image 4:161), and 11 mm at level 5
on the left (minimally enlarged, image 4:165), minimally changed compared to
the ___ neck CT.
No focal thyroid lesions are detected.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. Chronic bilateral sphenoid sinusitis and chronic small mucous retention
cyst in the right posterior ethmoid. Chronic near complete opacification of
the right mastoid air cells and partial opacification of the right middle ear
cavity. Please correlate with any associated active symptoms.
3. No evidence for flow-limiting stenosis in the cervical or major
intracranial arteries.
4. Partially visualized small bilateral pleural effusions with adjacent
atelectasis. Partially visualized ground-glass opacities with perihilar
predominance in the upper lobes are suggestive of pulmonary edema, but
infectious etiology is not excluded. Small peripheral ground-glass opacities
in the anterior right lower lobe are nonspecific. These abnormalities are new
compared to the ___ chest CT.
5. Extensive mediastinal and hilar lymphadenopathy is again partially
visualized. Prominent supraclavicular and bilateral cervical lymph nodes are
not significantly changed compared to the ___ neck CT. Etiology of
lymphadenopathy cannot be determined on this exam.
RECOMMENDATION(S):
1. MRI would be more sensitive for an acute infarction, if clinically
warranted.
2. Consider follow-up chest CT in 3 months, if clinically warranted.
NOTIFICATION: Impression items 1 and 3 were included in a wet read by a
radiology resident at the time of the exam. The entire impression and
recommendations above were entered by Dr. ___ on ___ at 15:04
into the Department of Radiology critical communications system for direct
communication to the referring provider.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Visual changes
Diagnosed with Dizziness and giddiness
temperature: 97.7
heartrate: 68.0
resprate: 19.0
o2sat: 96.0
sbp: 136.0
dbp: 72.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ presented with dizziness, gait instability, and
double vision that were concerning for stroke. CTA was normal.
Her symptoms improved to baseline after dialysis. She was
cleared by ___. No changes were made. She has had similar
presentation and workup for it multiple times. She should
continue her outpatient regimen, including her warfarin
according to her treating physicians recommendations.
- CTA revealed mall apical bilateral pleural effusions with
adjacent
atelectasis and ground glass opacities. Recommended follow-up CT
in 3 months.
- Continue home medications. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / Flaxseed
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparascopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ year old female with history of gallstones
and DM type 2 who presents with right upper quadrant pain
radiating to her back. The pain began the evening of ___
___ an hour after eating a meal of rice and cheese cake. The
pain persisted through the night, preventing her from sleeping.
She vomited 6 times on ___ at which point the pain subsided,
and she was pain free until ___. She reported no blood in her
vomit. ___ evening she at a meal consisting of fish at 6 ___
and her RUQ abdominal pain started at 7 ___. She rated the pain
___ at that time and could not find any position that relieved
the pain. She took Motrin for the pain that mildly reduced the
pain, which was a ___ upon arrival to ED. She denies any
diarrhea, dizziness, fever or chills in the past 3 days.
Past Medical History:
Past Medical History:
-Reactive follicular hyperplasia and progressive transformation
of germinal centers (PTGC). Dx ___
-Type 2 Diabetes Mellitus
-Hypertension
-Cholelithiasis
Past Surgical History:
-Right axillary lymph node biopsy ___
Social History:
___
Family History:
Mother - ___ and HTN
Father - HTN
Physical ___:
On admission:
Vitals: Temp 97, HR 96, BP 157/94, RR 14, SpO2 100% RA
GEN: A&O, NAD, shifted position multiple times due to pain
HEENT: No scleral icterus, mucus membranes moist, PERRL
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R, resonant to
percussion
bilaterally
ABD: Soft, distended. TTP in RUQ without rebound or guarding.
Negative ___ sign. Normoactive bowel sounds, no palpable
masses.
Ext: No ___ edema, ___ warm and well perfused, 3+ dorsalis pedis
pulses bilaterally.
Pertinent Results:
___ 02:37AM BLOOD WBC-8.1 RBC-4.96 Hgb-10.7* Hct-36.4
MCV-73* MCH-21.6* MCHC-29.4* RDW-15.7* Plt ___ Neuts-63.3
___ Monos-2.3 Eos-1.7 Baso-0.6 Glucose-135* UreaN-20
Creat-0.8 Na-140 K-3.4 Cl-104 HCO3-24 AnGap-15 ALT-12 AST-26
AlkPhos-92 TotBili-0.5 Lipase-22 Albumin-4.4 Lactate-0.8
___ LIVER OR GALLBLADDER US (SINGLE ORGAN):
IMPRESSION:
Preliminary Report1. Tensely distended gallbladder with two
stones, one of which may be impacted the gallbladder neck.
Findings are equivocal for cholecystitis and correlation with
lab evaluation and exam findings is recommended. If clinically
indicated, HIDA can be obtained for further assessment.
Echogenic liver compatible with fatty deposition. Other forms of
liver disease including advanced hepatic fibrosis/cirrhosis
cannot be excluded on this study.
Medications on Admission:
lisinopril 20', metformin ER 500', aspirin 81'
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose bowel movements.
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain: may cause increased drowsiness, avoid
driving while on this medication.
Disp:*20 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with known gallstones and right upper quadrant
pain without fever, assess for symptomatic cholelithiasis versus
cholecystitis.
COMPARISONS: ___.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is mildly echogenic, which may
reflect fatty deposition. There is no intra- or extra-hepatic biliary ductal
dilatation. The main portal vein is patent with hepatopetal flow. The common
duct measures 4 mm. The gallbladder is tensely distended without mural edema
or pericholecystic fluid. Two gallstones are seen measuring up to 1.7 cm.
One may be impacted in the gallbladder neck. Sonographic ___ sign was
unreliable in the setting of pain medication. The pancreas appears
unremarkable, though the distal body and tail are not well seen.
IMPRESSION:
1. Tensely distended gallbladder with two stones, one of which may be impacted
in the gallbladder neck. Findings are equivocal for cholecystitis and
correlation with lab evaluation and exam findings is recommended. If
clinically indicated, HIDA can be obtained for further assessment.
2. Echogenic liver compatible with fatty deposition. Other forms of liver
disease including advanced hepatic fibrosis/cirrhosis cannot be excluded on
this study.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with CHOLELITH W AC CHOLECYST, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 97.0
heartrate: 96.0
resprate: 14.0
o2sat: 100.0
sbp: 157.0
dbp: 94.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the Acute Care Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed a tensely distended
gallbladder with two stones, one of which may have impacted the
gallbladder neck, equivocal for cholecystitis. The patient was
subsequently placed on bowel rest, given intravenous fluids,
pain medication and Unasyn. The patient subsequently underwent
laparoscopic cholecystectomy, which went well without
complication; please see operative note for details. After a
brief, uneventful stay in the recovery room, the patient was
transferred to the general surgical ward for further
observation.
Post-operatively, pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet and well
tolerated. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirrometry, 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 on POD1, 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:
Lipitor / Deodorized Tincture of Opium
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Metastatic colon cancer (s/p right colectomy, right
heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___, Rectal
Wall dehiscence (c/b presacral abscess s/p ___ drain then
upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on
lovenox), who presents with vomiting found to have SBO
As per review of notes, patient recently with rectal wall
dehiscence with presacral abscess s/p ___ drain (___) and
upsizing x2 (___). She has been on vanc/cipro/flagyl at
home, followed by OPAT, with plan to hold chemotherapy until she
is off antibiotics (scheduled to stop ___.
On this admission, patient was very tired and refused to speak
at
length about her presentation. She noted that she was tired and
wanted to go to sleep so would not speak in depth. She did
however note that she had vomiting and no ostomy output at home,
without any abdominal pain, so presented to ED. She noted that
she felt slightly improved s/p NGT. She noted that sacral drain
has not had significant output. She noted that she was without
fever or chills. She noted that she had been tolerating her
antibiotics without issue.
In the ED, initial vitals: 98.1 103 123/84 18 100% RA. CBC with
WBC 7.6, Hgb 9.5, plt 1215, CHEM with HCO# 19 lactate wnl, AP
384
other LFTS ok, Alb 2.8. Lower extremity duplex of left was
negative for DVT. CT A/P revealed:
1. Small-bowel obstruction with transition point in ileal loops
in the right lower quadrant. No evidence of perforation or
ischemia. Small amount of free fluid.
2. Persistent dehiscence of the posterior rectal wall with
slight
interval decrease in associated presacral air and fluid
collection containing a percutaneous drain.
3. Moderate to severe right-sided hydronephrosis and hydroureter
which extends the level of the presacral collection. Degree of
hydroureter appears similar compared to the previous exams.
4. Interval increase in size of pulmonary metastases. Change in
the size of hepatic metastases is difficult to assess.
5. Small right greater than left pleural effusions.
Colorectal surgery was consulted, NGT was placed with feculent
material which came out. They noted that given malignant
progression documented in pulm metastases, that obstruction was
likely malignant and rec'd goals of care, medical management,
with possible venting GTube if it didn't resolve. They noted
that
surgical mgmt would only further delay chemotherapy and
therefore
would not be useful to patient. She was then given morphine,
Zofran, cipro, lovenox, Compazine and admitted to oncology.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IV colon cancer (liver mets) s/p 3 cycles of FOLFOX
neoadjuvant chemotherapy followed by hepatic/colonic resection
at
___ on ___ and then completed adjuvant FOLFOX for a total
of 12 cycles ___. On ___, Dr. ___ reported she had a
CT scan at ___, small old met noted and portal vv thrombosis
noted. He recommends RFA after chemo completed since resection
will be difficult. She underwent RFA ___ at ___. CEA was
normal preop but then started to rise once recurrence noted. PET
___ shows FDG avid at liver resection margin and the pelvic
mass - maybe resectable but would be extensive surgery including
vagina. Repeat ___ scan confirm response to chemotherapy. She
received C10 FOLFIRI/neulasta on ___ then admitted for
fever/Cdiff/neutorpenia so surgery postponed. In ___, the
rectosigmoid mass is stable and resectable and Dr ___
not
want to subject her to a big surgery if her small lung nodules
are mets that growing. They are too small to biopsy and PET
likely will be unhelpful due to the small size. She ultimately
underwent extensive resection with close margin. CT abd/pelvis
___ was neg for mets and CEA is normal and started xeloda/RT.
Cont xeloda/RT - finishes ___ and then have boost to vag. In
___, her PET showed recurrent disease. She has multiple
liver mets and likely lung mets. She has been on ___
since
then.
PAST MEDICAL HISTORY:
- Metastatic Colon Cancer, as above
- CAD s/p STEMI s/p ___ with stent placement
- Hypothyroidism
- Osteoporosis
- ___ Syndrome
- Eosinophilic Esophagitis
- Dysphagia with distal esophageal stricture which is
periodically dilated
- Hypertension
- Hyperlipidemia
- Fatty Liver Disease
- Toe Fracture
- s/p right hemicolectomy and R hepatic lobectomy ___ (Drs.
___ ___
- s/p right port-a-cath placement
- s/p right Colles' fracture repair ___
Social History:
___
Family History:
Grandmother had leukemia and urethral cancer.
Mother had skin cancer. Great aunt had colon cancer. Uncle had
bladder cancer.
Physical Exam:
Exam on Admission
=====================
Vitals: 24 HR Data (last updated ___ @ 2205)
Temp: 98.5 (Tm 98.5), BP: 117/75, HR: 99, RR: 16, O2 sat:
98%, O2 delivery: RA, Wt: 112 lb/50.8 kg
GENERAL: laying in bed, appears very tired, awakens to voice but
then closes her eyes and attempts to refuse answering questions
EYES: patient would not participate with exam
HEENT: OP clear, NGT in nare with feculent material in tubing
NECK: supple
LUNGS: CTA anteriorly as would not sit up, no
wheezes/rales/rhonchi, normal RR
CV: RRR normal distal perfusion, no murmurs heard
ABD: Soft, Has mild diffuse tenderness, was noted to have liquid
in ostomy bag, and when I palpated her abdomen a significant
amount of formed stool started emanating from ostomy, hypoactive
BS, NGT with feculent material being suctioned, sacral drain
with
small amt of green fluid
GENITOURINARY: no foley
EXT: warm, dry, thin extremities with poor muscle bulk
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: PORT in right chest, dressing c/d/I
.
Exam on discharge:
======================
24 HR Data (last updated ___ @ 938)
Temp: 98.3 (Tm 99.2), BP: 97/63 (92-104/58-65), HR: 89
(89-102), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: Ra,
Wt: 117.5 lb/53.3 kg
GENERAL: laying in bed, in NAD
EYES: No scleral icterus, PERRL bilaterally
HEENT: OP clear. MMM.
NECK: supple
LUNGS: CTAB, no wheezes/rales/rhonchi, normal RR
CV: RRR normal s1 and s2, no murmurs
ABD: Soft, minimally tender, liquid/formed green/brown stool in
ostomy bag
EXT: warm, dry, thin extremities with poor muscle bulk
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: PORT in right chest, dressing c/d/i
Pertinent Results:
ADMISSION
=========
___ 11:40AM BLOOD WBC-7.6 RBC-3.35* Hgb-9.5* Hct-30.0*
MCV-90 MCH-28.4 MCHC-31.7* RDW-18.4* RDWSD-59.9* Plt ___
___ 11:40AM BLOOD Neuts-91.1* Lymphs-3.3* Monos-4.8*
Eos-0.1* Baso-0.0 Im ___ AbsNeut-6.89* AbsLymp-0.25*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.00*
___ 04:33AM BLOOD ___ PTT-40.4* ___
___ 11:40AM BLOOD Glucose-91 UreaN-10 Creat-1.1 Na-135
K-4.5 Cl-101 HCO3-19* AnGap-15
___ 11:40AM BLOOD ALT-11 AST-26 AlkPhos-384* TotBili-0.3
___ 11:40AM BLOOD Albumin-2.8* Calcium-8.8 Phos-4.2 Mg-1.8
___ 11:55AM BLOOD Lactate-1.3
.
DISCHARGE
=========
___ 02:40PM BLOOD WBC-5.3 RBC-2.81* Hgb-8.0* Hct-25.1*
MCV-89 MCH-28.5 MCHC-31.9* RDW-17.8* RDWSD-57.1* Plt ___
___ 04:33AM BLOOD Neuts-81.6* Lymphs-8.7* Monos-8.2
Eos-0.6* Baso-0.2 Im ___ AbsNeut-4.40 AbsLymp-0.47*
AbsMono-0.44 AbsEos-0.03* AbsBaso-0.01
___ 02:40PM BLOOD Plt ___
___ 05:07AM BLOOD Glucose-88 UreaN-6 Creat-0.9 Na-133*
K-3.6 Cl-102 HCO3-19* AnGap-12
___ 04:33AM BLOOD ALT-9 AST-20 CK(CPK)-39 AlkPhos-393*
TotBili-0.2
___ 05:07AM BLOOD Calcium-7.5* Phos-2.1* Mg-1.7
.
MICRO
======
___ BCx - pending
.
IMAGING
========
Duplex LLE ___: Negative for DVT
.
CT A/P w/ contrast ___. Small-bowel obstruction with transition point in ileal loops
in the right lower quadrant. No evidence of perforation or
ischemia. Small amount of free fluid.
2. Persistent dehiscence of the posterior rectal wall with
slight interval
decrease in associated presacral air and fluid collection
containing a
percutaneous drain.
3. Moderate to severe right-sided hydronephrosis and hydroureter
which extends the level of the presacral collection. Degree of
hydroureter appears similar compared to the previous exams.
4. Interval increase in size of pulmonary metastases. Change in
the size of hepatic metastases is difficult to assess.
5. Small right greater than left pleural effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cholestyramine 4 gm PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
6. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. Vitamin E 400 UNIT PO DAILY
10. Tamsulosin 0.4 mg PO DAILY
11. Morphine SR (MS ___ 30 mg PO Q12H
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Enoxaparin Sodium 80 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
15. MetroNIDAZOLE 500 mg PO Q8H
16. Ciprofloxacin HCl 500 mg PO Q12H
17. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
18. Potassium Chloride 20 mEq PO DAILY
19. Magnesium Oxide 400 mg PO BID
20. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
21. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
22. Daptomycin 600 mg IV Q24H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s)
by mouth daily Disp #*1 Package Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Daptomycin 300 mg IV Q24H
RX *daptomycin 500 mg 0.6 bag IV daily Disp #*14 Vial Refills:*0
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours
Disp #*30 Tablet Refills:*0
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Cholestyramine 4 gm PO BID
11. Ciprofloxacin HCl 500 mg PO Q12H
12. Cyanocobalamin 1000 mcg PO DAILY
13. Enoxaparin Sodium 80 mg SC DAILY
14. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
15. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
16. Magnesium Oxide 400 mg PO BID
17. Morphine SR (MS ___ 30 mg PO Q12H
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Omeprazole 20 mg PO DAILY
20. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
21. Potassium Chloride 20 mEq PO DAILY
22. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
23. Rosuvastatin Calcium 40 mg PO QPM
24. Tamsulosin 0.4 mg PO DAILY
25. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Small bowel obstruction
Secondary
Metastatic colorectal cancer
DVT
rectal wall dehiscence
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: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with LLE swelling// evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Small amount of soft
tissue edema is seen in the leg.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: NO_PO contrast; History: ___ with history of rectal cancer,
status post colostomy, also with intra-abdominal abscess now with abdominal
pain and no output from colostomy to for the last 1.5 days NO_PO contrast//
Elevated for abscess, obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 9.4 mGy (Body) DLP = 473.8
mGy-cm.
Total DLP (Body) = 486 mGy-cm.
COMPARISON: CT pelvis ___
CT abdomen pelvis ___
Chest CT ___
PET-CT ___
FINDINGS:
LOWER CHEST: Small left greater than right bilateral pleural effusions. Mild
compressive atelectasis at the left base. There are several pulmonary nodules
in the right lower lobe measuring up to 11 mm (2:1, 2:7, 2:16), larger
compared to prior PET-CT. Tip of the catheter is seen terminating in the
right atrium. Moderate coronary artery atherosclerotic calcifications are
noted. Trace pericardial fluid likely physiologic.
ABDOMEN:
HEPATOBILIARY: Status post right hepatectomy. A 1.6 cm hypoenhancing lesion
in the caudate lobe (02:22) and a 1.5 cm hypoenhancing lesion in segment 2
(02:20) as well as a 2.1 cm hypoenhancing lesion in segment 3 (02:31) are
present on prior PET-CT, though size comparison is difficult given absence of
contrast on that study. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is surgically absent. Small amount of
perihepatic fluid is new in the interval.
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. Few calcifications within spleen are suggestive of
prior granulomatous disease.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is moderate to severe right-sided hydronephrosis and
hydroureter which extends to the level of the presacral collection described
below. Moderate right hydroureter is similar to that seen on prior CT pelvis.
There is delayed nephrogram on the right side. No evidence of focal lesions.
No perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. Stomach is otherwise unremarkable.
Proximal small bowel loops are diffusely dilated and fluid-filled measuring up
to 4.0 cm. There is transition to decompressed small bowel in ileal loops in
the right hemipelvis (601:30) compatible with a small bowel obstruction. Loop
ileostomy is noted in the right lower quadrant of the abdomen in a patient
status post right colectomy. Loss of definition and enhancement of the
posterior rectal wall is similar to prior exam and consistent with history of
dehiscence. An adjacent curvilinear collection containing air and fluid in
the presacral space is difficult to measure wall, but measures approximately
7.9 x 1.6 cm, and appears slightly decreased in size compared to the prior
exam. A right gluteal approach terminates in unchanged position in this
collection. There is trace mesenteric free-fluid.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The uterus is not visualized. There is no adnexal
abnormalities.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. IVC filter is noted in place.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Sacroplasty material is noted.
SOFT TISSUES: Right lower quadrant loop ileostomy is noted. There is mild
diffuse subcutaneous edema.
IMPRESSION:
1. Small-bowel obstruction with transition point in ileal loops in the right
lower quadrant. No evidence of perforation or ischemia. Small amount of free
fluid.
2. Persistent dehiscence of the posterior rectal wall with slight interval
decrease in associated presacral air and fluid collection containing a
percutaneous drain.
3. Moderate to severe right-sided hydronephrosis and hydroureter which extends
the level of the presacral collection. Degree of hydroureter appears similar
compared to the previous exams.
4. Interval increase in size of pulmonary metastases. Change in the size of
hepatic metastases is difficult to assess.
5. Small right greater than left pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NG tube placed for ?SBO// please confirm
placement of NG tube please confirm placement of NG tube
IMPRESSION:
Comparison to ___. The patient has received a feeding tube. The
course of the tube is unremarkable, the tip of the tube projects over the
central stomach. No complications, notably no pneumothorax. Stable position
of the right Port-A-Cath. Visualization of a vena cava filter.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Other specified soft tissue disorders, Unspecified abdominal pain
temperature: 98.1
heartrate: 103.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 84.0
level of pain: 5
level of acuity: 2.0 | ___ PMH of Metastatic colon cancer (s/p right colectomy, right
heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___, Rectal
Wall dehiscence (c/b presacral abscess s/p ___ drain then
upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on
lovenox), who presents with vomiting found to have SBO, reoslved
with 24 hours bowel rest.
#SBO
Patient with vomiting and lack of ostomy output at home with
imaging on admission consistent with small bowel obstruction,
surgery consulted, without acute complication requiring surgical
intervention. Made NPO, NG placed. Ostomoy output resumed fairly
quickly, NG tube removed, advanced diet slowly which was
tolerated well. Patient had some episodes of hypoglycemia which
resolved after resuming full diet.
#Anemia
Hb downtrended from 9.5 on admission to 7.1 on ___ AM. There was
some cncern about blood clots from NGT. However, Hgb stabilized,
and patient did not require transfusion.
#Chronic Malignant Pain
Symptoms at baseline. Transitioned to IV morphine given NPO
status, but then resumed home dose. Also started standing bowel
regimen. Slightly down-titrated oxycodone dose given SBO/?ileus
at discharge.
#Metastatic colon cancer (s/p right colectomy, right heparin
lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___ As per
Dr ___ recent note, was to have restaging after Abx
complete, as she is considering restarting FOLFOX at that time.
However, now CT with increased pulm mets, which will need to be
communicated to her oncologist
#Rectal Wall dehiscence
CT A/P on admission revealed persistent dehiscence of the
posterior rectal wall with slight interval decrease in
associated
presacral air and fluid collection. Having 50cc daily output
from
JP. Continued daptomycin, cipro, flagyl through ___. Daptomycin
dose was adjusted from 600mg daily to 300mg daily per OPAT.
#Right leg DVT (s/p IVC filter, on lovenox)
-Continued once daily lovenox
#Hypothyroidism
-Continued synthroid
Transitional Issues
[] increased size of pulmonary mets seen on CT AP
[] Please continue on standing bowel regimen to prevent SBO in
the
setting of chronic opioid use.
[] oxycodone dose reduced from ___ to 2.5mg-5mg while patient
was in the hospital with good pain control. Please assess
whether increased dose is needed
[] Daptomycin dose reduced from 600mg to 300mg daily per OPAT.
Patient to continue antibiotics through ___.
[] Consider removal of JP drain if persistent low output
#HCP/Contact: Mother ___ ___
#Code: Full confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a h/o provoked
post-surgical PE in ___ (negative thrombophilia w/u,
anti-coagulated for 6 mo), presenting with 2 days of worsening
substernal chest pain.
One week prior to admission, she underwent superficial venectomy
for painful veins. She did well post-operatively, but this
___, two days prior to admission, she followed up in
clinic where she had LENIs that showed 3 DVTs in her LLE
(operative leg). Per the patient, she was sent home on asa 325
po qd despite her positive history for PE. On ___, after
returning home from clinic, she then noticed the gradual onset
of substernal chest pain that felt somewhat like heartburn. This
progressed and though she does not subjectively endorse SOB, her
family feels like she has been panting when walking. She
otherwise denies leg swelling or tenderness, low grade fever,
chills, abd pain or dysuria.
On arrival to the ED:
- Initial vitals were 99 82 128/68 20 100% RA
- Labs revealed nl lytes, CBC and coags
- CTA Chest demonstrated RML, RLL and LLL segmental partially
occlusive PEs. No signs of right heart strain.
- She was given 70 mg SC Lovenox per weight based protocol and
admitted to the floor for further management.
Currently, is comfortable, complaining of mild chest discomfort
without SOB.
ROS: See HPI. Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
# h/o of DVTs and PE in ___
- ___ s/p c-section
- Chest CT scan showed multiples bilateral segmental and
sub-segmental pulmonary emboli
- Negative w/u for Factor V Leiden, prothrombin gene mutation,
proteins C and S, AT3, the lupus anticoagulant, anticardiolipin
antibodies
- Anti-coagulated for 6 months
# Raynaud's
Social History:
___
Family History:
Unclear
Physical Exam:
ADMISSION EXAM:
VS - 98.4 67 132/76 18 100%RA
General: NAD
HEENT: Sclera anicteria, MMM, no OP lesions
Neck: Supple, no JVD, no LAD
CV: RRR, no heave, no m/r/g
Lungs: CTAB
Abdomen: Soft, ND, +BS, NT to palpation, no hepatosplenomegaly
GU: Deferred
Ext: WWP, well-healing, non-purelent surgical scar extending
from knee to upper left leg; no tenderness, redness or swelling
Neuro: Alert and oriented, CN II-XII intact, no focal weakness,
sensation intact to light touch
Skin: No rash, abrasions or ulcers
DISCHARGE EXAM:
VS - 98.4 97.9 60-67 ___ 18 99-100%RA
General: NAD
HEENT: Sclera anicteria, MMM, no OP lesions
Neck: Supple, no JVD, no LAD
CV: RRR, no heave, no m/r/g
Lungs: CTAB
Abdomen: Soft, ND, +BS, NT to palpation, no hepatosplenomegaly
GU: Deferred
Ext: 1x0.5cm superficial mobile, tender nodule over L inguinal
area, WWP, well-healing, non-purelent surgical scar extending
from knee to upper left leg; no redness or swelling
Neuro: Alert and oriented, CN II-XII intact, no focal weakness,
sensation intact to light touch
Skin: No rash, abrasions or ulcers
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-7.2 RBC-4.52# Hgb-14.7# Hct-42.1#
MCV-93 MCH-32.6* MCHC-35.0 RDW-13.0 Plt ___
___ 12:45PM BLOOD Neuts-73.1* Lymphs-17.9* Monos-5.6
Eos-3.0 Baso-0.4
___ 12:45PM BLOOD Glucose-76 UreaN-16 Creat-0.7 Na-139
K-3.9 Cl-99 HCO3-28 AnGap-16
___ 01:17PM BLOOD ___ PTT-34.5 ___
PERTINENT LABS:
___ 07:00AM BLOOD cTropnT-<0.01 proBNP-24
___ 01:17PM BLOOD ___ PTT-34.5 ___
___ 07:00AM BLOOD ___ PTT-100.7* ___
___ 01:45PM BLOOD PTT-86.9*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-5.6 RBC-4.35 Hgb-14.4 Hct-41.2 MCV-95
MCH-33.2* MCHC-35.1* RDW-12.8 Plt ___
___ 01:45PM BLOOD PTT-86.9*
___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 07:00AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1
RADIOLOGY:
___ CTA CHEST WITH AND WITHOUT CONTRAST:
FINDINGS: Pulmonary arteries are well opacified to the
subsegmental level.
Nonocclusive filling defects are seen in the lobar, segmental
and subsegmental
pulmonary artery branches involving the right middle and right
lower lobes as
well as segmental branches of the left lower lobe. While some
of these
filling defects, particularly in the left lower lobe, were
present in the
study of ___, others are new. There is no sign of right heart
strain.
Thoracic aorta is of normal caliber without evidence of aneurysm
or
dissection.
There is no axillary, mediastinal or hilar adenopathy. Heart is
normal in
size. There is no pericardial effusion. Trachea is midline and
airways are
patent to the subsegmental level. Lungs are clear. There is no
pleural
effusion. There is no pneumothorax. Limited view of the upper
abdomen is
unremarkable.
Bones do not show suspicious lytic or sclerotic lesions and no
acute
fractures.
IMPRESSION: Partially occlusive RML and RLL lobar, segmental,
and
subsegmental pulmonary emboli and partially occlusive LLL
segmental and
subsegmental pulmonary emboli are demonstrated. No CT evidence
of right heart
strain
___ ULTRASOUND OF BILAT LOWER EXT VEINS WITH DOPPLER
(LENIS):
FINDINGS:
Gray scale, color, and spectral Doppler ultrasound examination
of the
bilateral common femoral, femoral, popliteal, posterior tibial,
and peroneal
veins was conducted. There is a large, expansile, occlusive
thrombus in the
left greater saphenous vein leading to the confluence with the
femoral vein.
All other imaged vessels showed normal compressibility, flow,
and
augmentation.
IMPRESSION:
Large occlusive expansile thrombus in the left greater saphenous
vein at its
confluence with the femoral vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
2. Enoxaparin Sodium 70 mg SC Q12H pulmonary embolus
You will stop these injections once your INR reaches goal.
RX *enoxaparin 80 mg/0.8 mL 70 mg IM every 12 hours Disp #*30
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- acute Pulmonary embolus
SECONDARY DIAGNOSIS:
- acute lower extremity Deep venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of DVT and PE, documented DVT today, chest pain,
shortness of breath; evaluate for pulmonary emboli.
COMPARISON: ___.
TECHNIQUE: Contiguous MDCT images were obtained through the chest with IV
contrast. Axial images were reviewed in conjunction with coronal and sagittal
reformats.
FINDINGS: Pulmonary arteries are well opacified to the subsegmental level.
Nonocclusive filling defects are seen in the lobar, segmental and subsegmental
pulmonary artery branches involving the right middle and right lower lobes as
well as segmental branches of the left lower lobe. While some of these
filling defects, particularly in the left lower lobe, were present in the
study of ___, others are new. There is no sign of right heart strain.
Thoracic aorta is of normal caliber without evidence of aneurysm or
dissection.
There is no axillary, mediastinal or hilar adenopathy. Heart is normal in
size. There is no pericardial effusion. Trachea is midline and airways are
patent to the subsegmental level. Lungs are clear. There is no pleural
effusion. There is no pneumothorax. Limited view of the upper abdomen is
unremarkable.
Bones do not show suspicious lytic or sclerotic lesions and no acute
fractures.
IMPRESSION: Partially occlusive RML and RLL lobar, segmental, and
subsegmental pulmonary emboli and partially occlusive LLL segmental and
subsegmental pulmonary emboli are demonstrated. No CT evidence of right heart
strain
Radiology Report
HISTORY: Evaluate for DVT in a patient with known pulmonary embolism.
COMPARISON: None available.
FINDINGS:
Gray scale, color, and spectral Doppler ultrasound examination of the
bilateral common femoral, femoral, popliteal, posterior tibial, and peroneal
veins was conducted. There is a large, expansile, occlusive thrombus in the
left greater saphenous vein leading to the confluence with the femoral vein.
All other imaged vessels showed normal compressibility, flow, and
augmentation.
IMPRESSION:
Large occlusive expansile thrombus in the left greater saphenous vein at its
confluence with the femoral vein.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with PULM EMBOLISM/INFARCT, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY
temperature: 99.0
heartrate: 82.0
resprate: 20.0
o2sat: 100.0
sbp: 128.0
dbp: 68.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a h/o PE in ___ (negative
thrombophilia w/u), presenting with gradual onset CP ___
partially occlusive PEs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, new weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with past medical history of idiopathic
pulmonary
fibrosis, hypertension, hyperlipidemia, depression, and
dysphagia
who presents with about 4 days of fever to a high of 102,
increased nonproductive cough, mild epigastric abdominal pain,
decreased appetite, and general weakness. Starting on ___
he found he was unable to get himself out of bed due to
weakness,
and states he has been very shaky. He denies dysuria or
hematuria
but states that his urine has been darker than usual. At
baseline
he ambulates unassisted. He and his son also note that around
the
time of onset of his symptoms, he had a fall at home, and his
wife was unable to get him up off the floor, so he was down for
about 1 hour. He denies head strike or loss of consciousness at
that time. Denies headaches, neck stiffness or vision changes.
Denies vomiting or diarrhea. Denies blood in his stool. His son
believes his mental status is at his baseline. HE ___ any sick
contacts, chest pain, dyspnea.
In the ED, initial VS were:
99.4 80 142/56 16 94% RA
Tmax 102.8
Exam notable for:
AOx3. Breathing comfortably on room air. On auscultation, there
are crackles throughout, worse on the right than the left. Mild
epigastric tenderness to palpation. Neuro exam nonfocal.
Labs showed: Cr 1.5 H/H 10.9/32.7, lactate 2.2. Flu is negative
and UA negative for infection
Imaging showed:
Liver Or Gallbladder Us (Single Organ)
1. Slight interval increase in size of right complex right
hepatic lobe cyst,unlikely to be retracting internal hemorrhage
considering time interval since ___. Nonurgent,
outpatient
multiphasic liver MR (___) or CT is recommended for
further evaluation.
2. Stable left hepatic lobe simple appearing cyst.
3. No evidence of cholelithiasis or acute cholecystitis.
CT ___ W/O Contrast
No evidence of acute fracture or traumatic malalignment.
CT Head W/O Contrast
No acute intracranial process. No evidence of intracranial
hemorrhage or fracture.
CXR:
IMPRESSION:
Diffuse abnormalities in the lungs compatible with underlying
interstitial lung disease. No definite superimposed acute
process
given stability compared to prior.
Patient received: APAP, ceftriaxone, and IVF
Transfer VS were:
99.6 85 125/47 16 98% RA
On arrival to the floor, patient reports the above story and
reports feeling much better with only complaint of cough. He
said
initially he came into the hospital because of profound chills
and aches which have dramatically improved since coming in.
Past Medical History:
Parotid tumor s/p resection ___ unclear neoplasm
BPH and overactive bladder
GERD
History of PPD+ in ___ (by online documents, CXR obtained which
showed apical capping but no other abnormality - patient not
believed to have active TB and not treated)
hypercholesterolemia
Hypertension
Hyperlipidemia
History of interstitial lung disease (UIP/IPF)
Syncope
History of Aspiration
History of PE no on anticoagulation
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 PO 138 / 64 72 18 96 ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Inspiratory crackles throughout lung fields.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 99.3PO 135 / 70 83 18 96 Ra
GENERAL: Pleasant, alert, and interactive. NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM. No pharyngeal erythema.
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffuse faint inspiratory crackles, most pronounced at
right base posteriorly.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally. 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose. CN ___
intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 04:32PM ___
___
___ 04:32PM ___
___ IM ___
___
___ 03:54PM URINE ___ SP ___
___ 03:54PM URINE ___
___
___
___ 03:54PM URINE ___
___
___ 03:54PM URINE ___
___ 03:54PM URINE ___
___ 04:32PM ___
___ 04:32PM ___
___ 04:32PM ALT(SGPT)-28 AST(SGOT)-39 ALK ___ TOT
___
___ 04:32PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 04:38PM ___
DISCHARGE LABS
==============
___ 07:00AM BLOOD ___
___ Plt ___
___ 07:00AM BLOOD ___
___
___ 07:00AM BLOOD ___
IMAGING:
========
CXR (___):
Lung volumes remain low. Bilateral increased interstitial
markings are seen throughout the lungs. These are unchanged
from prior and compatible with known underlying interstitial
process. No definite superimposed consolidation identified.
The cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
CT HEAD W/O CONTRAST (___):
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of ___
cerebral
volume loss. Periventricular and subcortical white matter
hypodensities are nonspecific, though likely sequelae of chronic
small vessel ischemic disease. Atherosclerotic vascular
calcifications are noted of bilateral vertebral and cavernous
portions of internal carotid arteries.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The orbits are
unremarkable.
CT ___ W/O CONTRAST (___:)
Alignment is normal. No fractures are identified. Multilevel
degenerative
changes are seen, most extensive at ___ and
notable for
uncovertebral hypertrophy, osteophytes and facet arthropathy
causing severe right neural foraminal stenosis at ___ and
___ and severe left neural foraminal stenosis at ___. There
is no prevertebral edema.
There are fibrotic changes at the lung apices, unchanged
compared to prior. Thyroid is unremarkable.
LIVER/GALLBLADDER U/S (___):
1. Slight interval increase in size of right complex right
hepatic lobe cystic lesion with internal avascular echogenic
contents. Nonurgent, multiphasic liver MR is recommended for
further evaluation. If contraindication to MR, CT could be
considered.
2. Stable left hepatic lobe simple appearing cyst.
3. No evidence of cholelithiasis or acute cholecystitis.
RECOMMENDATION(S): Nonurgent, multiphasic liver MR is
recommended for further evaluation. If contraindication to MR,
CT could be considered.
CT CHEST W/O CONTRAST (___):
FINDINGS:
The thyroid is unremarkable.
There are no enlarged axillary lymph nodes. There is stable 7
mm hypodense lesion in the right upper posterior back (image 6
series 2. This could represent a sebaceous cyst. The left
axillary lymph node measuring 18 mm has decreased in size it
previously measured 24 mm. There is stable mild to moderate
cardiomegaly. There are no enlargedmediastinal hilar lymph
nodes. There is no pericardial effusion.
There is coronary artery calcification.
There is mild atherosclerotic calcification involving the aorta.
There is no pleural effusion. Peripheral fibrosis and traction
bronchiectasis in the right middle lobe and the lingula is
unchanged. Mild bronchiectasis in both lower lobes with mild
peribronchial thickening is also unchanged. The interstitial
abnormality bilaterally is stable and is most likely related to
age related fibrosis.
No new nodules or consolidations.
Review of bones shows degenerative changes involving the
thoracic spine.
Limited sections through the upper abdomen shows a large
hypodense lesion
within the right lobe of liver, could represent a cyst or
hemangioma and is unchanged.
IMPRESSION:
No evidence of pneumonia.
Stable interstitial abnormality which most likely represents age
related
fibrosis.
Decrease in size of the left axillary lymph nodes which are most
likely
reactive.
MICRO:
======
___ 04:07PM OTHER BODY FLUID ___
___
___ BLOOD CULTURE: NGTD
___ BLOOD CULTURE: NGTD
___ URINE CULTURE: negative
Radiology Report
INDICATION: ___ with h/o pulmonary fibrosis p/w 4d fever, increased cough,
general weakness// eval for PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___. Chest CT from ___.
FINDINGS:
Lung volumes remain low. Bilateral increased interstitial markings are seen
throughout the lungs. These are unchanged from prior and compatible with
known underlying interstitial process. No definite superimposed consolidation
identified. The cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
IMPRESSION:
Diffuse abnormalities in the lungs compatible with underlying interstitial
lung disease. No definite superimposed acute process given stability compared
to prior.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with general weakness, s/p fall 4 days ago, now with neck
pain/C-spine TTP// eval for intracranial bleed or fracture
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of age-related cerebral
volume loss. Periventricular and subcortical white matter hypodensities are
nonspecific, though likely sequelae of chronic small vessel ischemic disease.
Atherosclerotic vascular calcifications are noted of bilateral vertebral and
cavernous portions of internal carotid arteries.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process. No evidence of intracranial hemorrhage or
fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with general weakness, s/p fall 4 days ago, now with neck
pain/C-spine TTP// eval for intracranial bleed or fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 23.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 535.7
mGy-cm.
Total DLP (Body) = 536 mGy-cm.
COMPARISON: CT C-spine ___.
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel degenerative
changes are seen, most extensive at C3-C4, C4-C5, C5-C6 and notable for
uncovertebral hypertrophy, osteophytes and facet arthropathy causing severe
right neural foraminal stenosis at C3-C4 and C4-C5 and severe left neural
foraminal stenosis at C5-C6. There is no prevertebral edema.
There are fibrotic changes at the lung apices, unchanged compared to prior.
Thyroid is unremarkable.
IMPRESSION:
No evidence of acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with fever, weakness, epigastric abdominal pain, decreased
appetite// eval for gallbladder pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound ___, CT abdomen pelvis ___.
FINDINGS:
LIVER: Again demonstrated, is a right hepatic lobe cystic lesion with
echogenic internal debris slightly larger than prior currently measuring 8.0 x
8.3 x 6.9 cm, previously measuring 7.0 x 6.7 x 7.2 cm, without internal
vascularity. In addition, there is a stable appearing simple cyst in the left
hepatic lobe measuring approximately 3.8 x 2.0 x 2.4 cm. Echogenic shadowing
focus is compatible with calcification. No additional focal lesions
identified. The contour of the liver is smooth. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD was not
identified.
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: The spleen was identified.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
IMPRESSION:
1. Slight interval increase in size of right complex right hepatic lobe cystic
lesion with internal avascular echogenic contents. Nonurgent, multiphasic
liver MR is recommended for further evaluation. If contraindication to MR, CT
could be considered.
2. Stable left hepatic lobe simple appearing cyst.
3. No evidence of cholelithiasis or acute cholecystitis.
RECOMMENDATION(S): Nonurgent, multiphasic liver MR is recommended for further
evaluation. If contraindication to MR, CT could be considered.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ ___ man with past medical history of
idiopathic pulmonary fibrosis, hypertension, hyperlipidemia, depression, and
dysphagia who presents with about 4 days of fever to a high of 102, increased
nonproductive cough// Pneumonia? Worsening IPF?
TECHNIQUE: Multi detector CT of the chest was performed without the
administration of Intravenous contrast. Axial coronal sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 19.1 mGy (Body) DLP = 680.0
mGy-cm.
Total DLP (Body) = 680 mGy-cm.
COMPARISON: To a prior study done on ___
FINDINGS:
The thyroid is unremarkable.
There are no enlarged axillary lymph nodes. There is stable 7 mm hypodense
lesion in the right upper posterior back (image 6 series 2. This could
represent a sebaceous cyst. The left axillary lymph node measuring 18 mm has
decreased in size it previously measured 24 mm. There is stable mild to
moderate cardiomegaly. There are no enlarged mediastinal hilar lymph nodes.
There is no pericardial effusion.
There is coronary artery calcification.
There is mild atherosclerotic calcification involving the aorta.
There is no pleural effusion. Peripheral fibrosis and traction bronchiectasis
in the right middle lobe and the lingula is unchanged. Mild bronchiectasis in
both lower lobes with mild peribronchial thickening is also unchanged. The
interstitial abnormality bilaterally is stable and is most likely related to
age related fibrosis.
No new nodules or consolidations.
Review of bones shows degenerative changes involving the thoracic spine.
Limited sections through the upper abdomen shows a large hypodense lesion
within the right lobe of liver, could represent a cyst or hemangioma and is
unchanged.
IMPRESSION:
No evidence of pneumonia.
Stable interstitial abnormality which most likely represents age related
fibrosis.
Decrease in size of the left axillary lymph nodes which are most likely
reactive.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified, Weakness
temperature: 99.4
heartrate: 80.0
resprate: 16.0
o2sat: 94.0
sbp: 142.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | ___ man with past medical history of idiopathic
pulmonary fibrosis, hypertension, hyperlipidemia, depression,
and dysphagia who presents with about 4 days of fever to a high
of 102, increased nonproductive cough, mild epigastric abdominal
pain, decreased appetite, and general weakness, likely a viral
infection.
#Weakness, poor po intake
#SHortness of breath
#Viral Syndrome
Patient presents with 4 days of high fevers, non productive
cough, sore throat, mild epigastric pain, poor po intake,
increased home O2 use, and weakness. Patient has diffuse
crackles on exam but consistent with his known IPF. CXR reading
is confounded by his concomitant ILD, could not rule out
underlying infection. Started on CAP therapy with azithromyicn
and ceftriaxone. CT scan done which did not show any evidence of
a PNA or aspiration (h/o aspiration PNA with normal video
swallow study), so abx were stopped. WBC remained wnl. Urine Cx
negative, blood cxs NGTD. He was saturating well on RA at rest,
but did become more visibly dyspneic with minimal exertion (such
as holding conversation), so patient was placed 1L NC for
comfort (uses O2 most of the time at home). Patient afebrile for
>24 hours prior to discharge. He reports feeling weak but much
better than when he came in to the hospital. ___ evaluated and
recommended rehab.
#Fall:
Patient had a fall at home in the setting of weakness. CT head
and CT neck were normal. He is normally independent at home but
was more deconditioned than baseline. Will be discharged to
rehab per ___ recs.
# ___ (Baseline Cr ___:
Patient had elevation in creatinine to 1.5, likely due to
hypovolemia in the setting of illness. Received 2L IVF
throughout his admission and Cr at time of discharge was 1.5.
# Liver lesion:
RUQUS showed slight interval increase in size of right complex
right hepatic lobe cystic lesion with internal avascular
echogenic contents. He will need nonurgent, multiphasic liver MR
for further evaluation.
CHRONIC ISSUES
--------------
# BPH
# Bladder thickening:
Continued on finasteride and tamsulosin.
# HLD:
He was continued on rosuvastatin
# Primary prevention:
He was continued on aspirin and home Vitamin D
# Rhinitis:
He was continued on loratadine. He should resume ipratrop nasal
spray after discharge as this was not on formulary.
# Depression:
Continued citalopram
# HTN:
Continued on home chlorthalidone
TRANSITIONAL ISSUES
=================
[ ] Please check Chem 7 in ___ days to check kidney function, as
patient's discharge Cr 1.5, which was stable throughout
admission but above recent baseline of ___.
[ ] Please encourage good PO fluid intake given patient's ___
and viral illness
[ ] Patient should be scheduled for follow up with his
Pulmonologist for follow up of his IPF.
[ ] Patient will need a ___, multiphasic liver MR for
further evaluation of interval increase in size of complex right
hepatic lobe cystic lesion with interval avascular echogenic
contents, which was identified on ultrasound during this
admission.
[ ] Patient saturates well and appears comfortable on RA at
rest, but does become more visibly dyspnic after minimal
exertion such as holding a long conversation. Please provide NC
O2 for patient as needed for exertion and as needed for patient
comfort.
[] Patient has history of aspiration but normal video swallow
study, showed no evidence of aspiration during admission and was
eating and drinking well, but would continue to monitor closely
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
T7-8 laminectomy
thoracotomy with drainage
History of Present Illness:
The patient is a ___ year old male with minimal PMH besides known
T7-8 osteomyelitis, discitis, and epidural abcess s/p prior
laminectomy who presented with worsening back pain. His MRI
showed worsening anterior T7-8 collapse with increased
prevertebral soft tissue edema and new paravertebral fluid
collections concerning for discitis and osteomyelitis with
prevertebral spread. MRI also noted new adjacent right lower
lobe consolidations. He was treated for pneumonia in the ED
with Levofloxacin and admitted to the Neurosurgery service. He
underwent ___ guided bone biopsy of back ___, with gram stain
showing GPCs in pairs and clusters. Of note, he had prior
cultures with MSSA. He was transferred to Medicine for further
medical management of his infection.
On transfer to medicine, he endorsed a productive cough which
started a week or two prior. He denied any fevers, chills,
night sweats, or systemic symptoms. He denied any focal
weakness, numbness, paresthesias, or bowel/bladder dysfunction.
He denied any difficulty ambulating. He did note that his mid
back pain occasionally radiates around his chest, and that the
area is sometimes numb. His back pain is currently under
reasonably good control, especially when he is not moving much.
REVIEW OF SYSTEMS:
(+) Per HPI. No BM in a few days. Reflux symptoms and
dyspepsia. Occasional cramping sensation in his chest and mild
SOB.
(-) No fevers, chills, night sweats, fatigue, or malaise. No
headache, sinus tenderness, rhinorrhea, or congestion. No
vertigo, presyncope, syncope, vision changes, hearing changes,
focal weakness, or paresthesias. No chest pain, palpitations,
SOB, DOE, or hemoptysis. No abdominal pain, nausea, vomiting,
diarrhea, melena, or BRBPR. No hematuria, dysuria, frequency,
or urgency. No joint or muscle pain. No rashes or concerning
skin lesions. No easy bleeding or bruising. Review of systems
was otherwise negative.
Past Medical History:
- Chronic low back pain since ___ after multiple MVAs and
construction
- IVDU in his teens (confirms using only once when he was ___,
none since)
- Pain medication abuse
PAST SURG HX:
- Right knee surgery for tib-fib fracture in ___ with
"fiberglass
rods"
Social History:
___
Family History:
# Mother: died at ___ from lung cancer
# Father: died at ___ from pancreatic cancer
Physical Exam:
PHYSICAL EXAM ON TRANSFER TO MEDICINE:
VS: T 99.1, BP 146/89, HR 91, RR 18, SpO2 93% on RA
Gen: Middle aged male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: No cervical lymphadenopathy.
CV: Exam limited by TLSO. RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored. Rhonchorous breath sounds and
crackles on the right.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No concerning rashes or lesions.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. Sensation grossly intact to light touch. Normal
speech.
PHYSICAL EXAM ON DISCHARGE:
AVSS
A&Ox3
HEENT: atraumatic, normocephalic
CV: RRR
EXT: Digital cap refill <2 sec. No C/C/E. Distal pulses intact
CN II-XII intact, strength ___ in all extremities. Sensation
intact
Incision: clean, dry, intact
Pertinent Results:
LABS ON ADMISSION:
___ 03:00PM BLOOD WBC-12.8* RBC-4.13* Hgb-14.0 Hct-40.0
MCV-97# MCH-33.8*# MCHC-35.0 RDW-14.3 Plt ___
___ 03:00PM BLOOD Neuts-84.8* Lymphs-7.9* Monos-6.9 Eos-0.1
Baso-0.2
___ 03:00PM BLOOD ___ PTT-27.3 ___
___ 03:00PM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-128*
K-3.7 Cl-89* HCO3-27 AnGap-16
___ 05:58PM BLOOD Lactate-2.2*
INFLAMMATORY MARKERS:
___ 03:00PM BLOOD ESR-97*
___ 03:00PM BLOOD CRP-237.6*
MEDICATION MONITORING:
___ 06:15AM BLOOD Vanco-9.3*
IMAGING / STUDIES:
# MR THORACIC SPINE W/O CONTRAST ___ at 1:38 ___:
FINDINGS: Since the ___ MRI examination there has
been interval anterior collapse of the T7 and T8 vertebral
bodies with focal kyphosis (2:5). Increased T2 signal intensity
across the vertebral bodies and T7/8 disc has also progressed
since the prior examination. There are new prevertebral
well-circumscribed T2 hyperintense lesions (7:14, 11, 15),
measuring up to 20 x 10 mm (7:14), which neighboring abnormal
increased signal intensity throughout the prevertebral soft
tissues and surrounding the aorta (7:12). New right lower lobe
consolidations are present(7:10). Small bilateral pleural
effusions are unchanged. A focus of signal intensity along the
posterior aspect of T7 and T8 abuts the spinal cord. An
adjacent epidural process is not seen, but cannot be excluded on
this noncontrast examination. No definite cord signal
abnormality is detected. There is chronic thickening of the
ligamentum flavum at this level. The remaining thoracic
vertebral bodies demonstrate normal heights and signal
intensities. A right T2 hemangioma appears unchanged (6:6).
IMPRESSION: Interval anterior collapse of T7 and T8 since ___, with increased prevertebral soft tissue edema and
new paravertebral fluid collections, and new adjacent right
lower lobe consolidations, concerning for discitis and
osteomyelitis with prevertebral spread.
# CHEST (PA & LAT) ___ at 4:10 ___:
FINDINGS: The heart is at the upper limits of normal size.
There is no pleural effusion or pneumothorax. An extensive
opacity involving the right lower lobe is consistent with
pneumonia, with lesser opacities noted along the right upper
lobe and probably the lingula. This includes a nodular focus
projecting over the right mid lung, new since the prior study
also. There is destruction of a mid thoracic interspace with
marked wedging of the adjoining vertebral bodies. This
appearance is consistent with sequelae of known
osteomyelitis/discitis.
IMPRESSION:
1. New opacification in the right lower lobe, with left lesser
opacities elsewhere, suggesting pneumonia.
2. Endplate destruction of a mid thoracic interspace,
consistent with sequela of spinal infection, including
increasing loss in height of adjoining vertebral bodies since
the prior MR, but better assessed on the accompanying dedicated
thoracic spine MR performed on the prior day.
# CT TORSO W/CONTRAST ___ at 3:46 AM):
FINDINGS: There are stable small bilateral pleural effusions
with associated atelectasis and pleural thickening. In addition
there are ___ opacities in the right middle and lower
lobes, consistent with infection. There is no pneumothorax.
The heart, pericardium, and great vessels are unremarkable.
Again seen is evidence of known discitis-osteomyelitis with
destructive change of the T7 and T8 vertebral bodies. There is
no further loss of height of the T7-T8 complex since the study
on ___. Patient has had laminectomies at these levels.
Also noted is an irregular lucency consistent with non-acute
fracture of the left articular facet of T7. Adjacent
air-containing fluid collections are minimally progressed in the
interval: a fluid collection and a collection posterior to the
aorta are slightly larger, and there is a new small fluid
collection medial to the aorta in the left paravertebral area
(2:34) measuring 23 mm x 7.5 mm. There is scattered mediastinal
lymphadenopathy. The liver enhances homogeneously without focal
lesion or intrahepatic biliary ductal dilatation. The spleen is
homogeneous and normal in size. The gallbladder is
unremarkable, and the portal vein is patent. The pancreas is
unremarkable without a focal lesion, peripancreatic stranding,
or fluid collection. The bilateral adrenal glands unremarkable.
The kidneys presents symmetric nephrograms and excretion of
contrast without solid or cystic lesions. There is a duodenal
diverticulum, and diverticula are also noted in the descending
colon. There is no wall thickening or obstruction in the small
or large bowel. There is no ascites.
IMPRESSION:
1. Redemonstration of osteomyelitis-discitis at T7-T8 with
slight increase in the previously seen paravertebral fluid
collections and a new small paravertebral collection as
described above.
2. ___ opacities in the right middle and lower lobes,
consistent with infection. Stable bilateral pleural effusions.
MRI T-Spine ___:
1. Allowing for the difference in technique between
non-contrast and
contrast-enhanced MR studies, there has been no significant
short-interval
change in the degree of osseous destruction at the T7-8 level
since ___, but there is progressive osseous
destruction since an earlier study of ___.
2. The current contrast-enhanced study better characterized\s
the T7-8
spondylodiscitis and vertebral osteomyelitis, demonstrating an
intervertebral rim-enhancing collection in direct communication
with the large right-sided paraspinal/pleural collection, likely
empyema.
3. Multiple additional smaller loculated pleural-based
collections in the
lung bases, compatible with additional empyemas. Extensive
adjacent airspace consolidations in the lung bases representing
with ongoing pneumonia. Clinical concern is raised for the
proximity of the collections to the descending aorta, with
potential for infectious aortitis.
CT T-Spine ___:
Re-demonstration of osteomyelitis-discitis at T7-T8. Bilateral
paravertebral fluid collections, greatest on the right, are
unchanged since MRI ___.
CT Chest ___:
Re- demonstration of osteomyelitis-discitis at T7 -T8 surrounded
by bilateral paravertebral and pleural collections. There is no
change since MRI of ___ and CT yesterday, ___.
Medications on Admission:
No current medications on admission.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
3. Senna 1 TAB PO BID
Please hold for loose stools.
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
5. Oxycodone SR (OxyconTIN) 40 mg PO Q8H pain
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*42 Tablet Refills:*0
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Nicotine Patch 21 mg TD DAILY
8. Nafcillin 2 g IV Q4H
9. Methocarbamol 750 mg PO QID
RX *methocarbamol 750 mg 1 tablet(s) by mouth four times a day
Disp #*56 Tablet Refills:*0
10. Ibuprofen 400 mg PO Q8H
11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3H
Disp #*224 Tablet Refills:*0
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Gabapentin 300 mg PO TID
14. Heparin 5000 UNIT SC TID
15. Docusate Sodium 100 mg PO BID
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing, or coughing
17. Bisacodyl 10 mg PO/PR DAILY
18. Cepacol (Menthol) 1 LOZ PO PRN throat irritation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T7-8 paraspinous abscesses
pleural effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Patient must wear his
TLSO brace when at or above 30 degrees in bed.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Productive cough.
COMPARISONS: Radiographs from ___ and MR studies from the prior
day and ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is at the upper limits of normal size. There is no
pleural effusion or pneumothorax. An extensive opacity involving the right
lower lobe is consistent with pneumonia, with lesser opacities noted along the
right upper lobe and probably the lingula. This includes a nodular focus
projecting over the right mid lung, new since the prior study also. There is
destruction of a mid thoracic interspace with marked wedging of the adjoining
vertebral bodies. This appearance is consistent with sequelae of known
osteomyelitis/discitis.
IMPRESSION:
1. New opacification in the right lower lobe, with left lesser opacities
elsewhere, suggesting pneumonia.
2. Endplate destruction of a mid thoracic interspace, consistent with sequela
of spinal infection, including increasing loss in height of adjoining
vertebral bodies since the prior MR, but better assessed on the accompanying
dedicated thoracic spine MR performed on the prior day.
Radiology Report
INDICATION: ___ year old man with prior T7/8 discitis/osteomyelitis status
post laminectomy and washout in ___, with persistent pain and signal
abnormality on MRI.
PROCEDURE: T7-8 disc aspiration and T8 superior endplate core biopsy.
PREPROCEDURE DIAGNOSIS: T7-8 discitis/osteomyelitis.
POST-PROCEDURE DIAGNOSIS: T7-8 discitis/osteomyelitis.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and midazolam throughout the total intra-service time of 37minutes
during which the patients hemodynamic parameters were continuously monitored.
In total, the patient received 100mcg of fentanyl and 2mg of midazolam.
PHYSICIANS: Dr. ___ (attending physician), and Dr. ___
___ (fellow).
PROCEDURAL DETAILS AND FINDINGS:
Prior to the procedure, written informed consent was obtained and the patient
demonstrated good understanding of the indication, risks, benefits and
alternatives. The patient was brought to the angiography suite and placed in
a prone position on the angiography table. A preprocedural timeout was
performed using standard ___ protocol. The skin was prepped and draped in
typical sterile fashion.
Fluoroscopic guidance was used to select the T7-T8 level. Confirmation of
appropriate level was made by repeating counting from the ___ and 12th ribs by
3 independant observers. Local anesthetia was achieved with 1% lidocaine
3.5cm to the left of the midline. Thereafter, an 11-gauge ___ needle was
carefully advanced under biplane fluoroscopic observation lateral to the left
pedicle and into the intervertebral disc space. Multiple disc space aspirates
taken. Thereafter, the ___ was used for guidance and an 11g ___
biopsy needle was advanced through it, into the T8 superior endplate under
biplane fluoroscopic observation. This was used to take 3 core biopsy samples
(1 of which was fixed in formalin for pathology, 2 of which were sent for
requested microbiology evaluation). Finally, the Acerman needle was removed,
the stylet of the ___ needle was replaced and then the ___ needle was
carefully removed.
Pressure was maintained at the dermatotomy site until good hemostasis was
achieved. A dry sterile dressing was applied, and the patient was
transferred from the angiography suite in stable condition.
IMPRESSION: Successful 11g core needle biopsy of the T8 superior endplate (x
3) and T7-8 disc aspirate. Specimens were sent to pathology/microbiology for
the requested laboratory analysis. Results are pending.
Radiology Report
HISTORY: Discitis osteomyelitis with right lower lobe pneumonia.
TECHNIQUE: Contiguous axial MDCT images were obtained through the chest,
abdomen, and pelvis after the administration of 130 cc of Omnipaque
intravenous contrast using a split bolus technique. Coronal and sagittal
reformats were also obtained, as well as reformats using bone algorithm.
DLP: 399.76 mGy-cm.
COMPARISON: MRI thoracic spine ___. Chest x-ray ___.
FINDINGS:
There are stable small bilateral pleural effusions with associated atelectasis
and pleural thickening. In addition there are ___ opacities in the
right middle and lower lobes, consistent with infection. There is no
pneumothorax. The heart, pericardium, and great vessels are unremarkable.
Again seen is evidence of known discitis-osteomyelitis with destructive change
of the T7 and T8 vertebral bodies. There is no further loss of height of the
T7-T8 complex since the study on ___. Patient has had laminectomies
at these levels. Also noted is an irregular lucency consistent with non-acute
fracture of the left articular facet of T7. Adjacent air-containing fluid
collections are minimally progressed in the interval: a fluid collection and a
collection posterior to the aorta are slightly larger, and there is a new
small fluid collection medial to the aorta in the left paravertebral area
(2:34) measuring 23 mm x 7.5 mm. There is scattered mediastinal
lymphadenopathy.
The liver enhances homogeneously without focal lesion or intrahepatic biliary
ductal dilatation. The spleen is homogeneous and normal in size. The
gallbladder is unremarkable, and the portal vein is patent. The pancreas is
unremarkable without a focal lesion, peripancreatic stranding, or fluid
collection. The bilateral adrenal glands unremarkable. The kidneys presents
symmetric nephrograms and excretion of contrast without solid or cystic
lesions. There is a duodenal diverticulum, and diverticula are also noted in
the descending colon. There is no wall thickening or obstruction in the small
or large bowel. There is no ascites.
IMPRESSION:
1. Redemonstration of osteomyelitis-discitis at T7-T8 with slight increase in
the previously seen paravertebral fluid collections and a new small
paravertebral collection as described above.
2. ___ opacities in the right middle and lower lobes, consistent with
infection. Stable bilateral pleural effusions.
Radiology Report
INDICATION: T7/T8 osteomyelitis/discitis with prevertebral fluid collection
and treated for possible right lower lobe pneumonia, needs pre-operative
evaluation prior to surgery.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph, two views.
FINDINGS: Heart size is top normal. Again appreciated is extensive opacity
involving the right lower lobe, which is slightly improved compared to ___. Small amount of fluid is seen tracking along the right major fissure.
Left lung is clear. There is no pneumothorax. Again noted is destruction of
the T7/T8 interspace with marked wedging of adjoining vertebral bodies
compatible with the given diagnosis of osteomyelitis/discitis.
IMPRESSION:
1. Minimal improvement in right lower lobe pneumonia with persistent effusion
tracking along the major fissure.
2. Endplate destruction of the T7/T8 interspace compatible with given
diagnosis of osteomyelitis/discitis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Spinal abscess, status post thoracotomy, evaluation for interval
change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The right chest tube is in constant position. Unchanged small
pleural effusion and atelectasis at the right lung bases. The plate-like
atelectasis on the left is constant in appearance. Unchanged size of the
cardiac silhouette. No pneumothorax.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with spinal abscess T7-T8, thoracotomy, washout.
Evaluate for right pneumothorax.
COMPARISON: ___.
FINDINGS:
Moderate subcutaneous air is due to recent surgery. There is no pneumothorax
and right chest tube projects at right lung base. Bibasilar consolidation
presumed to be atelectasis, right more than left is unchanged. Cardiac
contour is normal. There is no pleural effusion.
CONCLUSION:
Patient just had surgery for thoracic spine abscess. There is no
pneumothorax. Moderate subcutaneous air is due to the surgery.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chest tube, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The position of the chest tube at the bases of the right lung is
constant. No relevant changes in extent and severity of the pleural effusion
with an intrafissural component. The lung volumes remain overall low and no
overt pulmonary edema is present. Unchanged size of the cardiac silhouette.
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: ___ radiograph.
FINDINGS: Status post removal of right-sided chest tube, with persistent
small right pleural effusion and no visible pneumothorax. Cardiomediastinal
contours are stable in appearance. Atelectatic changes in both lower lobes
appear relatively similar compared to the prior radiograph except for slight
worsening in the left retrocardiac region.
Radiology Report
HISTORY: ___ man, status post I&D of T7/T8 osteomyelitis and
discitis. Evaluate for postoperative changes and residual collection.
COMPARISON: Outside MRI thoracic spine on ___ and in-house MR
thoracic spine on ___. Of note, two previous MRI thoracic spine was
performed without contrast. CT chest and abdomen on ___.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the thoracic spine before and after administration of IV
gadolinium contrast.
FINDINGS: Allowing for difference in technique between the previous
non-contrast MRI studies and the current contrast-enhanced MRI study, again
noted is the T7/T8 discitis osteomyelitis, with severe osseous destruction of
both vertebral bodies, grossly unchanged compared to ___, but
demonstrating progressive destruction since ___. There is
similar diffuse marrow abnormality at T7 and T8 vertebral bodies.
There are similar post-operative posterior decompression from T7 and T8
laminectomies. The rim-enhancing T7/T8 intervertebral disc collection
measures up to 9 mm in maximum thickness. This collection is in direct
communication with the large right-eccentric anterior paraspinal collection,
which measures approximately 2.5 x 7.9 x 7.4 cm (AP x SI x TV). The
collection extends to the right pleural space. There are additional, but
smaller rim-enhancing pleural-based collections bilaterally, representing
empyemas. Extensive adjacent air-space consolidations are noted in the lung
bases, better assessed in the recent CT chest and abdomen on ___.
There is exaggerated kyphosis centered at T7-8 level, but without significant
alignment changes since ___. There is corresponding kyphotic curvature of
the cord at T7/8, but without evidence of cord compression. The cord
demonstrates no leptomeningeal enhancement. The corresponding anterior
epidural space is thickening and enhancement. There is no evidence of
interval dissemination of infection to the other vertebral levels. The
remaining vertebral bodies are normal in height and signal intensity.
Again incidentally noted is a T1- and T2- hyperintense lesion in the T2
vertebral body, compatible with a low-flow vascular malformation (formerly,
"hemangioma"). No other focal vertebral bone marrow abnormality is seen
IMPRESSION:
1. Allowing for the difference in technique between non-contrast and
contrast-enhanced MR studies, there has been no significant short-interval
change in the degree of osseous destruction at the T7-8 level since ___, but there is progressive osseous destruction since an earlier study of
___.
2. The current contrast-enhanced study better characterized\s the T7-8
spondylodiscitis and vertebral osteomyelitis, demonstrating an intervertebral
rim-enhancing collection in direct communication with the large right-sided
paraspinal/pleural collection, likely empyema.
3. Multiple additional smaller loculated pleural-based collections in the
lung bases, compatible with additional empyemas. Extensive adjacent airspace
consolidations in the lung bases representing with ongoing pneumonia.
Clinical concern is raised for the proximity of the collections to the
descending aorta, with potential for infectious aortitis.
Radiology Report
HISTORY: T7-T8 osteomyelitis discitis and para-vertebral abscess status post
thoracotomy, drainage and debridement on ___. Now with recurrent fevers.
TECHNIQUE: MDCT data were acquired through the thoracic spine after the
uneventful administration of 90 cc of contrast. Images were displayed in
multiple planes.
COMPARISON: MRI ___. CT chest and abdomen ___.
FINDINGS:
Destructive changes of the T7 and T8 vertebral bodies are unchanged since ___. There are post-laminectomy changes at this these levels. A
fracture through the left T7 articular facet is stable. Large paravertebral
fluid collections are unchanged since MRI ___. The right
pleural/paravertebral collection measures up to 7 cm transverse. The
left-sided collection measures 3 cm AP (3:56. 3:69). There is an additional 2
cm collection within the collapsed left lower lobe (3:58), also stable. All
the aforementioned fluid collections have rim enhancement. Bibasilar
pulmonary volume loss is incompletely assessed.
IMPRESSION:
Re-demonstration of osteomyelitis-discitis at T7-T8. Bilateral paravertebral
fluid collections, greatest on the right, are unchanged since MRI ___.
Radiology Report
HISTORY: T7-T8 osteomyelitis discitis.
TECHNIQUE: MDCT data were acquired through the chest without intravenous
contrast. Images were displayed in multiple planes.
COMPARISON: CT thoracic spine yesterday and thoracic spine MRI ___.
CT chest and abdomen ___.
FINDINGS:
There has been no change in the appearance of T7-T8 osteomyelitis-discitis and
adjacent paraspinal and pleural fluid collections. There has been no new
intervention since the prior exam. Bilateral paravertebral rim enhancing
collections communicate with small bilateral pleural effusions. There is
associated atelectasis, but no nodule, consolidation or pneumothorax. The
thyroid gland enhances homogeneously. There is no supraclavicular or axillary
adenopathy. Subcarinal and right hilar nodes are enlarged. Heart size is
normal. There is no pericardial effusion. LAD and circumflex coronary artery
calcifications are moderate. There is no pericardial effusion. The sizes of
the aorta and pulmonary trunk are normal. Limited views of the upper abdomen
show no abnormalities.
Severe compression deformities and osteolyic destruction of the end plates of
T7 and T8 are unchanged.
IMPRESSION:
Re- demonstration of osteomyelitis-discitis at T7 -T8 surrounded by bilateral
paravertebral and pleural collections. There is no change since MRI of ___ and CT yesterday, ___.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with study of ___, there has been placement of a
right subclavian PICC line that extends into the right atrium. It could be
pulled back about 2.5 cm to be within the lower SVC.
Although the patient has taken a slightly poor inspiration, the opacification
at the right base have decreased. Atelectatic changes are still seen
bilaterally.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LOW BACK PAIN
Diagnosed with BACKACHE NOS, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.8
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 183.0
dbp: 102.0
level of pain: 8
level of acuity: 3.0 | ___ year old male with minimal PMH besides known MSSA
osteomyelitis, discitis, and epidural abcess at ___ s/p prior
laminectomy (___) and Nafcillin course who presented with
worsening back pain from continued infection and cough from CAP.
# MSSA T7-8 Osteomyelitis/Discitis: MRI spine ___ showed
interval anterior collapse of T7/T8 since ___, with
increased prevertebral soft tissue edema and new paravertebral
fluid collections, and new adjacent RLL consolidations,
concerning for discitis and osteomyelitis with prevertebral
spread. Patient was initially admitted to Neurosurgery service.
Underwent ___ guided deep bone biopsy of this area on ___,
with gram stain showing GPCs in pairs and clusters and cultures
growing MSSA. Antibiotics were held prior to the biopsy.
Following the biopsy, he was started on Vancomycin, and switched
to Nafcillin once MSSA confirmed. He was transferred to
Medicine service for further management of his infection, with
ID and Neurosurgery following. His pain was controlled with
oxycontin, gabapentin, with oxycodone and hydromorphone as
needed for breakthrough pain. The pain service was also
consulted for assistance with pain management. On medicine, he
remained afebrile and leukocytosis resolved. He was
neurologically intact, but given significant bony destruction
and instability in his spine, decision was made to operate. Due
to the prevertebral extension of his infection and fluid
collections in the thorax, he need a combined surgery with both
Thoracics and Neurosurgery, via an anterior approach. Went to
the OR on ___.
# RLL Pneumonia: His CXR on admission showed significant
consolidations concerning for pneumonia. He received
Levofloxacin 750 mg IV once in the ED on ___, but no other
antibiotics prior to his bone biopsy. His MRI showed increased
prevertebral soft tissue edema and new paravertebral fluid
collections with adjacent right lower lobe consolidations,
suggesting that his pneumonia may actually be prevertebral
spread from his spine infection rather than a typical CAP. He
was nevertheless treated for CAP with Levofloxacin 750 mg PO
daily for 5 days given evidence of possible aspiration and
___ opacities on CT torso. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with diastolic dysfunction and COPD
presenting with 1 week of dyspnea that acutely worsened today
with associated mild swelling in the legs and generalized
fatigue.
On arrival to the ED the patient triggered for room air sat of
80% and became intermittently somnolent with noted bilateral
crackles on exam. Given concern for somnolence ABG was obtained
with pH 7.21/PCO2 85/PaO292/HCO3 36 with hypercapnea for which
BIPAP was started. Initial concern for CHF exacerbation for
which cardiology was consulted though ultimately determined that
patient had a mixed picture and so recommended admission to the
MICU.
Per report patient has been exposed to sick contacts in her
family with viral illness. Additionally patient noted to have
fever to 100.4. In the ED initial vitals showed temp 97.9, HR
79, BP 125/41, RR 21. In the ED the patient was given 1000 mg IV
vanco and levofloxacin. Labs in the ED were notable for WBC
10.0, Hg 12.4, Hct 41.6, platelets 213. Chem-7 notable for Na
134, K 5.0, Cl 95, bicarb 29, BUN 103, Cr 1.6, glucose 140. Trop
elevated to 0.12 repeat 0.10. BNP 30788. EKG showed T wave
inversions. UA negative for signs/symptoms of infection.
In the ED the patient was evaluated by cardiology who felt
patient's picture was mixed and not consistent with CHF
exacerbation alone. For this reason it was determined that she
should be admitted to the MICU team.
On transfer, vitals were:
Temp 99.9, BP 104/65, HR 72, RR 25, 98% RA
On arrival to the MICU, the patient has BIPAP in place. She is
able to nod yes/no to some questions though exam and interview
is limited by BIPAP and patient's hearing impairment. The
patient denies chest pain, fever, diarrhea, nasuea, or
vomitting. Per discussion with her children the family notes
that the patient has had ongoing dyspnea for 1 week after
vacation in ___ and was exposed to grandchildren who
were febrile reportedly. Per report she has not had any
infectious symptoms as a result including fever, chills, cough,
or wheezing. Per report mid-week her mental status declined at
about the same time when she had reported worsening lower
extremity pain and started taking higher doses of tramadol up to
200 mg three times per day. She additionally had a fall forward
onto her knees while being moved out of a chair today and did
not have a head strike. This entire episode was witnessed by her
family.
Past Medical History:
- Lymphoma, in remisssion since ___
- ___
- Spinal stonsis, leg weakness and bowel/bladder incontinence at
baseline
- Atrial fibrillation s/p cardioversion
- COPD
- Glaucoma
Social History:
___
Family History:
No known history of cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: afebrile BP: 90/31 P: 62 CPAP FIO2 .36 PEEP 5
GENERAL: somnolent but awakens to voice and mild sternal rub.
Follows simple commands.
HEENT: Sclera anicteric,
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilateral upper airway sounds secondary to ventilation
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no edema, bilateral lower
extremity dressing in place. Left leg with dressing over
posterior calf.
SKIN: Back with dressing in place over wound from prior spinal
stenosis surgery
NEURO: grossly intact, able to follow simple commands
DISCHARGE PHYSICAL EXAM:
VS - 98.5 64 120/65 18 98%2L
Weight: 83.7kg
General: elderly female in NAD, lying comfortably in bed
HEENT: MMM, EOMI, JVD to mid neck at 45 degrees, PEERL
NEURO: AAOx3, CNII-XII intact, moving all extremnities,
sensation grossly intact to light touch
CV: Regular rate, no MRG, normal S1 and S2
Lungs: Bilateral crackles, no increased work of breathing
Abdomen: soft, nontender, nondistended, no HSM appreciated
Ext: WWP, trace edema below knees, trace edema in thighs
bilaterally
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-10.0# RBC-4.54 Hgb-12.4 Hct-41.6
MCV-92 MCH-27.3 MCHC-29.8* RDW-15.3 RDWSD-49.7* Plt ___
___ 04:00PM BLOOD ___ PTT-24.8* ___
___ 04:00PM BLOOD Glucose-140* UreaN-103* Creat-1.6* Na-139
K-5.0 Cl-95* HCO3-29 AnGap-20
___ 04:00PM BLOOD cTropnT-0.12*
___ 02:00AM BLOOD Calcium-8.3* Phos-5.9*# Mg-2.6
___ 04:17PM BLOOD Comment-GREEN TOP
INTERVAL LABS, IMAGING:
___ 04:00PM BLOOD cTropnT-0.12*
___ 10:05PM BLOOD cTropnT-0.10*
___ 02:00AM BLOOD CK-MB-2 cTropnT-0.08*
- ___ CXR
No acute cardiopulmonary abnormality.
- ___ BILATERAL KNEE XR
Osteopenia. Status post right TKR. Severe left knee
osteoarthritis. No
fracture or dislocation detected in either knee on the available
views. No right knee hardware loosening or failure detected.
- ___ BILATERAL HIP XR
Severe right and mild to moderate left hip osteoarthritis. No
definite
fracture detected involving either hip. If there is ongoing
clinical
suspicion for fracture, then CT or MRI could help further
assessment.
No displaced fracture detected about the pelvis.
Microbiology
==============================
___ 5:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 4:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ ___
10:55AM.
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-4.9 RBC-3.61* Hgb-9.8* Hct-33.4*
MCV-93 MCH-27.1 MCHC-29.3* RDW-14.6 RDWSD-48.4* Plt ___
___ 06:55AM BLOOD Glucose-96 UreaN-69* Creat-1.2* Na-148*
K-3.9 Cl-103 HCO3-39* AnGap-10
___ 06:55AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Mirtazapine 7.5 mg PO QHS
6. Torsemide 40 mg PO DAILY
7. TraMADOL (Ultram) 25 mg PO Q8 HOURS PRN pain
8. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Torsemide 40 mg PO DAILY
8. Duloxetine 20 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
Primary:
Acute respiratory failure
Secondary:
___ exacerbation
Opioid overdose
COPD exacerbation
UTI
Type II NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea and history of congestive heart failure
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___
FINDINGS:
Moderate enlargement of the cardiac silhouette persists. The aorta remains
tortuous. Hilar contours are relatively unchanged. There is no pulmonary
edema. Minimal streaky atelectasis is noted lung bases without focal
consolidation. No pleural effusion or pneumothorax is present. Clips from
prior cholecystectomy are demonstrated in the right upper quadrant of the
abdomen. Partially imaged is cervical spinal fusion hardware. Degenerative
changes are noted throughout the imaged thoracolumbar spine as well as within
the glenohumeral joints bilaterally.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with diastolic dysfunction and hypercarbia
presenting with respiratory distress // evaluate for pulmonary edema
COMPARISON: ___ at 16 16
FINDINGS:
The patient's chin and mask overlie and obscure the upper portion of both
lungs.
Inspiratory volumes are lower than on the prior film and the patient appears
more kyphotic. Allowing for this, the cardiomediastinal silhouette is grossly
unchanged. Mild vascular plethora and bibasilar atelectasis is similar to the
prior film. No frank consolidation or gross effusion. Incidental note made
of bilateral severe glenohumeral osteoarthritis.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: BILAT HIPS (AP,LAT AND AP PELVIS)
INDICATION: ___ year old woman s/p fall w/ hip pain // r/o fracture
TECHNIQUE: AP pelvis an AP and frog-leg lateral views of both hips. No
cross-table lateral views available.
COMPARISON: None.
FINDINGS:
Right hip: Severe osteoarthritis, with bone-on-bone narrowing of the joint and
prominent surrounding osteophytes. Subchondral cyst or possible slight
flattening along the superomedial femoral head is present . Probable subtle
acetabular protrusio. Linear density across the neck is likely an artifact
due to overlying osteophytes. No definite fracture is detected.
Left hip: There are mild to moderate degenerative changes, with probable
joint space narrowing inferomedially and with marginal osteophytes. Allowing
for the use of the frog-leg lateral view, no fracture is detected.
Pelvis: The pelvic girdle is grossly congruent. The sacrum is considerably
obscured by overlying bowel gas. No displaced fracture is identified .
Vascular calcification and injection granulomas noted.
IMPRESSION:
Severe right and mild to moderate left hip osteoarthritis. No definite
fracture detected involving either hip. If there is ongoing clinical
suspicion for fracture, then CT or MRI could help further assessment.
No displaced fracture detected about the pelvis.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) BILATERAL
INDICATION: ___ year old woman s/p fall // r/o acute fracture
TECHNIQUE: AP and lateral views of both knees. No oblique view available.
COMPARISON: None.
FINDINGS:
Right knee: Severe diffuse osteopenia. Status post 3 component knee
prosthesis, in overall anatomic alignment. No fracture or dislocation is
detected. No hardware loosening or failure is identified. Possible joint
effusion, but no lipohemarthrosis seen on the cross-table lateral view.
Extensive heterotopic ossification is noted anterior to the distal femur.
Left knee: There is diffuse osteopenia. There is severe osteoarthritis, with
femorotibial joint space narrowing and tricompartmental spurring. Probable
joint effusion, but no definite lipohemarthrosis is detected on the
cross-table lateral view. A small amount of heterotopic ossification is seen
anterior to the distal femur. If there is continuing concern for an occult
fracture in the right knee, then CT could help for further assessment.
IMPRESSION:
Osteopenia. Status post right TKR. Severe left knee osteoarthritis. No
fracture or dislocation detected in either knee on the available views. No
right knee hardware loosening or failure detected.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with COPD, CHF exacerbations // Interval
change Interval change
COMPARISON: Chest radiographs ___.
IMPRESSION:
Mild interstitial edema has developed since ___. Mild cardiomegaly is
long-standing. Pleural effusions are small if any. No pneumothorax. Band of
atelectasis at the base of the right lung is the only focal pulmonary
abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 97.7
heartrate: 79.0
resprate: 21.0
o2sat: 97.0
sbp: 125.0
dbp: 41.0
level of pain: 0
level of acuity: 1.0 | Summary
==========================
___ year old female with history of COPD not compliant with home
O2, HFpEF, spinal stenosis, severe OA, and neuropathy secondary
to chemotherapy who presented with respiratory failure requiring
BIPAP. She was found to have overdosed on tramadol along with
COPD and CHF exacerbations. She was treated with naloxone,
prednisone, antibiotics and lasix diuresis and improved. She was
transferred to acute rehab in good condition.
Acute Issues
==================
# Hypercapneic respiratory failure ___ opioid overdose, COPD and
CHF exacerbations
This was felt to be secondary to tramadol overdose with COPD and
CHF exacerbations. She was initially given naloxone and
improved. She was subsequently stabilized with 5 days of
levoquin and 5 days 40mg po prednisone for COPD exacerbation and
IV lasix diuresis for CHF exacerbation. She was subsequently
transitioned to home torsemide regimen. ___ evaluated patient
and recommended discharge to rehab. She was at her baseline
status with clear mentation and no daytime O2 requirement at
time of discharge.
#Toxic Encephalopathy. Patient with encephalopathy likely
secondary to some metabolic component of hypercarbia, as well as
supratherapeutic doses of tramadol. Improved with naloxine and
improved respiratory status. At baseline upon discharge.
# Acute Kidney Injury (baseline 1.1). Patient with ___ in
setting of likely hypovolemia and poor PO intake. Improved with
some IVF and improved PO intake.
# NSTEMI, type II. Patient with T wave inversions and mildly
elevated trops already downtrending suggestive of demand
ischemia in setting of COPD exarbation. Patient with known
history of demand NSTEMI in setting of COPD exacerbations.
Troponin peaked at 0.12. Aspirin continued. No chest pain
throughout admission.
# UTI
Urine culture grew >100,00 K. pneumonia with levoquin coverage
as above.
Chronic issues
============================
# Atrial fibrillation. Remained in normal sinus rhythm.
Continued metoprolol for rate control and aspirin.
# Neuropathic Pain
Patient trialed on Duloxetine 20mg and pain was well controlled
throughout admission.
Transitional Issues
==============================
- Patient was evaluated by ___ and requires acute rehab.
- She should follow up with her PCP following rehab stay.
- Tramadol was discontinued as it may have contributed to her
presentation of respiratory failure.
- She was started on duloxetine and tylenol with good pain
control.
- She was mildly hypernatremic during admission, Na 149 on
discharge. Please recheck Na on ___ and consider free water if
uptrending or not improved.
- Discharge weight: 83.7 kg
# CODE: Full (confirmed)
# CONTACT: ___ (___) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness and fall
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is an ___ with a h/o HTN and DM2 who presented with
a fall. History obtained from medical record as patient is not
reliable. Per ED and SW notes: According to his wife, the
patient fell last night while walking to the door when he
tripped and fell to the right. He was on the floor for 13 hours
before EMS was called; per wife he is stubborn and she thought
he could get up. SW was involved in the ED and called Elder
Protective services as his wife appeared confused. Daughter also
lives at home. In the ED pt deined LOC, cp/sob, f/c/s,
presyncope, but was feeling weak prior to fall. When EMS arrived
he was prone in the bedroom, cool, confused, slow to answer
questions, FSG was 467. Per wife has had multiple falls recently
but usually gets up.
In the ED, initial VS were T: 97.9, HR: 100, BP: 116/79, RR: 14,
O2%: 94%, FSBG: 402.
Exam was notable for abrasions on the bilateral knees and R
elbow. He also had a normal rectal tone initially with guaiac
negative stools. Had maroon colored emesis in the ED and guaiac
positive one hour after arrival, NG tube placed. KUB shot, read
pending, per report not c/w obstruction. Labs: BUN 88 and
creatinine of 3.0 (unknown baseline), CK of 1808, Trop-T of
0.04, WBC of 18.4 (86%N), and lactate of 3.2. Glu 513. Ca ___
alb 3.8. Repeat lactate 2.4. Urine >186 Wbc's, mod bacteria, no
epis.
CXR without acute cardiopulmonary processes or signs of
infection. C-spine showed no evidence of acute fracture or
prevertebral soft tissue abnormality. CT head showed no acute
hemorrhage or fracture.
GI was consulted in the ED for occult positive gastric contents
on NG lavage and maroon vomitus, they recommended 40mg bid po
ppi.
Patient received 3L of NS, 40 mg of IV pantoprazole, 8 units of
insulin (regular), ceftriaxone
Transfer VS were Today 19:27 0 98.2 104 135/83 23 95% RA FSBG:
499.
On arrival to the floor, patient says he feels well in spite of
everything that's happened.
After arrival to floor, ED resident paged that NG tube needed to
be advanced. Tip was not clearly visible on CXR but it was at
60cm with some dark material present in tube. Given no recent
vomiting and likelihood that it was coiled, it was removed.
Past Medical History:
Stage 3 CKD
Diverticulosis
Diabetes type 2
Hyperlipidemia
HTN
Cognitive impairment
Obesity
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION
VS - 98.8 159/86, 78, 22
General: Sleepy, AOx3 but difficulty maintaining attention
during interview
HEENT: Dry MM, EOMI, NG tube draining dark fluid
Neck: beard obscures neck veins
CV: ___ systolic murmur loudest RUSB
Lungs: CTAB
Abdomen: Obese, nt/nd
Ext: no c/c/e
Neuro: MAE
Skin: no rashes
DISCHARGE
VS (stable except as noted): 98.3 178/90 78 20 94/ra
General: More awake compared to yesterday, NAD, lying in bed
comfortably.
HEENT: Dry MM, EOMI
Cardiac: Normocardic, regular, ___ systolic murmur loudest RUSB
Vasc: extr wwp without ___ edema
Lungs: CTAB
Abdomen: Obese, nt/nd
Neuro: AOx3, maew
Skin: no rashes
Pertinent Results:
================================
LABS
================================
Admission labs:
134 | 99 | 88 AGap=19
---------------<513
4.5 | 21 | 3.0
Ca: 10.4 Mg: 2.1 P: 4.1
18.4 > 15.3/44.6 < 264
N:86.1 L:7.5 M:6.0 E:0.2 Bas:0.2
Lactate:3.2
CK: 1808
Trop-T: 0.04
UA: Urine >186 Wbc's, mod bacteria, no epis
================================
STUDIES
================================
CXR (___): NO acute cardiopulmonary processes or signs of
infection.
C-spine (___): no evidence of acute fracture or prevertebral
soft tissue abnormality.
CT head (___): showed no acute hemorrhage or fracture
KUB (___): Nonobstructive bowel gas pattern without evidence
of free intraperitoneal air.
EKG ___: sinus with pac's rate 96bpm, q waves in III and aVF
suggest old inf MI
Echo ___:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF = 70%). There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. There are focal calcifications in the aortic
arch. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area = 1.1cm2). Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Glargine 50 Units Breakfast
Glargine 42 Units Dinner
Humalog 15 Units Breakfast
Humalog 50 Units Lunch
Discharge Medications:
1. Losartan Potassium 100 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
Day 1 = ___. Should be continued for 10 day course for
complicated UTI.
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Glargine 50 Units Bedtime
NPH 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Enterococcus UTI, hyperglycemia due to poorly controlled T2DM,
___ and hypernatremia caused by hyperglycemia.
Code status: Full
Discharge follow-up with Dr. ___ (PCP) (___)
Discharge Condition:
Ambulating comfortably off O2 and taking a full diet without
difficulty. Mentating at baseline.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Status post fall with confusion. Evaluate for hemorrhage or
fracture.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: 53.6 mGy
DLP: 1003.4 mGy-cm
COMPARISON: None available.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are prominent, likely related to age-related involutional
changes. Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute hemorrhage or fracture identified.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: Status post fall with confusion. Evaluate for fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 66.9 mGy
DLP: 829.7 mGy-cm
COMPARISON: None available.
FINDINGS:
Mild anterolisthesis of the C3 and C4 vertebral bodies is likely degenerative.
Alignment is otherwise normal. No fractures are identified. Multilevel
degenerative changes are noted, most notable for intervertebral disc height
loss, posterior osteophyte formation and uncovertebral joint hypertrophy.
These changes result in up to moderate canal narrowing at C4-C5 and severe
left foraminal narrowing at C5-C6. There is no prevertebral soft tissue
abnormality. Thyroid and lung apices are unremarkable. Atherosclerotic
calcifications noted at the carotid bulbs and proximal ICAs bilaterally.
IMPRESSION:
1. No acute fracture or prevertebral soft tissue abnormality of the cervical
spine.
2. Mild anterolisthesis of the C3 on C4 vertebral bodies is likely
degenerative.
Radiology Report
INDICATION: ___ with fall, weakness // eval for PNA
TECHNIQUE: Single supine view of the chest.
COMPARISON: Correlation made to same day CT of the cervical spine.
FINDINGS:
Relatively low lung volumes are noted. The lungs are grossly clear without
confluent consolidation or evidence of pneumothorax on this supine film.
Cardiac silhouette is within normal limits for technique. There is widened
upper mediastinum compatible with prominent mediastinal fat seen on concurrent
chest CT. No displaced fractures identified.
IMPRESSION:
The lung volumes without acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (AP AND LATERAL)
INDICATION: History: ___ with emesis, maroon positive, // please eval for
obstruction and ng tube placement
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ at 14:44
FINDINGS:
There has been interval placement of a nasogastric tube with the tip not
visualized beyond the upper esophagus on the frontal view. While the lateral
view demonstrates a catheter which courses in the expected region of the
esophagus and into the upper abdomen, this cannot be confirmed on the frontal
view. The heart size is mildly enlarged. Mediastinal and hilar contours are
unchanged. Pulmonary vasculature is not engorged. No focal consolidation,
pleural effusion or pneumothorax is detected. Streaky atelectasis is noted in
the lung bases. Compression fracture of a vertebral body at the thoracolumbar
junction is noted, of indeterminate age. No subdiaphragmatic free air is
present.
IMPRESSION:
Nasogastric tube tip can only be traced to the proximal esophagus on the
frontal view. Recommend advancement.
Radiology Report
INDICATION: History: ___ with emesis maroon positive, // please eval for
obstruction and ng tube placement
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: Chest radiograph obtained at 20:17, ___
FINDINGS:
No enteric tube is identified. The bowel gas pattern is nonobstructive.
Moderate amount of stool is seen in the rectum. There are no dilated loops of
small bowel, free intraperitoneal air, or concerning soft tissue
calcifications demonstrated. Mild degenerative changes are noted in the imaged
thoracolumbar spine.
IMPRESSION:
1. No enteric tube identified.
2. Nonobstructive bowel gas pattern without evidence of free intraperitoneal
air.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Hyperglycemia, s/p Fall
Diagnosed with OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.9
heartrate: 100.0
resprate: 14.0
o2sat: 94.0
sbp: 116.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male with PMH of DM2, HTN, CKD
stage 3 who presents to the hospital after a fall. Because his
wife ___ certain that the fall was serious enough to call
EMS, he was on the ground for 13 hours. In the ED, found to have
hyperGlc (400s) and UA c/w UTI, thought to have been the cause
of the fall. Due to dehydration, pt had hypernatremia and mild
___. In the ED, he had a single episode of maroon-colored emesis
(guaiac+) for which NGT was placed; stools were guaiac negative
and rectal exam revealed brown stool. H/H were stable through
his admission, and NGT was discontinued. The derangements above
were treated as described below:
Problem List
# Falls
# UTI
# Hyperglycemia/DM2
# Hypernatremia
# ___
# Maroon-colored emesis/?GIB
# Disorientation
# Troponinemia
# HTN
# Falls: Pt with reported history of several falls at home. This
fall was most likely precipitated by UTI, hyperglycemia,
?delirium. Due to being on the ground for 13h, patient had
hypernatremia (see below), mild ___ (see below), and CK
elevation to 1800. No reported hx of seizure-like activity or
sxs of syncope; additionally, other causes better explain the
fall. Given murmur heard on exam, echo was obtained showing LVH,
LVEF 70%, moderate aortic valve stenosis (valve area = 1.1cm2).
Patient discharged to rehab for further evaluation and
treatment.
# UTI: Patient's UA c/w UTI and urine cx growing Enterococcus.
Sensitive to ampicillin, nitrofurantoin (contraindicated due to
___, and vancomycin. Given sensitive to ampicillin, patient
was started on amoxicillin-clavulanic acid ___ PO q12h for a 10d
course for complicated UTI. This should be continued at rehab to
completion.
# Hyperglycemia/DM2: Patient presented with hyperglycemia to
400s, most likely due to infection and missed insulin doses. He
is on a glargine (50u breakfast, 42u dinner) and humalog (15u
breakfast, 50 units lunch) at home. Follows with an
endocrinologist at ___. Needs to f/u with Endocrinology
on discharge from rehab.
# Hypernatremia: As high as Na 150. Most likely ___ dehydration
due to being on the ground without free water access for 13h.
Initially we corrected with D5W based on free water deficit; Na
remained normal once patient taking PO as usual.
# ___ / CKD: Has history of stage 3 CKD (Cr baseline 2.5); Cr
3.0 on arrival. ___ most likely multifactorial due to (1)
relative hypotension in setting of UTI and (2) dehydration from
osmotic diuresis/hyperglycemia + free water restriction while he
was stuck on the floor. Re: (1), the patient had relatively low
systolic pressures (120s) during ___ 48 hours of admission; with
appropriate antibiosis, systolic pressures rebounded to
170s-200s (see HTN below). Cr improving (3.0 -> 2.8 -> 2.6).
Almost at baseline on discharge. Follow up with ___
nephrology.
# Maroon-colored emesis/?GIB: Single episode guaiac pos emesis
with guaiac neg brown stools. Hgb stable in ___. NGT placed in
ED but removed due to malposition on KUB and clinical stability.
# Disorientation: Patient with 24h of waxing-waning mental
status in hospital in setting of hyperglycemia, hyperNa, UTI as
above. Resolved with tx of illnesses as described above and
appropriate delirium precautions.
# Troponinemia: Patient with very mild Tn-emia on presentation
(0.13->0.14) and ECG at baseline, no chest discomfort. Most
likely represents a minimal elevation in setting of relative
hypotension, multiple illnesses as above, and ___ preventing
clearance of Tn.
# HTN: Patient was normotensive off home BP meds on arrival to
the floor. Initially held BP meds due to ___. However, once UTI
was txed, SBPs 170s-200s. Losartan 100/day restarted the day of
discharge; HCTZ continues to be held. Can be restarted at
discretion of rehab physician or PCP.
# Social: Initially thought that wife ___ filed with ___ at the
Elder Abuse Hotline and faxed written report to Ethos given
patient was down for 13 hours before EMS was called. Discussed
further with wife who noted that she didn't realize a fall was
"serious enough" to call EMS but would do so in the future if
something similar happened.
TRANSITIONAL
-Home Eval for fall prevention measures
-UTI: needs Augmentin 10d course for complicated UTI
-Hyperglycemia/DM2: needs f/u with ___ endocrinology
-___: f/u with ___ nephrology
-HTN: restart HCTZ or add additional antihypertensives as
appropriate |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Biaxin / Shellfish
Attending: ___.
Chief Complaint:
___ pain and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo RHW with h/o chronic LBP s/p L4-5 fusion,
fibromyalgia, anxiety, depression, who presents with progressive
distal lower extremity numbness and weakness for the past 3
months.
The patient initially presented on ___ ___.
She had awoken that morning with severe numbness below the knees
bilaterally. Her legs were weak and she collapsed on attempting
to stand. She had a recent stomach flu a few days prior.
Examination demonstrated distal lower extremity weakness and
decreased sensation to pin and vibration, with diminished lower
extremity reflexes. There was concern for GBS. CSF was normal (0
cells, glucose 59, protein 24, neg CSF Lyme, neg bands). However
it was thought there was still benefit to treating empirically,
so patient received 3 doses IVIG. She developed fever to ___ F
after 3rd dose so no more were given. She also underwent MRI C,
T
and L spine, and MRI/A brain which were all unrevealing. Labs
were initially notable for CK almost 20K, attributed to fall,
but
this was mild and there was not prolonged down time. CRP 50, ESR
16, WBC 18.3. CK trended down with IVF and has been normal on
repeat checks since.
The pt was discharged to rehab and was then discharged home with
___. Neurologic work-up continued as an outpatient under care
of Dr. ___. EMG ___ showed acute length dependent
polyneuropathy with mixed axonal and demyelinating features.
Motor neuropathy and paraneoplastic Abs sent to ___ were
negative (GM1, GD1b, MAG, ___, CV2, amiphiphysin). Autoimmune
labs
neg ___, ANCA, SSa/b). On ___, CRP was down to 25, ESR 12.
The patient complains of severe pain, that was not part of the
initial presentation but began after returning home from rehab
and doing ___. It has become more severe and refractory to
medications in the past month. Pain includes R foot cramps,
sharp
pains at L posterior calf and feet, burning pain on soles of
feet, hypersensitivity to touch that is painful on L foot. Pain
is worse when putting pressure on the legs to stand, and on
touching the L foot. There are no paresthesias. She will
sometimes feel extreme cold but then legs are not cold to the
touch.
Pt also c/o losing muscle mass and bulk all over, including
upper
extremities, though there are no other symptoms in the upper
extremities (no weakness, numbness, tingling in hands/fingers).
She feels her health going downhill in general and is very
discouraged. She reports her L leg bends backwards on walking.
She had been using cane, but is now using a wheelchair.
Of note, the patient reports that her pain medications were
stolen from her 5 days ago. Since then she experienced severe
withdrawal symptoms (N/V/D and extreme pain). She had not slept
or ate well in days. She presented to ___ ED today, and her
neurologist felt she warranted additional workup since diagnosis
is unclear, and sent her to ___ ED. The patient reports she
was
supposed to have nerve and muscle biopsy tomorrow at ___. ___.
Past Medical History:
-fibromyalgia
-chronic LBP on narcotics
-s/p L4-5 fusion few years ago, "failed"
-GAD
-depression
-PTSD
-SBO s/p LOA
-COPD vs BOOP
Social History:
___
Family History:
negative for neurologic disease
Physical Exam:
At admission:
Vitals: T: 97.6 P:56 R: 14 BP:96/68 SaO2:100/ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with naming,
intact repetition and comprehension. Speech was not dysarthric.
Able to follow both midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. There was
initially horizontal diplopia on far right gaze but this
resolved
after a few seconds and did not return on repeat testing.
V: Facial sensation intact to light touch.
VII: No facial droop, upper and lower facial musculature full
strength and 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 quick lateral
movements.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
neck flexion and extension full strength
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5- 4 3 4 3 3
R 5 ___ ___ 5 5 5 5 5 4 5-
There is element of giveway and poor effort in all above where
weakness is noted.
-Sensory: No deficits to light touch or cold. Decreased pinprick
(50%) on left lower medial leg and medial and dorsal foot. Pin
on
left lateral foot causes severe burning.
Decreased vibratory sense at L>R great toes.
Intact proprioception to large amplitude movements at bilateral
great toes and DIPs. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 1 0
R 2+ 2 2+ 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally, cannot perform HKS.
No overshoot or rebound on horizontal or vertical saccades
-Gait: deferred due to pain
Discharge Physical Exam: As above, except notable for normal
strength in upper and lower extremities, with notable giveway
weakness in the lower left extremity. Normal positioning of the
left leg/foot, improved from admission. The patient was able to
ambulate with a very mildly antalgic gait with a cane. Her
sensation testing was notable for persistent pain and burning
across the dorsum of her ___ in non dermatomal, non
radicular patterns.
Pertinent Results:
___ 06:50PM BLOOD WBC-18.8* RBC-6.18* Hgb-17.3* Hct-52.6*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.1 Plt ___
___ 06:50PM BLOOD Neuts-51.1 ___ Monos-5.2 Eos-0.9
Baso-1.6
___ 06:50PM BLOOD Plt ___
___ 06:50PM BLOOD ESR-4
___ 06:50PM BLOOD Glucose-82 UreaN-39* Creat-0.9 Na-136
K-4.2 Cl-95* HCO3-26 AnGap-19
___ 06:50PM BLOOD ALT-7 AST-23 AlkPhos-112* TotBili-0.4
___ 06:50PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.2 Mg-2.3
___ 04:10PM BLOOD CEA-5.2*
___ 06:50PM BLOOD CRP-7.7*
___ 04:10PM BLOOD HIV Ab-NEGATIVE
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:10PM BLOOD CA ___ -PND
CXR: IMPRESSION: No acute cardiopulmonary process.
CT torso with contrast:
IMPRESSION:
1. Innumerable bilateral sub-2mm pulmonary nodules some of which
are calcified and shotty mediastinal lymphadenopathy.
Differential includes
tuberculosis/fungal infection/sarcoidosis or less likely
hematogenous mets
with calcification, ie osteogenic, mucinous, thyroid, breast
origin.
Calcification suggests a chronic granulomatous infection (TB)
should be
considered. Comparison with any old CT imaging is recommended.
2. Dilated CBD measuring up to 11-mm which abruptly terminates
at the
pancreatic head with no stone seen. Possible thickening of the
duodenum at the ampulla is suspicious for malignancy. Followup
ERCP/MRCP is strongly recommended.
3. 5mm indeterminate hepatic hypodensity.
MRI C-T-L-spine
IMPRESSION: Mild degenerative changes of the cervical,
thoracic, and lumbar spine as described above. Post-surgical
changes, status post disc spacers at L4-5 and L5-S1 levels. No
evidence of abnormal enhancement or abnormal signal in the
spinal cord.
MRI head with and without contrast:
IMPRESSION:
Unremarkable MRI of the head with and without contrast.
Medications on Admission:
Morphine SR (MS ___ 100 mg PO Q12H
Morphine Sulfate ___ 30 mg PO/NG Q6H:PRN pain Order date: ___
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheezing Order date:
Potassium Chloride 20 mEq PO DAILY Duration: 24
Aspirin 81 mg PO/NG DAILY
Polyethylene Glycol 17 g PO/NG DAILY:PRN
Amitriptyline 100 mg PO/NG HS
Pantoprazole 40 mg PO Q24H
Soma *NF* (carisoprodol) 350 mg Oral q8 pain
Fluticasone Propionate NASAL 1 SPRY NU DAILY
traZODONE 100 mg PO/NG HS:PRN insomnia
Lorazepam 1 mg PO/NG Q6H:PRN anxiety
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for stomach upset.
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
8. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
10. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
11. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO q8 ().
12. gabapentin 300 mg Capsule Sig: Instructions Capsule PO BID
(2 times a day): Take 600 mg in AM and afternoon. Take 900 mg at
bedtime.
Disp:*200 Capsule(s)* Refills:*0*
13. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
14. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*21 Tablet(s)* Refills:*0*
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Compression polyneuropathy, 2. Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Exam: AOx3, full strength in upper extremities. Largely
full strength in lower extremities with some giveway strength,
likely related to pain at the left ankle.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with elevated white blood cell count. Question
pneumonia.
FINDINGS: PA and lateral views of the chest. No prior. Small calcified
granulomas are identified at the upper lungs, more numerous on the right than
on the left. The lungs are otherwise clear without consolidation or effusion.
The cardiomediastinal silhouette is normal. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with polyradiculopathy, fevers and weight
loss, here to evaluate for occult malignancy.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet
to the pubic symphysis following the uneventful administration of 100 cc
Omnipaque intravenous contrast and oral contrast per oncology protocol.
Coronally and sagittally reformatted images were generated and reviewed.
DLP: 708 mGy-cm
FINDINGS: The thyroid gland is unremarkable. No axillary, hilar, or
supraclavicular lymphadenopathy is seen. Several prominent paratracheal lymph
nodes measuring up to 9 mm in short axis are noted. The pulmonary arterial
trunk is patent and normal in caliber. The thoracic aorta is also normal in
caliber without evidence of acute aortic syndrome. There is a normal
three-vessel takeoff from the aortic arch. The heart is normal in size
without pericardial effusion. The esophagus is normal in appearance with a
small amount of oral contrast retained in the mid-to-lower esophagus.
The central tracheobronchial tree is patent to subsegmental levels. Within
the pulmonary parenchyma, there are centrilobular emphysematous changes
predominantly affecting the lung apices. Bibasilar atelectasis is noted.
There are no pleural effusions, focal consolidations or pneumothoraces.
Innumerable sub-2-mm pulmonary nodules are present bilaterally with a random
distribution, but predominantly located in the right lung, some of which are
calcified (for example, 3:9, 10, 22, 26, 29). No other pulmonary nodules or
masses are seen.
CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously without perfusion
defect. A focal 5-mm hypodensity is noted in the right lobe of the liver
(3:47), which is too small to fully characterize by CT. No other focal liver
lesion is detected. The portal venous system opacifies satisfactorily with
intravenous contrast. There is mild-to-moderate central intrahepatic biliary
dilatation and extrahepatic biliary dilatation with the common bile duct
measuring up to 11 mm within the head of the pancreas. There is an abrupt
termination of the CBD at the pancreatic head with no calcified gallstones
seen. There is associated thickened appearance of the duodenum at the ampulla
concerning for underlying malignancy (3:68). The gallbladder is contracted
with a thick enhancing wall. The pancreatic parenchyma enhances normally,
with mild atrophy of the gland noted. The spleen, bilateral adrenal glands
and kidneys are unremarkable. Two splenules are incidentally noted at the
splenic hilum.
The stomach and duodenal bulb are distended. The intra-abdominal loops of
small and large bowel are unremarkable without evidence of wall thickening or
obstruction. The appendix is normal in appearance. No free air or ascites is
present. There is no retroperitoneal or mesenteric lymphadenopathy. The
abdominal aorta is normal in caliber with minimal calcified atherosclerosis of
the distal abdominal aorta extending into the bilateral common iliac arteries
proximally.
CT PELVIS WITH CONTRAST: The urinary bladder, prostate, seminal vesicles,
rectum, and sigmoid colon are unremarkable. There is no free pelvic fluid or
inguinal/pelvic lymphadenopathy.
OSSEOUS STRUCTURES: Intervertebral disc spacers are noted at the L4-L5 and
L5-S1 levels. A small sclerotic area in the left paramedian sacrum (3:86) may
represent a bone island. There is deformity at the right posterior superior
iliac spine at the right SI joint (3:87).
IMPRESSION:
1. Innumerable bilateral sub-2mm pulmonary nodules some of which are calcified
and shotty mediastinal lymphadenopathy. Differential includes
tuberculosis/fungal infection/sarcoidosis or less likely hematogenous mets
with calcification, ie osteogenic, mucinous, thyroid, breast origin.
Calcification suggests a chronic granulomatous infection (TB) should be
considered. Comparison with any old CT imaging is recommended.
2. Dilated CBD measuring up to 11-mm which abruptly terminates at the
pancreatic head with no stone seen. Possible thickening of the duodenum at the
ampulla is suspicious for malignancy. Followup ERCP/MRCP is strongly
recommended.
3. 5mm indeterminate hepatic hypodensity.
Radiology Report
INDICATION: ___ woman with diffuse weakness involving multiple motor
and sensory nerves.
COMPARISON: None.
TECHNIQUE: Multiplanar, multisequence images of the head were performed with
and without contrast.
FINDINGS:
There is no evidence of acute infarct or hemorrhage. There is no abnormal
enhancement. The ventricles and sulci are age appropriate. No mass effect or
midline shift. The major intracranial flow voids are preserved. The orbits
are unremarkable. The paranasal sinuses are clear.
IMPRESSION:
Unremarkable MRI of the head with and without contrast.
Radiology Report
INDICATION: ___ woman with diffuse weakness involving multiple motor
and sensory nerves.
COMPARISON: None.
TECHNIQUE: Multiplanar multisequence images of the cervical, thoracic, and
lumbar spine were performed with and without contrast.
FINDINGS:
CERVICAL SPINE: There is normal anatomic alignment, vertebral body height,
and bone marrow signal intensity. The posterior fossa is unremarkable. The
spinal cord demonstrates normal signal intensity. The paraspinal soft tissues
are unremarkable. At C2-3 level, there is a disc bulge, asymmetric to the
left, causing mild narrowing of the left neural foramen.
At C3-4 level, there is a mild disc bulge indenting the thecal sac but no
significant spinal canal stenosis or neural foraminal narrowing.
At C4-5 level, there is a mild disc bulge indenting the thecal sac but no
significant spinal canal stenosis or neural foraminal narrowing.
At C5-6 level, there is a disc bulge slightly flattening the spinal cord and
causing mild narrowing of the bilateral neural foramina.
At C6-7 level, there is a mild disc bulge, asymmetric to the right, indenting
the thecal sac and causing mild narrowing of the right neural foramen.
At C7-T1 level, there is no significant disc bulge, spinal canal stenosis, or
neural foraminal narrowing.
Note is made that images are degraded by motion.
THORACIC SPINE: There is normal anatomic alignment, vertebral body height,
and bone marrow signal intensity. The spinal cord demonstrates no abnormal
signal intensity.
At T6-7 level, there is a central disc protrusion indenting the spinal cord
but no significant spinal canal stenosis or neural foraminal narrowing.
At T7-8 level, there is a central disc protrusion indenting the spinal cord,
but no significant spinal canal stenosis or neural foraminal narrowing.
At T8-9 level, there is a disc bulge indenting the thecal sac but no
significant spinal canal stenosis or neural foraminal narrowing.
LUMBAR SPINE: There are post-surgical changes, status post disc spacer at
L4-5 and L5-S1 levels. There is normal anatomic alignment, vertebral body
height, and bone marrow signal intensity. The spinal cord terminates at L1-2
level with normal signal of the cauda equina nerve roots without enhancement.
The paraspinal soft tissues are grossly unremarkable. Please refer to same
day CT of the torso.
There is no significant disc bulge, spinal canal stenosis, or neural foraminal
narrowing.
There is no evidence of abnormal enhancement in the cervical, thoracic, and
lumbar spine.
IMPRESSION: Mild degenerative changes of the cervical, thoracic, and lumbar
spine as described above. Post-surgical changes, status post disc spacers at
L4-5 and L5-S1 levels. No evidence of abnormal enhancement or abnormal signal
in the spinal cord.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WORSENING NEUROPATHY
Diagnosed with MUSCSKEL SYMPT LIMB NEC, LEUKOCYTOSIS, UNSPECIFIED , MYALGIA AND MYOSITIS NOS
temperature: 97.6
heartrate: 56.0
resprate: 14.0
o2sat: 100.0
sbp: 96.0
dbp: 68.0
level of pain: 10
level of acuity: 3.0 | ___ yo RHW with h/o chronic LBP s/p L4-5 fusion, fibromyalgia,
anxiety, depression, who presents with progressive distal lower
extremity numbness and weakness for the past 3 months. Neuro
exam is signficant for weakness that is asymmetric L>R and
more prominent distally than proximally in the lower
extremities, though there is question of giveway/effort in
judging the true degree of the weakness. This also makes it
difficult to distinguish an upper vs lower motor neuron pattern.
There is
decreased pinprick mostly in L4 distribution up to the knee,
with hyperasthesia in L5. Vibration sense is also diminished L>R
great toe, and DTRs are diminished in lower extremities.
Etiology of this presentation is unclear despite extensive
outpatient workup including MRI brain and spine, EMG, LP, and
several lab studies.
The patient had vague, non-specific positive findings, including
elevated CRP which has trended down, and elevated CK at initial
presentation, as well as leukocytosis intermittently seen. The
patient was admitted and monitored. A CT of the abdomen was done
that showed a duodenal wall thickening. She received a EGD and
biopsy that revealed only a cyst and no signs of neoplasm. the
CT of chest showed multiple small pum nodules/calcifications
with mediatinal LAD, however these were thought for the most
part to be chronic (based on previous radiology reports from
___ and ___ faxed from PCP ___.
Over her week of hospitalization the patient gained weight and
her objective signs of weakness (left foot drop) improved. Prior
to hospitalization the patient was eating only one meal a day.
She was also treated with B12 for a low normal B12, that may
have also contributed to her improvement. The patient was very
uncomfortable and frustrated with a diagnosis of compression
neuropathy secondary to malnutrition.
The patient's chronic pain was treated while she was here on her
home regimen on ___ and gabapentin. Of note, when her
medications were at her home dosing the patient was very
somnolent, difficult to arouse and O2 sat to the low ___. This
may have contributed to the patient's decreased PO.
The patient received physical therapy during her time and was
much improved on discharge. She was able to ambulate with a cane
and was deamed ready for d/c home with ___ services. Her hospital
course was discussed with her primary neurologist who
coordinated a follow-up for her. She was discharged on the pain
regiment she was on inpatient as detailed below. |
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:
None
History of Present Illness:
___ y/o male with no significant pmh
who presents with left sided chest pain, found to have left
upper
lobe anterolateral lung abscess and pneumomediastinum.
He was in his usual state of health until 3 weeks ago when he
developed gradually worsening, sharp, persistent, left-sided
chest pain, worse with inspiration. He also has had a mild
nonproductive cough. He denies fevers, chills, chest trauma.
He
denies abdominal pain, joint pain, joint swelling. He denies
sore throat. He has never been incarcerated, works as a
___, and has no known TB exposure or significant healthcare
exposures.
He initially presented to ___ on ___ following an
abnormal CXR at urgent care. Because urgent care xray revealed
a
left upper lobe opacity, he underwent a CT scan which showed a
3.6 x 4.3cm abscess vs mass. He was discharged home with a
diagnosis of PNA, and given Levaquin x4 days.
Since then he has had resolution of the chest pain, but
continues
to have an intermittent cough. A repeat CT scan was performed
___, ordered by his PCP, which showed evolution of the mass, now
with possible involvement of the pleura, as well as
pneumomediastinum. Because of this he was referred to the ED at
___, and given the findings, he was transferred to ___
for further evaluation and thoracics consult.
In the ___ ED, he was given IV Vancomycin. Thoracics was
consulted who recommended admission to medicine with ID consult
and IV Antibiotics.
Regarding prior antibiotic exposures, he reports a prior 7 day
course of PO Abx in ___ for a R axillary abscess. Other than
this and the recent Levofloxacin, no other recent ABx.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- left inguinal hernia repair
- prior R axillary abscess treated ___
Social History:
___
Family History:
Father - DM2
Grandmother - ___, breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
VS: T 98.4, HR 77, BP 100/58, RR 16, 96% RA
GENERAL: NAD, well appearing
HEENT: AT/NC, EOMI, anicteric sclera, MMM, oropharynx clear w/o
lesion or exudate
NECK: supple, no LAD
HEART: RRR
LUNGS: CTAB, no wheezes, breathing comfortably on RA
ABDOMEN: nondistended, nontender
EXTREMITIES: no cyanosis, clubbing, or edema. No joint effusion
or swelling.
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=============================
VS: 98.0PO 128 / 85 74 18 99 Ra
GENERAL: NAD, well appearing
HEENT: EOMI, anicteric sclera, MMM
HEART: RRR, no murmurs
LUNGS: CTAB, no wheezes/crackles, breathing comfortably on RA
ABDOMEN: Soft, nondistended, nontender, +BS
EXTREMITIES: WWP, no edema.
NEURO: A&Ox3, moving all 4 extremities with purpose ==
Pertinent Results:
ADMISSION LABS:
====================
___ 07:52PM BLOOD WBC-10.4* RBC-4.25* Hgb-12.8* Hct-37.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.2 RDWSD-39.9 Plt ___
___ 07:52PM BLOOD Neuts-61.9 ___ Monos-8.7 Eos-1.4
Baso-0.5 Im ___ AbsNeut-6.45* AbsLymp-2.80 AbsMono-0.91*
AbsEos-0.15 AbsBaso-0.05
___ 07:52PM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-142
K-4.3 Cl-101 HCO3-28 AnGap-13
___ 07:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.4
___ 03:57PM URINE Color-Straw Appear-Clear Sp ___
___ 03:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 03:57PM URINE barbitr-NEG opiates-NEG cocaine-POS*
amphetm-NEG oxycodn-NEG mthdone-NEG
___ 07:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
PERTINENT LABS:
====================
___ 07:30AM BLOOD TSH-5.3*
___ 03:30PM BLOOD T3-95 Free T4-1.2
___ 08:10AM BLOOD ANCA-NEGATIVE B
___ 08:10AM BLOOD ___ CRP-29.6*
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 07:30AM BLOOD Vanco-19.4
___ 11:44PM URINE Hours-RANDOM Creat-62 Na-56
___ 11:44PM URINE Osmolal-197
DISCHARGE LABS:
====================
___ 05:54AM BLOOD WBC-9.6 RBC-4.33* Hgb-12.6* Hct-38.4*
MCV-89 MCH-29.1 MCHC-32.8 RDW-12.0 RDWSD-39.2 Plt ___
___ 05:54AM BLOOD Glucose-93 UreaN-11 Creat-1.3* Na-142
K-4.4 Cl-102 HCO3-29 AnGap-11
___ 07:30AM BLOOD ALT-10 AST-14 LD(LDH)-141 AlkPhos-53
TotBili-0.2
___ 05:54AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0
IMAGING:
====================
ECHO ___
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
number of aortic valve leaflets cannot be determined. 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.
JUGULAR VEIN ULTRASOUND ___
No evidence of deep vein thrombosis in the bilateral internal
and external
jugular veins.
CHEST XRAY ___
1. Right-sided PICC line ends at the cavoatrial junction. No
evidence of
pneumothorax.
2. Focal opacification located laterally within the left
hemithorax likely
represents infarct, secondary to adjacent pulmonary embolus as
seen on CT from ___. However in a patient of this
age, vasculitis cannot be entirely excluded.
3. Persistent pneumomediastinum.
MICROBIOLOGY:
====================
__________________________________________________________
___ 7:03 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 8:21 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:52 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 08:10AM BLOOD B-GLUCAN-PND
___ 08:10AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ertapenem Sodium 1 g IV DAILY
RX *ertapenem [Invanz] 1 gram 1 g IV Daily Disp #*30 Vial
Refills:*0
3.Outpatient Lab Work
ICD-9: 513.0 Lung Abscess
LABS:WEEKLY CBC with differential, BUN, Cr, AST, ALT, Total
Bili, ALK PHOS
FAX TO: ATTN: ___ CLINIC
FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left upper lobe mass, presumed abscess
Pneumomediastinum
Reduced ejection fraction
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILATERAL UP EXT VEINS US
INDICATION: ___ yo man without significant PMHx presents with progressive lung
mass and mid non-productive cough.// eval internal/external jugular veins for
thrombus
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: CT from ___.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The bilateral internal and external jugular veins are patent, show normal
color flow and compressibility.
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral internal and external
jugular veins.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with right PICC. Evaluation for placement of
right PICC.
TECHNIQUE: Chest portable AP
COMPARISON: CT chest from ___.
FINDINGS:
Right-sided PICC line ends at the cavoatrial junction. Cardiomediastinal
silhouette is within normal limits. The pulmonary vasculature is normal.
Focal opacification located laterally within the left hemithorax likely
represents infarct, secondary to adjacent pulmonary embolus as seen on CT from
___. However in a patient of this age, vasculitis cannot be
entirely excluded. There is persistent pneumomediastinum. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
1. Right-sided PICC line ends at the cavoatrial junction. No evidence of
pneumothorax.
2. Focal opacification located laterally within the left hemithorax likely
represents infarct, secondary to adjacent pulmonary embolus as seen on CT from
___. However in a patient of this age, vasculitis cannot be
entirely excluded.
3. Persistent pneumomediastinum.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abscess, Transfer
Diagnosed with Abscess of lung without pneumonia
temperature: 98.6
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 90.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ man with no chronic medical problems who presented with left
sided chest pain and cough, with outpatient imaging showing left
upper lobe mass felt to be an abscess. He was treated with
vancomycin/zosyn and transitioned to ertapenem at discharge.
# Lung Abscess with Pneumomediastinum:
Patient presented with lung mass on CT scan, felt most likely an
abscess possibly precipitated by aspiration event in the setting
of alcohol/drug use v. small nodular bacterial pneumonia that
coalesced into abscess given inadequate treatment with 4 days of
PO levoquin as outpatient. Differential diagnosis also included
atypical infection (e.g. fungal) v. inflammatory process v.
malignant process, all felt much less likely. CT imaging ___
with progression of mass and concern for pneumomediastinum.
Infectious disease was consulted who recommended treatment for
pyogenic lung abscess with vancomycin/zosyn. Thoracic surgery
and interventional pulmonology were consulted for consideration
of biopsy v. abscess drainage. Both teams recommended
conservative medical management with close follow up, given low
concern for pleural involvement and very low concern for
mediastinitis given patient very well appearing and stable
throughout admission. Pneumomediastinum may have occurred
secondary to intranasal cocaine use v. coughing. HIV was
negative. ___ and ANCA negative. Blood cultures were no growth
to date. TTE without evidence of pericardial seeding. Jugular
vein ultrasound without thrombosis. On discharge, he was
transitioned to ertapenem with plan for at least 4 weeks of
antibiotics [Day 1 ___, with repeat CT chest in 4 weeks and
close PCP, ___, interventional pulmonology, and
thoracic surgery follow up. He will need further workup if mass
persists on repeat imaging status post antibiotics.
# Reduced ejection fraction:
Patient's TTE was notable for reduced ejection fraction of 45%
and mild global left ventricular hypokinesis. Most likely
secondary to alcohol and cocaine use. TSH was elevated at 5.3,
but T3 and free T4 were normal. He will need repeat TTE in 3
months and further outpatient work-up if persistent depression
of ejection fraction.
# Acute kidney injury:
Patient developed ___ from 0.9 on admission to 1.3. This
remained stable the next day, without improvement with IV
fluids. ___ was felt secondary to zosyn he received in house.
Vancomycin level was 19, so vancomycin felt less likely to be
culprit. Urine sediment without concerning findings. Patient was
encouraged to continue good PO intake on discharge. He will need
a repeat creatinine in 1 week to ensure normalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsive episode
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with signficant PMH ESRD and
Afib on coumadin with history of CVA in ___ who presents
to the ED after being found unresponsive at her ECF. Per report,
patient was seen normal eating breakfast at 8am. She was then
found by staff unresponsive by staff sometime later, between 9am
and noon, although reports are conflicting. EMS was activated
and per report FSBG was normal. Her finger stick blood glucose
was normal per report and without complaint.
In the ED, initial VS were T 96.8 °F, P ___, RR 22, BP 136/58,
O2Sat: 95 3LNC. She was was unresponsive to vocal stimulation
but would withdraw all four extremities to painful stimuli. She
had no apparent posturing or seizure activity. Eyes were not
deviated nor had patterned movement. Gag reflex was intact and
she was breathing comfortably. NCHCT and CXR showed no acute
process. Initial bloodwork was remarkable for subtherapeutic INR
of 1.6 and Cr of 3.5 (c/w prior). She was given narcanx2 without
apparent effect. Patient was being prepared for intubation when
she apparently awoke spontaneously after the ED staff left to
gather supplies. She was not post ictal and was AAOx3. She had
no complaints.
On arrival to the floor, patient is comfortable. She notes
rememberign ride in the ambulance and being in the CT scanner.
She also notes someone 'pushing on my chest with their thumb'.
When asked why she didn't respond, she says 'I'm not sure'. She
denies SOB, cough, abominal pain, nausea or vomiting. She has no
dysuria and has been moving her bowels well. She denies recent
fevers or chills. She denies new weakness or numbness. She does
note increased blurriness of her vision and does not like the
artificial tears recently started.
Of note, she has had multiple recent admissions. She was
admitted with initiation of HD for ESRD from ___ to ___. She
was then readmitted with SOB contributed to under UF and mild
COPD exacerbation from ___ to ___. During this last admission,
zyprexa was started qhs for sundowning.
Past Medical History:
- CVA ___ when temporarily off coumadin, cannot fully
extend left arm. Strength mostly regained following ___.
- Afib on coumadin, goal INR ___
- ESRD ___ Polycystic kidney disease diagnosed ___ years ago.
Also hypertensive nephrosclerosis. Initiated on hemodialys
___
- Colon cancer s/p right hemicolectomy and chemotherapy in ___.
- Diverticulosis with numerous GI bleeds requiring transfusion
- Abdominal aortic aneurysm s/p surgery in ___ at ___.
- Chronic anemia
- Hypertension
- Arthritis
- S/p right hip replacement, inferior pubic ramus fracture
Social History:
___
Family History:
Positive for arthritis, throat cancer in her father, and
___ dementia in her mother.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS - Temp 98.2 F, BP 140/72, HR 96, RR 20, O2-sat 99% RA
GENERAL - Thin elderly woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Mildly labored on room air and speaking in short
sentences. Fair air movment. No wheeze noted. Soft crackles at
bases.
HEART - PMI non-displaced, RRR, no MRG, soft S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ left deltoid, sensation grossly intact throughout,
cerebellar exam notable for intention tremor of left arm on FTN,
gait deferred
NEUROLOGY CONSULT PHYSICAL EXAM:
Tm 98.3 Tc 98.3 HR 70 BP 130/75 RR 18 O2Sat 94% RA
Physical Exam
Gen: lying comfortably on dialysis bed, interactive and in NAD,
cachectic
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Crackles heard bilaterally anteriorly in bases. Not
in
respiratory distress.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted. No
rebound
or guarding.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: some bruises in lower extremities. No other lesions noted.
Neurologic:
-Mental Status: Patient is alert and oriented to ___, date and
her name, and able to follow complex and appendicular commands.
Patient is interactive with attention intact (able to spell
WORLD
backwards). Patient is able to calculate. No tactile neglect to
DSS. Speech is fluent with intact prosody. Naming intact to high
and low frequency words. Repetition and comprehension are
intact.
Memory and recall are intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam w/ no papilledema.
III, IV, VI: EOM intact, normal saccades.
V: Facial sensation intact to touch.
VII: No facial droop, facial musculature symmetric.
VIII: some hearing loss in left ear, but able to hear
bilaterally.
IX, X: Palate elevates symmetrically.
XI: Able to shrug shoulders
XII: Good tongue strength in both directions. Able to move
tongue
without difficulty.
-Motor: Normal bulk for her age, normal tone. No rigidity, or
adventitious movements noted. Left arm pronator drift. Able to
move all 4 extremities, and is able to follow commands. ___
strength in left arm in UMN pattern. Patient has a mild tremor
on
exam.
-Sensory: intact to touch
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 1
R - - - 0 1
Plantar response was downgoing bilaterally
-Coordination: Slow on rapid alternating movements. Exhibits
past
pointing on finger to nose exam along with an intention tremor.
-Gait: Deferred
PHYSICAL EXAM ON DISCHARGE:
VS - Tm 98.3 BP 138/76 HR 68 RR 18 O2 97%RA
GENERAL - Thin elderly woman in NAD, comfortable, appropriate,
sitting up in chair
HEENT - PERRL, sclerae anicteric, MMM, OP clear
NECK - supple, JVD not appreciated
LUNGS - Overall comfortable on room air but does use accessory
muslces. Fair air movement with crackles at bases bilaterally
more prominent on left.
HEART - Regular rate, irregularly irregular rhythm, no MRG, soft
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e,
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength
grossly unchagned since admission
Pertinent Results:
ADMISSION LABS:
___ 01:45PM BLOOD WBC-5.9 RBC-3.05* Hgb-8.5* Hct-30.0*
MCV-98 MCH-28.0 MCHC-28.5* RDW-18.5* Plt ___
___ 01:45PM BLOOD ___ PTT-37.6* ___
___ 01:45PM BLOOD Glucose-86 UreaN-38* Creat-3.5* Na-142
K-4.4 Cl-102 HCO3-30 AnGap-14
___ 01:45PM BLOOD ALT-23 AST-22 AlkPhos-110* TotBili-0.4
___ 01:45PM BLOOD Lipase-104*
___ 01:45PM BLOOD cTropnT-0.06*
___ 09:25PM BLOOD cTropnT-0.06*
___ 01:45PM BLOOD Albumin-3.1*
___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:34PM BLOOD ___ pO2-76* pCO2-53* pH-7.37
calTCO2-32* Base XS-3 Comment-GREEN TOP
___ 01:54PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-6.8 RBC-3.52* Hgb-9.6* Hct-34.6*
MCV-98 MCH-27.2 MCHC-27.7* RDW-19.1* Plt ___
___ 07:20AM BLOOD ___ PTT-36.2 ___
___ 07:20AM BLOOD Glucose-86 UreaN-20 Creat-2.2*# Na-140
K-3.6 Cl-98 HCO3-29 AnGap-17
___ 07:20AM BLOOD Calcium-9.1 Phos-2.8# Mg-2.1
URINE:
___ 06:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:20PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 06:20PM URINE RBC-2 WBC-35* Bacteri-FEW Yeast-NONE
Epi-17
___ 06:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
PERTINENT MICROBIOLOGY
___ 2:00 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 6:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Add'l Blood cx from ___ and ___ No significant growth to date
REPORTS:
___ Neurophysiology EEG
This is an abnormal EEG because of mild diffuse background
slowing. These findings are indicative of mild diffuse
encephalopathy which is etiologically non-specific. There were
no epileptiform features.
___ Radiology CT HEAD W/O CONTRAST
1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related volume
loss.
___ Radiology CHEST (PORTABLE AP)
1. No acute cardiopulmonary process.
2. Chronic left lower lobe opacitiy may be due to aspiration,
atelectasis or scarring.
Medications on Admission:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation every six (6)
hours.
3. ipratropium bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
5. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for intertrigo.
10. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q 8H (Every 8 Hours).
11. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic Q2H (every 2 hours): Hold while sleeping.
12. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Until INR becomes
therapeutic.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) for 10 days
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
4. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
8. miconazole nitrate 2 % Powder Sig: One (1) application
Topical four times a day as needed for intertrigo.
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1)
Injection three times a day: Until therapeutic on coumadin.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Medication side effect
2. End stage renal disease
3. Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Unresponsiveness. Evaluate for pneumonia.
COMPARISONS: Chest radiograph ___. Chest radiograph ___.
FINDINGS: There is an unchanged linear opacification at the left base, most
consistent with chronic atelectasis, aspiration or scarring. There is no
pulmonary edema, pleural effusion or pneumothorax. Moderate enlargement of
the cardiac silhouette is stable from the prior exam. Atherosclerotic
calcification is noted within a torturous aorta. Clips are noted in the
mediastinum. No definite fractures identified.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Chronic left lower lobe opacitiy may be due to aspiration, atelectasis or
scarring.
Radiology Report
INDICATION: Unresponsiveness.
COMPARISONS: CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin-slice
bone image reformats were obtained and reviewed.
FINDINGS: There is no evidence of acute hemorrhage, edema, mass, mass effect,
or infarction. The ventricles and sulci are prominent, suggesting age-related
atrophy. The basal cisterns are patent. Periventricular confluent white
matter hypodensities are consistent with chronic small vessel ischemic
disease. The gray-white matter differentiation is preserved. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. There has been no significant change from the prior
head CT on ___.
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related volume loss.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UNRESPONSIVE
Diagnosed with SEMICOMA/STUPOR, END STAGE RENAL DISEASE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ASSESSMENT & PLAN:
Ms ___ is a ___ year old with a history of ESRD, Afib on
coumadin, and history of CVA who presents from her ECF after
being found unresponsive this morning. She awoke spontaneously
in the ED during workup and is currently without significant
complaint.
# Unresponsive episode: Patient was last seen normal at 8am
morning of discharge. She was found unresponsive by staff at ECF
sometime between 9am and noon. She was brought to ED where she
was noted to be breathing comfortably with intact gag reflex.
She withdrew from pain in all four extremities. CT of head, CXR,
and initial lab work was unremarkable. During preparation for
intubation, patient apparently awoke spontaneously while staff
was out of the room. She was noted to be oriented and without
complaint. She was admitted to medicine for further workup and
observation. On arrival to the medicine floor she had no
significant complaint. Zyprexa was held. Troponins were negative
x2 and telemetry showed only occasional PVC's overnight. Given
concern for seizure, routine EEG was performed, which was
negative for epileptiform discharges per preliminary report.
Neurology was consulted who felt episode most likely due to
medication effect of zyprexa with poor baseline substrate given
recent hospitalziations and initation of HD. No further imaging
was felt to be indicated. Zyprexa should be discontinued on
discharge and any additional neuroleptic or sedating medications
should be used cautiously.
# Positive blood cultures: Patient noted to have GPC in clusters
growing from one culture set drawn in the ED. She was afebrile,
hemodynamically stable, and without complaint. She was
empirically started on daptomycin given recent VRE in urine
culture. Speciation of blood culture returned coagulase negative
staph, and antibiotics were discontinued as this was felt to be
contaminant
# VRE Bacteruria: Patient with VRE in urine culture on ___ prior
to previous discharge. She was not treated as she was
asymptomatic. Again had VRE in urine culture from ED on ___, and
again is asymptomatic. She did receive 1 dose of daptomycin
empirically for positive blood culture, as above. However,
antibiotics were discontinued with no current intention to treat
her VRE bacteruria.
# Afib: Continued rate controle with metoprolol tartrate 12.5mg
po bid. Discharged on home 25mg metoprolol succinate.
Additionally, patients CHADS-2 is at least 5 and she was
subtherapeutic on her INR on admission. However, given history
of GI bleed in past, she was not bridged with heparin drip.
Coumadin was increased to 2.5mg daily.
# ESRD. Due to PCKD. Initiated HD on ___. Continued HD on
TTS schedule. Continued home sevelemer.
# ?COPD: Patient recently treated for COPD exacerbation during
recent hospitalization. She was breathing comfortably now on
room air without signficant wheezes on exam. Continued home
albuterol and ipratroprium prn, which she did not require.
# Hx of CVA: Continued anticoagulation as above. Given embolic
nature of stroke, it was deemed reasonable for patient not to be
on statin.
# Hx of delerium/sundowning: Has occured with prior amissions.
Held zyprexa as above. Remained alert, oriented, and appropriate
during her stay.
# HTN: Continued metoprolol 12.5 bid as above. Discharged on
home 25mg metoprolol succinate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
ciprofloxacin / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Stroke
Major Surgical or Invasive Procedure:
tPA
History of Present Illness:
___ is a ___ male w/ hx of DM, HTN, prostate CA
(currently opting for observation), colon CA s/p resection, CAD,
and prior traumatic SDH who presents as OSH transfer for R arm
weakness/sensory loss and aphasia. History obtained mostly from
wife and OSH records d/t patient aphasia.
Watching TV at ___ when developed acute onset right sided
weakness and difficulty speaking. Wife called EMS who noted
plegia on right and grunting. Significant improvement in
ambulance w/ NIHSS 2 on arrival to OSH. Weakness worsened after
CT scans. Telestroke consult w/ repeat NIHSS 5 (1- R superior
quandrantanopsia, 1 L facial weakness (?chronic), 1 R arm
weakness, 1 R sensory loss, and 1 dysarthria). BP 211/110 on
arrival at OSH requiring IV metoprolol, IV labetalol, and
nicardipine gtt. Received tPA at 0152 at OSH. CTA H/N at ___ did
not show LVO, not thrombectomy candidate. Code Stroke on arrival
to ___ for further care (no ICU beds at ___.
ROS limited by inability of patient to answer questions but
completed w/ wife to best of her knowledge. On neuro ROS, the pt
denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. 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:
DM
HTN
Colorectal CA s/p resection
BPH
prostate CA (watchful waiting)
GERD
hx of traumatic SDH ___ years ago after MVA
CAD (diagnostic cath 1.5 wks ago, possible need for CABG)
Social History:
___
Family History:
No family hx of stroke.
Physical Exam:
Physical Exam on admission
===============
Vitals:
Pain 0 Temp 97.8F HR 110 BP 151/80 RR 16 SpO2 97% RA
General: Awake, cooperative, anxious but NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, ND
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert. Unable to answer orientation
questions or relate history. Language is fluent but frequently
nonsensical with intact repetition. Normal prosody. Pt was able
to name occasional high frequency objects. Able to read without
difficulty. Speech was not dysarthric. Inconsistently follows
midline and appendicular commands. Able to read w/o difficulty.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to blink to threat.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: mild L NLFF (unclear if chronic), facial musculature
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. RUE downward drift w/o
pronation. No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc
L 5 ___ 5 5 5 5 5 5
R 4+ 5 4+ 4+ 4+ 5 5 5 5 5
-Sensory: Decreased light touch in throughout RUE/RLE. Unable to
test further d/t aphasia.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: deferred
On Discharge:
AF, HR 60-80s, 140-s170s/80s
General: Awake, cooperative, NAD.
HEENT: MMM
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
Alert and oriented, to hospital my month year and situation
.Able to complete moyb without difficulty. Naming intact with
the
exception of a few low frequency objects like cuticle.
Repetition
intact. Able to complete multi step commands. No dyscalculia.
CN - EOMI, VFF to finger counting, no agraphesthesia, subtle R.
NLF Flattening
Motor
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA
L 5 5 5- ___ ___ 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch
-DTRs:
___
-___: no obvious dysmetria
-Gait: deferred
Pertinent Results:
___ 10:58AM BLOOD %HbA1c-8.3* eAG-192*
___ 10:58AM BLOOD Triglyc-99 HDL-45 CHOL/HD-3.9 LDLcalc-109
___ 10:58AM BLOOD TSH-1.2
CT HEAD ___
No evidence of acute hemorrhage or acute large territory
infarction. Please
note that MR would be more sensitive for evaluation of
infarction.
MRI HEAD ___
Some of the images are degraded by movement artifact.
There are multiple foci of restricted diffusion in the left
frontal, parietal and occipital lobes, and a small focus of
restricted diffusion adjacent to the trigone of the right
lateral ventricle, with associated T2/FLAIR hyperintensity. On
the gradient echo sequence, there is a small amount of
susceptibility in the left parietal lobe, in keeping with a
degree of hemorrhagic products. Susceptibility is also noted
peripherally within the right temporal lobe, in keeping with old
blood products. Note is made of encephalomalacia in the lateral
aspect of the right temporal lobe. There is an old lacunar
infarct in the head of the right caudate nucleus, and foci of T2
hyperintensity in the left basal ganglia, which may represent
old lacunar infarcts or dilated perivascular spaces. There are
nonspecific bilateral supratentorial T2/FLAIR hyperintensities,
which may represent the sequelae of chronic microangiopathy.
There is no mass, mass effect or midline shift. The
ventricles and sulci are normal in caliber and configuration.
IMPRESSION:
Multiple foci of restricted diffusion in the left cerebellar
hemisphere and
adjacent to the trigone of the right lateral ventricle, in
keeping with
multiple focal acute/subacute infarcts, which are likely embolic
in nature.
Susceptibility within the left parietal lobe in a region of
restricted
diffusion, suggestive of hemorrhagic products.
TTE
Mild global left ventricular systolic dysfunction with ? focal
hypokinesis of apex.Will recommend sonographer return and
perform additional lumason enhanced images and thisreport will
be ammended. No PFO identified. No clear LV thrombus, but will
confirm withlumason images.
CAROTID ULTRASOUND
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. glimepiride 4 mg oral BID
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Pantoprazole 40 mg PO BID
7. Tamsulosin 0.4 mg PO DAILY
8. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Dao;y Disp
#*30 Tablet Refills:*2
3. 70/30 50 Units Breakfast
70/30 40 Units Dinner
4. Praluent Pen (alirocumab) 150 mg/mL SC EVERY 2 WEEKS
5. Valsartan 160 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. glimepiride 4 mg oral BID
8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO DAILY
10. Pantoprazole 40 mg PO BID
11. Tamsulosin 0.4 mg PO DAILY
12.Outpatient Physical Therapy
___ Acute Ischemic stroke
Physical therapy at least 3x weekly
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
Non-ST elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with s/p TPA with worsened exam // eval for acute
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 18.0 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, acute large territory
infarction,hemorrhage,edema,or mass effect. There appear to be chronic
infarcts involving the right caudate head, the right internal capsule, the
left basal ganglia. There is prominence of the ventricles and sulci
suggestive of involutional changes.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Patient is status post right lens surgery.
IMPRESSION:
No evidence of acute hemorrhage or acute large territory infarction. Please
note that MR would be more sensitive for evaluation of infarction.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with aphasia, right sided weakness // Eval for
stroke. To be done ___ if possible
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT Head ___.
FINDINGS:
Some of the images are degraded by movement artifact.
There are multiple foci of restricted diffusion in the left frontal, parietal
and occipital lobes, and a small focus of restricted diffusion adjacent to the
trigone of the right lateral ventricle, with associated T2/FLAIR
hyperintensity. On the gradient echo sequence, there is a small amount of
susceptibility in the left parietal lobe, in keeping with a degree of
hemorrhagic products. Susceptibility is also noted peripherally within the
right temporal lobe, in keeping with old blood products. Note is made of
encephalomalacia in the lateral aspect of the right temporal lobe. There is
an old lacunar infarct in the head of the right caudate nucleus, and foci of
T2 hyperintensity in the left basal ganglia, which may represent old lacunar
infarcts or dilated perivascular spaces. There are nonspecific bilateral
supratentorial T2/FLAIR hyperintensities, which may represent the sequelae of
chronic microangiopathy. There is no mass, mass effect or midline shift.
The ventricles and sulci are normal in caliber and configuration.
IMPRESSION:
Multiple foci of restricted diffusion in the left cerebellar hemisphere and
adjacent to the trigone of the right lateral ventricle, in keeping with
multiple focal acute/subacute infarcts, which are likely embolic in nature.
Susceptibility within the left parietal lobe in a region of restricted
diffusion, suggestive of hemorrhagic products.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with stroke // Post tPA 24 hour non contrast CT
scan. Please perform it on ___ at 0200 am.
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 =
934.5 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: Head CT ___. Head MRI ___.
FINDINGS:
Infarcts of the left frontal and parietal lobes, along with the bilateral
occipital lobes, are better assessed on prior MRI. There is no evidence of
hemorrhage. Chronic infarcts of the right caudate and internal capsule and
the left basal ganglia are again seen. There is prominence of the ventricles
and sulci suggestive of involutional changes. Periventricular and subcortical
white matter hypodensities are better assessed on prior MRI, likely sequela of
chronic ischemic small vessel disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Aside from a right lens replacement, the visualized
portion of the orbits are normal.
IMPRESSION:
1. No evidence of hemorrhage.
2. Infarcts of the left frontal and parietal lobes, along with the bilateral
occipital lobes, are better assessed on prior MRI.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with stroke // EVal for bleed, s/p tPA on hep
gttPLEASE PERFORM AT 0100
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
There is no evidence of fracture, acute vascular territorial
infarction,hemorrhage,edema,or mass. There is encephalomalacia in the right
lateral temporal lobe as well as areas of evolving infarct in left frontal
parietal region and left occipital lobe, corresponding to findings on MRI,
more conspicuous than on previous CT. No hemorrhage. Chronic infarcts in the
bilateral basal ganglia and the right internal capsule again seen. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Hypoattenuation in the white matter is noted which is nonspecific but likely
reflects chronic small vessel disease in this age group.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal, with
right lens replacement noted.
IMPRESSION:
1. Redemonstration of left frontal and parietal infarcts as well as left
occipital infarct. No hemorrhage
2. Encephalomalacia in the lateral right temporal lobe is again seen likely
reflecting old infarct. Chronic bilateral basal ganglia lacunar infarcts and
right internal capsule lacunar infarct.
Radiology Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man with recent likely cardioembolic strokes, workup
for CABG // ? eval carotid stenosis, CABG workup
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
There is mild heterogenous atherosclerotic plaque in the right carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 124 cm/s / 18.5 cm/s
CCA Distal: 132 cm/s / 18 cm/s
ICA ___: 105 cm/s / 24.4 cm/s
ICA Mid: 104 cm/s / 16.8 cm/s
ICA Distal: 90.4 cm/s / 20.3 cm/s
ECA: 86.1 cm/s
Vertebral: 54.9 cm/s
ICA/CCA Ratio: 0.8
The right vertebral artery flow is antegrade with a normal spectral waveform.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 93.7 cm/s / 16.4 cm/s
CCA Distal: 153 cm/s / 29.5 cm/s
ICA ___: 87.6 cm/s / 20.3 cm/s
ICA Mid: 80.6 cm/s / 21.7 cm/s
ICA Distal: 68.6 cm/s / 18.8 cm/s
ECA: 158 cm/s
Vertebral: 50.4 cm/s
ICA/CCA Ratio: 0.57
The left vertebral artery flow is retrograde with a normal spectral waveform.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with recent stroke and NSTEMI // pre-op workup
for CABG Surg: ___ (CABG )
IMPRESSION:
In comparison with the outside study of ___, the cardiac silhouette is
within normal limits and there is no vascular congestion, pleural effusion, or
acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Weakness, Slurred speech
Diagnosed with Weakness
temperature: 97.8
heartrate: 110.0
resprate: 16.0
o2sat: 97.0
sbp: 151.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | SUMMARY
==========
___ is a ___ male w/ hx of DM, HTN, prostate CA
(currently opting for observation), colon CA s/p resection, CAD,
and prior traumatic SDH who presents as OSH transfer for R arm
weakness/sensory loss and aphasia, s/p TPA, course c/b NSTEMI.
TRANSITIONAL ISSUES
=====================
[ ] Follow-up w/ ___ expedited CABG, if patient were
to develop chest pain he would need to be urgently evaluated for
emergent PCI or CABG, please continue to monitor closely
[ ] Tentative plan to discharge on apixaban with Ziopatch, if
Ziopatch negative for occult arrhythmia will likely discontinue
apixaban and treat with Aspirin alone
[ ] Follow-up w/ interventional cardiology to discuss options
[ ] Continue optimization of diabetes given elevated A1c (8.3)
#Acute Ischemic Stroke
Pt presented w/ a mixed aphasia and RUE weakness concerning for
left MCA stroke. He received tPA on ___. CTA did not
demonstrate any large vessel occlusion or significant
atherosclerosis. MRI 24 hours s/p tPA demonstrated multifocal
acute infarcts in multiple vascular territories consistent w/ a
cardioembolic source, however TTE w/o an obvious source (EF
mildly reduced 50-55%). Per echocardiography fellow, windows
were appropriate and they didn't believe a TEE would offer
further advantage. Etiology of his stroke is believed to be
embolic stroke of undetermined source (ESUS), though given his
concurrent cardiac disease suspicion is highest for a transient
cardiac arrhythmia which led to cardiac thrombus formation. Pt
was transitioned to apixaban this admission (5mg BID), which we
will continue and consider stopping if his Ziopatch is negative.
Noted to have A1c of 8.2 and LDL of 109. Pt has an allergy to
statins and thus is on a PSCK9 inhibitor. He was seen by both
physical therapy, occupational therapy and speech therapy.
#NSTEMI
#CAD
Pt underwent recent LHC ___ (as an outpatient) and noted to
have 3V disease. Presented this admission w/ concern for chest
pain (was initially difficult to evaluate given aphasia) and
elevated troponin to 1.2. Cardiology was consulted and he was
started on a heparin gtt for an NSTEMI. Cardiac enzymes
downtrended. He was additionally evaluated by cardiothoracic
surgery who are pursuing an expedited workup for CABG. From a
stroke perspective he is okay for a heparin gtt as needed for
surgery. He additionally had a CXR, labs, and carotid dopplers
while inpatient. We also reached out to the structural heart
team for consideration of a complex PCI as an alternative to
surgery. Of note, the cardiology team did not believe there was
an acute indication for intervention during this
hospitalization. Pt was switched from atenolol to metoprolol
(consolidated at discharge to 50mg succinate). Also started on
ASA 81mg. He was discharged w/ a Ziopatch.
#DM
#HTN
Noted to have uncontrolled risk factors of DM and HTN. Increased
Valsartan this admission. Stopped atenolol and switched to
metoprolol as above.
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 =109) - () 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:
[ X] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() 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 in written
form? (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? () Yes - (X) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[X ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (X)
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (X) N/A -- high concern for atrial
fibrillation, so discharge on apixaban pending Ziopatch |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine
Attending: ___
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ woman with a deceased donor renal
transplant in ___ c/b stage IV chronic kidney disease in the
transplant ___ chronic allograft nephropathy, baseline Cr 3.7,
as well as secondary hyperparathyroidism, recurrent PEs
presenting with N/V/D and ___.
Pt developed N/V/D, HA, malaise approximately 1 week ago with
her children reporting similar symptoms. Vomiting resolved ~5
days ago but she has continued to have nausea and extensive
non-bloody brown loose stool, with associated epigastric pain.
Her stool is just now starting to have some form. No travel, new
foods or uncooked meat. She has been taking APAP but no NSAIDS.
She denies any pruritis or metallic taste. She has had GI side
effects from MMF in the past necessitating dose reduction. She
has not had any fevers or recent antibiotic or hospital
exposure. She has continued to take her immunosuppresants and
didnt see any pills in her vomitus. She also continued to take
her lasix despite poor PO intake. She noticed decreased UOP and
LH on standing 1 day PTA and presented for evaluation in the ED.
Her transplant course was complicated by acute humoral rejection
during her pregnancy in ___ and then acute cellular rejection
in
___. She is inactive on the kidney transplant wait list, blood
group O, with no potential live donors, with a plan to start
evaluating the patient for a new transplant. Most recent PRA 0
with no identified anti-HLA antibodies. Her BMI has been >40.
As an outpt, furosemide recently increased to 40 mg twice daily
as well as an increased dose of vitamin D. Her prednisone dose
was weaned to 10 mg ___. She had amlodipine resumed at that
time as well.
In the ED, VSS, labs notable for ___ with Cr 8.7 and associated
AG metabolic acidosis (nml lactate), K 3.4, Mg 1.2, tacro 21.
FeNa 0.62. Renal US nml. She received zofran, dilaudid, and 500
cc NS.
Past Medical History:
- CKD ___ hypertension and probably APOL1 genetic
predisposition, s/p status post DD renal transplant with prior
peripartum acute humoral and cellular rejection (s/p ATG and
plasmapheresis, IVIG, and rituximab), now with transplant
chronic rejection (stage IV CKD).
- Secondary hyperparathyroidism
- Iron deficiency (received feraheme as outpt)
- Recurrent PEs on coumadin, goal INR 2.5-3.5
- Status post cholecystectomy
- Status post ligation of AV fistula
Social History:
___
Family History:
Her family history is notable for a brother with end-stage
kidney
disease, and a mother with diabetes ___.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: 98.1 121/76 lying 86/56 standing 87 16 100% RA
General: NAD
HEENT: Dry MM, no obvious oral lesions
Neck: No JVD noted
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, obese, NT/ND, NABS
Ext: WWP, no edema. Non-functioning AVG on left.
Neuro: A+Ox3, moving all extremities symmetrically
Skin: Dry without obvious impairments
PHYSICAL EXAM ON DISCHARGE:
VS: 98.2 120/75 80 18 96% RA
General: NAD
HEENT: MMM, no obvious oral lesions
Neck: No JVD noted
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, obese, tender to palpation in upper quadrants,
NABS
Ext: WWP, no edema. Non-functioning AVG on left.
Neuro: A+Ox3, moving all extremities symmetrically
Skin: Dry without obvious impairments
Pertinent Results:
LABS ON ADMISSION:
___ 10:03PM ___ PO2-188* PCO2-30* PH-7.17* TOTAL
CO2-12* BASE XS--16
___ 08:44PM GLUCOSE-91 UREA N-65* CREAT-9.0* SODIUM-136
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-10* ANION GAP-24*
___ 08:44PM CALCIUM-8.1* PHOSPHATE-6.1* MAGNESIUM-1.1*
___ 08:44PM ___ PTT-61.8* ___
___ 11:58AM URINE HOURS-RANDOM CREAT-226 SODIUM-22
POTASSIUM-27 CHLORIDE-15
___ 11:58AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:58AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:58AM URINE RBC-14* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-3
___ 08:02AM LACTATE-1.6 K+-3.4
___ 07:33AM ALT(SGPT)-27 AST(SGOT)-13 ALK PHOS-128* TOT
BILI-0.1
___ 07:33AM LIPASE-49
___ 07:33AM ALBUMIN-4.0 CALCIUM-7.8* PHOSPHATE-6.2*#
MAGNESIUM-1.2*
___ 07:33AM HCG-<5
___ 07:33AM tacroFK-21.2*
___ 07:33AM WBC-10.3 RBC-5.70* HGB-12.2 HCT-40.9 MCV-72*
MCH-21.3* MCHC-29.7* RDW-17.5*
___ 07:33AM NEUTS-60 BANDS-0 ___ MONOS-9 EOS-0
BASOS-1 ___ MYELOS-0 NUC RBCS-2*
___ 07:33AM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-3+
MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-2+ PENCIL-1+ TEARDROP-OCCASIONAL
___ 07:33AM PLT SMR-NORMAL PLT COUNT-237
IMAGING:
___ RENAL TRANSPLANT ULTRASOUND
IMPRESSION:
Normal renal transplant ultrasound.
___ HEAD CT
IMPRESSION:
Mild paranasal sinus inflammatory changes. Otherwise normal
study.
___ VENOUS DUPLEX UPPER EXTREMITIES
IMPRESSION:
1. The brachial and radial arteries on both sides appear widely
patent. No evidence of calcifications.
2. Right cephalic and basilic veins in as indicated above.
3. The the forearm loop graft is occluded and only the basilic
vein is
visualized on the left side. Measurements as indicated above.
LABS ON DISCHARGE
___ 05:56AM BLOOD WBC-6.5 RBC-4.29 Hgb-9.2* Hct-30.0*
MCV-70* MCH-21.5* MCHC-30.8* RDW-17.4* Plt ___
___ 05:56AM BLOOD Glucose-99 UreaN-48* Creat-5.8* Na-139
K-3.4 Cl-109* HCO3-17* AnGap-16
___ 05:56AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.6
___ 05:56AM BLOOD tacroFK-5.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Acetaminophen Dose is Unknown PO Frequency is Unknown
3. Sodium Bicarbonate 1300 mg PO BID
4. Labetalol 300 mg PO BID
5. Warfarin 5 mg PO 5X/WEEK (___)
6. Warfarin 2.5 mg PO 2X/WEEK (___)
7. Amlodipine 10 mg PO HS
8. Mycophenolate Mofetil 500 mg PO TID
9. Tacrolimus 3 mg PO Q12H
10. Furosemide 40 mg PO BID
11. Magnesium Oxide 250 mg PO BID
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Calcitriol 0.25 mcg PO 6X/WEEK (___)
14. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Azathioprine 100 mg PO DAILY
RX *azathioprine 50 mg 2 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain, fever
3. Amlodipine 10 mg PO HS
4. Calcitriol 0.25 mcg PO 6X/WEEK (___)
5. Labetalol 300 mg PO BID
6. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
7. Outpatient Lab Work
Needs CBC, chem-10, INR, tacrolimus checked on ___, send
results to Dr. ___, ___ Phone: ___ Fax:
___
ICD-9: V42.0
8. PredniSONE 10 mg PO DAILY
9. Sodium Bicarbonate 1300 mg PO BID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 2 mg PO Q12H
12. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 4 tablet(s) by mouth Daily Disp
#*120 Tablet Refills:*0
13. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 capsule by
mouth four times a day Disp #*30 Capsule Refills:*0
14. Magnesium Oxide 250 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
___
Infectious gastroenteritis
Secondary diagnoses:
S/p renal transplant
Hypertension
Hypercoaguability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with epigastric pain. Evaluate for renal transplant
thrombosis.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound from ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.63 to 0.68, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 64 centimeter/second. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman with a deceased donor renal transplant in ___
with worse headache of her life and INR of 11. Please assesss for acute
intracranial process, evidence of hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 891 mGy-cm
CTDI: 52 mGy
COMPARISON: Head CT from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. Minimal mucosal thickening of the left
maxillary sinus and right anterior ethmoid air cells are noted, otherwise the
imaged paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The orbits are unremarkable.
IMPRESSION:
Mild paranasal sinus inflammatory changes. Otherwise normal study.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
INDICATION: ___ year old woman s/p L sided fistula with need for dialysis soon
// Please do vein mapping for possible dialysis
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: ___
FINDINGS:
Right arm: The right brachial artery measures 4.7 mm the radial artery 2 mm.
No calcifications noted.
The cephalic vein is patent and measures 1.8-2.6 mm in the forearm, 4.5 mm at
the elbow and 3.7-4.2 mm above the elbow. The basilic vein measures 1.5-1.9 mm
in the forearm, 2.8 mm at the elbow and 3-3.7 mm above the elbow.
Left arm: The distal forearm loop graft is occluded. The left brachial artery
measures 5.7 mm in diameter the radial artery 1.8 mm. No obvious
calcifications.
Unfortunately the cephalic vein cannot be followed. The basilic vein measures
1.1-1.5 mm in the forearm, 2.9 mm at the elbow and 3.1-3.3 mm above the elbow.
IMPRESSION:
1. The brachial and radial arteries on both sides appear widely patent. No
evidence of calcifications.
2. Right cephalic and basilic veins in as indicated above.
3. The the forearm loop graft is occluded and only the basilic vein is
visualized on the left side. Measurements as indicated above.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: N/V, Headache
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, KIDNEY TRANSPLANT STATUS
temperature: 98.3
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 65.0
level of pain: 6
level of acuity: 3.0 | This is a ___ woman with a deceased donor renal
transplant in ___ c/b stage IV chronic kidney disease in the
transplant ___ chronic allograft nephropathy, baseline Cr 3.7,
as well as secondary hyperparathyroidism, recurrent PEs who
presented with N/V/D and ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / IV Dye, Iodine Containing Contrast Media /
vancomycin
Attending: ___.
Chief Complaint:
Foot Ulcer
Major Surgical or Invasive Procedure:
Debridement of left foot first metatarsal and proximal phalanx
History of Present Illness:
Patietn seen and examined agree with house officer admission
note by Dr. ___ ___ with additions below
___ year old Male with Type 2 diabetes complicated by diabetic
retinopathy, diabetic neuropathy, and recurrent foot infections
who presents with worsening of an ulcer on his Left foot. In
___ he underwent left foot surgery on his ___ metatarsal head
with secondary closure of wound performed by Dr. ___. He
has had slow wound healing since that time, although without
fevers, frank discharge, pain or erythema. On the day prior to
admission he noticed his left foot was more swollen and
erythematous. He took some Keflex he had at home and went to
bed. The morning of admission it continued to look worse. He
reports no new drainage at the site, although he has yellow or
bloody drainage on his bandages daily. He denies any pain on his
foot, but noticed a malodorous smell around the area. He usualy
changes the bandages on his foot each day and applies betadine.
He currently is ambulating with crutches.
In the ED, his exam was notable for ulceration on the left foot.
Labs notable for WBC 9.6, neutrophils 79.8, and lactate 1.2 The
patient underwent an xray which showed no evidence of
osteomyelitis. The xray demonstrated: Post-surgical changes
involving the left first metatarsal head and a large plantar
soft tissue defect on the lateral view. He received zosyn and
vancomycin in the ED. He noticed soon after the vancomycin
infusion he began to feel very itchy and called the staff over.
He was found to have welts/hives(?) on his arms, so the
vancomycin infusion was stopped. He was seen by podiatry who
recommened IV antibiotics and daily wound dressing changes with
betadine.
Currently, the patient denies any pain from his foot or ulcer.
He reports minimal drainage from his ulcer/bandage site. He
denies fevers, chills, nightsweats, changes in energy or
appetite.
Past Medical History:
-Benign Hypertension
-Hyperlipidemia
-Type 2 Diabetes - retinopathy, neuropathy, and persistent
difficulties with foot ulcerations
-Anemia
-Obesity
-PVD
---Right BK POP-DP BPG and Rt ___ met head resection (___)
---I&D Rt ___ met head ulcer and balloon angioplasty of graft
(___)
---Left BK pop-pedal and left toe amputation (___)
---suspected occlusion of left graft, with plan for angiogram
Social History:
___
Family History:
Pt does not know history of mother or father.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.1, 168/63, 74, 18, 96%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, 4cm erythematous incision on Left Foot, no eschar or
frank pus
NEURO: CAOx3, Motor ___ ___ Spread
DISCHARGE PHYSICAL EXAM:
VS - Tm/c 98.3 BP 146-172/57-64 HR 66 RR 16 99%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - LLE with cast in place left foot to just below
left knee
SKIN - scattered seborhhic keratoses on back and cherry angiomas
on chest
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 06:25AM BLOOD WBC-8.5 RBC-3.89* Hgb-10.3* Hct-30.3*
MCV-78* MCH-26.4* MCHC-33.8 RDW-16.4* Plt ___
___ 11:10AM BLOOD WBC-9.6 RBC-4.13* Hgb-10.7* Hct-32.4*
MCV-78* MCH-26.0* MCHC-33.1 RDW-16.6* Plt ___
___ 11:10AM BLOOD Neuts-79.8* Lymphs-14.0* Monos-3.3
Eos-2.5 Baso-0.3
___ 06:25AM BLOOD Glucose-199* UreaN-21* Creat-0.9# Na-140
K-3.3 Cl-98 HCO3-32 AnGap-13
___ 11:20AM BLOOD Lactate-1.2
DISCHARGE LABS
___ 05:23AM BLOOD WBC-10.4 RBC-3.92* Hgb-10.3* Hct-31.0*
MCV-79* MCH-26.3* MCHC-33.3 RDW-16.7* Plt ___
___ 05:23AM BLOOD Glucose-231* UreaN-27* Creat-1.0 Na-137
K-3.7 Cl-97 HCO3-34* AnGap-10
MICROBIOLOGY
___ 2:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:35 pm SWAB Source: left foot woud.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:10 pm TISSUE LEFT ___ METATARSAL HEAD.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-2638N ___.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING
FOOT AP,LAT & OBL LEFT Study Date of ___ 11:15 AM
IMPRESSION:
1. Post-surgical changes involving the left first metatarsal
head. Although post-operative radiographs since the last
debridement are not available, indistinct bony borders,
fragmentation, and focal demineralization are concerning for
osteomyelitis. A large plantar soft tissue defect is depicted
on the lateral view.
2. Linear opacity overlying the third toe proximal phalanx,
likely a foreign body within the soft tissues, unchanged
compared to the prior study from ___.
MRI LEFT FOOT ___:
IMPRESSION: Osteomyelitis of the first metatarsal as well as
the base of the first proximal phalanx. Inflammation of the
soft tissues surrounding the amputated metatarsal head as
described above, with associated skin ulcer along the plantar
aspect- of the foot. No drainable fluid collections to suggest
abscess.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Torsemide 20 mg PO BID
6. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >4.8
7. Lantus *NF* (insulin glargine) 43 units Subcutaneous qhs
8. NovoLOG *NF* (insulin aspart) SSI Subcutaneous daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Torsemide 20 mg PO BID
6. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >4.8
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
apply to gluteal fold
RX *clobetasol 0.05 % 1 application twice a day Disp #*1 Tube
Refills:*0
8. Glargine 50 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. 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.
RX *heparin lock flush 10 unit/mL 2mL Line flush Disp #*100 Unit
Refills:*0
10. NovoLOG *NF* (insulin aspart) ___ UNITS SUBCUTANEOUS DAILY
according to sliding scale as above
11. Lantus *NF* (insulin glargine) 50 units SUBCUTANEOUS QHS
12. Nafcillin 2 g IV Q4H Duration: 6 Weeks
RX *nafcillin in D2.4W 2 gram/100 mL 2 grams every 4 hours Disp
#*504 Gram Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Osteomyelitis
Secondary: Diabetes mellitus, Congestive heart failure,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with crutches
Followup Instructions:
___
Radiology Report
INDICATION: History of diabetes and foot ulceration, with worsening
redness/drainage. Assess for osteomyelitis versus a lytic lesion.
COMPARISON: Left foot radiographs from ___.
LEFT FOOT, THREE VIEWS: There is redemonstration of prior left first
metatarsal head resection. A soft tissue defect is present along the plantar
aspect subjacent to the first metatarsophalangeal joint region. A linear
opacity overlying the third toe proximal phalanx is not significantly changed
in appearance, likely a foreign body within the soft tissues. Degenerative
changes are again seen throughout the midfoot. Superior and inferior
calcaneal enthesophytes are again noted. Vascular calcifications are
redemonstrated. Surgical clips are seen along the medial aspect of the distal
tibia, as before.
IMPRESSION:
1. Post-surgical changes involving the left first metatarsal head. Although
post-operative radiographs since the last debridement are not available,
indistinct bony borders, fragmentation, and focal demineralization are
concerning for osteomyelitis. A large plantar soft tissue defect is depicted
on the lateral view.
2. Linear opacity overlying the third toe proximal phalanx, likely a foreign
body within the soft tissues, unchanged compared to the prior study from ___.
Radiology Report
MRI LEFT FOOT:
CLINICAL INDICATION: ___ man with history of diabetic foot ulcer
status post prior left first metatarsal head resection. Patient with
worsening redness, drainage, concerning for underlying osteomyelitis.
TECHNIQUE: Multiaxial, multiplanar MRI of the left foot was obtained without
and with administration of intravenous contrast material.
Comparison is made to radiograph dated ___.
FINDINGS: Partial amputation of the first metatarsal head is noted, with
marked edema involving the residual metatarsal bone, with sparing at the base,
as well as edema in the base of the first proximal phalanx. Subtle
indistinctness of lateral first proximal phalanx base articular surface. Skin
and soft tissue defect along the plantar aspect of the first
metatarsal-phalangeal joint extending into the surgical bed of prior
metatarsal head surgery. Large amount of granulation tissue/phlegmon situated
between first metatarsal and proximal phalanx. No drainable fluid collections
are identified. Susceptibility artifact reflecting prior surgery. Following
administration of contrast, there is enhancement in the first metatarsal and
base of the proximal phalanx.
Edema and enhancement is also seen involving the muscles of the fore- and mid
foot, likely due to the diabetic denervation injury.
Old amputation of the fifth toe is noted, without evidence of edema or
osteomyelitis.
Limited evaluation of the extensor and flexor tendons of the foot, as well as
the peroneal tendons demonstrated no significant abnormality.
Susceptibility artiface overlies third proximal phalanx and may represent a
foreign body or post-surgical change and should be correlated.
IMPRESSION: Osteomyelitis of the first metatarsal as well as the base of the
first proximal phalanx. Inflammation of the soft tissues surrounding the
amputated metatarsal head as described above, with associated skin ulcer along
the plantar aspect- of the foot. No drainable fluid collections to suggest
abscess.
These critical findings were discussed with Dr. ___ at 12:01pm on
___ by Dr. ___ (fellow)
Radiology Report
EXAM: X-ray of the foot, AP, lateral, oblique.
CLINICAL INDICATION: ___ man with left foot ulcer status post
surgical debridement.
COMMENTS: Frontal, lateral and oblique views of the left foot are compared to
study from ___, and demonstrates overlying splint material around the
foot.
Compared to the prior exam, there has been further interval surgical
debridement and osteotomy/washout of the first metatarsal head, with tiny
residual bone fragment seen at the surgical site. Mild surrounding osteopenia
is present. There is a linear (needle-like) radiopaque foreign body seen
within the soft tissues adjacent to the the third metatarsophalangeal joint,
measuring approximately 1.4 cm. Old resection of the left toe is again
noted. There are scattered vascular calcifications.
IMPRESSION:
1. Postoperative changes status post resection of the first metatarsal head
as described above.
2. Linear (needle-like) foreign body seen along the soft tissues adjacent to
to the third metatarsophalangeal joint. These may represent the foreign body,
unchanged.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Left PICC tip is in the upper SVC. Cardiac size is top normal. The lungs are
clear aside from minimal bibasilar atelectasis. There is no pleural effusion
or pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WOUND RED
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 80.0
resprate: 20.0
o2sat: 97.0
sbp: 162.0
dbp: 57.0
level of pain: 0
level of acuity: 3.0 | ___ year old gentleman with h/o of type 2 diabetes complicated by
diabetic retinopathy, neuropathy, and persistent foot infections
presenting with acute worsening of an ulcer on his L foot, found
to have osteomyelitis of ___ metatarsal and ___ proximal
phalanx.
ACTIVE ISSUES
1. Osteomyelitis: The patient was started on empiric
antibiotics for cellulitis and suspected osteomyelitis upon
admission. He received 1 dose each of linezolid and cefepime,
and then was started on ampicillin-sulbactam on ___. The
foot ulcer was cultured and grew Group B streptococcus as well
as coagulase positive, methicillin-sensitive staphylcococcus
aureus. An MRI of the foot was performed which showed
osteomyelitis, and the patient was taken to the OR for
debridement and deep tissue culture by the Podiatry service on
___. Infectious diseases was consulted for antibiotic
management and agreed with coverage by ampicillin-sulbactam
pending final cultures. Deep tissue cultures revealed the same
organisms as above, and the patient was switched to nafcillin 2g
q4h per ID recommendations for a total course of 6 weeks. A
PICC line was placed, and the patient was discharged. He
remained afebrile and without signs of systemic infection
throughout the admission. Blood cultures remained negative.
Baseline ESR and CRP were drawn to be followed for improvement
as an outpatient. The patient will follow up with Podiatry in 1
week after admission and with ID in the ___ clinic in 2 weeks.
2. Type 2 Diabetes: The patient's diabetes is uncontrolled with
complications, including diabetic retinopathy and neuropathy.
He was initially started on his home regimen of Lantus 43 units
qhs and Humalog 8 units QAC, but due to uncontrolled blood
glucose levels (elevated to high 300s at times throughout
admission), his Lantus was titrated up to 50 units qhs and
Humalog was titrated to 20 units qac with SSI. The
hyperglycemia was likely caused, in part, by his acute
infection. He was discharged on this new insulin regimen and
will follow up with his primary physician for further
adjustments.
3. Rash: The patient was found to have multiple erthematous
papules covalesecing into plaques on the gluteal fold.
Differential diagnosis includes inverse psorias vs eczema. He
was empirically treated with topical Clobetasol Propionate 0.05%
Ointment. He was scheduled for a follow up appointment with
Dermatology as an outpatient.
CHRONIC ISSUES
1. Chronic Diastolic Congestive heart failure: the patient's
last echocardiogram ___ showed the left atrium was
moderately dilated, with mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The patient was continued on his home carvedilol 25
mg BID and torsemide 20 mg BID. CHF was stable throughout the
admission.
2. Coronary artery disease: Stable during admission. Home
aspirin 81 mg and atorvastatin 80 mg were continued.
3. Hypertension: Stable during admission. Home torsemide 20 mg
BID was continued.
TRANSITIONAL ISSUES
1. The patient has a PICC line placed in his left arm and will
receive IV nafcillin q4h for 6 weeks. He received teaching from
___ prior to discharge. The PICC should be removed upon
completion of antibiotic course. He will follow up with ID in
the ___ clinic in 2 weeks for management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ruptured abdominal aortic aneursym
Major Surgical or Invasive Procedure:
open infrarenal AAA repair
History of Present Illness:
___ xfer from ___ hemodynamic instability
in setting of newly diagnosised ruptured AAA. Per OSH report, pt
presented to ___ of severe abdominal pain
radiating to back x ___ days. Has had associated anorexia w
reported 15# weight loss in last one week. Endorses substantial
increase in abdominal pain this ___ following episode of
coughing.
Reported to ___ for further evaluation. On arrival to
___ ED noted to have SBP ___ which improved w 1L resuscitation.
CT I- performed which showed contained rupture of 7cm juxtarenal
AAA. Arranged for emergent xfer to ___ for further
management.
Past Medical History:
Hx ischemic CVA (multiple B/L cerebellar infarctions, L
occipital infarction), HTN, HLD,
PSH: Repair L-spine herniated disc
Social History:
___
Family History:
Possibly hypertension, no known stroke
Physical Exam:
Temp:
Gen: lying in bed no distress
HEENT: non icteric sclera
CV: Regular rate, no m,r,g
Resp: clear to ausculation bilaterally
Abd: midline incision c/d/i with staples, non tender, non
distended
right groin small incision c/d/i wiht 2 staples no hematoma
Ext: palapble distal pulses, no edema
Pertinent Results:
___ 06:52AM BLOOD WBC-10.5 RBC-4.20* Hgb-13.2* Hct-40.0
MCV-95 MCH-31.5 MCHC-33.0 RDW-14.4 Plt ___
___ 07:54AM BLOOD WBC-11.0 RBC-4.38* Hgb-13.6* Hct-41.0
MCV-94 MCH-31.1 MCHC-33.3 RDW-14.7 Plt ___
___ 04:52AM BLOOD WBC-10.6 RBC-4.04* Hgb-12.5* Hct-37.1*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.8 Plt ___
___ 01:21AM BLOOD WBC-16.1* RBC-4.09* Hgb-12.6* Hct-37.3*
MCV-91 MCH-30.8 MCHC-33.7 RDW-14.6 Plt ___
___ 05:25PM BLOOD WBC-16.9* RBC-4.18* Hgb-13.2* Hct-37.7*
MCV-90 MCH-31.6 MCHC-35.0 RDW-14.6 Plt ___
___ 01:35AM BLOOD WBC-19.2* RBC-4.48* Hgb-14.2 Hct-40.7
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.6 Plt ___
___ 02:41AM BLOOD WBC-13.2* RBC-4.20*# Hgb-13.1*#
Hct-37.9*# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.3 Plt ___
___ 12:00AM BLOOD WBC-15.9* RBC-3.24* Hgb-10.1* Hct-30.3*
MCV-93 MCH-31.1 MCHC-33.3 RDW-14.2 Plt ___
___ 09:30PM BLOOD WBC-14.6*# RBC-4.17* Hgb-12.8* Hct-38.2*
MCV-92 MCH-30.6 MCHC-33.4 RDW-14.1 Plt ___
___ 07:38PM BLOOD WBC-16.7* RBC-4.71 Hgb-14.7 Hct-42.7
MCV-91 MCH-31.2 MCHC-34.5 RDW-14.1 Plt ___
___ 07:03AM BLOOD Glucose-117* UreaN-27* Creat-1.2 Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 06:52AM BLOOD Glucose-106* UreaN-34* Creat-1.3* Na-138
K-4.2 Cl-102 HCO3-28 AnGap-12
___ 07:54AM BLOOD Glucose-114* UreaN-43* Creat-1.4* Na-140
K-4.0 Cl-103 HCO3-26 AnGap-15
___ 04:00PM BLOOD Glucose-124* UreaN-42* Creat-1.4* Na-138
K-3.8 Cl-102 HCO3-25 AnGap-15
___ 04:52AM BLOOD Glucose-116* UreaN-44* Creat-1.4* Na-141
K-3.3 Cl-104 HCO3-27 AnGap-13
___ 03:56PM BLOOD Glucose-117* UreaN-43* Creat-1.5* Na-137
K-3.6 Cl-103 HCO3-23 AnGap-15
___ 01:21AM BLOOD Glucose-118* UreaN-40* Creat-1.6* Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
___ 05:25PM BLOOD UreaN-39* Creat-1.7* Na-139 K-3.4 Cl-105
HCO3-25 AnGap-12
___ 01:35AM BLOOD Glucose-110* UreaN-34* Creat-1.8* Na-138
K-4.1 Cl-108 HCO3-23 AnGap-11
___ 04:25PM BLOOD Glucose-118* UreaN-34* Creat-1.8* Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
___ 02:41AM BLOOD Glucose-188* UreaN-32* Creat-1.5* Na-139
K-3.9 Cl-107 HCO3-21* AnGap-15
TA TORSO:
Large infrarenal abdominal aortic aneurysm with evidence of
recent rupture
along its anterolateral left wall (05:34) with significant
adjacent fat
stranding and blood along the anterior para renal fascia, left
greater than
right. No active arterial extravasation. Rupture starts at the
left renal
artery. Just above the renal arteries the aorta measures 3.1 x
3.4 cm (3:123).
Bilateral common iliac arteries measure 3.8 x 4 cm and 3.5 x 3.4
cm left and
right respectively. The infra renal aortic aneurysm measures 6.3
x 5.3 cm at
its maximal width. Just above the iliac bifurcation the distal
aorta measures
5.0 x 4.9 cm (3:165). Dilated proximal patent bilateral internal
iliac
arteries measuring 0.9 and 1 cm right and left respectively. The
celiac axis,
SMA, and bilateral single renal arteries are patent.
Circumferential
atherosclerotic mural calcifications are seen throughout the
aorta and its
major branches. The hepatic arterial anatomy is conventional.
Assessment of
the venous vasculature is somewhat limited by the timing of
contrast.
CHEST:
The thyroid is normal.No axillary, supraclavicular, mediastinal,
or hilar
lymph node enlargement. There are coronary as well aortic and
mitral valvular
calcifications. No pericardial effusion.The airways are patent
to the
subsegmental levels. No pleural effusion or pneumothorax.
Lungs are notable for diffuse paraseptal emphysematous changes
as well as
areas of mild interstitial change most notable within the left
lung base,
where there is also probably coinciding superimposed
atelectasis.
Two 0.8 x 0.5 and 0.7 x 0.5 cm opacities within the right lower
lobe may
represent mucous plugging however given solid appearance
findings are
concerning for pulmonary nodules. (03:10 3 and 3:96). No
additional pulmonary
nodule identified. A 2 mm calcified granuloma is noted within
the right upper
lobe (3:60).
ABDOMEN:
A 0.7 x 0.5 cm (3:112) hypodensity within segment 8 of the liver
is too small
to characterize.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 and are
without suspicious solid mass. A 0.8 x 0.8 cm (3: 126) right
upper pole
hypodensities too small to characterize.
There is a small hiatal hernia. The appendix is normal without
evidence of
acute appendicitis. Sigmoid diverticulosis is moderate in
severity. No
retroperitoneal or mesenteric lymph node enlargement by CT size
criteria. No
pneumoperitoneum. No abdominal wall hernia.
PELVIS:
The bladder is unremarkable. No pelvic side-wall or inguinal
lymph node
enlargement.No free pelvic fluid is identified. The prostate
and seminal
vesicles are unremarkable.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative
changes are seen
within the visualized thoracolumbar spine. No focal lytic or
sclerotic lesion
concerning for malignancy.
IMPRESSION:
1. Acute rupture of large infrarenal aortobi-iliac abdominal
aortic aneurysm
along its anterolateral left aortic wall with acute hemorrhage
in the
retroperitoneum. No evidence of active arterial extravasation.
2. Sigmoid diverticulosis without evidence of acute
diverticulitis.
3. Chronic emphysematous changes of the lungs with interstitial
changes and
focal left lower lobe opacity suggesting superimposed
atelectasis.
4. 0.8 and 0.7 cm pulmonary nodules. Followup CT in ___ months
is recommended
for surveillance.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Clopidogrel 75 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Pravastatin 40 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth 8 hours Disp #*30
Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth 4 hours
Disp #*20 Tablet Refills:*0
8. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*1
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured abdominal aortic aneursym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: History: ___ with ruptured AAA. Ruptured AAA- anatomy
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:
Large infrarenal abdominal aortic aneurysm with evidence of recent rupture
along its anterolateral left wall (05:34) with significant adjacent fat
stranding and blood along the anterior para renal fascia, left greater than
right. No active arterial extravasation. Rupture starts at the left renal
artery. Just above the renal arteries the aorta measures 3.1 x 3.4 cm (3:123).
Bilateral common iliac arteries measure 3.8 x 4 cm and 3.5 x 3.4 cm left and
right respectively. The infra renal aortic aneurysm measures 6.3 x 5.3 cm at
its maximal width. Just above the iliac bifurcation the distal aorta measures
5.0 x 4.9 cm (3:165). Dilated proximal patent bilateral internal iliac
arteries measuring 0.9 and 1 cm right and left respectively. The celiac axis,
SMA, and bilateral single renal arteries are patent. Circumferential
atherosclerotic mural calcifications are seen throughout the aorta and its
major branches. The hepatic arterial anatomy is conventional. Assessment of
the venous vasculature is somewhat limited by the timing of contrast.
CHEST:
The thyroid is normal.No axillary, supraclavicular, mediastinal, or hilar
lymph node enlargement. There are coronary as well aortic and mitral valvular
calcifications. No pericardial effusion.The airways are patent to the
subsegmental levels. No pleural effusion or pneumothorax.
Lungs are notable for diffuse paraseptal emphysematous changes as well as
areas of mild interstitial change most notable within the left lung base,
where there is also probably coinciding superimposed atelectasis.
Two 0.8 x 0.5 and 0.7 x 0.5 cm opacities within the right lower lobe may
represent mucous plugging however given solid appearance findings are
concerning for pulmonary nodules. (03:10 3 and 3:96). No additional pulmonary
nodule identified. A 2 mm calcified granuloma is noted within the right upper
lobe (3:60).
ABDOMEN:
A 0.7 x 0.5 cm (3:112) hypodensity within segment 8 of the liver is too small
to characterize.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 and are
without suspicious solid mass. A 0.8 x 0.8 cm (3: 126) right upper pole
hypodensities too small to characterize.
There is a small hiatal hernia. The appendix is normal without evidence of
acute appendicitis. Sigmoid diverticulosis is moderate in severity. No
retroperitoneal or mesenteric lymph node enlargement by CT size criteria. No
pneumoperitoneum. No abdominal wall hernia.
PELVIS:
The bladder is unremarkable. No pelvic side-wall or inguinal lymph node
enlargement.No free pelvic fluid is identified. The prostate and seminal
vesicles are unremarkable.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy.
IMPRESSION:
1. Acute rupture of large infrarenal aortobi-iliac abdominal aortic aneurysm
along its anterolateral left aortic wall with acute hemorrhage in the
retroperitoneum. No evidence of active arterial extravasation.
2. Sigmoid diverticulosis without evidence of acute diverticulitis.
3. Chronic emphysematous changes of the lungs with interstitial changes and
focal left lower lobe opacity suggesting superimposed atelectasis.
4. 0.8 and 0.7 cm pulmonary nodules. Followup CT in ___ months is recommended
for surveillance.
NOTIFICATION: The findings were discussed by Dr. ___ with vascular
surgery in person on ___ at time of discovery of findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with AAA // ptx
TECHNIQUE: Single portable AP radiograph of the chest.
COMPARISON: Prior chest CTA dated ___.
FINDINGS:
There has been interval placement of an endotracheal tube, with the tip ending
7.9 cm from the carina, this could be advanced 4 cm for optimal seating within
the trachea. A right IJ Cordis line is in place. The enteric tube extends
outside of the field of view but likely ends within the stomach. There is new
mild atelectasis and a small-to-moderate left-sided plueral effusion.
IMPRESSION:
1. Endotracheal tube tip ends 7.9 cm from the carina, and could be advanced 4
cm for optimal seating within the trachea.
2. New mild bibasilar atelectasis.
3. New small to moderate left-sided pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with as above // s/p AAA repair w/increased
shortness of breath r/o PTX
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has been extubated. And
the nasogastric tube was removed. The venous introduction sheet in the right
internal jugular vein remains in situ. Increasing left retrocardiac
atelectasis. Slightly increasing left pleural effusion. No pulmonary edema.
Unchanged appearance of the cardiac silhouette.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: AAA
Diagnosed with ABDOM AORTIC ANEURYSM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was transferred to ___ with a ruptured AAA on
___. He underwent emergent open repair. Despite the magnitude
of blood loss and surgery he tolearted the surgery well and his
post-operative course was uneventful. He was discharged home on
POD#6. His hospital course by system is summarized below.
Neuro: At the conclusion of the surgery an epidural was placed
for pain control. The patient suffered from some perioperative
delirium however this resolveed by POD#2. His epidural was
removed on POD#3 and he was transititoned to oral oxycodone and
tylenol which he required minimal amounts of up to the time of
discharge.
CV: The patient had a large amount of intra-op blood loss (7.2L)
requiring 9 units of PRBC as well as FFP and platelets
intraoperatively. He was hemodynamically post-operatively. On
POD#1 he was briefly on a nitroglycerin drip for pain control
which was weaned and he was started on home lisinopril as well
as metoprolol for blood pressure control. His blood pressure
remained in good control with the lisinopril and metoprolol
which he was discharged on.
Resp: The patient remained intubated following surgery. He was
weaned from the ventilator on POD#1. Due to the resuscitation
during the operation he was significantly fluid overloaded and
required lasix diuresis for seveal days. After diuresis his
oxygen was weaned and he was stable on room air by POD#3. There
were some incidental pulmonary nodules commented upon on his CT
scan that will require follow up scans in ___ months.
Renal: During the operation the aorta was clamped between above
the left renal artery. His creatinine peaked at 2.2 upon
admission and steadily improved post-operatively. He was
diuresed each day and his weight returned within 2 kgs of his
dry weight.
Endo: The patient initially was on an insulin sliding scale. His
blood sugar remained in good control and this was stopped. He
had no other endo issues.
Heme: Following the ___ transfusions the patient did
not require any further transfusions. His plavix and aspirin
were restarted following removal of the epidural. He was on subq
heparin for DVT prophylaxis.
ID: The patient was afebrile throughout the hospitalization. His
white count was initially elevated likely to a SIRS response to
the surgery but he never manifested any signs of infeciton and
was discharged without antibiotics.
Transitional issues:
1) Hypertension: The patient was started on metoprolol in
additon to his lisinopril for blood pressure control. He was
discharged on metoprolol and was instructed to follow up with
his PCP in the next week or two for a blood pressure check and
titration of his medication.
2) Pulmonary nodules that were incidentally found on his CTA
will need follow up in ___ months. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Codeine / Peanut / Rapamune / sodium bicarbonate
Attending: ___
Chief Complaint:
Right shoulder pain
Major Surgical or Invasive Procedure:
Placement of left IJ central line
History of Present Illness:
___ year old woman with a history of renal transplant and prior
shoulder effusions who presented with 3 days of shoulder pain.
She reported "sleeping funny" on her shoulder and awaking with
severe pain on ___. She went to her PCP and orthopedic surgeon
on ___ who prescribed flexeril and suggested rest, ice, and
NSAIDs. The night of ___ the pain significantly increased with
swelling of the entire arm. She reported severe shooting pain
down her arm with any motion of the shoulder, elbow, or wrist.
No constitutional symptoms or other complaints elsewhere in her
body.
She has had weight loss for the past year associated with poor
intake with intermittent N/V. There has been no acute change in
these symptoms.
In the ED, initial vitals: Pain ___, Temp 97.3, HR 74 BP
104/85 RR16 98RA
Exam: right arm swollen and erythematous. Present brachial and
radial pulses. Neuro exam limited ___ pain but has motion of all
fingers and wrist. No active motion of elbow or
shoulder--patient carried her arm with her other hand.
ED labs showed Na 118, K 5.8 Bicarb 12, Creatinine 2.6, Uric
Acid 12.6, Hgb 8.3, INR 1.2
Imaging: UE US without DVT, CXR without mass
She wave given PO oxycodone 10 and Dilaudid 0.25 mg IV x2
On transfer, vitals were: Pain ___ HR 70 BP 144/71 RR20 93% RA
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CAD: ___ Stress test c large rev anterior defect s/p DES
to LAD
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ DES to LAD; 70% Lcx
untreated
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
ESRD s/p live related transplant now stage IV CKD
Focal segmental glomerulosclerosis
Anemia
Osteoporosis
Proteinuria
Tobacco abuse
s/p tubal ligation ___
Social History:
___
Family History:
Her father died at age ___ of pneumonia. He had a history of a
"blood disease." Her mother died at age ___ from complications
status post hip fracture, she had a history of hypertension. She
has nine brothers, seven sisters and one son. One of her
brothers has diabetes and several of her siblings have
hypertension. There is no family history notable for stroke,
hyperlipidemia, early coronary artery disease or sudden cardiac
death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 98.2 117/66 74 16 94RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: bibasilar rales, otherwise CTAB
CV: regular, normal S1 S2, systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple rheumatic nodules and deformity of small joints.
RUE: nonpitting edema of RUE, limited AROM and PROM of shoulder
___ pain, sensation intact. R radial pulse thrill and bruit.
SKIN: mild erythema over R upper arm and shoulder
NEURO: Moves all extremities. Sensation intact.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 99.3 | 120/76 | 80 | 18 | 96%RA
I&O: 1480 | 3150
GENERAL: Thin woman, non-diaphoretic, sitting in bed in no acute
distress.
HEENT: Moist mucous membranes. Oropharynx clear. 1 purpuric
lesion on ___ each lip. None in mouth.
NECK: Supple. L CVL in place.
CV: Regular rate and rhythm. II/VI holosystolic murmur heard
___ at left midaxillary line. JVP at 9 cm.
RESPIRATORY: L lower lung field crackles. Intermittent rhonci
halfway up right lung field, decreased/absent lung sounds in
right lower lung field; present w/ crackles in lateral right
field.
ABDOMEN: Soft, nontender, nondistended. Well-healed scars.
Pelvic kidney non-tender. +BS.
LYMPH: No right axillary lymph nodes appreciated on exam. 1 0.5
cm R epitrochlear lymph node, non-tender, mobile.
EXTREMITIES: RIGHT SHOULDER: Minimally swollen, warm, mildly
tender to palpation. RUE edema resolved.
UPPER EXTREMITIES: Left radial artery with AV fistula + bruit +
thrill (appreciable on palpation). Right radial artery with
small thrill. MCP/PIP arthritis on several digits.
LOWER EXTREMITIES: Warm, well-perfused, without cyanosis.
SKIN: No rashes. Multiple facial and chest telangectasias.
Multiple non-blanching purpura on both lower extremities below
knee, L > R with ecchymosis on upper extremities and by site of
shoulder tap.
NEURO: Face symmetric. Moves all limbs against gravity.
PSYCH: Pleasant. Answers questions appropriately.
Pertinent Results:
ADMISSION LABS
==============
___ 03:00PM BLOOD WBC-8.1 RBC-2.87* Hgb-8.3* Hct-25.0*
MCV-87 MCH-28.9 MCHC-33.2 RDW-13.9 RDWSD-44.0 Plt ___
___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-9 Eos-0
Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-7.13*
AbsLymp-0.24* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00*
___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-9 Eos-0
Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-7.13*
AbsLymp-0.24* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00*
___ 03:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear
Dr-1+
___ 03:00PM BLOOD ___ PTT-30.0 ___
___ 03:00PM BLOOD Glucose-89 UreaN-51* Creat-2.6* Na-118*
K-5.8* Cl-96 HCO3-12* AnGap-16
___ 11:14PM BLOOD ALT-12 AST-28 CK(CPK)-116 AlkPhos-101
TotBili-0.4
___ 11:14PM BLOOD CK-MB-2 cTropnT-<0.01 ___
___ 03:00PM BLOOD UricAcd-12.6*
___ 11:14PM BLOOD Albumin-3.6 Calcium-7.8* Phos-4.0 Mg-1.1*
___ 03:00PM BLOOD Osmolal-265*
___ 11:14PM BLOOD TSH-1.5
___ 08:02AM BLOOD Cortsol-25.3*
___ 11:14PM BLOOD CRP-198.4*
___ 07:27PM BLOOD tacroFK-23.4*
___ 08:05PM URINE Type-RANDOM Color-Yellow Appear-Clear Sp
___
___ 08:05PM URINE Blood-TR Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG
___ 08:05PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 08:05PM URINE Hours-RANDOM Creat-102 Na-<20 K-28
Cl-LESS THAN TotProt-112 Prot/Cr-1.1*
___ 08:05PM URINE Osmolal-319
SELECT INTERVAL LABS
======================
Complete blood counts
___ 06:17AM BLOOD WBC-5.9 RBC-2.45* Hgb-6.9* Hct-21.2*
MCV-87 MCH-28.2 MCHC-32.5 RDW-14.0 RDWSD-44.5 Plt ___
___ 09:25AM BLOOD WBC-4.1 RBC-2.37* Hgb-6.8* Hct-21.0*
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.6 RDWSD-46.8* Plt ___
Coags
------
___ 08:02AM BLOOD ___ PTT-45.9* ___
___ 06:36AM BLOOD ___ PTT-24.7* ___
Chem-10
-------
___ 04:30PM BLOOD Glucose-103* UreaN-56* Creat-2.5* Na-120*
K-5.7* Cl-93* HCO3-14* AnGap-19
___ 03:00PM BLOOD Glucose-179* UreaN-52* Creat-2.2* Na-128*
K-4.5 Cl-92* HCO3-22 AnGap-19
___ 02:14AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.5*
Miscellaneous
-------------
___ 06:17AM BLOOD VitB12-250
___ 06:30PM BLOOD CK-MB-3 cTropnT-0.03*
___ 02:14AM BLOOD CK-MB-3 cTropnT-0.06*
___ 06:30PM BLOOD CK(CPK)-69
___ 09:00AM BLOOD Cortsol-10.3
___ 10:00AM BLOOD Cortsol-12.4
___ 12:35AM BLOOD Free T4-1.3
___ 06:36AM BLOOD C3-85* C4-31
___ 11:14PM BLOOD CRP-198.4*
___ 06:36AM BLOOD RheuFac-15*
___ 06:36AM BLOOD PEP-HYPOGAMMAG IgG-815 IgA-187 IgM-22*
IFE-NO MONOCLO
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-5.7 RBC-2.82* Hgb-7.9* Hct-24.3*
MCV-86 MCH-28.0 MCHC-32.5 RDW-14.6 RDWSD-45.4 Plt ___
___ 05:50AM BLOOD Glucose-91 UreaN-66* Creat-2.2* Na-131*
K-4.2 Cl-94* HCO3-29 AnGap-12
___ 05:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.5
___ 05:50AM BLOOD tacroFK-4.6*
MICRO
=====
BLOOD CULTURES ___: FINAL REPORT: NO GROWTH
URINE CULTURE ___: FINAL REPORT: NO GROWTH
JOINT FLUID ___:
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
LYME SEROLOGY ___: NO ANTIBODY TO B. ___ DETECTED
BY EIA.
IMAGING
========
___ RUE U/S IMPRESSION: No evidence of deep vein thrombosis
in the right upper extremity.
___ CXR IMPRESSION: Comparison to ___. In the
interval, the patient has developed moderate pulmonary edema.
The size of the cardiac silhouette is enlarged and there are
signs of basal apical blood flow redistribution. In addition,
the lateral radiograph shows signs of fissure oral fluid
marking. Larger pleural effusions are not present. No evidence
of pneumonia. No suspicious nodules or masses.
___ MR SHOULDER WITHOUT CONTRAST IMPRESSION:
1. The study is significantly degraded by patient motion.
2. Large complex glenohumeral joint effusion with
intermediate/low T2 signal and subtle high T1 signal,
significantly increased since ___, increased laxity of
the glenohumeral joint, increased bone marrow edema in the
proximal humerus, and new soft tissue edema about the shoulder.
The differential includes some degree of hemorrhagic and/or
proteinaceous content within the glenohumeral joint. Although
the appearance is non-specific, glenohumeral joint infection
should be excluded. A severe noninfectious inflammatory process
of this extent would be unusual, but might also account for this
appearance.
3. The significance of subtle cortical effacement about the
glenoid, progressed slightly compared with ___, is
dependent on the presence or absence of infection within the
joint. Otherwise, no bone erosion detected.
4. Severe end-stage osteoarthritis of the glenohumeral joint
with essentially complete loss of hyaline cartilage and of the
glenoid labrum, similar to ___.
5. Severe tendinosis of the supraspinatus and subscapularis
tendons with tendon attenuation and partial thickness tearing.
The distal ubscapularis
may be expanded by complex fluid within the tendon.
Supraspinatus tendon is probably fenestrated, with
intrasubstance tearing. These changes have both progressed
considerably compared with ___.
6. Severe tenosynovitis and tendinosis of the biceps tendon.
7. Moderate subacromial subdeltoid bursitis. Fluid in the SA/SD
bursa is much simpler than fluid seen within the joint.
___ MR ELBOW WITHOUT CONTRAST IMPRESSION: Trace elbow joint
effusion. Marked dense and extensive subcutaneous edema. No
bone marrow edema or bony erosion is detected. Ligaments,
tendons and muscles are grossly unremarkable. Note made of
prominent high-flow vessels in the subcutaneous soft tissues.
___: RIGHT UPPER EXTREMITY ARTERIAL DUPLEX IMPRESSION:
patent right upper extremity arterial system
___: ECHOCARDIOGRAM IMPRESSION: Normal global and regional
biventricular systolic function. Mild to moderate mitral
regurgitation.
___: CHEST CT WITHOUT CONTRAST IMPRESSION: Diffuse
ground-glass opacities, combined to small left pleural effusion,
likely reflect infection. The absence of an interstitial
component. Is not consistent with pulmonary edema. Small
pleural effusion. Signs of pulmonary hypertension.
___ CHEST X-RAY PA AND LATERAL IMPRESSION: In comparison
with the study of ___, there has been a substantial increase
in asymmetric pulmonary edema, more prominent on the right.
Blunting of the costophrenic angles is consistent with
developing effusions and bibasilar atelectasis. This in the
appropriate clinical setting, given the extensive pulmonary
changes. The left IJ catheter extends to the lower SVC.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Acetaminophen 500 mg PO Q8H:PRN pain
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Mycophenolate Mofetil 250 mg PO BID
6. PredniSONE 4 mg PO DAILY
7. Sodium Bicarbonate 650 mg PO BID
8. Tacrolimus 1.5 mg PO Q12H
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Carvedilol 6.25 mg PO BID
11. Lisinopril 2.5 mg PO DAILY
12. TiCAGRELOR 90 mg PO BID
13. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection EVERY
2 WEEKS
14. Ranitidine 150 mg PO BID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q24H Duration: 9 Doses
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once per day Disp
#*18 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate Duration: 6 Days
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth twice per day
as needed Disp #*12 Tablet Refills:*0
3. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times per day Disp #*90 Tablet Refills:*0
4. Tacrolimus 1 mg PO QPM
RX *tacrolimus 1 mg 1 capsule(s) by mouth QPM Disp #*28 Capsule
Refills:*0
5. Tacrolimus 1.5 mg PO QAM
RX *tacrolimus 0.5 mg 3 capsule(s) by mouth QAM Disp #*84
Capsule Refills:*0
6. Acetaminophen 500 mg PO Q8H:PRN pain
7. Amlodipine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Carvedilol 6.25 mg PO BID
11. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection
EVERY 2 WEEKS
12. Lisinopril 2.5 mg PO DAILY
13. PredniSONE 4 mg PO DAILY
14. Ranitidine 150 mg PO BID
15. TiCAGRELOR 90 mg PO BID
16.Outpatient Lab Work
Chem 10, CBC, tacro level
End stage renal disease N18.6
___
FAX: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
SEPTIC ARTHRITIS
HYPONATREMIA
LOWER EXTREMITY EDEMA
GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH
PNEUMONIA
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE
HYPERKALEMIA
ANEMIA
SECONDARY DIAGNOSES
===================
END STAGE RENAL DISEASE STATUS-POST KIDNEY TRANSPLANT
CORONARY ARTERY DISEASE STATUS-POST DRUG ELUTING STENT ___
HYPERTENSION
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 right arm swelling // Please evaluate for DVT
or signs of chest mass Please evaluate for DVT or signs of chest mass
IMPRESSION:
Comparison to ___. In the interval, the patient has developed
moderate pulmonary edema. The size of the cardiac silhouette is enlarged and
there are signs of basal apical blood flow redistribution. In addition, the
lateral radiograph shows signs of fissure oral fluid marking. Larger pleural
effusions are not present. No evidence of pneumonia. No suspicious nodules
or masses.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ with right arm swelling, evaluate for DVT or signs of chest
mass
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: MR ELBOW ___ CONTRAST RIGHT
INDICATION: ___ year old woman with R shoulder pain, swelling and limited
motion // R elbow effusion
TECHNIQUE: Multiplanar multi sequence MRI of the right elbow performed on a
1.5 tesla magnet without IV contrast with the following sequences: Axial and
coronal T1, axial and coronal T2 with fat sat, sagittal proton density with
fat sat, sagittal T2, and coronal gradient echo. Motion suppression blade
images were also attempted.
COMPARISON: None available
FINDINGS:
The study is moderately degraded by patient motion. This exam was tailored to
evaluation of
Bone marrow signal: Within normal limits. No bone marrow edema detected to
suggest contusion, fracture, or focal bone lesion.
Joint effusion: Trace
Radio-capitellar joint: Congruent. No gross osteoarthritis.
Ulnar-trochlear joint: Congruent. No gross osteoarthritis.
Radial collateral ligament: Grossly intact
Ulnar collateral ligament: Grossly intact
Lateral ulnar collateral ligament: Grossly intact.
Common extensor tendon: Grossly normal.
Common flexor tendon: Grossly normal
Biceps tendon: Within normal limits.
Brachialis tendon: Within normal limits.
Triceps tendon:Within normal limits.
Muscles: Muscle mass is grossly preserved, without muscle edema.
Radio-bicipital bursa: No significant fluid.
Olecranon bursa: No significant fluid.
Cubital tunnel: No mass detected within the cubital tunnel. Assessment of
the ulnar nerve is limited, but grossly unremarkable.
There is profuse subcutaneous interstitial edema. Allowing for the absence of
IV contrast, no focal fluid collection or mass is detected.
Note is made of prominent subcutaneous vessels, with signal void suggestive of
high flow.
IMPRESSION:
Trace elbow joint effusion. Marked dense and extensive subcutaneous edema.
No bone marrow edema or bony erosion is detected.
Ligaments, tendons and muscles are grossly unremarkable.
Note made of prominent high-flow vessels in the subcutaneous soft tissues.
Radiology Report
EXAMINATION: MR SHOULDER ___ CONTRAST RIGHT
INDICATION: ___ year old woman with R shoulder pain, swelling and limited
motion // concern for septic arthritis effusions
TECHNIQUE: Multiplanar multi sequence MRI of the right shoulder without IV
contrast on a 1.5 Tesla magnet with the following sequences, sagittal T1,
axial proton density with fat sat, coronal sagittal T2 BLADE with fat sat.
COMPARISON: MR shoulder ___. Radiographs of the right shoulder ___.
FINDINGS:
The study is degraded by patient motion.
There is marked soft tissue edema about the shoulder, including subcutaneous
soft tissue edema and areas of intramuscular edema particularly about the
scapula. .
Acromio-clavicular joint: Mild degenerative change.
Subacromial-subdeltoid bursa: Moderate effusion. Fluid in the
subacromial/subdeltoid bursa appears relatively high T2 signal and simple.
Supraspinatus tendon: The fibers of the supraspinatus tendon are severally
attenuated and redundant with elevated signal (08:15). Intact fibers are
present, though areas of intrasubstance partial tearing administration are
likely present.
Infraspinatus tendon: Grossly intact
Teres minor tendon: Grossly intact
Subscapularis tendon: Severely attenuated and redundant with increased signal
(07:20) compatible with severe tendinosis. Alternatively, the outer in inner
fibers of the subscapularis tendon may be separated in distended by fluid from
the biceps tendon sheath/glenohumeral joint.
Glenohumeral joint: The joint is distended with large complex intermediate
signal fluid significantly increased since ___. Of note, this
material is heterogeneously low signal on the fluid sensitive images, with
subtle areas of increased signal on the T1 weighted images. The labrum is
extensively markedly diminutive. No normal labrum is identified. There is
full-thickness cartilage loss of both the humeral head and glenoid. There are
subchondral cystic changes in the glenoid, which appears to progressed
compared with ___ (08:16). There is no definite bony erosion. Of
note, the glenohumeral joint is widened compared with ___.
Biceps tendon: The biceps tendon is appropriately positioned within the
intertubercular groove. A large amount of complex intermediate/low T2 signal
fluid surrounds the intertubercular portion of the biceps tendon (07:19). The
intra-articular portion of the biceps tendon is attenuated with increased
signal. The biceps labral anchor is severely diminutive (08:16).
Muscles: Probable mild atrophy of the supraspinatus, infraspinatus and
subscapularis muscles, though this is difficult to assess due to displacement
by the large glenohumeral joint effusion and extension of edema into the
musculature surrounding the scapula. Background muscle mass appears grossly
preserved.
Bone marrow: There is extensive heterogeneous bone marrow edema in the
visualized portions of the proximal humerus. This is more pronounced than the
periarticular edema seen about the glenohumeral joint on ___. .
However, on the sagittal T1 weighted images, most of this remains
hyperintense compared to muscle, which is more suggestive of red marrow.
IMPRESSION:
1. The study is significantly degraded by patient motion.
2. Large complex glenohumeral joint effusion with intermediate/low T2 signal
and subtle high T1 signal, significantly increased since ___,
increased laxity of the glenohumeral joint, increased bone marrow edema in the
proximal humerus, and new soft tissue edema about the shoulder. The
differential includes some degree of hemorrhagic and/or proteinaceous content
within the glenohumeral joint. Although the appearance is non-specific,
glenohumeral joint infection should be excluded. A severe noninfectious
inflammatory process of this extent would be unusual, but might also account
for this appearance.
3. The significance of subtle cortical effacement about the glenoid,
progressed slightly compared with ___, is dependent on the presence
or absence of infection within the joint. Otherwise, no bone erosion
detected.
4. Severe end-stage osteoarthritis of the glenohumeral joint with essentially
complete loss of hyaline cartilage and of the glenoid labrum, similar to ___.
5. Severe tendinosis of the supraspinatus and subscapularis tendons with
tendon attenuation and partial thickness tearing. The distal subscapularis
may be expanded by complex fluid within the tendon. Supraspinatus tendon is
probably fenestrated, with intrasubstance tearing. These changes have both
progressed considerably compared with ___. .
6. Severe tenosynovitis and tendinosis of the biceps tendon.
7. Moderate subacromial subdeltoid bursitis. Fluid in the SA/SD bursa is much
simpler than fluid seen within the joint.
NOTIFICATION: At the time of this dictation the primary team is aware of the
patient's joint effusion and concern for infection. Imaging guided
arthrocentesis is planned.
Radiology Report
Study arterial duplex upper extremity
Reason pain
Findings. The right subclavian, axillary, brachial, radial and ulnar arteries
are patent with normal waveforms and velocities.
Impression patent right upper extremity arterial system
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old woman with right shoulder pain and swelling //
please perform right shoulder arthrocentesis
COMPARISON: MRI ___
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained. It was noted that the patient
is taking baby aspirin and has a higher risk of bleeding as well as bruising.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
10 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a 20-gauge spinal needle was advanced into the right
glenohumeral joint. Appropriate position was confirmed by the injection of a
small amount of water soluble contrast. 8 cc of bloody fluid was aspirated.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications or complaints.
FINDINGS:
Nodular appearance at the joint space upon injection may be secondary to
synovitis.
IMPRESSION:
1. Imaging Findings - nodular synovium in the secondary to synovitis.
2. Procedure - Technically successful aspiration of the right glenohumeral
joint. Requested laboratory examinations are pending.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ with a history of ESRD ___ FSGS s/p LRRT ___, on
prograft/cellcept/prednisone, now with chronic scarring and CKD IV, CAD (s/p
DES to LAD), with right shoulder presumed septic arthritis, RUE swelling,
found to have severe hyponatremia and hyperkalemia and ICU monitoring course
c/b afib with RVR (now in NSR), now on abx for septic arthritis and receiving
electrolyte management. // Eval placement of L CVL Contact name: J.A.
___: ___ placement of L CVL
IMPRESSION:
Comparison to ___. Newly inserted left internal jugular vein
catheter. The course of the catheter is unremarkable, the tip projects over
the upper to mid SVC. No complications, notably no pneumothorax. Decrease in
severity of the pre-existing pulmonary edema. Stable appearance of the
cardiac silhouette.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with CKD s/p renal transplant, new ___ edema,
asymptomatic hyponatremia. // concern for siADH due to chest malignancy vs.
lymph obstructing process
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 167 mGy-cm
COMPARISON: No comparison.
FINDINGS:
Given the lack of contrast material, the question of potential vascular
obstruction cannot be addressed. Mild adenopathy in the axillary regions.
The patient is asymmetrically positioned within the scanner. Severe aortic
wall calcifications. Moderate to severe dilatation of the main pulmonary
artery, indicative of pulmonary hypertension. Severe coronary calcifications,
mild to moderate aortic valve calcifications, mild mitral valve
calcifications, no pericardial effusion. Mild cardiomegaly. The posterior
mediastinum is unremarkable. Diffuse calcifications in the left upper
quadrant, combined to perisplenic and perihepatic acites. Minimal
degenerative vertebral disease. No vertebral compression fractures. No
osteolytic lesions at the level of the ribs, the sternum, or the vertebral
bodies. The lung parenchyma shows, in relatively diffuse manner, stones of
increased ground-glass like opacities located both in the periphery and in the
central parts of the lung. These opacities are not associated with
interstitial changes. Simultaneously, the diameter of the vascular structures
is markedly dilated. The airways are patent. A small effusion is present on
the left. The only other abnormality is as scar in the lingula as well as an
atelectasis in the left upper lobe, at the level of the lateral portion of the
aortic arch.
IMPRESSION:
Diffuse ground-glass opacities, combined to small left pleural effusion,
likely reflect infection. The absence of an interstitial component. Is not
consistent with pulmonary edema. Small pleural effusion. Signs of pulmonary
hypertension.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with ESRD (s/p LRRT), with CKD-IV, here with R
shoulder septic arthritis. Initially no respiratory symptoms, despite GGOs
demonstrated on CT chest, though now with mild hypoxia (94% on RA) and cough.
Initially on vanc/CTX, then mono-CTX, now PO cefpodoxime. // Eval for new
infiltrate, volume overload? Eval for new infiltrate, volume overload?
IMPRESSION:
In comparison with the study of ___, there has been a substantial increase
in asymmetric pulmonary edema, more prominent on the right. Blunting of the
costophrenic angles is consistent with developing effusions and bibasilar
atelectasis.
This in the appropriate clinical setting, given the extensive pulmonary
changes.
The left IJ catheter extends to the lower SVC.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm pain, R Arm swelling
Diagnosed with Other specified soft tissue disorders
temperature: 97.3
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 104.0
dbp: 85.0
level of pain: 10
level of acuity: 3.0 | ___ with a history of End Stage Renal Disease (secondary to
Focal segmental glomerulosclerosis, status post living-relative
renal transplant in ___, on Tacrolimus/Mycophenolic
acid/prednisone), now with chronic scarring and Chronic Kidney
Disease stage IV, coronary artery disease (status post
drug-eluting stent to left anterior descending artery), with
right shoulder presumed septic arthritis, right-upper extremity
swelling, found to have severe hyponatremia and hyperkalemia.
Patient was monitored in ICU, and course complicated by atrial
fibrillation with rapid ventricular response, which
spontaneously converted to normal sinus rhythm. She was given
antibiotics for presumed septic arthritis and found on CT to
have ground glass opacities consistent with pneumonia.
#PRESUMED SEPTIC ARTHRITIS: Sudden-onset pain, swelling, and
reduced range of motion, in setting of known shoulder/rotator
cuff injuries. Acute pain began on ___ and worsened over
subsequent days, not improved with pain medication. She
presented to the ED for evaluation but was admitted to the ICU
for hyponatremia and received a dose of ampicillin-sulbactam
prior to arthrocentesis by interventional radiology. In this
setting, white blood count on tap was well below threshold for
septic arthritis. MRI findings supported infectious process. She
had no leukocytosis or fever, but is chronically
immunosuppressed and thus unlikely to mount full response.
Notably, crystal stain negative for gout and lyme serology
negative. In terms of rheumatoid labs, none were conclusive.
C-reactive protein and erythrocyte sedimentation rate both
elevated at 198 and 38 respectively. Other labs included:
Rheumatoid Factor 15 (nml ___ C3-85 (nml 90-180); C4 31 (nml
___ anti-CCP negative. Consulted infectious disease, who
recommended ceftriaxone for lung as below while working up
shoulder. Progressed to cefpodoxime and had clinical improvement
on this regimen. Arthrocentesis culture data all negative though
acid fast culture is pending. Plan to continue cefpodoxime for a
total of 2.5 weeks.
#LOWER EXTREMITY EDEMA: Onset ___ afternoon. Recent
echocardiogram normal, no history of liver disease, bilateral
deep-vein thromboses unlikely on anticoagulation. Known historic
nephrotic syndrome though on admission urine protein was 1.1g,
elevated but not nephrotic range, increased to 2.2 on ___.
Concerning for worsening of underlying FSGS in setting of
reduced immunosuppression (discontinued mycophenylate,
prednisone switched to dexamethasone briefly for cortisol
stimulation test) vs. consequence of holding home lisinopril vs.
could be from fluid shifts in setting of repletion (though none
3 days prior to development). On 2-liter restriction. Given 60mg
IV furosemide on ___ with good urine output (1L),
-1650 on ___. Recommended to weigh self daily on discharge and
contact the renal transplant clinic if her weights are
increasing.
#GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH
PNEUMONIA: CT chest was ordered to evaluate for etiology of RUE
edema (see below) but showed diffuse ground-glass opacities,
combined to small left pleural effusion, likely reflect
infection. Mild symptoms (intermittent nonproductive mild cough,
mild worsening of vitals though nothing severe). Treated with
cefpodoxime since ___, previously ceftriaxone/vancomycin
(started ___. Of note, ___ chest x-ray consistent with
worsening pulmonary edema, though patient remained without
dyspnea, tachypnea. Consider repeat imaging after antibiotic
therapy to ensure resolution and no underlying pulmonary
pathology.
RESOLVED HOSPITAL ISSUES
===========================
#HYPONATREMIA: Asymptomatic. Baseline 127-133. Admitted due to
hyponatremia to 117. This improved with normal saline in ICU and
3 amps bicarb in D5W on the floor. She required no repletion
after ___. Free T4 normal. Could have component of adrenal
insufficiency (see below) but difficult to assess given chronic
prednisone.
#CONCERN FOR ADRENAL INSUFFICIENCY (AI): Could fit clinical
picture on presentation (weight loss, hyponatremia,
hyperkalemia, acidosis, hypotension, anemia), though many of
these symptoms can be explained by chronic kidney disease, and
AI typically causes hypercalcemia. On cosyntropyn stimulation
test she technically met criteria for adrenal insufficiency
(prednisone replaced with dexamethasone for 2 days preceding).
However, patient chronically on prednisone ___ years) since
transplant. Patient is thus iatrogenically adrenally suppressed
for transplant, and we would expect insufficient physiologic
response to cosyntropin. Would consider stress dose steroids in
future times of acute illness, though she did not receive any
this hospitalization.
#RIGHT UPPER EXTREMITY EDEMA: Resolved over hospitalization.
Likely reactive from presumed septic arthritis, though this is
not well described in literature. Imaging was negative for
right-upper extremity DVT; normal arterial duplex. Chest CT
could not evaluate vasculature without contrast. Not consistent
with thoracic outlet syndrome or SVC syndrome. Normal capillary
refill; no associated neurologic symptoms.
#NEW ATRIAL FIBRILLATION: Noted to have new onset atrial
fibrillation with raid ventricular response while in the ICU.
Converted spontaneously to normal sinus rhythm. Unclear
precipitant; probably presumed septic arthritis. Thyroid
stimulating hormone and free T4 normal. Started on empiric
antibiotics (as above) for concern that an infection may have
been the precipitating factor. Discontinued telemetry ___ due
to normal rate/rhythm.
#HYPERKALEMIA: K was elevated on admission (K peaked to 6.3),
treated with insulin, dextrose and kayexelate with improvement.
Likely secondary to renal failure although adrenal insufficiency
possible. No EKG changes during admission.
#END-STAGE RENAL DISEASE (ESRD) s/p LIVING RELATIVE RENAL
TRANSPLANT: Surgery in ___. Creatinine around baseline. UPEP
negative. SPEP with hypogammaglobulinemia (Immunoglobulin M 22,
normal is 40-230). Discontinued Mycophenylate on ___ per
transplant renal recommendations. Held home lisinopril on
admission but restarted on ___ in setting of increasing
proteinuria. Discharged on 1mg tacrolimus in the morning and
1.5mg at night due to subtherapeutic troughs on 1mg BID.
Continued on prednisone 4mg (though this was replaced with
dexamethasone preceding cosyntropin stimulation test).
#METABOLIC ACIDOSIS: Pt with chronic non-anion gap metabolic
acidosis. Was not tolerating oral sodium bicarb at home due to
abdominal pain. At baseline during admission. Possibly secondary
to ESRD, although concern adrenal insufficiency may be
contributing. Received 3 amps sodium bicarb as above.
#ANEMIA: History of anemia in setting of ESRD, on Darbepoetin
alfa injections. Baseline hemoglobin ___. Hemoglobin slightly
below baseline with no evidence of active bleeding currently.
Received 1u packed RBC each on ___ and ___, with appropriate
rise in hemoglobin. B12 250, Iron (on ___ was 59.
CHRONIC ISSUES:
======================
#HYPERTENSION: On amlodipine, carvedilol, and lisinopril at
home. These were initially held due to hypotension in the MICU.
They were all restarted prior to discharge.
#CORONARY ARTERY DISEASE: Patient with drug-eluting stent in
___. Last Echo in ___ was largely normal. Continued
Aspirin and Ticagrelor while in house. Reached out to
cardiologist Dr. ___ about stopping Ticagrelor >12
months out from Drug-eluting stent, but did not hear back prior
to discharge. Scheduled patient for follow up with Dr. ___ to
discuss. Additionally continued atorvastatin.
#h/o WEIGHT LOSS: Pt with recent weight loss. Fairly up to date
with cancer screenings. Needs outpatient follow up for repeat
colonoscopy.
#CODE: full code
#CONTACT: ___, husband, ___
TRANSITIONAL ISSUES
===================
[] MYCOPHENOLATE MOFETIL: discontinued on admission per Dr.
___
[] TACROLIMUS: reduced to 1.5 QAM and 1 mg QPM from 1.5 BID.
(Trough was elevated on admission, but low while inpatient on
1mg BID.)
[] ANTIBIOTICS: Patient should continue Cefpodoxime PO 400 mg
once per day until ___ for a 2.5 week course.
[] GROUND GLASS OPACITIES ON CT: Asymptomatic, though read as
most consistent with infection. Recommend repeat imaging in ___
weeks to evaluate for resolution.
[] LEG SWELLING: This developed on ___, 3+ edema, in setting of
worsening proteinuria. Her lisinopril was restarted. The
swelling was somewhat responsive to 60mg IV furosemide x3. Per
transplant nephrology team, she should weigh herself daily and
call if she is gaining weight. Otherwise she will have follow up
with Dr. ___ in 2 weeks.
[] CXR WITH PULMONARY EDEMA: Worsened on ___ compared to ___.
Described as "substantial increase in asymmetric pulmonary
edema, more prominent on the right. Blunting of the costophrenic
angles is consistent with developing effusions and bibasilar
atelectasis." Patient was asymptomatic with reassuring vitals
saturating well w/o dyspnea on room air. Correlate clinically on
follow up appointment.
[] ADRENAL INSUFFICIENCY: Technically, cosyntropin stimulation
test confirmed adrenal insufficiency, however, this is difficult
to interpret in setting of iatrogenic suppression of adrenals
with prednisone. It was ordered due to metabolic abnormalities
on admission and concern that the patient was not mounting a
systemic response to presumed infection. ___ consider stress
dose steroids for severe illnesses in the future.
[] WEIGHT LOSS: Recent history of weight loss. She is only 80lb
currently. She is fairly up to date on cancer screening. Further
workup should be discussed and considered in outpatient setting.
[] TICAGRILOR: In setting of ecchymoses, purpura, and ___ year
since stenting, would consider discontinuing ticagrilor pending
conversation with cardiology (Dr. ___.
[] PENDING RESULTS: Joint aspirate acid fast stain pending from
___, no growth as of ___. Low suspicion given improvement
without treatment for mycobacterium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
latex
Attending: ___.
Chief Complaint:
chest pain/SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o COPD on home o2 p/w to OSH w dyspnea, CP, cyanosis.
pt, visiting ___, says that she woke up this AM with a 2
coughing spell followed by chest pain and dyspnea. pt's spouse
says she became cyanotic, which prompted them to OSH ED. Cardiac
enzymes and EKG at OSH was negative. CXR shows R ptx 50% w
slight
medastinal left shift. A chest tube was place. Serial CXR shows
resolution of ptx with mild R lung opacity. CT was done and
reveals spontaneous ptx, blebs, and lung nodules. pt was
transferred to ___ for further mgt.
During the transfer, chest tube was clamped. At ___ ED, chest
tube is put on suction and leakage was noted. CT had no o/p.
Repeat CXR shows emphesymatic lungs with no clear evidence of
ptx.
Past Medical History:
PAST MEDICAL HISTORY:
Stage IV COPD
HTN
HLD
Breast CA s/p lumpectomy s/p chemo
Neuropathy ___ chemo
Afib
Osteoporosis
PAST SURGICAL HISTORY:
Lumpectomy
Social History:
___
Family History:
Mother - etoh abuse
Father - CAD
Physical ___:
Temp 98 BP 105/57 HR 75 RR 18 O2 sat 99% on 2LPM
Gen: AAOx3 NAD
HEENT: wnl
CV: rrr s1 s2
PULM: decrease breath sounds ___.
GI: s/nt/nd. +bsx4
EXT/MS/SKIN: no c/c/e. +2 pulses
NEURO: grossly intact
Pertinent Results:
___ 05:00PM WBC-11.0* RBC-4.66 HGB-13.4 HCT-40.8 MCV-88
MCH-28.8 MCHC-32.8 RDW-14.6 RDWSD-46.7*
___ 05:00PM ___ PTT-25.9 ___
___ 05:00PM PLT COUNT-242
___ 05:00PM GLUCOSE-189* UREA N-14 CREAT-0.7 SODIUM-130*
POTASSIUM-3.4 CHLORIDE-91* TOTAL CO2-26 ANION GAP-16
___ CXR :
Right apical opacity may be due to prominent apical
thickening/scarring,
correlate with more remote radiographs to ensure stability, if
not, consider followup chest CT. Bibasilar reticular opacities
suggest chronic lung disease. Relative lucency of the mid lungs
likely relates to pulmonary emphysema.
Blunting of the right costophrenic angle suggesting a small
right pleural
effusion. Right chest tube is seen. Subcutaneous emphysema
along the right chest wall.
___ CXR with pneumostat in place :
1. Chest tube in appropriate positioning without evidence of
pneumothorax.
2. Unchanged bilateral diffuse interstitial thickening
representing chronic interstitial lung disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Amlodipine 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Atorvastatin 80 mg PO QPM
7. Hydrochlorothiazide 25 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Aspirin 325 mg PO DAILY
10. Temazepam 7.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth every six
(6) hours Disp #*8 Capsule Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Sarna Lotion 1 Appl TP TID:PRN pruritis
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 % 1
application three times a day Refills:*0
6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
7. Amlodipine 10 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Hydrochlorothiazide 25 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
15. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right spontaneous pneumothorax
Left lower lobe lung nodule
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 pnuemo at OSH, chest tube placed, images
getting uploaded of prior // residual pnuemothorax?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ at 12:56 from ___.
FINDINGS:
Right apical opacity may be due to prominent apical thickening/scarring,
correlate with more remote radiographs to ensure stability, if not, consider
followup chest CT. Bibasilar reticular opacities suggest chronic lung
disease. Relative lucency of the mid lungs likely relates to pulmonary
emphysema. There is blunting of the right costophrenic angle suggesting a
small right pleural effusion. Right chest tube is seen coursing into the
right lower chest. Right chest wall subcutaneous emphysema is again seen.
The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Right apical opacity may be due to prominent apical thickening/scarring,
correlate with more remote radiographs to ensure stability, if not, consider
followup chest CT. Bibasilar reticular opacities suggest chronic lung disease.
Relative lucency of the mid lungs likely relates to pulmonary emphysema.
Blunting of the right costophrenic angle suggesting a small right pleural
effusion. Right chest tube is seen. Subcutaneous emphysema along the right
chest wall.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right pneumothorax, chest tube. // please
assess for pneumo. please assess for pneumo.
COMPARISON: Comparison to ___ at 16 57
FINDINGS:
Portable upright chest radiograph ___ at 07:35 is submitted.
IMPRESSION:
There is some overlying motion artifact which limits the examination. A right
basilar chest tube remains in place. There is air within the right lateral
chest wall and neck soft tissues consistent with subcutaneous emphysema.
Rounded lucency at the right apex likely represents a small pneumothorax.
There is bilateral parenchymal distortion with fibrotic changes at the bases
consistent with fibrotic lung disease. Multiple small nodular opacities with
associated right apical pleural thickening are again seen and may reflect
prior granulomatous infection. Clinical correlation is advised. Overall
cardiac and mediastinal contours are stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ptx // post water seal
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Right chest tube is in place although more distally located than previously.
Apical opacity on the right is unchanged. No definitive pneumothorax is seen.
Interstitial changes and fibrosis in the lung bases is similar to previous
study
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with spont ptx // interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___. .
FINDINGS:
The right chest tube appears unchanged in comparison to the prior chest
radiograph. There is small amount of subcutaneous emphysema. No pneumothorax.
There is bilateral apical pleural thickening, worse on the right. There is
bilateral diffuse interstitial thickening, worse at the bases which is
unchanged. Heart size is normal. The mediastinal and hilar contours are
normal. The pulmonary vasculature is normal. No pleural effusion is seen.
There are no acute osseous abnormalities.
IMPRESSION:
1. Chest tube in appropriate positioning without evidence of pneumothorax.
2. Unchanged bilateral diffuse interstitial thickening representing chronic
interstitial lung disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right ptx // R/O ptx with ct on
pneumostat
IMPRESSION:
As compared to ___ radiograph from earlier the same date, a right
chest tube remains in place, with persistent loculated hydro pneumothorax at
right lung apex and small dependent pleural effusion at right lung base.
Overall, allowing for differences in technique and projection, there has not
been a substantial change in appearance of the chest since the recent study
from several hr earlier.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Pneumothorax, Transfer
Diagnosed with OTHER AIR LEAK
temperature: 97.8
heartrate: 100.0
resprate: 22.0
o2sat: 94.0
sbp: 127.0
dbp: 67.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of her chest tube. She was having some discomfort at
the tube insertion site which was relieved with Oxycodone. She
also had a one chamber air leak from her pleurovac.
Following admission to the Surgical floor her chest tube
remained on waterseal with the same air leak and her chest xray
showed almost full expansion of the right lung. Her oxygen
saturations were 99% on 2 LPM nasal cannula and attempts were
made to wean it off. She admits to being on oxygen at home but
states she uses it mainly with activity. She has been off of it
for 3 weeks during her stay in ___ as she couldn't fly with
an O2 tank.
After 48 hours on waterseal her air leak persisted and a
pneumostat was placed so that she could go home with her chest
tube while the lung healed and be followed in clinic. A
pneumostat was placed on ___ and 2 subsequent chest xrays
showed almost complete re expansion of the lung. Her oxygen
saturations were 95-99% on 2 LPM but attempts at weaning failed
with room air resting saturations of 85%. She had pleuritic
chest pain with deep breathing but was otherwise stable.
Arrangements were made for home oxygen therapy.
Of note, her Chest CT which was done at ___ on ___
showed a spiculated nodule in the left lower lobe and a PET CT
was recommended by Radiology after she is stable from this
pneumothorax. I explained the findings to the patient and her
husband and suggested that they stop at ___ Radiology
before they return to ___ so that they can get a hard
copy to give to her pulmonologist Dr. ___ ___
___. ___.
Ms. ___ was discharged to home on ___ with ___ services
for her pneumostat and home oxygen and will return to see Dr.
___ in the ___ Clinic on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Leaking ostomy appliance
Major Surgical or Invasive Procedure:
Gastrograffin enema
History of Present Illness:
___ recent sigmoid colectomy with diverting ileostomy on
___ with Dr. ___ divericulitis. Postop she recovered
well and was discharged home on ___. Was re-admitted
___ for leaking appliance and midline wound infection.
She was on vanco a few days, had her wound partially opened, and
was discharged home on Bactrim. She presents again tonight with
the same problem, that is, stool leaking out of the ostomy and
contaminating the laparotomy incision. There was increased
erythema around the incision today so she presented to an
outside
hospital and was subsequently transferred here for evaluation.
Ostomy output has been normal, no change.
Past Medical History:
diverticulitis ___ hospitalized for 4 days at ___ for a
3cm abscess), high cholesterol, HTN, migraines, asthma,
depression
PSH: Bilateral tubal ligation; C-Section; Bilateral ___ Vein
Stripping; ___ drainage of abcess ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: T 99.5 P 96 BP 134/85 RR 18 O2 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, nontender, no rebound or guarding,
Incision: moderate erythema surrounding the length of the
incision, more pronounced at each staple. Stoma pink, peristomal
skin with excoriation but no cellulitis.
Ext: 1+ ___ edema, ___ warm and well perfused
Pertinent Results:
GASTROGRAFIN ENEMA: Gastrografin contrast was instilled through
an 18 ___ flexible catheter into the rectum. Contrast flowed
freely into the rectum, past the colorectal anastomosis and into
the distal colon. There is no evidence of leaks or strictures.
The patient tolerated the procedure well.
IMPRESSION: No evidence of leaks at the colorectal anastomosis.
Medications on Admission:
1. levothyroxine 50 mcg Daily
2. atenolol 25 mg Daily
3. furosemide 80 mg Daily
4. simvastatin 80 mg Daily
5. aspirin 81 mg Daily
6. hydromorphone ___ mg Q4H as needed for pain
7. butalbital/acetaminophen/caffeine 50mg/325mg/40mg as needed
for headache
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
Disp:*1 bottle* Refills:*2*
9. Ostomy supplies
ConvaTec Surfit Moldable Large Convex it ___: # ___
10. Ostomy supplies
ConvaTec Drainable Pouch ___: ___ ___
11. Ostomy supplies
Ostomy Belt: manf # ___
12. Dressing/Wound supplies
Aquacel AG rope
Sig: Commercial wound cleanser, pat dry.
Aquacel AG rope, dry gauze, change daily.
Disp: 1 tube
Refills: 4
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Leaking ostomy appliance
Candidiasis skin infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Status post sigmoidectomy for diverticulitis. Evaluate
colorectal anastomosis prior to ileostomy takedown.
COMPARISONS: None.
GASTROGRAFIN ENEMA: Gastrografin contrast was instilled through an 18 ___
flexible catheter into the rectum. Contrast flowed freely into the rectum,
past the colorectal anastomosis and into the distal colon. There is no
evidence of leaks or strictures. The patient tolerated the procedure well.
IMPRESSION: No evidence of leaks at the colorectal anastomosis.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: WOUND EVAL
Diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS
temperature: 99.5
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 134.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | She was admitted to the Acute Care Surgery team for management
of her leaking ostomy appliance and treatment for fungal skin
infection. Due to the location of the stoma and patient's body
habitus the ostomy location was very close to her mid-line
incision. The wound itself was not infected. Wound ostomy
nursing was consulted and were able to make adjustments in her
appliances to new equipment which adhered over 24 hour period
without leakage. Miconazole powder was ordered for the fungal
irritation which showed signs of improvement during her stay.
She remained on her home medications during her stay and is
being discharged to home with services. She will follow up in
Acute Care Surgery clinic as instructed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Naprosyn / Nsaids / Statins-Hmg-Coa Reductase Inhibitors /
Niaspan Starter Pack / Lisinopril / Biaxin / Fosamax / adhesive
tape / Bactrim / doxycycline / Ditropan / General Anesthesia /
latex
Attending: ___.
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
1) EGD (___)
2) Colonoscopy (___)
3) Capsule endoscopy (___)
History of Present Illness:
___ female with a past medical history notable for
polycythemia ___, systolic heart failure s/p bioprosthetic
mitral valve replacement in ___, recent hospitalization
requiring ICU admission for GI bleed (___), who
presented with 1 week of weakness. The patient additionally
reports several episodes of dark stools over the past week. The
patient was seen by her PCP earlier on the day of admission and
found to be profoundly anemic and was sent to the ED for further
evaluation. The patient also reported significant dyspnea on
exertion, which had been steadily worsening. Despite her history
of CHF, she had not been taking her home lasix for some time.
She denied any fever/chills, chest pain, abdominal pain, and
dysuria. Rectal exam showed guaiac positive stools.
Of note, patient had been recently admitted from
___ for hematochezia. At that time, patient had a
CTA abdomen/pelvis with and without contrast which showed
"linear area of hyperdensity at level of right anus on arterial
phase, best seen on the coronal views, which disseminates and
enlarges on the delayed phases." Anoscopy showed thrombosed
internal hemorrhoids. During that hospitalization, received 4
units pRBC and underwent banding of internal hemorrhoids by
anoscopy--banded x 2 (left posterior and anterior midline).
In the ED, initial VS were 96.4 116 104/52 16 100% RA.
Exam notable for pallor and guaiac positive stool on rectal. She
also had bilateral lower extremity edema.
Labs showed hemoglobin/hematocrit of 6.3/19.7
Chest X-ray showed small bilateral pleural effusions and mild
interstitial edema.
Received pantoprazole gtt.
Transfer VS were 99/4, 118, 98/49, 26, 99% on RA
GI was consulted in the ED and followed the patient through
initial hospital course.
Past Medical History:
Medical History:
-sCHF (EF=25%)
-Mitral Valve replacement ___ Mitral regurgitation and prolapse
-GI bleed (?upper vs. lower)
-Polycythemia ___
-Basal Cell Carcinoma s/p Mohs Surgery of right cheek in ___
-DCIS s/p lumpectomy & radiation
-Hyperlipidemia
-Hypertension
-Hypothyroidism
-Osteoarthritis
-Squamous Cell Carcinoma
-Urinary Tract Infections, recurrent
-Varicose Veins s/p venous stripping b/L ___
Surgical History:
-Lumpectomy for DCIS
-___ surgery, right cheek (___)
-Prolapsed bladder surgery, failed
-Rotator cuff surgery (___)
-Salpingo-oophorectomy for dermoid cyst in ___, right
-Total abdominal hysterectomy w/ removal of left ovary (___)
-Vein stripping bilateral legs
Social History:
___
Family History:
Positive for lung cancer in one sister. Another
sister died of cardiac disease.
Physical Exam:
===================
ADMISSION PHYSICAL:
-------------------
Vitals: 97.8, 99/69, 118, 24, 97% on RA.
General: Elderly appearing, pale appearing female, laying in
bed, dry cough.
HEENT: Sclera anicteric, PERRL, EOMI, pale conjunctiva.
Neck: Supple, elevated JVD.
CV: Irregularly irregular rhythm, S1 and S2, prominent
prosthetic sound in apex.
Lungs: Minimal bibasilar crackles, no wheezes.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding, normoactive bowel sounds.
Ext: 1+ pitting edema in bilateral lower extremities. Varociose
veins appreciated in bilateral lower extremities.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
===================
DISCHARGE PHYSICAL:
-------------------
VS- Tm 98.6 Tc 98.6 HR 110-113 BP 110/69 RR ___ 02 97% RA
___ over last 8h
Weight: 69.3kg (from 70.8kg standing on ___
General: Elderly female, NAD. Less pallid compared to admission.
HEENT: MMM. PERRLA. EOMI.
Neck: Supple, JVP not appreciated.
CV: Irregular rhythm, not tachycardic. +S1/S2, prominent
prosthetic sound in apex with ___ systolic murmur.
Lungs: +Rales b/L in lower to mid lung fields. No wheezes, no
rhonchi. Lung sounds diminished in right base.
Abdomen: Soft, non-tender, non-distended, no rebound or
guarding. Normoactive bowel sounds.
Ext: Minimal edema in bilateral lower extremities. Varociose
veins appreciated in bilateral lower extremities. ___
stockings.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
Pertinent Results:
===============
ADMISSION LABS:
---------------
___ 01:55PM BLOOD WBC-8.3# RBC-1.95* Hgb-6.3* Hct-19.7*
MCV-101* MCH-32.3* MCHC-32.0 RDW-19.9* RDWSD-70.1* Plt ___
___ 01:55PM BLOOD Neuts-75* Bands-2 Lymphs-15* Monos-2*
Eos-0 Baso-3* Atyps-1* Metas-2* Myelos-0 AbsNeut-6.39*
AbsLymp-1.33 AbsMono-0.17* AbsEos-0.00* AbsBaso-0.25*
___ 01:55PM BLOOD UreaN-28* Creat-0.8 Na-135 K-5.0 Cl-101
HCO3-23 AnGap-16
___ 01:55PM BLOOD ALT-10 AST-13 AlkPhos-117* TotBili-0.4
DirBili-0.2 IndBili-0.2
___ 01:55PM BLOOD TotProt-7.2 Albumin-3.9 Globuln-3.3
Calcium-9.0 Phos-4.3 Mg-2.6
===============
KEY LABS:
---------------
___ 05:25PM BLOOD WBC-7.2 RBC-1.85* Hgb-6.1* Hct-18.7*
MCV-101* MCH-33.0* MCHC-32.6 RDW-20.1* RDWSD-68.9* Plt ___
___ 07:00AM BLOOD ___ PTT-28.3 ___
___ 07:00AM BLOOD Glucose-104* UreaN-22* Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-19* AnGap-20
___ 06:40AM BLOOD Glucose-107* UreaN-17 Creat-1.0 Na-137
K-4.4 Cl-105 HCO3-21* AnGap-15
===============
DISCHARGE LABS:
---------------
___ 07:00AM BLOOD WBC-5.9 RBC-2.62* Hgb-8.1* Hct-25.2*
MCV-96 MCH-30.9 MCHC-32.1 RDW-17.6* RDWSD-59.0* Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
___ 07:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3
===============
IMAGING:
---------------
___ CHEST XR: IMPRESSION:
1. Small bilateral pleural effusions with bibasilar atelectasis.
2. Mild interstitial pulmonary edema.
___ CHEST XR: IMPRESSION:
Heart size and mediastinum are stable including cardiomegaly.
Mild vascular enlargement is demonstrated but no overt pulmonary
edema is seen. Bilateral pleural effusions are most likely
present, small to moderate.
___ CHEST XR: IMPRESSION:
In comparison with the study of ___, there is continued
enlargement of the cardiac silhouette with only minimal
elevation of pulmonary venous
pressure that is unchanged from previous studies. No acute focal
pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN pain/temp
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO BID
5. Ranitidine 150 mg PO BID
6. Aspirin EC 81 mg PO DAILY
7. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain/temp
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
----------------
# GI BLEED
# Acute anemia
# Acute on chronic systolic congestive heart failure
SECONDARY:
----------------
# Polycythemia ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with h/o recent vavle/heart surgery and more
recent bleed; now w incr dyspnea/cough eval for evid of congestion
/aspiration or pul etiology to cough // ___ year old woman with h/o recent
vavle/heart surgery and more recent bleed; now w incr dyspnea/cough eval for
evid of congestion /aspiration or pul etiology to cough
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The sternotomy wires appear intact and appropriately aligned.
There are small bilateral pleural effusions with bibasilar atelectasis, worse
on the left. Mild interstitial pulmonary edema. The lungs are otherwise
clear. Heart size is stable. The mediastinal and hilar contours are stable.
No pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
1. Small bilateral pleural effusions with bibasilar atelectasis.
2. Mild interstitial pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, with intermittent dyspnea //
Evaluate for edema, infection
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable including cardiomegaly. Mild vascular
enlargement is demonstrated but no overt pulmonary edema is seen. Bilateral
pleural effusions are most likely present, small to moderate
Old first rib fracture is re- demonstrated on the left
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening dyspnea // worsening pulmonary
edema? worsening pulmonary edema?
IMPRESSION:
In comparison with the study of ___, there is continued enlargement of
the cardiac silhouette with only minimal elevation of pulmonary venous
pressure that is unchanged from previous studies. No acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Anemia
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS
temperature: 96.4
heartrate: 116.0
resprate: 16.0
o2sat: 100.0
sbp: 104.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ female with history of polycythemia ___, systolic CHF
complicated by mitral regurgitation and mitral valve prolapse
now s/p recent mitral valve replacement in ___, as well as
recent admission & ICU stay for GI bleed presented with weakness
and dyspnea x1 week with dark, guaiac positive stools. Found to
be profoundly anemic in ED and tranfused 2U PRBC, then
transfused a third unit on ___. After transfusions, patient's
anemia was improved and she had no active bleeding during
hospitalization. She was also treated for volume overload in the
setting of acute on chronic congestive heart failure.
============================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / piperacillin-tazobactam / Thorazine
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses
who is sent in from her nursing home after she complained of
back pain and was found to have O2 sats in the ___ on her home
oxygen.
Per EMS report, nursing home called requesting transport to
hospital for evaluation of back pain this morning. EMS found
sats to be 97% on home O2 and lung exam was notable for rhonchi
on auscultation of all lung fields and productive cough.
Vitals on arrival to the ED: T 98.5 P 96 BP 94/58 RR 16 O2 97%
4L Nasal Cannula.
Labs notable for: D-Dimer of 543, UA with + nitrite, large
leuks, WBC 37 and 0 Epis. WBC 10.8 (83.4%N). Cr 1.0 with
baseline closer to 0.5-0.6. Patient given Duonebs x6,
Levofloxacin 750mg x1, Flagyl 500mg IV, Ceftriaxone 1gram,
Methylprednisolone 125mg, 2L NS and 1gr of Acetaminophen. CXR
showed bibasilar opacities and there was concern for PNA. The
patient initially had high O2 requirement and was on a NRB at
one point in the ED. Bed request was for ICU given hypotension,
tachycardia, tachypnea, hypoxia, then changed to medicine floor
as patient improved with above therapy.
Vitals prior to transfer: T 98.7 P ___ BP 111/63 RR 27 O2 98%
Nasal Cannula.
This morning, the patient notes her breathing feels improved,
and notes that he cough and sputum is new, though is unclear
about the timeline. Denies any chest pain, fevers/chills,
coughing with eating, trouble swallowing, abdominal pain, N/V.
Denies LH/dizziness. Tells me she walks without assistance
without difficulty (notes report walks with a walker). Reports
her BMs are at baseline. No urinary complaints, or blood in
stool or urine.
Per discussion with group home, patient is on 2L O2 at night,
nothing during the daytime. Also on puree diet with honey
thickened liquids.
Past Medical History:
1. Mild intellectual disability
2. Dementia
3. COPD, on 2L NC
4. h/o Multiple falls
5. bronchiectasis
6. lumbar stenosis
7. L chronic rotator cuff tear, followed by orthopedics, h/o
past steroid injection
8. osteoporosis
9. DJD
10. GERD
11. Hypercholesterolemia
12. B12 deficiency
13. MRSA PNA in ___ and ___
14. Cellulitis in ___, MRSA + per wound swab
Past Psychiatric History (per OMR):
1. Anxiety
2. Depression
3. Psychotic disorder/schizophrenia
4. Bipolar disorder
Social History:
___
Family History:
(Per OMR) Mother lived to her mid-___ then suffered an MI.
Father lived to his mid-___ before dying of natural causes. Pt
is unable to state her family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
Vitals - T: 98.8 BP: 95/57 HR: 102 RR: 20 02 sat: 97% 4L NC
GENERAL: NAD, frail appearing elderly woman with red hair.
Occasionally shouts out in pain.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, edentulous
NECK: nontender supple neck, no JVD appreciated
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Overall clear, difficult to appreciate good lung sounds
given patient difficulty cooperating and moaning, no overt
rhonchi/wheezes
ABDOMEN: nondistended, +BS, mild tenderness to deep palpation
throughout but no rebound or guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, alert and oriented to self, knows she
is in a hospital. Guesses the day is ___ and year is ___.
___ strength bilateral lower extremities.
SKIN: warm and well perfused, multiple ecchymoses on arms
bilaterally
DISCHARGE PHYSICAL EXAM:
====================
Vitals - Tm 98.1, Tc 97.6, HR 106 (88-106), BP 110/74
(97-120/55-83), RR ___, O2 Sat 93-100% on 2L
GENERAL: NAD, frail appearing elderly woman with red hair,
sleeping this morning.
HEENT: AT/NC, PRRL, some mild 1.5mm anisocoria L>R, EOMI, dry
MM, tongue midline
CARDIAC: RRR, distant S1/ normal S2, no murmurs, gallops, or
rubs
LUNG: More clear lung exam this morning, with intermittent
minimal expiratory rhonchi, decreased air movement on sides
anteriorly, no wheezes.
ABDOMEN: nondistended, +BS, completely nontender, no rebound or
guarding.
EXTREMITIES: no cyanosis, clubbing or edema, 2+ DP pulses
bilaterally.
SKIN: warm and well perfused, multiple ecchymoses on arms
bilaterally.
Pertinent Results:
==== ADMISSION LABS ====
___ 07:15AM BLOOD WBC-10.8# RBC-4.00*# Hgb-11.5*#
Hct-35.3*# MCV-88 MCH-28.6 MCHC-32.5 RDW-16.1* Plt ___
___ 07:15AM BLOOD Neuts-83.4* Lymphs-11.2* Monos-4.8
Eos-0.5 Baso-0.1
___ 07:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:15AM BLOOD ___ PTT-42.3* ___
___ 07:15AM BLOOD Glucose-127* UreaN-19 Creat-1.0 Na-137
K-4.3 Cl-95* HCO3-32 AnGap-14
___ 07:15AM BLOOD D-Dimer-543*
___ 11:04AM BLOOD ___ pO2-49* pCO2-52* pH-7.37
calTCO2-31* Base XS-2
___ 07:23AM BLOOD Lactate-2.0
___ 11:04AM BLOOD O2 Sat-80
___ 11:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:00AM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 11:00AM URINE RBC-0 WBC-37* Bacteri-FEW Yeast-NONE
Epi-0
___ 11:00AM URINE 3PhosX-RARE
___ 11:00AM URINE Mucous-RARE
==== DISCHARGE LABS ====
___ 10:40AM BLOOD WBC-20.2*# RBC-4.18* Hgb-11.5* Hct-37.1
MCV-89 MCH-27.6 MCHC-31.1 RDW-16.2* Plt ___
==== MICROBIOLOGY ====
___ BLOOD CULTURES X2: No growth.
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ URINE CULTURE: No growth.
___ 1:07 am SPUTUM Site: EXPECTORATED
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
==== IMAGING ====
___ ECG:
EKG: poor R wave progression, normal axis. Earlier EKGs with
poor baseline, showing mild ST segment depressions in lateral
leads.
___ CXR (PA AND LAT)
FINDINGS:
AP upright and lateral views of the chest provided. Bibasilar
streaky opacities are again seen which may represent
scarring/atelectasis. Difficult to exclude a component of
aspiration/ pneumonia. A tiny right effusion is likely present.
Cardiomediastinal silhouette is stable. No pneumothorax. No
convincing signs of edema. Severe degenerative disease at
bilateral shoulders again noted. There is a mild dextroscoliosis
centered in the lumbar spine.
IMPRESSION:
Bibasilar opacities likely due to a combination of atelectasis,
scarring, difficult to exclude a component of
aspiration/pneumonia.
___ CXR (PORTABLE)
AP portable upright view of the chest. Patient is rotated to
her right. Bibasilar opacities with small right pleural effusion
re- demonstrated without significant interval change from prior
exam performed 3 hr earlier. No overt edema is seen.
___ CXR (PORTABLE)
There is right lower lobe consolidation, which could be
pneumonia. Left lung base atelectasis is similar to prior. There
is small bilateral pleural effusions. Cardiomediastinal
silhouette is unchanged.
IMPRESSION:
No notable interval change. Possible pneumonia at right lower
lobe.
___ VIDEO OROPHARYNGEAL SWALLOW
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was significant
aspiration of honey and puree consistencies, with penetration of
nectar thick consistencies. Due to aspiration risk, this
swallow study was terminated early.
IMPRESSION:
Significant aspiration of honey NP ray consistencies, with
penetration of
nectar-thick consistency.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
___ PORTABLE ABDOMINAL
1. Oral contrast and air seen in multiple loops of nondilated
bowel, without evidence of obstruction.
2. Lucency in the right lower quadrant is likely air in the
ascending colon. However, upright/lateral radiographs could be
obtained to assess for free intraperitoneal air.
___ ABD SUPINE AND LAT DECUBITUS
Oral contrast again seen in multiple loops of large bowel. On
decubitus views, no evidence of free intraperitoneal air or
obstruction. Previously identified right lower quadrant bowel
loops containing air and contrast no longer identified.
Unchanged dextroscoliosis of bilateral degenerative changes of
the hips.
IMPRESSION:
No evidence of free intraperitoneal air or obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Docusate Sodium 100 mg PO BID
3. Artificial Tears 1 DROP BOTH EYES QID
4. Calcium Carbonate 600 mg PO BID
5. Divalproex Sod. Sprinkles 250 mg PO TID
6. ClonazePAM 0.5 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Atorvastatin 10 mg PO QPM
9. Multivitamins 1 TAB PO DAILY
10. Senna 8.6 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Acetaminophen 650 mg PO TID
13. Ascorbic Acid ___ mg PO BID
14. Vitamin D ___ UNIT PO DAILY
15. Sertraline 150 mg PO DAILY
16. OLANZapine 10 mg PO QHS
17. Bisacodyl 10 mg PO DAILY:PRN constipation
18. Bacitracin Ointment 1 Appl TP BID:PRN cuts/scrapes
19. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob
20. Guaifenesin ER 600 mg PO Q12H
21. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
heartburn
22. Milk of Magnesia 30 mL PO Q24H:PRN constipation
23. Fluticasone Propionate NASAL 1 SPRY NU BID
Discharge Medications:
1. Artificial Tears 1 DROP BOTH EYES QID
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Calcium Carbonate 600 mg PO BID
4. ClonazePAM 0.5 mg PO BID
5. Divalproex Sod. Sprinkles 250 mg PO TID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Guaifenesin ER 600 mg PO Q12H
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. OLANZapine 10 mg PO QHS
11. Sertraline 150 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Acetaminophen 650 mg PO TID
14. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
heartburn
15. Bacitracin Ointment 1 Appl TP BID:PRN cuts/scrapes
16. Fluticasone Propionate NASAL 1 SPRY NU BID
17. Milk of Magnesia 30 mL PO Q24H:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Methicillin resistant Staph aureus pneumonia
- Urinary tract infection
- Aspiration
- COPD exacerbation
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 (AP AND LAT)
INDICATION: ___ with dyspnea, tachypnic // evidence of pneumonia
COMPARISON: Chest radiograph ___
FINDINGS:
AP upright and lateral views of the chest provided. Bibasilar streaky
opacities are again seen which may represent scarring/atelectasis. Difficult
to exclude a component of aspiration/ pneumonia. A tiny right effusion is
likely present. Cardiomediastinal silhouette is stable. No pneumothorax. No
convincing signs of edema. Severe degenerative disease at bilateral shoulders
again noted. There is a mild dextroscoliosis centered in the lumbar spine.
IMPRESSION:
Bibasilar opacities likely due to a combination of atelectasis, scarring,
difficult to exclude a component of aspiration/pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with dyspnea // evidence of fluid overload
COMPARISON: Prior exam performed 3 hr earlier.
FINDINGS:
AP portable upright view of the chest. Patient is rotated to her right.
Bibasilar opacities with small right pleural effusion re- demonstrated without
significant interval change from prior exam performed 3 hr earlier. No overt
edema is seen.
IMPRESSION:
No change.
Radiology Report
INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses who presents
with hypoxia at her nursing home, found to have possible PNA on CXR, likely
UTI, meeting SIRS criteria. // Please assess for interval change.
EXAMINATION: CHEST (PORTABLE AP)
TECHNIQUE: Portable Chest radiograph, AP view
COMPARISON: Chest radiograph ___
FINDINGS:
There is right lower lobe consolidation, which could be pneumonia. Left lung
base atelectasis is similar to prior. There is small bilateral pleural
effusions. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
No notable interval change. Possible pneumonia at right lower lobe.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses who presents
with hypoxia at her nursing home, found to have possible PNA on CXR, likely
UTI, meeting SIRS criteria. Please assess for evidence of aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2 min 13 seconds.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was significant aspiration of honey and puree
consistencies, with penetration of nectar thick consistencies. Due to
aspiration risk, this swallow study was terminated early.
IMPRESSION:
Significant aspiration of honey NP ray consistencies, with penetration of
nectar-thick consistency.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses who presents
with hypoxia at her nursing home, found to have MRSA PNA likely UTI, meeting
SIRS criteria. Please assess for acute intraabdominal process.
TECHNIQUE: Supine portable views of the abdomen.
COMPARISON: Abdominal radiograph from ___ and video swallow from ___.
FINDINGS:
Oral contrast from the recent video swallow is present within the descending
and sigmoid colon. Air is present multiple loops of nondilated bowel. Right
lower quadrant lucency is likely air and contrast in the ascending colon,
which could be within the pannus or possibly in a hernia. However, free air
cannot be excluded on this single supine view. Dextroscoliosis of the lumbar
spine and bilateral degenerative hip changes are also noted.
IMPRESSION:
1. Oral contrast and air seen in multiple loops of nondilated bowel, without
evidence of obstruction.
2. Lucency in the right lower quadrant is likely air in the ascending colon.
However, upright/lateral radiographs could be obtained to assess for free
intraperitoneal air.
Radiology Report
EXAMINATION: ABD SUPINE AND LAT DECUB
INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses who presents
with hypoxia at her nursing home, found to have MRSA PNA likely UTI, meeting
SIRS criteria. Evaluate for obstruction, free air.
TECHNIQUE: Supine and decubitus views of the abdomen.
COMPARISON: Abdominal x-ray from earlier on the same date.
FINDINGS:
Oral contrast again seen in multiple loops of large bowel. On decubitus views,
no evidence of free intraperitoneal air or obstruction. Previously identified
right lower quadrant bowel loops containing air and contrast no longer
identified. Unchanged dextroscoliosis of bilateral degenerative changes of the
hips.
IMPRESSION:
No evidence of free intraperitoneal air or obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Productive cough
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPOXEMIA
temperature: 98.5
heartrate: 96.0
resprate: 16.0
o2sat: 97.0
sbp: 94.0
dbp: 58.0
level of pain: 13
level of acuity: 2.0 | ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses
who presents with hypoxia at her group home, found to have MRSA
PNA, UTI, meeting SIRS criteria on admission, found to be
grossly aspirating on video swallow.
ACTIVE ISSUES
=============
# Sepsis, MRSA PNA:
Patient initially with complaints of back pain at her group
home, noted to have an oxygen saturation in the ___. EMS arrived
and noted O2 sats 97% on patient's home O2, transported to our
ED where she was hypoxic requiring nonrebreather briefly,
tachycardic, tachypneic, with leukocytosis up to 19 this
admission, meeting sepsis criteria, with dirty UA and concerning
CXR for pulmonary source. Sputum cultures grew MRSA, and patient
was treated with an 8 day course of vancomycin to complete HCAP
course (lives in group home). Grossly dirty UA on admission (+
nitrite, large leuks, WBC 37 and 0 Epis), though with mixed
flora on urine culture, treated with 5 day course of cefepime,
transitioned to ceftriaxone once cultures resulted.
# COPD exacerbation:
Given history of COPD, with worsening productive cough, SOB,
consistent with COPD flare in the setting of above infection,
treated with 5 days total of steroids, standing duonebs, prn
albuterol neb, as well as home medications (guaifenesin and
advair). Additionally, given relative immobility, tachypnea, and
tachycardia, PE on the differential, however Ddimer is 548,
which is negative based on age-adjusted upper limit for Ddimer
(in her case, 500 + 270), making this less likely.
# Aspiration:
Given concern for aspiration during observed meals, speech and
swallow team consulted who on bedside evaluation cleared for
ground solids, nectar thickened liquids, meds whole in puree.
However, given continued concern with worsening lung exam and
repeat CXR with new R lower lobe opacity, video swallow obtained
which showed gross aspiration. Given patient with end-stage
dementia, and poor outcomes of gastric tubes in demented
patients (pressure ulcers, infections, delirium, and lack of
evidence for decreased aspiration events), continued patient on
ground solids, nectar thickened liquids, essential meds whole in
puree. Recommend mechanical soft diet, 1:1 feeding with frequent
encouragement to clear airways, oral care TID, standard
aspiration precautions (feeding when patient fully alert, seated
upright during PO intake and 30 minutes after, small bites/sips
at slow rate).
# ?UTI:
Grossly dirty UA on admission (+ nitrite, large leuks, WBC 37
and 0 Epis), though with mixed flora on urine culture. Given
mixed flora on initial culture despite floridly positive UA,
repeat UA and culture were done, however patient had been on
antibiotic coverage for 48 hours, and repeat UA/cultures were
negative. Patient incontinent and demented, unable to provide
reliable history regarding symptoms, thus given low risk for
antibiotics and high potential benefit if patient with true UTI,
treated with 5 day course of cefepime, transitioned to
ceftriaxone once cultures resulted with mixed flora.
# Abdominal pain:
Patient complained one evening of right sided abdominal pain,
exam unremarkable with stable vital signs, however given poor
historian abdominal films were obtained, which were negative for
obstruction or intraabdominal free air. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
Dyspnea And Edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with history of Mitral valve
prolapse ___ bioprosthetic MVR, atrial flutter (on coumadin)
morbid obesity, sleep apnea who presents with 2 days of
worsening dyspnea, orthopnea, peripheral edema. At baseline she
is able to walk ___ blocks before feeling short of breath.
Recently she was becoming short of breath with minimal exertion.
No shortness of breath at rest. Additionally she normally
sleeps on three pillows but recently was using four pillows. Per
records patient's dry weight is 180lbs however in the past 2
weeks patient reports ___ lb weight gain. She usually tries
to limit her salt intake but at times family makes food with
salt in it including canned soup. Her lasix dose was halved to
20mg daily in ___ by Dr. ___ increased back to 40mg
daily by PCP 2 weeks ago. She reports mild dry cough worse with
lying flat but denies any fevers, chills, night sweats, chest
pain, lightheadedness, palpitations. She was seen by PCP
yesterday who noted 15lb weight gain and asked patient to go to
ED for diuresis.
Initial VS in the ED: 97.3 75 124/97 20 95%.
Exam notable for ___ edema, weight gain, and crackles.
Labs notable for BUN 27, INR 2.5, and a negative pregnancy test.
CXR showed pulmonary congestion. Patient was not given any
medications while in the ER. Overnight she received 40mg IV
lasix and had 1L urine ouptut.
Past Medical History:
MVP/MR ___ bioprosthetic mitral valve in ___.
Moderate MR ___ MVR.
Depression, Diverticulosis
Atrial Flutter on coumadin
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: Tc 97.5 BP 117/70 HR 78 RR 20 97% RA
General: NAD
HEENT: EOMI
Neck: Supple
CV: RRR, nl S1/S2, no murmur appreciated
Lungs: Crackles at the bilateral bases
Abdomen: S/NT/ND
Ext: 2+ Pitting edema bilaterally
Neuro: AAOx3
Pertinent Results:
Pertinent Labs:
___ 06:11PM BLOOD WBC-9.1 RBC-4.41 Hgb-13.6 Hct-40.4 MCV-92
MCH-30.8 MCHC-33.6 RDW-16.6* Plt ___
___ 06:11PM BLOOD ___ PTT-34.1 ___
___ 06:11PM BLOOD Glucose-118* UreaN-27* Creat-1.0 Na-139
K-4.1 Cl-102 HCO3-26 AnGap-15
___ 07:55AM BLOOD ALT-24 AST-33 AlkPhos-79 TotBili-0.9
___ 06:11PM BLOOD ___
___ 06:11PM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
___ 08:19AM BLOOD %HbA1c-5.7 eAG-117
___ 11:01AM URINE Color-Straw Appear-Clear Sp ___
___ 11:01AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 11:01AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
___ 11:01AM URINE UCG-NEGATIVE
.
CXR: ___
FINDINGS: The patient is status post median sternotomy and
mitral valve replacement. The cardiac silhouette is moderate to
severely enlarged but unchanged. The mediastinal contours are
stable with continued dilatation of the azygos vein. There is
mild pulmonary edema, slightly improved compared to the previous
exam. No pleural effusion or pneumothorax is clearly
identified. There are no acute osseous abnormalities.
.
IMPRESSION: Mild congestive heart failure.
.
TTE: ___
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is mildly depressed (LVEF=
40%) secondary to markedly abnormal systolic septal
motion/position (the latter consistent with right ventricular
pressure overload) . The right ventricular cavity is markedly
dilated with severe global free wall hypokinesis. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The prosthetic
mitral valve leaflets are thickened. Motion of the mitral
annulus is abnormal and suggestive of partial dehiscence. The
gradients are higher than expected for this type of prosthesis.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
gradients across the mitral valve bioprosthesis and the degree
of mitral regurgitation are similar (severely increased). Again
slight abnormal motion of the mitral prosthesis is noted in the
absence of a paravalvular leak. The right ventricle appears now
severely dilated with worse systolic function and worse
functional tricuspid regurgitation. Pulmonary pressures are
higher.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Warfarin 5 mg PO 4X/WEEK (___)
4. Warfarin 6 mg PO 3X/WEEK (___)
5. Furosemide 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Warfarin 5 mg PO 4X/WEEK (___)
4. Warfarin 6 mg PO 3X/WEEK (___)
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride [Klor-Con M20] 20 mEq 20 mEq by mouth
daily Disp #*30 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Partial Dehiscence of Mitral valve replacement
RV dilation w/RV failure
CHF exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Congestive heart failure.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The patient is status post median sternotomy and mitral valve replacement.
The cardiac silhouette is moderate to severely enlarged but unchanged. The
mediastinal contours are stable with continued dilatation of the azygos vein.
There is mild pulmonary edema, slightly improved compared to the previous
exam. No pleural effusion or pneumothorax is clearly identified. There are
no acute osseous abnormalities.
IMPRESSION:
Mild congestive heart failure.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: DYSPNEA AND BLE EDEMA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS, MITRAL VALVE DISORDER, ATRIAL FIBRILLATION
temperature: 97.3
heartrate: 75.0
resprate: 20.0
o2sat: 95.0
sbp: 124.0
dbp: 97.0
level of pain: 2
level of acuity: 2.0 | ___ year old lady with history of Mitral valve prolapse ___
bioprosthetic MVR, atrial flutter (on Coumadin) morbid obesity,
sleep apnea who presented with 2 days of worsening dyspnea,
orthopnea, peripheral edema, weight gain consistent with acute
on chronic CHF exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chlorthalidone / lisinopril / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Low hemoglobin
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
History of Present Illness:
This is a ___ yo M with HFpEF, Afib on Apixaban, RCC with right
nephrectomy ___, and CKD stage III who was getting
outpatient labs in preparation for outpatient catheterization
when he was found to have Hct of 21, and he was told to go to
the emergency room, where his Hb was 5.7. He has had progressive
dyspnea and dizziness and difficulty walking longer distances
over the past few days and c/o lightheadedness worse with
exertion/standing up. He says this issue has gotten
progressively worse since he had his cardioversion in ___. He
reports multiple family members and his cardiologist told him
his color did not look good in the past month or so. Last known
value was Hgb 12 in ___, with Hb ___ of 15.7. He also
endorses increasing lower extremity and abdominal swelling of
the last month, with noticeable worsening also after his recent
cardio version. Notes pain in calves bilaterally which he has
never had before. Denies any chest pain, abdominal pain, nausea,
vomiting, diarrhea. No black or bloody stools, palpitations,
tachycardia, irregular heart beat, chest pain, exertional chest
pain or pressure. He has never had a colonoscopy, has a history
of IBS.
In the ED, initial VS were:
98.6
70
137/72
20
98% RA
Labs showed: Heme negative rectal exam. Hgb 5.7
Imaging showed:
Received: 1U PRBCs, 100 IV Lasix
Transfer VS were:
97.8
71
118/64
16
100% RA
On arrival to the floor, patient reports the findings noted in
HPI above. He feels MUCH better after the unit of blood. Has not
noticed any black or bloody stools.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
-HF with preserved EF
* dry weight: 300, dry BNP: < 200
* Hospitalization: ___ in setting of AFib with RVR with BNP
400, weight 315 on admit and assume 300 on d/c, he also had
concomitant transaminitis with hypocoagulopathy with the heart
failure
- anemia: mild anemia unknown etiology
- atrial fibrillation: CHADSVASC score 4, on apixban
*failed DCCV ___, then started on amio
*successful DCCV mid ___
Hypertension [I10]
Obesity [E66.9]
GERD
Hyperlipidemia [E78.5]
Erectile dysfunction [N52.9]
Testicular hypogonadism [E29.1]
Nuclear cataract [H25.10]
Pseudophakia [Z96.1]
PCO (posterior capsular opacification) [H26.499]
BPH (benign prostatic hyperplasia) [N40.0]
Midline low back pain without sciatica [M54.5]
Liver failure [K72.90]
Rhabdomyolysis [M62.82]
Thyroid nodule [E04.1]
Left adrenal mass [E27.9]
Coagulopathy [D68.9]
Testicular hypogonadism [E29.1]
R nephrectomy for malignancy
Social History:
___
Family History:
Family History: per chart review
includes Anemia in his son (likely due to ulcer); Asthma in his
daughter; CAD/PVD in his father; Cancer - ___ in his
mother; Cancer - ___ in his father; ___ in his
mother; ___ in his maternal grandmother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: NAD
HEENT: Pale conjunctiva, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, mildly elevated JVD
HEART: RRR, S1/S2 with possible S4 gallop heard but difficult
to tell
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended, tense, but no pain to palpation.
EXTREMITIES: Has fingernail bed scooping. ___ 3+ pitting edema
to mid thigh.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 133 / 69 71 18 96 RA
GENERAL: NAD
HEENT: Pale conjunctiva, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, JVD remains elevated
HEART: RRR, S1/S2, no mgr
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended, tense, but no pain to palpation.
EXTREMITIES: Has fingernail bed scooping. ___ 1+ pitting edema up
to knee, shins erythematous
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:30PM BLOOD WBC-7.3 RBC-3.14* Hgb-5.7* Hct-22.8*
MCV-73* MCH-18.2* MCHC-25.0* RDW-19.9* RDWSD-51.3* Plt ___
___ 10:30PM BLOOD Neuts-82.0* Lymphs-7.9* Monos-8.5
Eos-0.7* Baso-0.5 NRBC-0.3* Im ___ AbsNeut-5.99
AbsLymp-0.58* AbsMono-0.62 AbsEos-0.05 AbsBaso-0.04
___ 07:30AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-1+* Polychr-OCCASIONAL Ovalocy-1+* Tear
Dr-1+* Bite-OCCASIONAL Ellipto-OCCASIONAL
___ 02:02AM BLOOD ___ PTT-48.5* ___
___ 10:30PM BLOOD Glucose-105* UreaN-25* Creat-1.8* Na-133
K-3.9 Cl-90* HCO3-29 AnGap-14
___ 10:30PM BLOOD LD(LDH)-178 TotBili-0.8
___ 10:30PM BLOOD cTropnT-0.01 proBNP-5137*
___ 10:30PM BLOOD Iron-23*
___ 10:30PM BLOOD calTIBC-450 ___ Ferritn-12* TRF-346
___ 10:39AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:39AM BLOOD PEP-AWAITING F IgG-1150 IgA-253 IgM-87
IFE-PND
___ 10:30PM BLOOD GreenHd-HOLD
___ 07:07PM BLOOD HCV Ab-NEG
DISCHARGE LABS:
===============
___ 07:55AM BLOOD WBC-5.2 RBC-3.80* Hgb-7.8* Hct-29.6*
MCV-78* MCH-20.5* MCHC-26.4* RDW-20.9* RDWSD-58.9* Plt ___
___ 07:55AM BLOOD Glucose-89 UreaN-13 Creat-1.4* Na-142
K-4.1 Cl-97 HCO3-27 AnGap-18*
___ 07:55AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
MICRO:
======
___ 11:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING:
========
___ CXR PA/LAT
FINDINGS:
Lung volumes are low. No definite focal consolidation is seen.
There is mild
distinctness of pulmonary vessels, which may reflect pulmonary
vascular
congestion, but no frank pulmonary edema. The heart is mildly
enlarged. No
pleural effusion or pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion without pulmonary edema.
___ CT Ab/pelvis
IMPRESSION:
1. Small to moderate volume simple density ascites and small
right-sided
pleural effusion with mild diffuse superficial soft tissue
stranding of
unclear source, is most likely secondary to volume overload.
Though the
contour of the liver remains smooth, there is moderate
splenomegaly.
Cirrhosis with portal hypertension is a possibility despite the
relative
smooth contour of the liver and relative lack of volume
redistribution.
Hematologic dyscrasias are also within the differential.
Correlate with lab
values.
2. No retroperitoneal hemorrhage, or other definite source of
hemorrhage.
3. 19 mm high density left renal lesion is likely a
proteinaceous or
hemorrhagic cyst. Confirmation with renal ultrasound is
recommended.
4. Post right nephrectomy. Otherwise no definite evidence of
malignancy or
metastatic disease within the abdomen or pelvis given the
confines of a
noncontrast examination.
5. Probable left adrenal myelolipoma.
6. Anemia.
7. Diffuse diverticulosis.
___ ABD US
FINDINGS:
LIVER: Views of the liver are technically limited due to body
habitus and
noise. The contour of the liver is smooth. There is no focal
liver mass.
The main portal vein is patent with hepatopetal flow. There is
small volume
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The pancreas is completely obscured by overlying bowel
gas.
SPLEEN: Normal echogenicity, measuring 16.4 cm.
KIDNEYS: The right kidney is surgically absent. The left kidney
measures 14.9
cm. Normal cortical echogenicity and corticomedullary
differentiation is seen
bilaterally. There is no evidence of masses, stones, or
hydronephrosis in the
kidneys. 2 cysts are identified ranging from 2.4-3.3 cm in
size. The smaller
cyst has a thin septation but no other concerning features.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
Moderate splenomegaly and small volume ascites. Limited views
of the liver
show no focal lesions. Portal vein is patent with hepatopetal
flow.
2 left kidney cysts are noted with no other concerning lesions.
Status post
right nephrectomy.
___ ___ DUPLEX
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and global systolic function (LVEF>55%). Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The
ascending aorta is mildly dilated. 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. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Moderate PA systolic hypertension. Mild symmetric
left ventricular hypertrophy with preserved global systolic
function. Mildly dilated ascending aorta.
These findings are suggestive of a primary pulmonary process
(e.g., sleep apnea, pulmonary embolism, COPD, etc.).
___ EGD
Normal esophagus. Normal stomach. Normal duodenum.
___ Colonoscopy
Diverticulosis of the both left and right colon. Due to
redundant colon, we were unable to reach the cecum to assess for
mass or source of bleed.
Otherwise normal colonoscopy to distal ascending colon
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HydrOXYzine 25 mg PO QHS
2. Apixaban 5 mg PO BID
3. Metolazone 5 mg PO 1X/WEEK (MO)
4. Amiodarone 200 mg PO DAILY
5. Bumetanide 3 mg PO BID
6. Metoprolol Succinate XL 200 mg PO QHS
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Amiodarone 200 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Bumetanide 3 mg PO BID
5. HydrOXYzine 25 mg PO QHS
6. Metolazone 5 mg PO 1X/WEEK (MO)
7. Tamsulosin 0.4 mg PO QHS
8. HELD- Metoprolol Succinate XL 200 mg PO QHS This medication
was held. Do not restart Metoprolol Succinate XL until you
discuss with your cardiologist.
Discharge Disposition:
Home
Discharge Diagnosis:
Severe anemia secondary to chronic blood loss
Acute on Chronic diastolic CHF
CKD stage III
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: AP and lateral chest radiographs
INDICATION: History: ___ with SOB// evaluate for pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lung volumes are low. No definite focal consolidation is seen. There is mild
distinctness of pulmonary vessels, which may reflect pulmonary vascular
congestion, but no frank pulmonary edema. The heart is mildly enlarged. No
pleural effusion or pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion without pulmonary edema.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old man with symptomatic anemia on abixiban, presented
with Hb 5.7. initially responsive to transfusion but Hb 7.5-> 6.7 over 12
hours.// Retroperitoneal bleeding, signs of malignancy
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 59.7 cm; CTDIvol = 6.6 mGy (Body) DLP = 392.0
mGy-cm.
Total DLP (Body) = 392 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Heart size is mildly enlarged without significant pericardial
effusion. There is a small right-sided pleural effusion with mild adjacent
compressive atelectasis. The imaged lung bases are otherwise grossly clear.
There is relative hypoattenuation of the blood pool compared to the cardiac
musculature.
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. There is small to
moderate volume simple density ascites.
PANCREAS: There is diffuse fatty atrophy of the pancreas without definite
focal mass given the confines of a noncontrast examination and no main
pancreatic duct dilatation. There is no pancreatic ductal dilatation. There
is no peripancreatic stranding.
SPLEEN: The spleen is enlarged measuring 17.5 cm in maximal axis. No gross
splenic lesion is identified.
ADRENALS: The right adrenal gland is unremarkable. There is some expansion of
the left adrenal gland with areas of fatty attenuation, suggestive of a 32 mm
left adrenal myelolipoma.
URINARY: Patient is status post right nephrectomy. There is a 35 mm simple
cyst in the right interpolar kidney. There is a somewhat heterogeneous, high
density exophytic lesion off the left lower pole kidney measuring 19 mm
(02:45). Otherwise, there is no left-sided renal calculus or hydronephrosis.
There is no frank left perinephric abnormality.
GASTROINTESTINAL: The stomach is collapsed and grossly unremarkable. The
duodenum and distal small bowel loops are normal caliber without evidence of
obstruction. There is diffuse, extensive sigmoid predominant diverticulosis
without secondary evidence for diverticulitis. Otherwise the large bowel is
thin-walled without gross pericolonic fat stranding or organizing fluid
collection given the fact that there is pre-existing ascites. The appendix is
not definitively visualized though there is no secondary evidence for
appendicitis. The rectum is grossly unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are moderate lumbar degenerative changes, focally severe at the L5-S1
level. There is moderate bilateral hip osteoarthritis.
SOFT TISSUES: There are changes from prior abdominal surgery. There is mild
diffuse superficial soft tissue stranding suggestive of fluid overload. The
abdominal and pelvic wall is otherwise within normal limits. No organizing
fluid collection or hematoma is visualized.
IMPRESSION:
1. Small to moderate volume simple density ascites and small right-sided
pleural effusion with mild diffuse superficial soft tissue stranding of
unclear source, is most likely secondary to volume overload. Though the
contour of the liver remains smooth, there is moderate splenomegaly.
Cirrhosis with portal hypertension is a possibility despite the relative
smooth contour of the liver and relative lack of volume redistribution.
Hematologic dyscrasias are also within the differential. Correlate with lab
values.
2. No retroperitoneal hemorrhage, or other definite source of hemorrhage.
3. 19 mm high density left renal lesion is likely a proteinaceous or
hemorrhagic cyst. Confirmation with renal ultrasound is recommended.
4. Post right nephrectomy. Otherwise no definite evidence of malignancy or
metastatic disease within the abdomen or pelvis given the confines of a
noncontrast examination.
5. Probable left adrenal myelolipoma.
6. Anemia.
7. Diffuse diverticulosis.
RECOMMENDATION(S):
1. Correlate with lab values and serology use for the possibility of cirrhosis
or hematologic dyscrasia.
2. Renal ultrasound.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with HFpEF, admitted in volume overload with
significant anemia of Hb 5.7. CT abd/pelvis showed ?L renal lesion, possible
cirrhosis of the liver.// Evidence of cirrhosis, portal vein thrombosis,
characterize L renal lesion
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT ___.
FINDINGS:
LIVER: Views of the liver are technically limited due to body habitus and
noise. The contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is small volume
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is completely obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.4 cm.
KIDNEYS: The right kidney is surgically absent. The left kidney measures 14.9
cm. Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys. 2 cysts are identified ranging from 2.4-3.3 cm in size. The smaller
cyst has a thin septation but no other concerning features.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Moderate splenomegaly and small volume ascites. Limited views of the liver
show no focal lesions. Portal vein is patent with hepatopetal flow.
2 left kidney cysts are noted with no other concerning lesions. Status post
right nephrectomy.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with bilateral leg pain, HFpEF,+lupus
anticoagulant// 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 is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Anemia, Dyspnea
Diagnosed with Anemia, unspecified
temperature: 98.6
heartrate: 70.0
resprate: 20.0
o2sat: 98.0
sbp: 137.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old male with past medical history of
diastolic CHF, atrial fibrillation on apixaban, CKD stage III
admitted ___ with severe symptomatic anemia requiring
transfusion, suspected to be related to chronic GI blood loss,
workup without clear etiology, subsequently leaving the
hospital against medical advice.
Severe Anemia of Chronic Blood Loss secondary to occult GI
bleed
Patient presented with dizziness, found to have Hgb 5.7. He was
transfused 4 units of PRBCs with improvement in Hgb > 7, and
resolution of symptoms. Labs consistent with severe iron
deficiency. No signs of bleeding on cross-sectional imaging
,but did show splenomegaly, felt to relate to CHF below (and
not cirrhosis, per discussion with GI). Patient was seen by GI
and underwent ___ on ___, which showed no clear signs of
upper GI bleed, and was incomplete due to colonic redundancy
preventing visualization to the cecum on colonoscopy. Of note,
colonoscopy did show diverticulosis. Patient was seen by
Hematology who agreed with diagnosis of iron deficiency anemia
and recommended outpatient IV iron infusions. Given severity
of his initial anemia, and unknown cause, patient was
recommended for inpatient CT colonography and pill endoscopy,
however patient left against medical advice as below
# Discharge against medical advice
Team discussed recommendation for above workup with patient and
also the risks of not pursuing, including bleeding/hemorrhage,
cancer or death; patient was able to verbalize his
understanding of these risks and our recommendations; he
requested discharge home with outpatient GI, PCP and hematology
___. Team arranged for outpatient ___, discharged
against medical advice.
#Acute on Chronic Diastolic CHF
Patient with diastolic CHF who was admitted with 22lb weight
gain since last admission ___. Exam notable for JVD, lower
extremity edema. TTE without new wall motion abnormality.
Patient was IV diuresed from 322lbs to 308lb, but was not at
his dry weight at time of discharge against medical advice. Of
note, TTE did show elevated R sided filling pressures--would
consider repeat TTE when patient is euvolemic, and if still
present could consider additional workup. Discharged on home
Bumex 3mg BID.
#Splenomegaly
As above, attributed to CHF exacerbation. Could consider
repeat imaging when euvolemic, and if still present consider
additional workup
# Paroxysmal Atrial fibrillation
Initially held apixaban. Continued on amiodarone. Per
discussion with ___ cardiology, stopped patient's metoprolol
given good rate control with amiodarone and patient feeling
like metoprolol was causing side effects. Given that patient
had never had acute bleed (felt to be chronic and slow as
above), risk benefit was felt to favor restarting patient's
apixaban. Discussed with patient who agreed.
# ___ on CKD stage 4 - Cr 1.9 on admission, improved to
baseline 1.6 with diuresis.
#GERD: continued omeprazole 20mg daily
#BPH: Continued Flomax
# Lower Back pain: Tylenol PRN |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Geodon / Toradol / Penicillins / Maalox Total Relief (bismuth) /
sticky tape
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with PMHx notable for
DM2, HTN, HLD bipolar disorder, s/p CCY who presents with
abdominal pain and testicular pain. The patietn reports that he
had onset of epigastric and ___ pain at 1800 on the
day prior to admission. He reports that he had nausea and
diarrhea associated with it. He reports that the pain was
different than the pain that he was seen in the ___ ED for on
___. Work up at that time consisted of labs and CT scan which
did not show an acute process. Patient was discharged and was
doing well until the day of admission. He reports that he
developed the ___ abdominal pain at the ___ game.
Abdominal pain in the epigastric region, RUQ, RLQ. He reports
that he had intercourse for the first time yesterday but that he
used a condom. He denies dysuria or penile discharge. He also
denies fevers, chills, vomiting.
In the ED, initial vitals were: 98.9 96 134/72 20 97% RA
Labs were notable for Lip: 165, WBC 11.8 with 70.8% Neuts and a
negative U/A. Imaging was notable for unremarkable RUQ US and
negative scrotal U/S. He recieved dilaudid 0.5mg IV x2, tylenol
___ PO x1, and 2L of IVF. He is being admitted for
pancreatitis per the ED.
Vitals on transfer are: 97.9 78 133/91 16 95% RA.
On the floor, the patient reports the pain that had been
periumbilical is now in the RLQ. He reports that the pain is a
___. He reports that he is unable to recount more of his
medical history but his mother ___ is able to give his
medication list.
On speakign with his mother she reports that hs has a history of
abdominal pain daiting back to the age of ___. She reports that
her husband and the ___ father passed away recently and
since then ___ has been depressed. She reports that the
patient feels that his brothers do not have time for him. She
reports that he often "runs away" to ___ and gets seen for
abdminal pain and she does nto know what is causing it. She
reports that he does nto drink but that he has not been taking
any medication. She reports that he saw a provider on ___
prior to admission for the first time and that he was started on
a number of medications but the patient did not like the
provider ans she reports that he is not going back to them.
Past Medical History:
Bipolar disorder
DM2
HLD
HTN
Fatty Liver
s/p Lab Chole
Social History:
___
Family History:
Father HTN
No family History of IBD.
Paternal Uncle with ___ cancer.
Physical Exam:
>> Admission Phyiscal Exam:
Vital Signs: 98, 110/71, 87, 18, 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, tender to palpation in the RLQ. Non-distended,
+BS, + rebound. RLQ pain with straight leg raise and
internal/external rotation of the right leg. Guiac negative.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait normal.
.
>> Discharge Physical Exam:
Vital Signs: 98, 90-110s/70s, 80s , 18, 99%RA
General: NAD. No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI. PERRL.
Neck supple.
CV: RRR, S1, S2. No extra sounds heard
Abdomen: Soft, mildly tender in the lower region. +BS. No
rebound/guarding.
Extremities: well perfused, 2+ pulses, no clubbing,
cyanosis/edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait normal.
Pertinent Results:
>> Admission Labs:
___ 12:31AM BLOOD WBC-11.8* RBC-4.39* Hgb-13.0* Hct-37.0*
MCV-84 MCH-29.6 MCHC-35.2* RDW-14.0 Plt ___
___ 07:10AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.3
.
>> Discharge Labs:
___ 07:10AM BLOOD WBC-9.5 RBC-4.30* Hgb-12.8* Hct-36.9*
MCV-86 MCH-29.8 MCHC-34.8 RDW-14.0 Plt ___
___ 07:10AM BLOOD Glucose-116* UreaN-15 Creat-0.9 Na-139
K-4.6 Cl-99 HCO3-29 AnGap-16
___ 12:31AM BLOOD ALT-21 AST-19 AlkPhos-53 TotBili-0.1
___ 12:31AM BLOOD Lipase-165*
.
>> Pertinent Reports:
___ Imaging CT PELVIS W/CONTRAST:
The visualized large and small bowel loops are normal. The
appendix is normal in appearance. Prostate and seminal vesicles
are grossly unremarkable allowing for the limitations of CT
assessment. The urinary bladder and distal ureters are
unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid
in the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic
wall is within normal limits.
IMPRESSION: Normal appendix
.
___ Imaging LIVER OR GALLBLADDER US
Markedly limited right upper quadrant ultrasound due to bowel
gas and body habitus. The patient is status post
cholecystectomy. No fluid seen within the gallbladder fossa.
There is no ascites identified. The portal vein is patent.
Common bile duct not visualized. The liver appears echogenic
but may be exaggerated due to body habitus.
.
IMPRESSION:
1. Markedly limited right upper quadrant, the liver appears
echogenic but this may be exaggerated due to body habitus.
Echogenic liver may be seen in setting of hepatic steatosis.
2. Common bile duct not visualized.
.
___ Imaging SCROTAL U.S. :
The right testicle measures: 2.7 x 3.4 x 2.1 cm.
The left testicle measures: 2.8 x 4.0 x 1.9 cm.
The testicular echogenicity is normal, without focal
abnormalities.
The epididymis is normal bilaterally.
Vascularity is normal and symmetric in the testes and
epididymis.
.
___BD & PELVIS WITH CO:
1. Likely old L2 superior endplate compression fracture.
Clinical correlation
is recommended to assess for focal tenderness.
2. Normal appendix.
3. Hepatic steatosis.
.
>> MICROBIOLOGY :
__________________________________________________________
___ 7:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:47 am URINE Source: Unknown.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
__________________________________________________________
___ 11:06 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Gabapentin 300 mg PO BID
3. GlyBURIDE 5 mg PO DAILY
4. Ibuprofen 600 mg PO Q8H:PRN pain
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Fenofibrate 160 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. DiCYCLOmine 20 mg PO QID
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. DiCYCLOmine 20 mg PO QID
3. Fenofibrate 160 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. Levothyroxine Sodium 100 mcg PO DAILY
7. GlyBURIDE 5 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Abdominal Pain
SECONDARY DIAGNOSES: 2. Bipolar Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ male with right testicular pain, tender on exam,
evaluate for torsion.
TECHNIQUE: Grey scale with color and spectral Doppler ultrasound of the
scrotum was performed with linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 2.7 x 3.4 x 2.1 cm.
The left testicle measures: 2.8 x 4.0 x 1.9 cm.
The testicular echogenicity is normal, without focal abnormalities.
The epididymis is normal bilaterally.
Vascularity is normal and symmetric in the testes and epididymis.
IMPRESSION:
Normal scrotal ultrasound.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ s/p CCY, here with abdominal pain, lipase elevation, evaluate
for stones
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Comparison is made to abdominal and pelvic CT from ___.
FINDINGS:
Markedly limited right upper quadrant ultrasound due to bowel gas and body
habitus. The patient is status post cholecystectomy. No fluid seen within
the gallbladder fossa. There is no ascites identified. The portal vein is
patent. Common bile duct not visualized. The liver appears echogenic but may
be exaggerated due to body habitus.
IMPRESSION:
1. Markedly limited right upper quadrant, the liver appears echogenic but
this may be exaggerated due to body habitus. Echogenic liver may be seen in
setting of hepatic steatosis.
2. Common bile duct not visualized.
Radiology Report
INDICATION: ___ year old man with RLQ abdominal pain, diarrhea, N/V // ?
appendicitis.
TECHNIQUE: MDCT axial images were acquired through pelvis following
intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
No oral contrast was administered.
DOSE: DLP: 538.74 mGy-cm (pelvis)
IV Contrast: 130 mL Omnipaque injected at a rate of 2 cc/sec
COMPARISON: None.
FINDINGS:
PELVIS:
The visualized large and small bowel loops are normal. The appendix is normal
in appearance. Prostate and seminal vesicles are grossly unremarkable
allowing for the limitations of CT assessment.
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
Normal appendix.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Testicular pain
Diagnosed with ACUTE PANCREATITIS
temperature: 98.9
heartrate: 96.0
resprate: 20.0
o2sat: 97.0
sbp: 134.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | This is a ___ year old male with past medical history of type 2
diabetes, bipolar disorder, chronic abdominal pain of unclear
etiology admitted ___ with reports of abdominal pain,
workup notable for CT pelvis, scrotal ultrasound within
normal limits, lipase of 165, but clinical picture not
consistent with acute pancreatitis (symptomatically improved
with eating), with course notable for pain migrating throughout
abdomen depending on who asked him.
>> ACTIVE ISSUES:
# Abdominal Pain: Upon admission, patient was complaining of
abdominal pain with radiation to the groin. Patient underwent a
RUQ ultrasound which was negative for any abnormalities other
than mild hepatic steatosis, and patient also underwent a
scortal ultrasound for concerns for testicular pathology, which
was also negative. Patient then underwent a dedicated pelvic low
dose CT scan which did not reveal any appendicitis. Initial labs
were notable for a mild leukocytosis, thought to be stress
related and downtrended on HD#1. Other abnormalities including a
mildly elevated lipase, however not significant for
pancreatitis. Patient was treated conservatively with pain
regimen (oral no IV pain medications) and started to have
improvement in symptoms. Collateral information obtained from
family members reports that patient has had a history of
abdominal pain in the past with negative workup,
and per his mother, this may be a manifestation of personal
stress. He tolerated a normal diet, symptoms improved and he was
discharged home
# Concern for Steatosis - RUQ ultrasound showed possible
echogenic liver; this was communicated to patient's PCP; workup
deferred to outpatient
# Hypertension: Patient was restarted on home dose of atenolol
50 mg, however soon became hypotensive to the ___, asymptomatic.
It was considered that patient not compliant on this regimen,
and therefore was given low dose 12.5 mg daily. However because
of significant effect on blood pressure, this medication was
discontinued. This was relayed to patient's mother as well.
Patient to make appointment with PCP at which point can restart
this medication as an outpatient. No lightheadedness, dizziness,
syncopal episode or episodes of hypertension while inpatient.
.
# Diabetes Mellitus Type II: Patient on oral agents at home, and
was continued on insulin sliding scale while inpatient. Patient
did not have episodes of hyperglycemia or hypoglycemia while
inpatient.
.
# Hyperlipidemia: Patient was continued on home statin and
fenfibrate while inpatient.
.
# Bipolar Disease: Per patient, has not been on any psychiatric
type medication for several months. Patient previously was on
seroquel 600 mg PO QHS per his mother, and has an upcoming
intaking appointment at ___ (mental health ___ in ___
___. Patient appeared stable, and able to make informed
decisions, and therefore reinitiation of his therapy was not
indicated while inpatient. To be titrated by psychiatry as an
outpatient.
.
# Disposition: Patient was seen by social work prior to
discharge. Patient was given $15 for bus pass to return to ___
___, and was given a T-ticket for public transit. Patient
voiced understanding of plan to see a PCP upon discharge from
the ___ to ensure stability, and reinforced continuity of
care as paramount to patient's health. Communication with family
also through Mr. ___ mother.
.
>> TRANSITIONAL ISSUES:
# Steatosis: RUQ ultrasound showed possible echogenic liver, can
consider outpatient follow-up
# HTN: Patient's atenolol was held at discharge given normal
pressures without it and reported non-compliance at home
# Bipolar Disease: Patient to f/u with intake at ___ (___
Health Provider in ___, to consider re-initiation of
therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Lipitor / Decadron
Attending: ___.
Chief Complaint:
Altered mental status, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male known to the Neurosurgery service following
recent admission and diagnosis of a ___ mass in the setting of
a lung mass, now s/p left occipital craniotomy for tumor
resection on ___ re-presents with fever and altered mental
status. He was recently discharged on ___.
Past Medical History:
- PVD - Angioplasty x 3
- HTN
- Hyperlipidemia
- Gout
- Solidtary kidney by birth
- CKD stage III
- Appenectomy
- Tonsillegtomy
- Left cataract surgery
Social History:
___
Family History:
Mother deceased: ___ disease
Father deceased: CHF
Sister alive ___, unknown history
No additional family history known
Physical Exam:
ON ADMISSION
============
O: T: 98.4 HR 74 BP 153/73 RR20 Sat 96% 3L NC
Gen: lethargic
HEENT: soft fluctuat fluid collection at the incision site.
Incision is healed well without erythema
Extrem: right knee and right leg edema.
Neuro:
Mental status: lethargic, minimally verbal, opens eyes to voice
Orientation: Oriented to person only
Language: minimally verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields unable to test
III, IV, VI: Extraocular movements appear intact but unable to
test
V, VII: Facial strength appears intact. unable to test sensation
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to test.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. mild tremor in bilat
UE,
right greater than left
Grips full bilaterally but pt does not follow a full motor exam.
Grips billet to command, shows 2 fingers bilaterally
Wiggles toes bilaterally
Does not lift legs off bed to command
Sensation: unable to test but responds to light touch
bilaterally
Coordination: unable to test
ON DISCHARGE
============
Gen: awake
HEENT: soft fluctuant fluid collection at the incision site.
Incision is well healed without erythema
Extrem: right knee and right leg edema.
Neuro:
Mental status: opens eyes to voice, confused
Orientation: Oriented to person only
Language: expressive dysphasia, perseverating, hallucinating
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. RIGHT hemianopsia
III, IV, VI: Extraocular movements appear intact but unable to
test
V, VII: Facial strength appears intact. unable to test sensation
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to test.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. mild tremor in bilat
UE,
right greater than left
Grips full bilaterally but pt does not follow a full motor exam.
Grips billet to command, shows 2 fingers bilaterally
Wiggles toes bilaterally
At least antigravity in all 4 extremities
Sensation: responds to light touch bilaterally
Coordination: unable to test
Pertinent Results:
Please see OMR for pertinent imaging & labs
___ 06:00AM BLOOD WBC-12.3* RBC-3.36* Hgb-10.2* Hct-31.6*
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt ___
___ 06:00AM BLOOD Neuts-74.3* Lymphs-8.7* Monos-10.1
Eos-1.5 Baso-0.9 Im ___ AbsNeut-9.16* AbsLymp-1.07*
AbsMono-1.25* AbsEos-0.19 AbsBaso-0.11*
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-95 UreaN-26* Creat-0.7 Na-146
K-3.8 Cl-104 HCO3-27 AnGap-15
CFS
-------------
TUBE #2
CSF
Chemistry Protein
111 Glucose
38
TUBE #1
CSF WBC
1265 RBC
5
Poly
78 Lymph
4 Mono
18 EOs
Comments: CSF TNC: Hazy And Colorless
CSF TNC: Clear Supernatent
CSF TNC: Reported To And Read Back By
___ TNC: ___ ___ On ___
___ 2:15 am CSF;SPINAL FLUID TUBE #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
---------------
___ 5:52 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
-----------
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
----------------
___ 6:10 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
---------------
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN fever or pain, Allopurinol
50 mg PO DAILY, Colchicine 0.3 mg PO DAILY, Docusate Sodium 100
mg PO BID, Heparin 5000 UNIT SC BID, Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime, Senna 17.2 mg PO QHS,
Valproic Acid ___ mg PO Q8H, amLODIPine 10 mg PO DAILY, Aspirin
81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO/PR Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6h Disp
#*20 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*3
Suppository Refills:*0
3. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*3
Capsule Refills:*0
4. Haloperidol 0.5 mg PO Q6H:PRN agitation
RX *haloperidol 0.5 mg 1 tablet(s) by mouth every 6h Disp #*12
Tablet Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8h as needed
Disp #*9 Tablet Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4h Disp #*22
Tablet Refills:*0
7. Rivaroxaban 20 mg PO ONCE Duration: 1 Dose
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tab by mouth twice daily Disp #*6 Tablet
Refills:*0
9. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
10. Allopurinol 50 mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic neuroendocrine tumor to the ___
Lung lesion
Fever, resolved
Altered mental status
Aseptic meningitis
Toxic-metabolic encephalopathy
Bilateral lower extremity DVT
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ yo M hx left occipital craniotomy for mass resection
discharged ___ presents with fever and AMS// ? abscess. Please perform with
DWI sequences as well
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: Prior CT brain done ___ and pre discharge CT done ___
FINDINGS:
Motion artifact degrades the diagnostic quality of the imaging.
The patient is status post resection of a left occipital tumor. There is
prominent peripheral restricted diffusion and enhancement in relation to the
surgical bed. Centrally there is no restricted diffusion. The enhancement
appears slightly more confluent along the lateral edges of the resection
margin, with peripheral enhancement involving the posterior margins. Given
that the region of peripheral enhancement along the posterior edge of the
resection margin appears to correspond to the parenchyma, this is felt to be
less likely abscess formation and rather represent a combination of
postoperative change, ischemia/devitalized tissue, hemorrhage product and
possible residual lesion.
In the occipital horn of the right lateral ventricle there is soft tissue
material which demonstrates restricted diffusion, and isointense T1 signal
without evidence gradient echo susceptibility artifact. Although there is
suggestion of mildly increased enhancement on motion degraded postcontrast
sequence of series 19, image 13, no definite enhancement is seen on
postcontrast image of series 20, image 13 series 21, image 15. Given lack of
gradient echo susceptibility artifact, this raises concern for possible
purulent material given the patient's clinical presentation, however
hemorrhage product is a differential consideration.
There is interval increase in size of the ventricular system suggesting
communicating hydrocephalus.
Fluid overlying the left occipital parietal bone measures 5 mm in sagittal
diameter demonstrates mild rim enhancement and appears to communicate with the
subarachnoid space immediately deep to the left occipital parietal bone and
this most likely represents a CSF leak/pseudomeningocele. This is similar
compared to most recent CT, but increased compared to pre discharge CT done ___. There is small 1.1 cm peripherally enhancing fluid collection
inferior to the left mastoid tip (series 19, image 1) likely a postoperative
seroma.
Area of blooming and subtle T1 intrinsic hyperintensity in the left frontal
lobe measuring 10 x 7 mm in the axial plane appear similar compared to prior.
This lesion demonstrates avid postcontrast enhancement and on T2, the lesion
does not demonstrate peripheral rim of hypointensity and central
hyperintensity. There is mild FLAIR edema pattern surrounding the lesion.
The pituitary appears normal. The craniocervical junction appears normal.
The orbits appear normal. Mild mucosal thickening involving the paranasal
sinuses. Moderate severe periventricular and deep white matter T2 and FLAIR
hyperintense changes are most likely sequela of microangiopathy.
IMPRESSION:
1. There is prominent diffusion-weighted hyperintense signal along the left
occipital resection margins with regions of confluent enhancement along the
lateral margins and regions of rim enhancement along the posterior inferior
margins demonstrating central hypoenhancement. The regions of rim enhancement
with central hypoenhancement appear to correspond to brain parenchyma on FLAIR
and T1 precontrast sequences and therefore is felt to be unlikely abscess, but
rather a combination of devitalized tissue, postsurgical ischemia/inflammatory
changes, residual hemorrhage product and possible residual lesion.
2. Soft tissue material in the occipital horn of the right lateral ventricle
demonstrates restricted diffusion and is without gradient echo susceptibility
blooming artifact. Lack of blooming artifact does raise possibility of
purulent material. However, there is no definitive associated enhancement.
The lesion does appear to demonstrate mild postcontrast enhancement on 1
motion degraded postcontrast sequence, but not on subsequent postcontrast
images and therefore hemorrhage product remains a differential consideration.
3. Interval increase in size of the ventricle suggest communicating
hydrocephalus.
4. Interval increase in size of the fluid/CSF signal intensity collection
overlying the left occipital parietal bone which appears to communicate with
the subarachnoid space most likely represents a pseudomeningocele. There does
appear to be a 1.1 cm peripherally enhancing fluid collection inferior to the
left mastoid tip, likely a seroma however close attention is recommended to
exclude infectious process.
5. Left frontal lesion demonstrating prominent gradient echo susceptibility
artifact is unchanged. The lesion does not demonstrate of T2 hypointensity
and central T2 hyperintensity and demonstrates avid postcontrast enhancement.
There is surrounding edema pattern. This is unchanged from outside hospital
MRI head of ___ and are not features typical for cavernoma, unless
there has been recent hemorrhage. This raises suspicion for additional site
of metastatic disease. Of note, no lesion was noted on outside hospital CT
head of ___.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 2:08 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with NGT// placement Contact name: ___:
___ placement
IMPRESSION:
Compared to chest radiographs ___.
Nasogastric drainage tube ends in the upper portion of a mildly distended
stomach.
Right apical lung lesion is presumably still present, but difficult to assess
on conventional radiographs. Heart size normal. Lungs elsewhere clear. No
pleural abnormality. Normal mediastinal and hilar contours.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with L neuroendocrine tumor, metastatic to the
brain// worsening dysphasia, AMS, please include DWI studies also
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: MR head with and without contrast ___
FINDINGS:
Patient is post left occipital craniotomy and mass resection. Small amount of
subdural and subgaleal fluid collection surrounding the left occipital
craniotomy is slightly increased from ___. Subdural component
measures 7 mm in thickness, increased from 6 mm before. Sub glial component
measures 8 mm in thickness, increased from 7 mm before. Ischemic changes
surrounding the resection margin is similar to before. The enhancement at the
resection margin and overlying dural enhancement appears more conspicuous than
before.
9 mm lesion in the right occipital horn demonstrates T1 hyperintensity,
restricted diffusion, and lack of susceptibility artifact, unchanged compared
to ___.
9 mm enhancing lesion in the left frontal lobe with susceptibility artifact is
again demonstrated.
Previously noted small fluid collection inferior to the left mastoid tip is
not demonstrated on this exam.
Marked periventricular and subcortical white matter FLAIR hyperintensities are
similar to before and consistent with chronic small vessel disease. There is
no evidence of new hemorrhage, acute infarct, or midline shift. The
ventricles and sulci are stable in caliber and configuration.
IMPRESSION:
1. Subdural and subgaleal fluid collection surrounding the left craniotomy is
larger compared to ___. No restricted diffusion is seen within this
collection. However, possibility of superimposed infection cannot be excluded
on MRI appearances.
2. Enhancement at the resection margin and overlying dural enhancement appears
more conspicuous than before. Findings may reflect evolution of postoperative
changes or differences in study techniques/artifact.
3. Ischemic changes at the resection margin appears similar to before. No new
acute infarct is identified.
4. 9 mm left frontal lobe enhancing lesion is again demonstrated. Finding
remains suspicious for metastatic lesion.
5. 9 mm lesion in the right occipital horn is unchanged .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever and elevated WBC.// Evaluation of
elevating WBC with fever.
IMPRESSION:
In comparison with study of ___, the opacification in the right apical
region is again seen, though difficult to assess on plain radiographs. This
was well demonstrated on the CT study of ___.
The cardiomediastinal silhouette is stable and there is no evidence of
vascular congestion or pleural effusion.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with history of neuroendocrine tumor. Evaluate
for lumbar spinal metastatic disease.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: ___ contrast abdomen and pelvis CT.
FINDINGS:
Study is severely degraded by motion, especially on fat-suppressed and axial
imaging. Within these confines:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
There is levoscoliosis of the lumbar spine. There is transitional anatomy
with partial sacralization of L5. Approximately 30% L1 anterior compression
deformities again noted. L1-2 and L4-5 probable type ___ ___ changes without
definite epidural collection are noted. L2-3 type ___ ___ changes are noted.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber.
There is loss of intervertebral disc height and signal throughout the lumbar
spine.
At T12-L1 there is no vertebral canal or neural foraminal stenosis.
At L1-2 there is disc bulge,mild vertebral canal and no neural foraminal
narrowing.
At L2-3 there is disc bulge,mild vertebral canal and no neural foraminal
narrowing. Nonspecific left facet joint fluid is noted.
At L3-4 there disc bulge,mild vertebral canal and moderate bilateral neural
foraminal narrowing. Nonspecific left facet joint fluid is noted.
At L4-5 there is disc bulge,mild vertebral canal and moderate left neural
foraminal narrowing. Nonspecific bilateral facet joint fluid is noted.
At L5-S1 there is disc bulge,mild vertebral canal and mild bilateral neural
foraminal narrowing.bilateral facet joint probable synovial cysts are noted.
Nonspecific bilateral facet joint fluid is noted.
OTHER:
Nonspecific bilateral L3 through L5 dorsal soft tissue T2 and STIR
hyperintensity is noted. Mild STIR hyperintensity in bilateral psoas muscle
and paraspinal muscles at L3-4 levels are noted.
Patient's left atrophic partially cystic kidneys again noted (see 6:9). Right
kidney probable extrarenal pelvis is again noted. Nonspecific fluid
surrounding the right kidney is noted, not definitely seen on prior abdomen
pelvis CT.
Within limits of this motion degraded, noncontrast study, no definite evidence
of paraspinal, paravertebral, or epidural mass identified.
IMPRESSION:
1. Study is severely degraded by motion.
2. Additionally, evaluation for metastatic disease is limited due to lack
administration of contrast, which was not administered due to patient
inability to tolerate examination. If clinically indicated, consider repeat
exam when patient can tolerate study.
3. Within limits of study, no definite evidence of lumbar spinal mass
identified.
4. Extremely atrophic a partially cystic left kidney again noted.
5. Nonspecific right perinephric fluid not definitely seen on prior abdomen
pelvis CT. If clinically indicated, consider renal ultrasound for further
evaluation.
6. Nonspecific lower lumbar dorsal soft tissue and psoas muscle probable edema
as described.
7. Approximately 30% L1 chronic anterior compression deformity.
8. Multilevel lumbar spondylosis as described, most pronounced at L3-4, where
there is mild vertebral canal and moderate bilateral neural foraminal
narrowing.
9. L4-5 moderate left neural foraminal narrowing.
Radiology Report
INDICATION: ___ with NG tube placed// Position
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the Dobhoff projects over the stomach.
There is no new focal consolidation, pleural effusion or pneumothorax
identified. Unchanged opacification at the right lung apex. The size of the
cardiac silhouette is within normal limits.
IMPRESSION:
The tip of the Dobhoff projects over the stomach. Otherwise no significant
interval change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Altered mental status, unspecified
temperature: 98.4
heartrate: 76.0
resprate: 20.0
o2sat: 96.0
sbp: 153.0
dbp: 76.0
level of pain: ua
level of acuity: 2.0 | #Altered mental status/Fever/aseptic meningitis/metabolic
encephalopathy/metastatic neuroendocrine tumor to the ___
On ___, Mr. ___ was admitted to the Neuro ICU with altered
mental status. LP in the ED had elevated protein, low glucose
and high opening pressure. Cultures were sent. He was noted to
have a mass on his neck on admission felt to be lymphadenopathy.
MRI was performed which did not show abscess. His wound was
noted to have purulent drainage and he was started on empiric
vancomycin, cefepime and ampicillin. Infectious disease was
consulted. Ampicillin was discontined on ___ per ID. He was
placed on EEG on ___ which was negative for seizure. He had
leukocytosis on admission which downtrended. He was transferred
to ___ on ___. Repeat MRI was stable and negative for clear
abscess but there was concern for ventriculitis ___ he had a
fever to 101.2 with WBC up trending, urine cultures and blood
cultures were sent and were all negative. Repeat CXR was done
and was negative. His family was consented for PICC line ___.
Placement of PICC was deferred in setting of elevated WBC with
unknown source. CSF culture was negative. Due to continued
fevers, worsening altered mental status, and continuing
elevation of WBC a family discussion was had regarding
additional surgical procedures verse CMO, after thorough
discussion, the patient was transitioned to CMO care with
Palliative care consult on ___. The patient's case was
re-discussed at ___ TUmor Conference on ___ and consensus
was that given the negative cultures, the profound
encephalopathy that the patient developed aseptic meningitis
with poor prognosis due to disease progression. All invasive
intervention were stopped per family's request as the patient
transitioned to CMO. Over ___ to ___ the patient
gradually improved, still confused, with expressive aphasia, non
lethargic anymore so the family asked for guidance in whether
the CMO status should be reversed or continue care. With the
involvement of Palliative Care, Hem/Onc, ID, nursing and
neurosurgery as discussed with Dr. ___ family
meeting took place on ___ where the family was presented
with the grim prognosis due to the pathology of the tumor
(neuroendocrine tumor, STAGE IV metastatic lesion possibly due
to lung). After hearing different opinions the family elected to
proceed with hospice care option and continue CMO status.
#Dysphagia
Due to altered mental status, the patient was made NPO on
admission. NGT was attempted to be placed on ___ for tube
feeding, but was unsuccessful as the patient non-compliant with
placement. SLP evaluated and recommended puree consistency with
thin liquids and 1:1 feeding. Family was consented ___ for PEG
placement for nutrition supplementation, however NGT was placed
over concern for patient self d/c'ing PEG. Tube feeds were
started ___. Given CMO status on ___ and repeat family meeting
on ___ to agree to hospice, the Dobhoff was removed and the
patient was allowed to eat to comfort.
#Bilateral lower extremity DVT's
On admission, the patient was found to have b/l DVT's and was
started on heparin drip with PTT goal of 50-70. Given CMO the
family elected to stop needle sticks with SQH and PTT checks,
and after discussion with Dr. ___ (patient's son)
elected to start Xarelto po for DVT and PE prophylaxis. ___
acknowledged the fact that there is a possibility for ___
hemorrhage while on anticoagulation. ___ discussed with his
mother ___ who also agreed on the patient being discharged
on Xarelto 20mg daily for patient compliance and minimal
medications since he is CMO status. It was also explained that
this medication provides prophylaxis protection but does not
guarantee that a PE or a DVT will not happen or expand.
Palliative care / hospice team to re-assess need for
anticoagulation. Per their request and after discussing with Dr
___ will discharge the patient on Xarelto and Hospice may
decide for continuation after discussion with the patient and
family and agree.
#Pain
Patient appeared to be in pain with movement on ___. MRI L
spine was ordered to evaluate for spinal metastasis. The patient
was moving to much in the scan so MRI was not obtained with
contrast, but non-enhanced scan was found to be negative for
metastasis. IV morphine and po oxycodone PRN were given
#Gout
On prior admission patient was found have gout flair in right
knee. Rheumatology had been consulted and colchicine started.
___ Rheumatology was consulted for updated recommendations for
persistent redness and swelling in right knee and new redness of
right ankle. Colchicine was titrated up per their
recommendation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
syncope, bradycardia
Major Surgical or Invasive Procedure:
Single Chamber PPM placed ___
History of Present Illness:
___ with history of atrial fibrillation on Coumadin, severe AS
s/p bioprosthetic AVR/CABG in ___, hypoparathyroidism, and
hypothyroidism, transferred from ___ with ICH. The patient
has dementia and is unable to provide much history. Per records
from the outside hospital, the nursing home and found that the
patient was increasingly bradycardic over the last 2 days. She
also has had multiple falls. CT scan of the head performed at
the outside hospital shows an intraparenchymal hemorrhage. The
patient is awake and alert and oriented x2 which is baseline per
the daughter's report. She denies any weakness, numbness,
tingling. She denies any chest or abdominal pain. She denies any
headache. She denies any vision changes. Her INR was 4.58 at the
outside hospital.
She has a known history of bradycardia and had discussions as an
outpatient regarding a pacemaker placement.
In the ED, initial VS were 97.2 40 190/80 20 98% RA.
The patient was alert and oriented x1-2. She was having trouble
finding the right words and was not always answering the
question asked.
Labs were notable for INR: 5.4 that went down to 1.3 after
reversal with vitamin K and K-centra. She was also noted to have
elevated creatinine to 2.3 from a baseline of 1.5 and anemia to
9.4
ECG: Irregular rhythm , absence of P waves, wide QRS 160 ms
suggestive of LBBB, PVC, as well as prolonged QTc.
CT A/P ___: showed
1. No acute fracture.
2. 3.5 cm infrarenal abdominal aortic aneurysm.
3. Small amount of pericholecystic fluid is likely secondary to
third spacing. If there is clinical concern for acute
cholecystitis, abdominal ultrasound
___ Knee XR: No acute fracture or dislocation. Moderate
tricompartmental degenerative changes of both knees.
CT Head ___:
1. No intracranial hemorrhage or mass effect.
2. 6 mm linear calcification in the right posterior parietal
lobe is likely dystrophic in etiology and has been present since
at least ___. This may have been the finding thought to
reflect intracranial hemorrhage on the outside head CT.
Received VitaminK, Kcentra, Hydral x2, 2L NS, Keppra 500,
Synthroid 75mcg, and IM olanzapine x2.
Neurosurgery and trauma were consulted. Per NSG, no intracranial
bleed. Trauma did not identify any acute injuries.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient notably obtunded with
alternating cycles of tachypnea and apnea. She did not
verbalize. She did follow commands. Per discussion with HCP, she
was last seen in her alert, occasionally confused state 1 week
ago. Yesterday, she was noted to be far more confused but alert.
Today, she was nonverbal, agitated until olanzapine.
Past Medical History:
Atrial Fibrillation
CAD (s/p CABG with SVG to OM1)
Chronic sinusitis
Hypoparathyroidism
Hypothyroidism
Aortic Stenosis s/p AVR in ___
Restless leg syndrome
Hypertension
Hyperlipidemia
Scoliosis Kyphosis
PVD
AAA
carotid stenosis
6 mm linear calcification in the right posterior parietal lobe
Social History:
___
Family History:
Brother died of heart attack at ___, father passed at ___ from
a heart condition, but patient is unsure of what type. Mother
also died of unclear heart condition at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 150/82 55 16 97%RA
GENERAL: lethargic in bed, difficult to arouse
HEENT: NC/AT. PERRL. Mild conjunctival pallor. No scleral
icterus.
PERRLA/EOMI. Dry mucous membranes. OP clear. +thyromegaly. No
elevated JVP.
CARDIAC: Irregularly irregular. nl s1/s2, III/VI
systolic murmur best appreciated at ___.
LUNGS: Loud upper airway sounds. Pt with mixed episodes of
tachypnea and apnea.
ABDOMEN: Soft, NTND, +BS.
EXT: Trace edema, 2+ ___.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Oriented x0, did not verbalize. CN II-XII unable to
assess accurately but grossly normal. No pronator drift. Moving
extremities, following commands for brief period when awakened
DISCHARGE PHYSICAL EXAM:
PHYSICIAL EXAM
VS - 97.8 154/68 83 16 100RA
GENERAL: alert laying in bed, NAD
HEENT: NC/AT. PERRL. Mild conjunctival pallor. No scleral
icterus.
PERRLA/EOMI. More moist mucous membranes. OP clear.
+thyromegaly. No elevated JVP.
CARDIAC: Irregularly irregular. nl s1/s2, III/VI systolic murmur
best appreciated at ___.
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, NTND, +BS.
EXT: Trace edema, 2+ ___.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Oriented x2 (___, ___, ___, mild
confusion. CN II-XII intact. Baseline slightly droopier R side.
No pronator drift. Moving all extremities.
Pertinent Results:
ADMISSION LABS
___ 05:35AM BLOOD WBC-5.5 RBC-3.40* Hgb-9.4* Hct-30.8*
MCV-91 MCH-27.6 MCHC-30.5* RDW-16.3* RDWSD-54.4* Plt ___
___ 05:35AM BLOOD Neuts-53.1 ___ Monos-12.3 Eos-6.0
Baso-0.7 Im ___ AbsNeut-2.94 AbsLymp-1.53 AbsMono-0.68
AbsEos-0.33 AbsBaso-0.04
___ 05:35AM BLOOD ___ PTT-50.4* ___
___ 05:35AM BLOOD Glucose-105* UreaN-38* Creat-2.3* Na-139
K-3.4 Cl-103 HCO3-27 AnGap-12
___ 05:50AM BLOOD ALT-27 AST-35 LD(LDH)-222 AlkPhos-295*
TotBili-0.7
___ 05:35AM BLOOD Calcium-13.7* Phos-4.7* Mg-2.6
___ 05:50AM BLOOD PTH-5*
___ 08:20PM BLOOD Lactate-1.3
___ 06:15AM URINE Color-Straw Appear-Hazy Sp ___
___ 06:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
___ 06:15AM URINE RBC-1 WBC-4 Bacteri-MOD Yeast-NONE Epi-<1
TransE-<1
___ 06:15AM URINE Hours-RANDOM UreaN-288 Creat-34 Na-35
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
___ 06:20AM BLOOD WBC-5.7 RBC-3.09* Hgb-9.0* Hct-28.4*
MCV-92 MCH-29.1 MCHC-31.7* RDW-17.0* RDWSD-57.0* Plt ___
___ 06:20AM BLOOD ___ PTT-39.9* ___
___ 06:20AM BLOOD Glucose-85 UreaN-28* Creat-1.7* Na-138
K-3.9 Cl-107 HCO3-22 AnGap-13
___ 06:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
IMAGING
CT Head ___
1. No intracranial hemorrhage or mass effect.
2. 6 mm linear calcification in the right posterior parietal
lobe is likely dystrophic in etiology and has been present since
at least ___. This may have been the finding thought to
reflect intracranial hemorrhage on the outside head CT.
KNEE XR ___
No acute fracture or dislocation. Moderate tricompartmental
degenerative
changes of both knees.
CT A/P without contrast ___
1. No acute fracture.
2. 3.5 cm infrarenal abdominal aortic aneurysm.
3. Small amount of pericholecystic fluid is likely secondary to
third spacing.
If there is clinical concern for acute cholecystitis, abdominal
ultrasound
could be obtained for further evaluation.
CXR ___
Compared to chest radiographs since ___, most recently ___.
Moderate cardiomegaly has worsened. Lungs are grossly clear.
No pleural
abnormality.
CXR ___
New cardiac pacemaker lead terminates the right ventricle. No
pneumothorax.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain, ___
2. Aspirin EC 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Ranitidine 150 mg PO DAILY
9. Warfarin 3 mg PO DAILY16
10. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
11. Vitamin D ___ UNIT PO 1X/WEEK (___)
12. Atorvastatin 40 mg PO DAILY
13. mometasone 50 mcg/actuation nasal DAILY
14. Potassium Chloride 10 mEq PO DAILY
15. Bisacodyl ___AILY:PRN constipation
16. Baclofen 10 mg PO QHS:PRN restless leg
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, ___
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO DAILY
10. Warfarin 3 mg PO DAILY16
11. amLODIPine 10 mg PO DAILY
12. Baclofen 10 mg PO QHS:PRN restless leg
13. mometasone 50 mcg/actuation nasal DAILY
14. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
15. Potassium Chloride 10 mEq PO DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Calcium Carbonate 1250 mg PO BID
18. Calcitriol 0.25 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Toxic-Metabolic Encephalopathy
Hypercalcemia
Sick Sinus Syndrome
Hypoparathyroidism
Hypothyroidism
Afib
___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with intracranial hemorrhage// please repeat CT
head at 930 AM to evaluate for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 1.0 s, 4.2 cm; CTDIvol = 48.2 mGy (Head) DLP =
200.7 mGy-cm.
2) Sequenced Acquisition 4.5 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP =
903.1 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: CT head ___ at 03:38 from outside institution, CT head ___ and ___
FINDINGS:
There is no evidence of acute large infarction, hemorrhage, edema, or mass.
Linear hyperdensity measuring 6 mm within the right parietal lobe is unchanged
from at least ___, and likely reflects dystrophic calcification. There
is prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular, subcortical, and deep white matter hypodensities are
nonspecific, but likely the sequela of chronic microvascular infarction.
There is no evidence of fracture. Small mucous retention cyst is seen within
the right maxillary sinus. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral lens replacement. Dense atherosclerotic calcifications
are noted in the cavernous carotid arteries and distal left vertebral artery.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. 6 mm linear calcification in the right posterior parietal lobe is likely
dystrophic in etiology and has been present since at least ___. This
may have been the finding thought to reflect intracranial hemorrhage on the
outside head CT.
Radiology Report
INDICATION: History: ___ with falls, lumbar -spine/sacral tenderness, knee
swelling // Eval for injuries
TECHNIQUE: Bilateral knees, three views each
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is identified within either knee. Moderate
tricompartmental degenerative changes are most pronounced involving the
patellofemoral compartments bilaterally with loss of joint space, subchondral
sclerosis, and osteophyte formation. A small joint effusion is present in
both knees. There are prominent superior patellar enthesophytes bilaterally.
Diffuse vascular calcifications are noted in both knees. There are no
concerning lytic or sclerotic osseous abnormalities.
IMPRESSION:
No acute fracture or dislocation. Moderate tricompartmental degenerative
changes of both knees.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast.
INDICATION: ___ woman status post fall, now with lumbar spine and
sacral tenderness. Evaluate for evidence of traumatic injury.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 46.0 cm; CTDIvol = 10.5 mGy (Body) DLP = 483.3
mGy-cm.
Total DLP (Body) = 483 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Smooth, septal thickening at the lung bases is consistent with
mild pulmonary edema. There is no evidence of pleural or pericardial
effusion. There is coronary artery calcification. There is mitral annular
and aortic valve calcification.
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 mildly distended with a small amount of
pericholecystic fluid, most likely secondary to third spacing.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The distal ureters are unremarkable. A Foley catheter seen within the
bladder. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is an infrarenal abdominal aortic aneurysm measuring up to 3.5
cm. Extensive atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is right convex lumbar scoliosis. There are severe degenerative changes
throughout with bony vertebral canal stenosis.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute fracture.
2. 3.5 cm infrarenal abdominal aortic aneurysm.
3. Small amount of pericholecystic fluid is likely secondary to third spacing.
If there is clinical concern for acute cholecystitis, abdominal ultrasound
could be obtained for further evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS. hx of CAD, EF40% with dyspnea //
evidence of infiltrate/pulm edema evidence of infiltrate/pulm edema
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Moderate cardiomegaly has worsened. Lungs are grossly clear. No pleural
abnormality.
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: ___ year old woman s/p single chamber PPM. // Assess lead
placement and r/o PTx.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ portable chest radiograph
FINDINGS:
Interval placement of a single lead left pectoralis cardiac pacemaker with a
lead that terminates in the right ventricle. No pneumothorax or pleural
effusion. Lungs are fully expanded and clear. Mild cardiomegaly.
Cardiomediastinal and hilar silhouettes are unremarkable. Median sternotomy
wires are midline and intact.
IMPRESSION:
New cardiac pacemaker lead terminates the right ventricle. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, s/p Fall, Transfer
Diagnosed with Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 97.2
heartrate: 40.0
resprate: 20.0
o2sat: 98.0
sbp: 190.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of chronic A-Fib on coumadin, tachy-brady syndrome,
severe AS s/p bioprosthetic AVR/CABG in ___, CKD,
hypoparathyroidism, and hypothyroidism transferred for syncope,
bradycardia and suspected intracranial hemorrhage that was
revealed to be a calcification. She was admitted for
encephalopathy, ___, and PPM.
# Toxic Metabolic Encephalopathy: Patient with baseline dementia
but generally alert and confused. However, declining mental
status per HCP over past week; she presented agitated and
nonverbal. Patient noted to be obtunded and minimally arousable
on arrival to floor. Did follow commands and grossly appeared to
have cranial nerves intact. Suspicion was medication induced
given olanzapine IM 5mg x2 in ED with concurrent ___.
Additioanlly, patient with history of AMS with hypercalcemia.
She was found to be hypercalcemic to a corrected value >14. With
time and treatment of hypercalcemia, her mental status improved
to baseline.
#Hypercalcemia in setting of hypoparathyroidism: Pt with history
of hypercalcemia and AMS in past secondary to increased
exogenous calcium/vitD. Pt in ___ discharged on 0.25
calcitriol BID, appears to have been receiving 0.5mg BID at
nursing home. Her PTH was 5, suggesting again an exogenous
source of calcium. She was treated with IVFs, furosemide, and
48hrs of calcitonin. Her calcium supplementation was held as
calcium normalized. She was discharged on 0.25mg calcitriol once
daily and calcium carbonate 1250 mg BID.
Endocrinology follow up was scheduled. She will need to have her
calcium checked weekly. If corrected calcium falls below 8,
please increase calcitriol to 0.25 BID. Patient would benefit
from regular labs as below.
# Tachy-Brady syndrome and syncope: Patient with known
tachy-brady
syndrome. ECG with evidence of LBBB and LAFB in slow AF. Patient
was having symptomatic bradycardia with syncope. A
single-chamber PPM was placed ___ without complication.
Follow-up with ___ device clinic is scheduled.
# A-fib: patient with chronic A-fib on warfarin with goal INR
___. INR supratherapeutic on admission to 5.3. She was reversed
with Kcentra and Vitamin K given suspected ICH. No ICH on CT
Head re-read. Her CHADS-VASC2 is at least 6. She was restarted
on her home Coumadin.
___ on CKD: Patient presented with elevated Cr to 2.3, baseline
somewhere between 1.1 and 1.5. Urine lytes and hypercalcemia
consistent with intrinsic renal disease from hypercalcemia. Her
discharge creatinine was 1.7.
# HTN: Patient with known HTN presented with SBP to 200 treated
initially with hydralazine in ER. Patient apparently not on
antihypertensives although had prior discharge on amlodipine.
She was restarted on amlodipine 10mg daily.
# Hypothyroidism: Patient with known h/o hypothyroidism.
Continued on ___ synthroid per recent prescription refill.
# Microcytic hypochromic anemia: Consistent with baseline,
continue to monitor
# Chronic ischemic congestive heart failure (40-45%) with
history of aortic valve replacement and coronary artery bypass
graft ___: Patient with known h/o AVR and CABG (SVG to OM1)
both done at same
procedure in ___. She was maintained on aspirin and
atorvastatin. By discharge, she was restarted on home Lasix.
# Restless Leg Syndrome: Baclofen PRN |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Unsteady gait and confusion
Major Surgical or Invasive Procedure:
___ - Left Craniotomy for Subdural hematoma evacuation
History of Present Illness:
___ yo M hx Afib known to Neurosurgery for bilat SDH Right > Left
and s/p right burr hole evacuation of ___ on ___ presented
with worsening unsteady gait over the past week and fall, no
headstrike, 4 days prior. Coumadin was stopped at his last
hospitalization. He complains also of general weakness. He
denies numbness, vision changes, nausea, vomiting.
Past Medical History:
-Afib on Coumadin
-Hypertension
-Hyperlipidemia
-h/p prostate CA s/p prostatectomy in ___
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
O: T:98.3 BP: 126/95 HR:88 R20 O2Sats97%
Gen: WD/WN, comfortable, NAD.
HEENT: right burr hole incision well healed
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date, difficulty
with
month.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout with the exception
of
right tricep 4+/5
Bilateral upward drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
========================================
ON DISCHARGE:
Pertinent Results:
Please refer to ___ for pertinent imaging and lab results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
4. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
5. Loratadine 10 mg PO DAILY
6. TraZODone 25 mg PO QHS:PRN sleep
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain
2. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
3. Loratadine 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
8. TraZODone 25 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral subdural hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man s/p left burr hole x 2 for ___ evacuation//
postop eval, please perform at 2:30pm
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 1,339 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
Interval placement of a left frontal approach subdural drain is visualized and
terminates in the left subdural space with interval decrease in subdural fluid
collections now measuring 13 mm, previously measuring 21 mm. There is
postoperative pneumocephalus, and a small amount of dense material is
visualized adjacent to the drain site likely representing acute blood products
(03:35). There is re-demonstration of a left convexity layering acute on
chronic subdural collection that is grossly unchanged in appearance measuring
up to 1.8 cm (03:34), unchanged in size from prior.
There is no evidence of infarction or mass. The ventricles and sulci are
stable in size and configuration. Periventricular and subcortical white matter
hypodensities are nonspecific, but likely reflect sequelae of chronic small
vessel ischemic disease.
A left frontal burr hole and right posterior parietal burr hole are unchanged
in appearance. 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. Status post placement of left frontal approach subdural drain with interval
decrease in size of subdural collection though high-density products are
visualized adjacent to drain terminus.
2. Grossly unchanged left convexity acute on chronic subdural hematoma.
NOTIFICATION: The findings were discussed with ___, N.P. by
___, M.D. on the telephone on ___ at 3:38 pm.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with left SDH now s/p crani/evac// eval for
interval change- please ob tain @ 0500 on ___
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 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 ___.
FINDINGS:
There is interval evolution of postoperative changes status post left
craniotomy and multi compartment intracranial hemorrhages/subdural fluid
collections. Similar volume/degree of bilateral mixed density subdural
hematomas and left superior frontal subarachnoid hemorrhage, without evidence
of new hemorrhage. A left frontal subdural drain is again visualized.
There is no evidence of infarction or new hemorrhage. The ventricles and
sulci are unchanged configuration.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
Expected evolution of postoperative changes status post left craniotomy and
multi compartment intracranial hemorrhages, without significant change. No
evidence of new hemorrhage or mass effect.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Nontraumatic subdural hemorrhage, unspecified
temperature: 98.3
heartrate: 88.0
resprate: 20.0
o2sat: 97.0
sbp: 126.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old male known to the
neurosurgery service s/p right burr hole evacuation on ___
for chronic bilateral subdural hematoma. Patient was readmitted
on ___ from OSH with worsening gait and confusion, found to
have worsening bilateral SDH Left > right.
#Chronic bilateral Subdural hematoma
Mr. ___ was admitted to neurosurgery service on ___
with worsening chronic bilateral SDH, Left>right. Consent was
obtained from health care proxy, and patient was taken to the OR
on ___ for Left burr holes for subdural hematoma evacuation
with placement of left subdural drain. The procedure went
accordingly with no intraoperative compilations. Please refer to
op note in OMR for further intraoperative details. Patient was
taken to Post operative area for further monitoring, where he
remained intact on exam, and was then transferred to the step
down unit for continued care. Post op head CT demonstrated a an
area of hyperdenisty at the drain terminus concerning for new
hemorrhage. The patient remained intact and a repeat CT on ___
remained stable. Subdural drain was pulled on ___. The patient
was evaluated by ___ and OT on ___ who recommended discharge
home with inhome ___ services. Patient remained stable and was
cleared to be discharged home on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of Factor V Leiden, tobacco
abuse, and chronic LBP, known herniated discs at L4-L5 and
L5-S1, who was recently admitted to ___ for back pain, now
presents after multiple reported falls with diffuse pain. At
___, she was treated for acute gouty arthritis with
prednisone and colchicine, the latter of which she continued at
discharge. She was seen by neurosurgery and nuerology, who opted
for conservative management, ordered an outpatient EMG for a
___ sign, increased her gabapentin, and planned for her to
be seen in the pain clinic for outpatient steroid injections.
She reports a fall on ___ when she was walking in her yard
and then fell because her body gave out. It was reportedly
witnessed by her neighbor. She denies seizure like activity, CP,
SOB, dizziness or LH prior to the fall. She denies mechanical
fall. She then reports putting the dishes away ___ night
when she fell from standing into her wheelchair, again because
her body gave out on her. She then was going to bed and reports
falling on to her bed. Her nephew found her and she reports that
she looked unconscious. She notes that she couldn't see him
(because of her baseline blindness) but could hear what he was
saying. She reports being unable to move or keep her eyes open.
She woke up in bed, not remembering what happened after her
nephew found her. She was then sitting at her table outside with
her family when she couldn't move or talk. She denies urinary or
bowel incontinence or retention with last BM this morning. She
denies any fevers or chills at home. Her son called ___ who
brought her to ___, where she was transferred to ___ for
MRI evaluation of the lower ___.
In the ED, initial VS: 98.0 82 123/73 16 98% 2L pain 10.
-exam with diminished rectal tone, no saddle anesthesia
-given 15mg morphine, last 9pm
-INR >7, no signs of bleeding, had been escalating coumadin as
an outpt
-cord consult: Discussed with Dr. ___ resident.
Patient is a poor historian. Difficult to distinguish between
giveway weakness and true weakness on her, generally effort is
quite poor and pain limited examination. No sensory level with
intact reflexes. Proximal > distal weakness in lower extremities
as well as some weakness in upper extremities (full note to
follow). Given her coumadin use, prior history of inflammatory
disease (gout), degenerative joing disease of ___ (prior L5/S1
disc prolapse and S1 foraminal stenosis), I am concerned for
cord and root pathology. Please image with MRI: C/T and L ___,
with and without contrast MRI ___ imaging seems unremarkable
save some cervical discs not causing any cord immpingement.
Motion limited axials.
-MRI ___ done without acute pathology
-was asleep for the past two hours
Most Recent Vitals: 98.2 79 117/78 16 96% 2L.
Currently, the patient reports diffuse body pain and is thirsty.
ROS:
+Per HPI, occaisional chest heaviness that lasts for hours,
vomiting and dizziness with every vertigo spell, dysuria.
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, diarrhea, constipation, BRBPR, melena,
hematochezia, hematuria.
PHYSICAL EXAM:
VS - 98.0 141/83 82 18 97% on RA 105.7kg
GENERAL - well-appearing female in NAD, sleeping when I walked
in, speaking softly and slowly
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no JVD
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 - +BS, soft/ND, diffusely tender, not tender with deep
auscultation, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, exam limited by
patient effort, reports trouble moving but when distracted full
ROM intact, no clonus, neg Babinski's, able to support
extremities when lifted
LABS:
139 97 18 125 AGap=15 estGFR: 65 / >75
4.2 31 0.9
Ca: 9.6 Mg: 2.4 P: 4.0
12.8 14.4 242 MCV 84
41.9
N:78.8 L:17.0 M:2.6 E:0.9 Bas:0.6
___: 72.7 PTT: 42.8 INR: 7.3
MICROBIOLOGY:
___ urine culture pending
STUDIES:
___ MR ___: no evidence of cord
compression. mild disc bulge at L4-L5 and L5-S1.
ASSESSMENT & PLAN: ___ yo female with history of Factor V Leiden,
tobacco abuse, and chronic LBP, known herniated discs at L4-L5
and L5-S1 who presents after multiple falls at home.
# Falls: Patient reports diffuse body pain after multiple falls.
She is vague about the descriptions of each fall and describes
no prior events. Her exam is limited by her efforts, and she is
quite distractable. She will perform a movement she says she
cannot perform when she thinks the examiner is not currently
watching - for instance grapping a cup of soda or the remote
when MD and RN are outside the door.
-monitor on telemetry
-continue home pain regimen with percocet
-continue neurotin, changed to tid dosing for convenience
-check ESR in setting of blindness and reported weakness
-consider neurology consult
-check orthostatics
-outpatient ___ for vertigo
-continue meclizine
-home ___ for med administration
-tox screens
-touch base with PCP
-___ cord team recs
# Back Pain: She does not describe any bowel or bladder
involvement with her back pain and MRI is also reassuring that
there is no evidence of cord compresson. No evidence of hematoma
in light of elevated INR. Could consider RP bleed but hematocrit
is 41.
-___ consult
-follow up final read of MRI
-trend hct
# Elevated INR: Currently 7.4, when patient reports that
outpatient providers were ___. Likely medication
administration error. No evidence of bleeding.
-trend coags
-evaluate other options for anticoagulation as an outpatient
# Depression and Anxiety: Appears dysthmic.
-consider psych evaluation
-continue ___ need to decrease in setting of multiple
falls
-continue citalopram, wellbutrin
# HTN: Stable.
-continue doxepin, lasix, inderal
-may want to readdress BP regimen
# Gout: No current pain in right podagra.
-continue colchicine
-consider transitioning to allopurinol
# Med rec:
-continue nicoderm at lower dose based on reported smoking
history
-continue hydroxyzine, omeprazole
-hold potassium replacements
# FEN: no IVFs / replete lytes prn / regular diet
# PPX: heparin SQ, bowel regimen
# ACCESS: PIV
# CODE: DNR/DNI confirmed
# CONTACT: son ___ ___
# DISPO: floor for now
___, MD
PGY-2 ___
Past Medical History:
Asthma/Bronchitis
Obesity
Factor V Leiden
Legal Blindness
Learning Problem
GERD
Migraine Headaches
HL
Social History:
___
Family History:
Brother: ___ - Type II; Factor V ___
Sister: ___ - Type I; Factor V ___
Physical Exam:
On Admission:
VS - 98.0 141/83 82 18 97% on RA 105.7kg
GENERAL - well-appearing female in NAD, sleeping when I walked
in, speaking softly and slowly
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no JVD
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 - +BS, soft/ND, diffusely tender, not tender with deep
auscultation, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, exam limited by
patient effort, reports trouble moving but when distracted full
ROM intact, no clonus, neg Babinski's, able to support
extremities when lifted
On Discharge:
VS - 97.6, 134/85, 20, 95% RA
GENERAL - alert, pleasant, talkative
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no JVD
LUNGS - CTAB
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft/ND, diffusely tender, not tender with deep
auscultation, no masses or HSM, no rebound/guarding, obese
EXTREMITIES - WWP, no edema b/l, 2+ peripheral pulses (radials,
DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, motor strength
___ upper and lower extremities, sensation intact, no
asterixis
Pertinent Results:
Admission Labs:
139 97 18 125 AGap=15 estGFR: 65 / >75
4.2 31 0.9
Ca: 9.6 Mg: 2.4 P: 4.0
12.8 14.4 242 MCV 84
41.9
N:78.8 L:17.0 M:2.6 E:0.9 Bas:0.6
___: 72.7 PTT: 42.8 INR: 7.3
Interim Labs:
___ 07:10 ALT155* AST64* LDH 237 ALKPHOS121* TBILI
0.2
___ 07:00AM ALT(SGPT)-267* AST(SGOT)-249* LD(LDH)-307*
CK(CPK)-33 ALK PHOS-132* TOT BILI-0.4
___ 07:00AM CK-MB-<1 cTropnT-<0.01
___ 07:00AM VIT B12-761
___ 07:00AM ETHANOL-NEG ACETMNPHN-NEG
___ 07:00AM HCV Ab-NEGATIVE
___ 07:00AM WBC-10.6 RBC-4.88 HGB-13.7 HCT-41.3 MCV-85
MCH-28.2 MCHC-33.3 RDW-14.5
___ 07:00AM PLT COUNT-227
___ 07:00AM ___ PTT-42.8* ___
___ 07:00AM SED RATE-9
___ 06:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:00PM CK-MB-<1 cTropnT-<0.01
___ 05:00PM CK(CPK)-53
MICROBIOLOGY:
___ urine culture pending
STUDIES:
MR ___ W/O CONTRAST Study Date of ___.
Final Report
EXAM: MRI of the cervical, thoracic, and lumbar ___.
CLINICAL INFORMATION: Patient with lower extremity and upper
extremity
weakness, history of L4-L5 disc herniation, for further
evaluation.
TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial
images of
cervical, thoracic, and lumbar ___ were acquired.
FINDINGS: Mild degenerative changes are seen in the cervical
and thoracic
region. There is no significant disc bulge, herniation,
compression fracture,
or marrow edema identified. There is no evidence of cord
compression seen or
intrinsic spinal cord signal abnormalities identified. Mild
atelectatic
changes are seen at the right lung base.
In the lumbar region, mild degenerative disc disease identified.
There is no
evidence of spinal stenosis, disc herniation, or high-grade
thecal sac
compression seen. Slightly increased signal in the posterior
subcutaneous fat
in the upper lumbar region appears to be due to a mild degree of
soft tissue
edema. There is no fluid collection. No compression fracture
is seen.
IMPRESSION: No evidence of cord compression, spinal stenosis,
or acute
compression fracture. No spinal stenosis seen. No abnormal
signal within the
spinal cord. Multilevel mild degenerative changes without
spinal stenosis.
MR THORACIC ___ W/O CONTRAST Study Date of ___
EXAM: MRI of the cervical, thoracic, and lumbar ___.
CLINICAL INFORMATION: Patient with lower extremity and upper
extremity
weakness, history of L4-L5 disc herniation, for further
evaluation.
TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial
images of
cervical, thoracic, and lumbar ___ were acquired.
FINDINGS: Mild degenerative changes are seen in the cervical
and thoracic
region. There is no significant disc bulge, herniation,
compression fracture,
or marrow edema identified. There is no evidence of cord
compression seen or
intrinsic spinal cord signal abnormalities identified. Mild
atelectatic
changes are seen at the right lung base.
In the lumbar region, mild degenerative disc disease identified.
There is no
evidence of spinal stenosis, disc herniation, or high-grade
thecal sac
compression seen. Slightly increased signal in the posterior
subcutaneous fat
in the upper lumbar region appears to be due to a mild degree of
soft tissue
edema. There is no fluid collection. No compression fracture
is seen.
IMPRESSION: No evidence of cord compression, spinal stenosis,
or acute
compression fracture. No spinal stenosis seen. No abnormal
signal within the
spinal cord. Multilevel mild degenerative changes without
spinal stenosis.
CT HEAD W/O CONTRAST Study Date of ___
INDICATION: Elevated INR and chronic falls. Evaluate for
subdural hematoma.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through
the brain
without the administration of intravenous contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. The ventricles and sulci are mildly prominent,
consistent with
age-related atrophy. The basal cisterns are patent. Mild
periventricular
confluent white matter hypodensities are consistent with chronic
small vessel
ischemic disease. Calcifications are noted in the internal
carotid arteries.
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. There is rightward
deviation of the
nasal septum. The soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild age-related atrophy and chronic small vessel ischemic
disease.
CHEST (PORTABLE AP) Study Date of ___
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lung volumes are quite low with crowding of vessels.
Nevertheless, there is
suggestion of several small nodules in the right mid and lower
lung zone.
Patient is rotated to the right exaggerating the caliber of the
mediastinum in
the region of the ascending aorta and obscuring the right hilus.
Radiodensity
in that region could be due to large hilar lymph node
calcifications or
additional nodules. In any case prior chest CT should be
consulted, and if
unavailable, should be supplemented by a chest CT performed
here. Heart is
normal size. Pleural effusion is small if any on the right. No
pneumothorax.
DUPLEX DOPP ABD/PEL Study Date of ___
ABDOMINAL ULTRASOUND AND LIVER DOPPLER
CLINICAL INDICATION: Patient with complex medical history,
elevated liver
function tests, to assess for portal vein abnormalities or any
liver or
biliary abnormalities.
The patient relates having had a prior cholecystectomy. There
is no evidence
of any intra- or extra-hepatic biliary dilatation. The head and
body of the
pancreas are normal in appearance but the tail is partially
obscured by bowel
gas. The abdominal aorta and inferior vena cava are
unremarkable.
The liver is diffusely increased in echogenicity, consistent
with hepatic
steatosis. There are no focal liver lesions seen and there is
no evidence of
ascites. The spleen is mildly enlarged, however, to 13.8 cm
length.
The kidneys show no evidence of hydronephrosis, stones or
masses. The right
kidney is 11.2 cm in length, while the left kidney appears
smaller, measuring
only 9.4 cm in length.
Color flow and pulse Doppler waveform analysis was performed.
The portal vein
is patent with normal forward flow and slightly flattened pulse
Doppler
waveforms. Left and right portal veins are fully patent, as are
the hepatic
veins. Arterial signals within the liver are normal. Splenic
vein was also
seen to be patent with normal direction and flow, but the SMV
could not be
imaged due to overlying gas.
CONCLUSION:
1. Fatty liver and mild splenomegaly. The possibility of more
significant
underlying liver disease, including fibrosis and cirrhosis,
should be
considered, particularly in view of the flattened portal venous
waveforms.
2. Status post cholecystectomy with no biliary dilatation.
3. Slightly small left kidney compared to the right, of
uncertain clinical
significance.
Portable TTE (Complete) Done ___
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
CT CHEST W/CONTRAST Study Date of ___
HISTORY: Incidental lung nodules found on chest radiograph.
The patient has
chest pain and smokes tobacco.
TECHNIQUE: Multidetector helical scanning with intravenous
infusion of 75 mL
Omnipaque nonionic iodinated contrast agent reconstructed as
contiguous 5- and
1.25-mm thick axial and 5-mm thick coronal and parasagittal
images reviewed in
the absence of prior chest CT scans.
FINDINGS:
Fine detail in the lungs is degraded by respiratory motion, but
is sufficient
to show that there is no consolidation or nodulation, and only
mild
heterogeneity, reflected in ground-glass infiltration
surrounding the bronchus
to the anterior segment of the right upper lobe, 4:79, and
nodular looking
subpleural edema in the posterior segment, extending to the
major fissure. A
6-mm wide oval nodule in the right lower lobe, 4:100, and 4-mm
right middle
lobe nodule, 4:106, in combination with what was probably mild
pulmonary
edema, may account for the interpretation of the conventional
radiograph on
___ that the lungs were full of nodules. A nodular
opacity where two
bands of atelectasis originate in the right lower lobe, 4:157
should not be
mistaken for a third lung nodule. Central lymph nodes are not
pathologically
enlarged, ranging in diameter up to 8 mm in the prevascular
aortopulmonic
windows station of the mediastinum. There is no pleural or
pericardial
effusion. This study is not designed for subdiaphragmatic
diagnosis, but
shows there is no adrenal mass, while the patient has had a
cholecystectomy.
IMPRESSION:
1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with
repeat CT scanning
in six months.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT Study Date of
___
HISTORY: Anterior hip pain.
FINDINGS: Three views show the bony structures and joint spaces
to be within
normal limits and symmetric with the opposite side. There is
contrast
material in the bladder from recent CT scan. Contrast material
in the bladder
from recent CT.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient OSH d/c summary.
1. Nicotine Patch 21 mg TD DAILY
2. Warfarin 10 mg PO DAILY16
3. Clonazepam 0.5 mg PO QID:PRN anxiety
4. HydrOXYzine 50 mg PO Q6H:PRN pruritis
5. Meclizine 50 mg PO Q6H:PRN vertigo
6. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN severe
pain
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN mild to
moderate pain
8. Citalopram 20 mg PO DAILY
9. Doxepin HCl 150 mg PO DAILY
10. Furosemide 20 mg PO BID
11. Gabapentin 400 mg PO QID
12. Omeprazole 20 mg PO DAILY
13. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
14. Propranolol 60 mg PO BID
15. BuPROPion 150 mg PO BID
16. Colchicine 0.6 mg PO DAILY
Discharge Medications:
1. BuPROPion 150 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Clonazepam 0.5 mg PO QID:PRN anxiety
4. Colchicine 0.6 mg PO DAILY
5. Doxepin HCl 150 mg PO DAILY
6. Furosemide 20 mg PO BID
7. HydrOXYzine 50 mg PO Q6H:PRN pruritis
8. Meclizine 50 mg PO Q6H:PRN vertigo
9. Nicotine Patch 21 mg TD DAILY
10. Omeprazole 20 mg PO DAILY
11. Propranolol 60 mg PO BID
12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
hold for sedation, RR < 10
RX *oxycodone 10 mg 1 Tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
13. Warfarin 5 mg PO DAILY16
14. Outpatient Lab Work
- Please draw INR on ___ for warfarin monitoring.
ICD-9 289.81
- Fax result or notify primary care doctor:
Name: ___
___
Address: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute encephalopathy secondary to medication
side effect, chronic back pain, transaminitis, atypical chest
pain
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: Elevated INR and chronic falls. Evaluate for subdural hematoma.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are mildly prominent, consistent with
age-related atrophy. The basal cisterns are patent. Mild periventricular
confluent white matter hypodensities are consistent with chronic small vessel
ischemic disease. Calcifications are noted in the internal carotid arteries.
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. There is rightward deviation of the
nasal septum. The soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild age-related atrophy and chronic small vessel ischemic disease.
Results were discussed with Dr. ___ at 9:50 a.m. on ___ via
telephone by Dr. ___.
Radiology Report
AP CHEST 10:50 A.M., ___
HISTORY: ___ woman with ill-defined chest pain, ruled out for MI.
Evaluate other causes.
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:
Lung volumes are quite low with crowding of vessels. Nevertheless, there is
suggestion of several small nodules in the right mid and lower lung zone.
Patient is rotated to the right exaggerating the caliber of the mediastinum in
the region of the ascending aorta and obscuring the right hilus. Radiodensity
in that region could be due to large hilar lymph node calcifications or
additional nodules. In any case prior chest CT should be consulted, and if
unavailable, should be supplemented by a chest CT performed here. Heart is
normal size. Pleural effusion is small if any on the right. No pneumothorax.
Findings were posted to the online record of critical radiology findings, for
notification of the referring physician, at 12:23 p.m.
Radiology Report
ABDOMINAL ULTRASOUND AND LIVER DOPPLER
CLINICAL INDICATION: Patient with complex medical history, elevated liver
function tests, to assess for portal vein abnormalities or any liver or
biliary abnormalities.
The patient relates having had a prior cholecystectomy. There is no evidence
of any intra- or extra-hepatic biliary dilatation. The head and body of the
pancreas are normal in appearance but the tail is partially obscured by bowel
gas. The abdominal aorta and inferior vena cava are unremarkable.
The liver is diffusely increased in echogenicity, consistent with hepatic
steatosis. There are no focal liver lesions seen and there is no evidence of
ascites. The spleen is mildly enlarged, however, to 13.8 cm length.
The kidneys show no evidence of hydronephrosis, stones or masses. The right
kidney is 11.2 cm in length, while the left kidney appears smaller, measuring
only 9.4 cm in length.
Color flow and pulse Doppler waveform analysis was performed. The portal vein
is patent with normal forward flow and slightly flattened pulse Doppler
waveforms. Left and right portal veins are fully patent, as are the hepatic
veins. Arterial signals within the liver are normal. Splenic vein was also
seen to be patent with normal direction and flow, but the SMV could not be
imaged due to overlying gas.
CONCLUSION:
1. Fatty liver and mild splenomegaly. The possibility of more significant
underlying liver disease, including fibrosis and cirrhosis, should be
considered, particularly in view of the flattened portal venous waveforms.
2. Status post cholecystectomy with no biliary dilatation.
3. Slightly small left kidney compared to the right, of uncertain clinical
significance.
Radiology Report
CHEST CT, ___
HISTORY: Incidental lung nodules found on chest radiograph. The patient has
chest pain and smokes tobacco.
TECHNIQUE: Multidetector helical scanning with intravenous infusion of 75 mL
Omnipaque nonionic iodinated contrast agent reconstructed as contiguous 5- and
1.25-mm thick axial and 5-mm thick coronal and parasagittal images reviewed in
the absence of prior chest CT scans.
FINDINGS:
Fine detail in the lungs is degraded by respiratory motion, but is sufficient
to show that there is no consolidation or nodulation, and only mild
heterogeneity, reflected in ground-glass infiltration surrounding the bronchus
to the anterior segment of the right upper lobe, 4:79, and nodular looking
subpleural edema in the posterior segment, extending to the major fissure. A
6-mm wide oval nodule in the right lower lobe, 4:100, and 4-mm right middle
lobe nodule, 4:106, in combination with what was probably mild pulmonary
edema, may account for the interpretation of the conventional radiograph on
___ that the lungs were full of nodules. A nodular opacity where two
bands of atelectasis originate in the right lower lobe, 4:157 should not be
mistaken for a third lung nodule. Central lymph nodes are not pathologically
enlarged, ranging in diameter up to 8 mm in the prevascular aortopulmonic
windows station of the mediastinum. There is no pleural or pericardial
effusion. This study is not designed for subdiaphragmatic diagnosis, but
shows there is no adrenal mass, while the patient has had a cholecystectomy.
IMPRESSION:
1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with repeat CT scanning
in six months.
Radiology Report
HISTORY: Anterior hip pain.
FINDINGS: Three views show the bony structures and joint spaces to be within
normal limits and symmetric with the opposite side. There is contrast
material in the bladder from recent CT scan. Contrast material in the bladder
from recent CT.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN
Diagnosed with LUMBAGO, OTHER MALAISE AND FATIGUE, DIFFICULTY WALKING
temperature: 98.0
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 123.0
dbp: 73.0
level of pain: 10
level of acuity: 2.0 | ___ history of Factor V Leiden, tobacco abuse, chronic low back
pain, known herniated discs at L4-L5 and L5-S1 who presents
after multiple falls at home. There was concern for cord
compression based on ER exam with resultant MRI showed no acute
cord compression. Hospital course was significant for fall and
transient loss of consciousness work-up that revealed no serious
etiologies. Etiology of falls and transient loss of
consciousness was attributed to oversedation from gabapentin and
narcotics. Secondary issue was transaminitis of unknown
etiology.
# Recurrent falls secondary to acute toxic-metabolic
encephalopathy: Patient reported inability to move upper and
lower limbs after multiple falls. She is vague about the
descriptions of each fall but does not give a clear history of
syncope. Differential diagnosis includes primary neurological,
toxic-metabolic, medication side effect, orthostasis among other
considerations. On physical exam the patient was noted to be
very sedated but arousable. She also had small non-reactive
pupils. Her neurological exam was limited by effort, but
initially revealed decreased strength in the lower extremity
greater than upper extremity. Neurology was consulted and felt
that the patient had a functional problem. Serial exam showed
normalization of function after withholding sedating
medications. She had an MRI of the ___ done which showed no
cord compression with mild disc buldge at L4-L5 and L5-S1, no
spinal stenosis, and mild degenerative changes. The patient was
place on telemetry, no malignant arrhythmias were seen. A head
CT was done to look for an acute bleed given history of falls
and elevated INR but no evidence of SDH. The head CT showed no
acute process with mild age-related atrophy and chronic small
vessel ischemic disease. A tylenol level was performed, given
transaminiitis and percocet use, but was normal. An ESR was
done to evaluate for inflammatory myopathy, but was normal.
It was felt that her falls, difficulty moving her limbs and
sedation represented acute toxic-metabolic encephalopathy
secondary to percocet use and gabapentin. After holding
percocet and decreasing her gabapentin dose, the patient
improved remarkably. Her strength improved to ___ in upper
and lower limbs. ___ reevaluated patient and she was able to
resume her normal activity level. Her mental status improved and
she was alert and oriented x3 and talkative. It was decided to
discontinue her gabapentin and percocet and restart her on a
lower dose of oxycodone as needed for pain. Patient much more
alert today and strength is restored to normal after
discontinuing sedating medications.
The etiology of her likely recurrent falls is secondary to
medication side effect - specifically excessive sedation from
gapabentin and narcotics.
She was discharged home with ___ and services.
# Transient loss of consciousness- The patient reported a
possible loss of consciousness. It was unclear if this
represented syncope vs. transient loss of consciousness from
sedating medications as above. The patient did not describe any
syncopal prodrome nor did she describe a seizure like episode.
There was no evidence of malignant arryhthmia on telemetry and
an ECHO performed showed preserved EF without valvular lesions.
Neurology did not recommend any further imaging. Patient was
initially very sedated and mental status cleared after
decreasing sedating medications. Possible transient loss of
conscious was likely due to combination of gabapentin and
oxycodone causing sedation. No evidence of primary cardiac or
neurological process was observed.
# Transaminitis -
Patient noted to have elevated LFTs ___ 07:00AM
ALT(SGPT)-267* AST(SGOT)-249* LD(LDH)-307* CK(CPK)-33 ALK
PHOS-132* TOT BILI-0.4). Patient has history of elevated LFTs
(Atrius records show ALT/AST in low 40-50, negative recent
Hepatitis panels for A,B). She drinks only rarely. The patient
also complained of some nausea and vomiting. A RUQ ultrasound
with doppler was performed and showed status post
cholecystectomy with no biliary dilatation with fatty liver and
mild splenomegaly or vascular issues given history of Factor V
Leiden. Liver function tests have improved significantly.
Tylenol level was within normal limits. The patient had been
tested for hepatitis in the past. A hepatitis C test was done
and negative. Hepatotoxic medications were discontinued and the
patient was instructed not to take anymore tylenol and follow up
as an outpatient.
Patient should have further outpatient work-up.
# Elevated INR: INR was >7 on admission and trended down to ~4
and then ~ 2. The patient reports carefully following
outpatient provider ___. There was no evidence of
bleeding and a head CT was done to rule out intracranial bleed
after fall. The patient was restarted on 5 mg of warfarin per
day and will follow up with ___ clinic.
# Headache: Patient reported new onset frontal headache that
she describes as typtical migraine. Given fall and elevated
INR, concern for hematoma. No evidence of increaesed ICP or
bleed on CT. Headache resolved on own.
# Chest Pressure: The patient incidentally reporting vague chest
pain on morning of admission. MI has been ruled out, ECG without
ischemic changes, telemetry benign. CXR revealed incidental
nodules and ___ on CXR. ECHO showed normal LVEF without
valvular pathology. Her home omeprazole was continued.
Symptoms subsided.
# Back Pain: She does not describe any bowel or bladder
involvement with her back pain and MRI is also reassuring that
there is no evidence of cord compresson. Patient recently
evaluated at ___ by neurology and neurosurgery. Likely
chronic back pain. No evidence of cord compression, spinal
stenosis, or acute compression fracture. No spinal stenosis
seen. No abnormal signal within the
spinal cord. Multilevel mild degenerative changes without
spinal stenosis. Pain medication changed to oxycodone and
gabapentin discontinued. Patient may follow up as outpatient
with PCP.
# Depression and Anxiety: Patient reports anxiety at baseline.
She denied SI/HI. Is followed as outpatient by psychiatrist.
Outpatient meds including ___, wellbutrin were
continued.
# Hypertension: Stable. Continued doxepin, lasix, inderal.
# Gout: No evidence of acute gout flare. Colchicine was
continued.
# Incidental findings:
A. ___ CXR
Radiodensity in that region could be due to large hilar lymph
node calcifications or additional nodules. In any case prior
chest CT should be consulted, and if
unavailable, should be supplemented by a chest CT performed
here.
B. Chest CT performed on ___:
1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with
repeat CT scanning
in six months.
C. Fatty liver and mild splenomegaly. The possibility of more
significant
underlying liver disease, including fibrosis and cirrhosis,
should be
considered, particularly in view of the flattened portal venous
waveforms.
# Transitional Issues
- continue titration of pain regimen as outpatient, avoid
oversedation
- home with ___, continued assessment of fall risk
- follow-up LFTs on outpatient basis, consider work-up if still
elevated
- continuing management of anti-coagulation
- follow-up incidental findings as above related to lung nodule
and fatty liver |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Intitial ED Note:
This patient is a ___ year old female who BIBEMS complains of
fall. History is per EMS this patient is altered. She was found
at the bottom of her stairs with obvious facial
trauma. She has started to open her eyes spontaneously on
arrival.
Past Medical History:
Depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Constitutional: lying comfortable in bed
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, left periorbital ecchymoses improved
over hospital course, repaired L temporal laceration
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: Regular Rate
Abdominal: Soft, non-tender, non-distended
Extr/Back: No cyanosis, clubbing or edema, no pelvic
tenderness
Skin: Warm and dry
Neuro; alert and oriented x 3.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ s/p fall w/ AMS // eval for trauma
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: DLP: 798 mGy-cm
CTDI: 37 mGy
COMPARISON: None
FINDINGS:
Cervical vertebral bodies are maintained in height and alignment. There is no
fracture. There is preservation of the normal cervical lordosis. Prevertebral
soft tissues are unremarkable.
Multilevel degenerative changes are seen with disc height loss and posterior
osteophytes and uncovertebral joint hypertrophy most extensively at C5-C6.
There secondary likely moderate canal, modearte right and mild left foraminal
narrowing. Disk bulges are also identified at C3-4, C5-6 and C6-7 causing some
degree of canal narrowing.
1 cm left thyroid nodule is identified. Included lung apices are unremarkable.
Please see dedicated CT facial bones for description of facial fractures.
IMPRESSION:
Degenerative changes without fracture or malalignment.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ s/p fall down stairs // eval for vascualr injury
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
brain during infusion of 70 cc of Omnipaque intravenous contrast material.
Images were processed on a separate workstation with display of curved
reformats, 3D volume redendered images, and maximum intensity projection
images.
DOSE: DLP: 1426.95 mGy-cm; CTDI: 79.02 mGy
COMPARISON: CTA head without contrast ___, CT sinus of ___, CT C-spine of ___.
FINDINGS:
Head and neck CTA: There is a normal 3 vessel arch. The carotid and vertebral
arteries and their major branches are patent with no evidence of stenoses.
There is no extracranial internal carotid artery stenosis by NASCET criteria.
The the cervical vertebral arteries are codominant. The intracranial internal
carotid arteries, middle cerebral arteries, anterior cerebral arteries and
their major branches are unremarkable. The posterior circulation is also
unremarkable. There is no evidence of aneurysm larger than 3 mm or other
vascular abnormality.
Other: The left lobe of thyroid demonstrates a hypoattenuating 8 mm nodule.
The remainder the thyroid gland is unremarkable. Lung apices are clear. The
aerodigestive tract is unremarkable. There is no cervical lymphadenopathy by
CT size criteria.
Unchanged appearance of a left zygomaticomaxillary complex fracture. Layering
fluid level within the right maxillary sinus is again seen as well as
subcutaneous emphysema overlying the subcutaneous soft tissues anteriorly.
Although the exam is not optimized for evaluation of brain parenchyma, the
visualized brain is unremarkable.
IMPRESSION:
1. Unremarkable CTA of the head and neck. No evidence of vascular injury or
aneurysm.
2. The left lobe of the thyroid gland demonstrates a hypoattenuating 8 mm
nodule. This may be further evaluated with ultrasound if clinically indicated.
3. Unchanged appearance of a left zygomaticomaxillary complex fracture.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT
INDICATION: ___ with fall, left wrist pain. Assess for fracture.
TECHNIQUE: Three views of the left wrist, two views of the left forearm.
COMPARISON: None.
FINDINGS:
Comminuted distal radius fracture with mild impaction and extension of
fracture line to the articular surface. No dislocation. Scapholunate interval
is preserved. No additional fracture. No soft tissue calcification or
radiopaque foreign body. Moderate soft tissue swelling is noted at site of
fracture.
No proximal radius or ulnar fracture. Limited assessment of the elbow is
grossly unremarkable.
Mild ulnar positive variance may be as result of fracture fragment impaction.
IMPRESSION:
1. Comminuted distal radius fracture with mild impaction and intra-articular
extension.
2. Moderate soft tissue swelling.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ who fell down stairs, +EtOH, does not remember event; has
lateral ventricle hemorrhages, L zygomaticomaxillary fracture, and L sphenoid
sinus wall fracture // interval changes in intraventricular bleeding. now w
bradycardia, fixed L pupil compared to right
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal and
thin-section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 891 mGy-cm
CTDI: 49 mGy
COMPARISON: CT head ___ and CTA head/neck ___
FINDINGS:
There is blood noted within the occipital horns of the lateral ventricles,
slightly more and denser without significant change in appearance compared to
the initial CT on ___. There is no new hemorrhage. No evidence of cerebral
edema or major vascular territory infarction.
There is persistent bi-frontal extra-axial hypodensities, which may be due to
atrophy or possibly old subdural hematomas, unchanged from yesterday.
Prominent ventricles and sulci are consistent with age-related atrophy.
Periventricular hypodensities suggest chronic small vessel ischemic disease.
Gray-white matter differentiation is preserved.
There are multiple facial fractures, as described in the dedicated CT
performed ___, partly imaged now. With the exception of the right
maxillary sinus being relatively clear, there is fluid/secretions within all
other visualized paranasal sinuses. Bilateral mastoid air cells and middle ear
canals are clear. A superficial contusion is noted over the left zygomatic
arch.
IMPRESSION:
1. Stable intraventricular hemorrhage-slightly more and denser without
significant change in appearance compared to the initial CT on ___. No
new hemorrhage.
2. Multiple facial fractures as previously described on ___, incompletely
imaged as not targeted .
3. Bi-frontal extra-axial hypodensities may be related to atrophy or chronic
subdural hematomas.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old woman with distal radius fx s/p reduction splinting
// eval reduction
TECHNIQUE: Three views left wrist
COMPARISON: Earlier same day.
FINDINGS:
Intra-articular distal radial fracture, with impaction. There is dorsal
angulation of the distal fracture fragments which appears slightly worse than
previous. Mild ulnar positive variance may be as result of fracture fragment
impaction. Incidental mild from interphalangeal joint degenerative change.
IMPRESSION:
Increased dorsal angulation of intra-articular impacted comminuted distal
radial fracture.
Radiology Report
INDICATION: ___ s/p fall w/ AMS // eval for trauma
TECHNIQUE: Supine views of the chest and pelvis.
COMPARISON: None.
FINDINGS:
Within the limitation given overlying trauma board and external equipment, the
following is noted:
Chest: The lungs are clear. The cardiomediastinal silhouette is within normal
limits. No displaced fractures identified.
Pelvis: There is no fracture. Pubic symphysis and SI joints are preserved.
Degenerative changes are noted in the lower lumbar spine. Phleboliths
identified in the pelvis.
IMPRESSION:
No acute cardiopulmonary process. No pelvic fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ s/p fall w/ AMS // eval for trauma
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1003 mGy-cm
CTDI: 52 mGy
COMPARISON: None available
FINDINGS:
There is minimal amount of hemorrhage in the lateral ventricles in the body of
the right and layering dependently in the occipital horns bilaterally. No
other intracranial hemorrhage is detected. The ventricles and sulci are mildly
prominent suggesting age-related atrophy. Prominent bifrontal extra-axial CSF
density could be due to volume loss or low-density subdural fluid collections.
The basal cisterns are patent. Gray-white matter differentiation is preserved.
Left facial and skullbase fractures are better depicted on concurrent CT of
the face. There is hemorrhagic opacification of the left maxillary sinus and
sphenoids. The mastoid air cells and middle ear cavities are clear.
IMPRESSION:
1. Minimal amount of hemorrhage in the lateral ventricles as detailed above.
2. Left facial and skullbase fractures better depicted on concurrent CT of the
face.
3. Prominent bifrontal extra-axial CSF potentially due to volume loss and
prominent subarachnoid space although low-density subdural fluid is also
possible. This can be further assessed at time of CTA.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ s/p fall w/ AMS // eval for trauma
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal reformatted images were also obtained
DOSE: DLP: 541 mGy-cm; CTDI: 26 mGy
COMPARISON: None available
FINDINGS:
Left lateral orbital fracture is medially displaced into the orbit
approximately 5 mm. There is comminuted fracture of the left zygomatic arch.
Fracture fragments of the zygomatic arch are seen approximately 3 mm from
coronoid process. There is comminuted fracture of the anterior and lateral
left maxillary walls. Left orbital floor fracture is seen to traverse the
inferior orbital canal. The inferior left orbital rim is fractured. The globe
is unremarkable. There is no CT evidence of extraocular muscle entrapment.
Small amount of extraconal hematoma seen adjacent left lateral rectus muscle.
There is fracture of the left sphenoid sinus walls extending to the left
carotid canal (02:55). Fractures are also seen involving the posterior wall
the pterygopalatine fossa (02:53).
Hemorrhage seen layering within the left maxillary sinus and sphenoid sinuses.
There is partial opacification of the ethmoid air cells. The mandible is
intact. The temporomandibular joints are anatomically aligned. Pterygoid
plates are also intact.
IMPRESSION:
Left zygomaticomaxillary complex fracture. Left sphenoid sinus wall fracture
involving the left carotid canal should be further evaluated with CTA of the
head and neck to exclude vascular injury. Left zygomatic arch fracture
fragments seen approximately 3 mm from the coronoid process.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with CL SKUL BASE FX-COMA NOS, FX MALAR/MAXILLARY-CLOSE, FX ORBITAL FLOOR-CLOSED, OPEN WOUND OF FOREHEAD, OPEN WOUND OF AURICLE, ALCOHOL ABUSE-UNSPEC, FALL ON STAIR/STEP NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented to pre-op/Emergency Department on ___.
Pt was evaluated by upon arrival to ED with X-ray (Chest, Wrist,
pelvis) and CAT scan (head, c-spine, Maxillofacial, CTA head &
neck) which were notable for Minimal amount of hemorrhage in the
lateral ventricles, Left zygomaticomaxillary complex fracture.
Left sphenoid sinus wall fracture, and comminuted distal radius
fracture with mild impaction and intra-articular extension.
Given findings, the patient was admitted to the Acute Care
Surgery/Trauma Surgery service for further evaluation and
management.
Neuro/Traumatic IVH: Given findings on CT, neurosurgery was
consulted upon arrival to the ED. Initial recommendations given
traumatic IVH were non surgical management with q1 neuro checks,
repeat head CT, seizure precautions with Keppra, blood pressure
control and CTA head and neck all of which were implemented.
Findings on repeat CT Head/CTA were reassuring and no further
neurosurgical management was indicated. Neurological status was
closed monitor and the patient was alert and oriented throughout
hospitalization
Facial Fractures: Given multiple facial fractures, plastic
surgery was consulted who recommended no acute surgical
intervention, a short course of augmenting, sinus precautions,
and soft diet, along with outpatient follow for consideration of
surgical intervention. All recommendations were implemented. An
ophthalmology consult given orbital fracture was also obtained.
Recommendations included conservative management with oral
antibiotics and sinus precautions as per Plastics and followup
as outpatient with ___ were implemented.
Radial Arm Fractures: Given with left distal radial fracture
Hand Surgery was consulted who attempted
bedside reduction and splint and recommended followup as an
outpatient in Hand Clinic.
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 were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO for possible
operative intervention. The diet was advanced sequentially to a
soft diet, which was well tolerated. Patient's intake and output
were closely monitored
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.
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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex / Haldol / gabapentin
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV,
and seizure disorder presents to the ED with c/o increasing
frequency of seizures.
Pt reports that she has had more frequent seizures lately
including several in the last week and one on ___ where she
was
admitted to ___. She reports not taking Keppra for
the last 6 days because her PCP "told her to stop," given that
her "Keppra levels were always low" despite taking the
medication. She has not seen a neurologist for over ___ years and
is managed by her PCP.
In the ED:
- Initial vital signs: 96.6 118 140/89 18 96% RA
- Exam notable for: WNL
- Labs were notable for: CBC WNL, Bicarb 19, lactate 7.0 -> 1.1
- Studies performed include:
CT Head w/o Contrast: No acute intracranial abnormality
- Meds:
___ 20:15 IM LORazepam 2 mg ___
___ 23:56 IV Gentamicin 80 mg ___
- Consults: None
- ED Course:
Pt had witnessed GTC seizure in ED with lactatemia, s/p IM
lorazepam with resolution. Given c/f endocarditis, pt given
gentamicin.
Upon arrival to the floor, pt endorsed the history above. In
addition, she states she last used IV heroin 6 days ago. She
does
endorse one isolated fever at home of ___ F a few days ago and
redness on her right hand. She denies CP, palpitations, dyspnea,
cough, ___ edema. She reports a history of endocarditis
approximately ___ year ago with no recent issues with her heart.
ROS: Complete ROS obtained and is otherwise negative.
Past Medical History:
- Seizure disorder
- Bipolar dz
- Anxiety
- Attention deficit syndrome and
- ___ abuse, IV drug user, heroin. Per patient last
used ___. Cocaine, sober for one-year.
- History of heavy alcohol abuse with first detoxification ___
years ago. She reports no current alcohol use for more than one
year.
- Endocarditis
Social History:
___
Family History:
- Mother has ___ use.
- Does not know her father.
- 4 children who are alive and healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 0135 Temp: 98.7 PO BP: 118/86 HR: 119 RR: 18 O2
sat: 94% O2 delivery: ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
Extremely poor dentition. Tachy MM
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, borderline tachycardia. No
murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales.
ABDOMEN: Soft, NT, ND
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: WWP. Area of 4 cm area of erythema, warmth over dorsum of
Rt hand. In setting of IVDU. Multiple sites of previous
injection
b/l including 2 cm nodules in b/l brachial fossas. No ___
lesions, ___ nodes, or splinter hemorrhages
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
Vitals:24 HR Data (last updated ___ @ 926)
Temp: 98.1 (Tm 98.3), BP: 99/63 (83-110/53-77), HR: 84
(75-93), RR: 16 (___), O2 sat: 93% (91-95)
GEN: young woman lying in bed, NAD
HEENT: EEG leads in place
CV: well perfused
RESP: normal WOB on RA
EXTR track marks on arms bilaterally
NEURO:
mental status: awake, alert, oriented to medical situation.
Provides linear and logical history. Speech fluent without
paraphasic errors. Normal grammar and syntax.
Pupils 5->3mm and brisk. EOMI with fatiguable, horizontal
endgaze
nystagmus. Facial activation symmetric. No dysarthria.
Moves all extremities briskly.
FNF without dysmetria.
Pertinent Results:
ADMISSION LABS
---------------
___ 08:42PM BLOOD WBC-6.6 RBC-4.66 Hgb-12.0 Hct-36.9
MCV-79* MCH-25.8* MCHC-32.5 RDW-17.3* RDWSD-49.1* Plt ___
___ 08:42PM BLOOD Neuts-41.3 ___ Monos-5.8 Eos-4.3
Baso-0.8 Im ___ AbsNeut-2.71 AbsLymp-3.09 AbsMono-0.38
AbsEos-0.28 AbsBaso-0.05
___ 08:42PM BLOOD Glucose-98 UreaN-9 Creat-1.1 Na-139 K-3.9
Cl-98 HCO3-19* AnGap-22*
___ 08:42PM BLOOD Calcium-9.9 Phos-4.1 Mg-1.6
___ 04:50PM BLOOD HIV Ab-NEG
___ 08:42PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 08:52PM BLOOD Lactate-7.0*
___ 11:59PM BLOOD Lactate-1.1
DISCHARGE LABS
-----------------
___ 05:00AM BLOOD WBC-6.8 RBC-4.55 Hgb-11.6 Hct-37.7 MCV-83
MCH-25.5* MCHC-30.8* RDW-17.6* RDWSD-53.1* Plt ___
___ 06:08AM BLOOD Glucose-105* UreaN-19 Creat-1.0 Na-139
K-4.5 Cl-101 HCO3-24 AnGap-14
___ 05:00AM BLOOD Glucose-75 UreaN-21* Creat-1.0 Na-141
K-5.5* Cl-105 HCO3-18* AnGap-18
___ 05:00AM BLOOD ALT-9 AST-27 AlkPhos-109* TotBili-<0.2
___ 05:00AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.0 Mg-2.1
___ 04:50PM BLOOD HIV Ab-NEG
___ 12:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
CT HEAD
No acute intracranial abnormality.
CXR
Patchy opacification at the left lung base, concerning for
infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. CloNIDine 0.1 mg PO TID
3. Prazosin 2 mg PO QHS
4. Mirtazapine 30 mg PO QHS
5. Pregabalin 150 mg PO BID
6. TraZODone 100 mg PO QHS
7. linaCLOtide 145 mcg oral DAILY
8. Ranitidine 150 mg PO BID:PRN GERD
9. QUEtiapine Fumarate 100 mg PO BID
10. QUEtiapine Fumarate 200 mg PO QAM
11. Sertraline 200 mg PO BID
12. BusPIRone 15 mg PO QID
13. Methadone 150 mg PO DAILY
14. QUEtiapine Fumarate 400 mg PO QHS
Discharge Medications:
1. DICYCLOMine 20 mg PO TID
RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day as
needed Disp #*21 Tablet Refills:*0
2. LOPERamide ___ mg PO QID:PRN loose stools
RX *loperamide 2 mg ___ tablet(s) by mouth every six hours as
needed Disp #*28 Tablet Refills:*0
3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation ___ spray intranasally as
needed for opiate overdose Disp #*2 Spray Refills:*0
4. Simethicone 40-80 mg PO TID
RX *simethicone 80 mg 1 tablet(s) by mouth three times a day as
needed for stomach cramps Disp #*21 Tablet Refills:*0
5. Zonisamide 400 mg PO QHS
RX *zonisamide 100 mg 4 capsule(s) by mouth at bedtime Disp
#*120 Capsule Refills:*3
6. BusPIRone 15 mg PO QID
7. Cetirizine 10 mg PO DAILY
8. CloNIDine 0.1 mg PO TID
9. linaCLOtide 145 mcg oral DAILY
10. Methadone 150 mg PO DAILY
Consider prescribing naloxone at discharge
11. Mirtazapine 30 mg PO QHS
12. Prazosin 2 mg PO QHS
13. Pregabalin 150 mg PO BID
14. QUEtiapine Fumarate 200 mg PO QAM
15. QUEtiapine Fumarate 400 mg PO QHS
16. QUEtiapine Fumarate 100 mg PO BID
17. Ranitidine 150 mg PO BID:PRN GERD
18. Sertraline 200 mg PO BID
19. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
epilepsy
history of traumatic brain injury
homelessness
___ abuse
bipolar disorder
chronic hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall and head strike// Please evaluate for
large infarct, mass, bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 759 MGy-cm
COMPARISON: CT dated ___
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with seizure, c/f endocarditis// Please evaluate for
PNA or effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Patchy opacities at the left lung base, concerning for infection. The right
lung is clear. No pulmonary edema. Normal cardiomediastinal silhouette. No
pleural effusion. No pneumothorax.
IMPRESSION:
Patchy opacification at the left lung base, concerning for infection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 96.6
heartrate: 118.0
resprate: 18.0
o2sat: 96.0
sbp: 140.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | ___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV,
and seizure disorder presented with increasing seizure
frequency and witnessed GTC in the ED. She was monitored with
EEG off home keppra for spell capture and characterization who
course was complicated by symptoms of opioid withdrawal.
# Seizure Disorder
Patient reports epilepsy secondary to traumatic brain injury in
___, now with increasing frequency in setting of stopping her
keppra recently. She had witnessed GTC in the ED with high
lactate. Patient states she has not seen a neurologist in ___
years(last saw Dr. ___ @ ___) and is managed by PCP (Dr.
___ ___. Given her complex social history, she may have
both seizures and pseudoseizures, so home keppra was held for
EEG monitoring. Her EEG did not show any epileptiform discharges
or electrographic seizures even with sleep deprivation. She was
not comfortable with restarting keppra, because she thinks that
it doesn't work for her so she was discharged on zonisamide
400mg qhs. She will follow-up with epilepsy outpatient in one
month.
#Opioid withdrawal
The patient has a history of IVDA with last use of heroin 6 days
prior to admission. During this admission she experienced
withdrawal symptoms, which had improved significantly by the
time of discharge. She was given a prescription for a week of
dicyclomine and Simethicone.
#Right Hand Cellulitis
Gives history of significant swelling and pain, though currently
exam is not impressive. With history, and high risk nature of
site of injection, was treated with a 5 day course of
doxycycline
# ___ use including IV opiates
Last used IV heroin 6 days prior to admission. On chronic
methadone at ___ at ___
___ in ___, ___. Confirmed methadone dose 150mg daily, last
taken ___. During admission she was found to be using heroin.
She readily admitted to the incident and her needles were
confiscated. There were no other issues. She was seen by
addiction specialists and social work.
# Bipolar disorder
Reports mood is "okay" and denies SI/HI. Recent inpatient
psychiatric hospitalization in past ___. She was
continued on home Seroquel, sertraline, buspirone, prazosin,
mirtazapine, trazodone.
# Hx of endocarditis
History of endocarditis at ___ reportedly within past year.
No suspicion at this time for recurrent endocarditis, though is
at somewhat elevated risk due to active IVDU. Blood cultures
were negative.
# Chronic HCV
LFTs WNL. Plan to be treated at ___ (no need for GI
follow-up
at this time)
# IBS
Held home linaclotide since it was non-formulary, and patient
was exhibiting diarrhea from withdrawal.
# Fibromyalgia
Patient states she has a history of fibromyalgia and takes
Pregabalin and has been maintained on her home dose
TRANISTIONAL ISSUES
--------------------
AEDs on discharge:
Zonisamide 400mg qHS
[] follow up with neurologist
[] follow up chronic hepatitis C for treatment |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
___: Placement of IVC filter
History of Present Illness:
Ms. ___ is a ___ y/o F with history of duodenal ulcers and
dementia who presented as a transfer from ___ for
management of pulmonary embolism, arrived on heparin gtt. Per
reports, she is a resident of ___, and had a syncopal
episode lasting 30 seconds to 1 minute, prompting her to be
taken to the ED. At ___, she was found to have extensive
bilateral pulmonary emboli with right heart strain and elevated
troponins. She was transferred to ___ on heparin gtt which was
started around 1440 on ___. MASCOT was consulted and
recommended remaining on heparin gtt at this time, and
recommended further workup with lower extremity dopplers and
formal TTE. After discussion with the family and patient, they
clearly expressed not wanting to pursue aggressive measures at
this time, including IVC filter. However, should further
complications develop, they are willing to discuss more advanced
therapies at this time.
On the floor, she had two further syncopal episodes with BP
dropping as low as SBP ___, requiring up to 2L O2 via NC,
prompting transfer to the MICU. She was started on 1 L NS with
SBP increasing to ___.
On arrival to the MICU, patient reports feeling well without
complaints. Alert, awake, interactive. Breathing comfortably.
Past Medical History:
Anemia
Esophagitis
Peptic ulcer disease on PPI/sucralfate
Bullous pemphigoid on prednisone
Alzheimer's dementia on donepezil
Social History:
___
Family History:
n/c
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: BP 95/56 HR 93 RR 19 O2 100%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, oropharynx clear
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Extensive bruising on left arm and right hand. Large fluid
filled bullae on right foot. No edema. WArm
SKIN: No rashes, bruising as above
NEURO: Moving all extremities
============================
DISCHARGE PHYSICAL EXAM
============================
Vitals: 97.4 106/67 81 20 94 Ra
General: bedbound, comfortable, AO x 1 (said she was in a
___ hospital and the month/year was ___, speaking in
___ word sentences answering "I don't know" and "everything
hurts".
Neck: supple
Lungs: breathing comfortably, CTAB, good respiratory effort
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Abdomen: soft, non-tender, non-distended, no suprapubic
tenderness or fullness
Ext: 2+ painful non pitting edema of the bilateral lower
extremities to level of knees, some associated erythema,
non-tender to palpation. No further edema of upper extremities.
GU: Foley in place
Skin: Diffuse ecchymoses, dry dressing on bulla of R foot
Neuro: Alert and fully oriented
Pertinent Results:
=============================
ADMISSION LABS
=============================
___ 06:56PM BLOOD WBC-20.1* RBC-4.31 Hgb-12.5 Hct-39.5
MCV-92 MCH-29.0 MCHC-31.6* RDW-16.4* RDWSD-55.3* Plt ___
___ 06:56PM BLOOD Neuts-89.7* Lymphs-4.9* Monos-4.0*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-18.03* AbsLymp-0.98*
AbsMono-0.81* AbsEos-0.00* AbsBaso-0.04
___ 06:56PM BLOOD ___ PTT-150* ___
___ 06:56PM BLOOD Glucose-156* UreaN-57* Creat-1.7* Na-138
K-4.6 Cl-92* HCO3-27 AnGap-19*
___ 06:56PM BLOOD CK-MB-8 proBNP-6954*
___ 06:56PM BLOOD cTropnT-0.30*
___ 12:15PM BLOOD Calcium-8.0* Phos-4.4 Mg-1.7
___ 03:50AM BLOOD ___ pO2-29* pCO2-54* pH-7.42
calTCO2-36* Base XS-7
___ 03:50AM BLOOD Lactate-4.4* Na-138 K-3.8 Cl-88*
___ 10:40PM URINE Color-Straw Appear-Clear Sp ___
___ 10:40PM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:40PM URINE RBC-116* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
=============================
DISCHARGE LABS
=============================
___ 05:30AM BLOOD WBC-8.5 RBC-2.42* Hgb-7.2* Hct-23.2*
MCV-96 MCH-29.8 MCHC-31.0* RDW-17.2* RDWSD-58.4* Plt ___
___ 05:30AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-10
___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7
=============================
INTERVAL LABS
=============================
___ 10:28AM BLOOD CK-MB-4 cTropnT-0.15*
___ 06:05AM BLOOD CK-MB-3 cTropnT-0.16* proBNP-5272*
___ 12:15PM BLOOD CK-MB-8 cTropnT-0.23* proBNP-6919*
___ 06:56PM BLOOD cTropnT-0.30*
___ 06:56PM BLOOD CK-MB-8 proBNP-6954*
___ 10:28AM BLOOD Cortsol-15.3
___ 05:26AM BLOOD calTIBC-225* VitB12-592 Ferritn-394*
TRF-173*
___ 05:26AM BLOOD TSH-8.7*
___ 05:26AM BLOOD Free T4-0.6*
___ 12:33PM BLOOD ___ pO2-33* pCO2-43 pH-7.46*
calTCO2-32* Base XS-5
___ 12:33PM BLOOD Lactate-1.0
=============================
IMAGING
=============================
___ ___
1. Deep venous thrombosis of the right femoral and popliteal
veins.
2. Nonvisualization of posterior tibial and peroneal veins
bilaterally. Within these limits, no evidence of deep venous
thrombosis in the leftlower extremity veins.
___ ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF = 75%). There is AT LEAST a mild resting left
ventricular outflow tract obstruction (with premature closure of
the aortic valve) due to the hyperdynamic and underfilled nature
of the left ventricle. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal with
normal free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
___ CXR
Cardiac size is top-normal. Patient has a large hiatal hernia.
Enlargement of the pulmonary arteries is again noted. There is
no pneumonia, pulmonary edema, evident pneumothorax or pleural
effusions.
___ CXR
Right internal jugular line tip is in the proximal right atrium.
Heart size and mediastinum are unchanged including cardiac
enlargement. Left
retrocardiac opacities concerning for infectious process. No
appreciable
pleural effusion. Hiatal hernia is large, re-demonstrated.
***Incidental radiology findings from ___ scan***
-complete intrathoracic stomach with organoaxial rotation,
without ___ volvulus.
-dilatation of the esophagus with air-fluid levels identified.
-cholelithiasis
-Colonic diverticula
-5 mm left lower lobe pulmonary nodule.
-Enlarged thyroid gland with heterogeneous parenchyma and
densely calcified bilateral nodules
=============================
PROCEDURES
=============================
___ IVC FILTER PLACEMENT
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins and no evidence of a clot.
2. Successful deployment of an infra-renal retrievable IVC
filter.
=============================
MICRO
=============================
__________________________________________________________
___ 5:50 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:53 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 3:54 pm BLOOD CULTURE Source: Line-R IJ #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:28 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
__________________________________________________________
___ 10:28 am BLOOD CULTURE Source: Line-R IJ #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:10 pm BLOOD CULTURE Source: Line-CL.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:10 pm BLOOD CULTURE Source: Line-CL.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Donepezil 5 mg PO QHS
3. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Levofloxacin 500 mg PO Q24H Duration: 1 Day
last dose: ___ on ___, to complete a ___. Pantoprazole 40 mg PO BID prior to meals
4. Sucralfate 1 gm PO QID
5. PredniSONE 10 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. Donepezil 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
===========================
Primary:
===========================
Syncope secondary to massive pulmonary embolism
Catheter-associated urinary tract infection
=============================
Secondary:
=============================
Anemia
Esophagitis
Peptic ulcer disease
Bullous pemphigoid
Alzheimer's dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with massive PE, now with regression of mental
status// evaluate previously described infiltrate
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right internal jugular central venous catheter projects over
the right atrium, unchanged. Increasing retrocardiac opacities may reflect
atelectasis and/or consolidation. There is no pneumothorax or large pleural
effusion. The size of the cardiac silhouette is enlarged but unchanged.
Calcification of the aortic arch again noted.
IMPRESSION:
Increased retrocardiac opacities may reflect atelectasis or consolidation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: History: ___ with pe, eval for dvt// pe, eval for dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral vein. However, there is expansile, echogenic thrombus in the right
femoral and popliteal veins with no color flow or compressibility.
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. The posterior tibial and peroneal
veins were not clearly seen on either side.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep venous thrombosis of the right femoral and popliteal veins.
2. Nonvisualization of posterior tibial and peroneal veins bilaterally. Within
these limits, no evidence of deep venous thrombosis in the leftlower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new PE hypoxemia// Assess for infiltrate
or cause of hypoxemia
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest CT ___
IMPRESSION:
Cardiac size is top-normal. Patient has a large hiatal hernia. Enlargement
of the pulmonary arteries is again noted. There is no pneumonia, pulmonary
edema, evident pneumothorax or pleural effusions.
Radiology Report
INDICATION: ___ year old woman with submassive PE and large RLE DVT// Please
place IVC filter
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ and
Dr. ___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Local anesthesia was utilized with 1% lidocaine was injected in
the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None.
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 5 min, 76 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal retrievable IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. Both groins were prepped and draped in the usual sterile
fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible right
common femoral vein was punctured using a 21G micropuncture needle. Ultrasound
images of the access was stored on PACS. A ___ wire was advanced through
the micropuncture sheath into the inferior vena cava. A 5 ___ sheath was
exchanged for the micropuncture sheath. After the inner dilator was removed,
an Omniflush catheter was advanced over the wire into the IVC. The ___
wire was exchanged for an angled Glidewire, which was advanced into the left
common iliac vein and the catheter tip was advanced into the left common iliac
vein.
A left common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
retrievable, infrarenal IVC filter. The catheter and sheath were removed over
the wire and the sheath of the retrievable filter was advanced over the wire
into the IVC past the take-off of the renal vessels. An inferior vena cava
filter was advanced over the wire until the cranial tip was at the level of
the inferior margin of the lower renal vein. The sheath was then withdrawn
until the filter was deployed. The wire and loading device were then removed
through the sheath and a repeat contrast injection was performed, confirming
appropriate filter positioning. The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes, at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal retrievable IVC filter.
IMPRESSION:
Successful deployment of an infrarenal retrievable IVC filter.
RECOMMENDATION(S): Please contact the department of Interventional Radiology
with questions or concerns about the retrievable filter and for follow-up for
retrieval if clinically feasible.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with PE s/p RIJ CVL// CVL placement, ?interval
changes
COMPARISON: Chest radiographs from ___ through ___
FINDINGS:
Semi-erect portable AP view of the chest provided.
The right IJ central venous catheter tip is in the right atrium, approximately
1.5 cm below the estimated location of the superior cavoatrial junction. A
large hiatal hernia is again seen and is unchanged. Enlargement of the
pulmonary artery is stable, and there is no pleural effusion or pulmonary
edema. There is no focal consolidation. No pneumothorax. The cardiac size
is top normal, unchanged.
IMPRESSION:
1. The right IJ central venous catheter tip is in the right atrium,
approximately 1.5 cm below the estimated location of the superior cavoatrial
junction.
2. Enlargement of the pulmonary artery is stable. No evidence of pulmonary
vascular congestion or pulmonary edema.
3. Large hiatal hernia, unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with massive PE (stabilized on heparin gtt with
VC filter in place) but with ongoing hypotension// evaluate for infiltrate
(?hospital-acquired pneumonia) evaluate for infiltrate (?hospital-acquired
pneumonia)
IMPRESSION:
Right internal jugular line tip is in the proximal right atrium. Heart size
and mediastinum are unchanged including cardiac enlargement. Left
retrocardiac opacities concerning for infectious process. No appreciable
pleural effusion. Hiatal hernia is large, re-demonstrated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Syncope and collapse
temperature: 98.4
heartrate: 97.0
resprate: 18.0
o2sat: 97.0
sbp: 140.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | ==========================
BRIEF SUMMARY
==========================
___ yo F with a history of bullous pemphigoid on steroids,
Alzheimer's dementia, who presented with syncope and found to
have extensive bilateral pulmonary emboli with right heart
strain. She received an IVC filter and was treated with a
heparin drip, transitioned to oral apixaban prior to discharge.
========================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lithium
Attending: ___.
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with bipolar disorder and
alcohol use disorder who presented to the ED with alcohol
intoxication and withdrawal.
He drinks more than a quart of hard liquor per day. His last
drink was the day before he came to the ED. He estimates it was
about 4 hours before he presented to the ED in the early morning
of ___. He usually starts withdrawing after he has gone without
alcohol for about 4 hours. His most bothersome withdrawal
symptom has been tremors. He has a mild headache as well. He has
some mild anxiety. He does not feel like eating but is not
nauseated. No vomiting. No diaphoresis. He feels better after
receiving phenobarbital PO x2. He has not been hallucinating. He
has a history of withdrawal seizures. He thinks the last one was
about ___ years ago. He has been admitted to the ICU almost every
time he has been hospitalized for alcohol withdrawal. He has
never been intubated.
He had been sober for over a year until this past ___. He
was living in a nursing home and the nursing home closed. He had
an option to move to a different nursing home, but he did not
want to and decided to live on the streets instead. He started
drinking again when he left the nursing home. He has been
drinking since the age of ___. The longest he has been sober
has been for about ___ years. Keeping busy/working/exercising has
been helpful to maintain sobriety in the past.
He hears himself wheezing but does not feel short of breath. He
occasionally coughs, but it is not productive. No fevers/chills.
He has not vomited. He has never smoked.
ED COURSE: VS: Tmax 98.3, HR ___, BP 120s-140s/60s-80s, RR
___, SpO2 96-98% on RA Exam: "On exam, he is initially
sleeping comfortably, however when aroused, is immediately
profoundly tremulous, including arms, legs, and face/head. He is
not hallucinating or otherwise confused, although doesn't know
exactly where he is or what led to him coming here" Labs: Mag
1.4, serum EtOH 104, urine tox positive for benzos,
barbiturates, and opiates, AST 59, LDH 606 Imaging: CXR clear
Interventions/Meds: Diazepam 20 mg PO x1 Duoneb x1 Levofloxacin
750 mg IV x1 LR 1L x1 Diazepam 20 mg IV x1 Diazepam 20 mg PO x1
Thiamine 100 mg PO x1 Multivitamin 1 tab PO x1 Phenobarbital
259.2 mg PO x1 Magnesium sulfate 4 grams IV x1
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Psych:
-Bipolar disorder: Over 10+ hospitalizations since ___.
Multiple suicide attempts via overdose and wrist cutting.
History of ECT. History of manic episodes.
-Depression: history of multiple medication trials including
Trileptal, Seorquel, and Wellbutrin.
-Alcohol Abuse: Long history of abuse with 2 ICU stays for
withdrawal as well as multiple seizures. Notes family history
of alcoholism. Has had trouble with alcohol for around ___
years.
- Hep A: +HAVAb but -HAV IgM ___.
-Hep B: VL not detected ___
-Hep C: HCV VL 3,460,000 IU/mL, HBV not detected on ___.
-likely cirrhosis with evidence of portal hypertension and
thrombocytopenia; patient self-reports a history of cirrhosis,
not followed yet by hepatology
-COPD: 20 pack year smoking history. Quit in ___.
-GERD
-Chronic lower back pain - received 3 steroid injections.
PAST SURGICAL HISTORY:
-Cholecystectomy - ___
-Urethral stent placement - ___
Social History:
___
Family History:
- FATHER: alcoholism, died of esophageal cancer
- MOTHER: alcoholism, died of esophageal cancer
- SISTER: fibromyalgia
- BROTHER: diabetes ___
Physical Exam:
ADMISSION:
==========
VITALS: 24 HR Data (last updated ___ @ 1804)
Temp: 97.7 (Tm 97.7), BP: 147/80, HR: 97, RR: 18, O2 sat:
96%, O2 delivery: RA, Wt: 180.6 lb/81.92 kg
GENERAL: Alert, NAD, somnolent but easily arousable
EYES: Anicteric, PERRL, no nystagmus
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: Diffuse expiratory wheezing
ABD/GI: Soft, ND, NTTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
bilateral coarse resting tremor in hands/arms, mouth, tongue
PSYCH: pleasant, appropriate affect
Discharge exam:
===============
98.7 PO 117 / 68 62 18 97 Ra
General: Pleasant, comfortable
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities. Essential tremor (rest and movement) of
bilateral upper extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 06:15AM BLOOD WBC-5.2 RBC-4.48* Hgb-13.7 Hct-39.4*
MCV-88 MCH-30.6 MCHC-34.8 RDW-13.3 RDWSD-42.7 Plt ___
___ 06:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-146
K-4.5 Cl-105 HCO3-21* AnGap-20*
___ 06:55AM BLOOD ALT-19 AST-20 LD(LDH)-187 AlkPhos-50
TotBili-1.1
MICRO:
=====
Cdiff Positive PCR, Cdiff toxin positive
IMAGING/OTHER:
==============
___ CXR
No pneumonia or evidence of cardiac decompensation.
LABS ON DISCHARGE:
==================
___ 07:20AM BLOOD WBC-4.8 RBC-4.40* Hgb-13.7 Hct-40.8
MCV-93 MCH-31.1 MCHC-33.6 RDW-13.9 RDWSD-46.5* Plt ___
___ 07:20AM BLOOD Glucose-121* UreaN-14 Creat-0.7 Na-142
K-4.1 Cl-103 HCO3-26 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN mild to severe
2. FoLIC Acid 1 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QPM
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Propranolol 20 mg PO TID
7. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Alcohol Withdrawal
# Alcohol Use Disorder
# Clostridium difficile infection
# Bipolar Disorder with depressive symptoms
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 wheezing/cough. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph performed ___.
FINDINGS:
Lungs are well inflated and clear. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits.
Healed left rib fractures are long-standing.
IMPRESSION:
No pneumonia or evidence of cardiac decompensation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH
Diagnosed with Pneumonia, unspecified organism
temperature: 98.2
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 142.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with bipolar disorder and
alcohol use disorder who presented to the ED with alcohol
intoxication and withdrawal with course complicated by severe
bipolar depression and Clostridium difficile infection.
# Alcohol use disorder
# Alcohol withdrawal, history of withdrawal seizures:
Patient has a long-standing history of heavy alcohol use
complicated by severe withdrawal with seizures. He received PO
phenobarbital (about 4mg/kg) in the ED after receiving a few
doses of PO and IV diazepam. The diazepam did not significantly
improve his withdrawal symptoms but the phenobarbital did help.
Upon arrival to the floor, his CIWA score was 12 so he was given
an additional ~4mg/kg dose of PO phenobarbital with improvement
in his symptoms. He had no further symptoms of withdrawal. He
was counseled on EtOH cessation.
# BPD
# Major depression:
No current signs of mania but rather severe depression. He did
not endorse any SI. He does have a complex psychiatric history
including multiple inpatient hospitalizations requiring ECT. Due
to concern for a manic episode prompting recent EtOH binge,
psychiatry was consulted and recommended inpatient psychiatric
admission for bipolar disorder with depressive symptoms. Due to
diagnosis of Cdiff as below, ECT was initiated while on the
medicine floor with treatments on ___ and ___ before completion
of cdiff treatment. He was transferred to an inpatient
psychiatry facility for ongoing management of bipolar disorder
on discharge.
# C. diff diarrhea:
Developed liquid stools, C.diff PCR positive, toxin positive
confirming active infection. Was started on PO vancomycin on
___. His mild diarrhea resolved rapidly, within 2 days of
starting PO vancomycin. Last dose on ___ for total course
of 10 days of PO vancomycin for a first episode of non-severe
CDI.
# Tremor:
In the setting of EtOH withdrawal. Persisted for a significant
time after all other withdrawal symptoms subsided. Based upon
subsequent history obtained from the patient, sounds chronic and
most likely essential tremor. He reports having been
treated with propranolol in the past with success (he was able
to tell me the typical doses or propranolol without any
prompting). He reported a good initial response to 20 mg
propranolol, but this eventually stopped being as effective, and
his treatment was apparently limited by lightheadedness
("wooziness") at a dose of 40 mg of propranolol. Given this
history and patient having some significant difficulty with
tremor during eating/drinking (e.g. trouble holding cup of water
to mouth), propranolol started at 20mg TID. Outpatient neurology
f/u scheduled for ongoing evaluation of tremor.
# Dyspepsia:
Suspect EtOH-induced gastritis. Improved w/ empiric PPI which he
should continue through ___.
# Thrombocytopenia: Suspect EtOH-related. Remained stable in
110s. Will need outpatient follow-up of thrombocytopenia after
discharge.
# Chronic back pain:
Treated conservatively with heat packs, tylenol, and lidocaine
ointment/patch.
# Housing instability
Currently living on the streets. SW consulted for resources. He
will benefit from ongoing SW involvement at the inpatient
psychiatric unit. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim / Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with history of CAD (70% mid LAD, 80%
Diagonal,
100% occlusion of the LCx, mid RC 50-60%), PVD, T2DM, peripheral
neuropathy, CKD who presents with complaint of wheezing and
shortness of breath.
Evening of ___ she woke up in the middle of the night to
urinate
and noted shortness of breath and wheezing which resolved on its
own. Evening of ___ she again noted shortness of breath with
wheezing which she stated was ___. She also noted a chest
flutter sensation, denies any chest pain or palpitations. She
took a nitro SL but it did not change her symptoms. Her symptoms
started acutely. She denied any nausea, vomiting, chest pain,
abdoinal pain, palpitations, fevers, chills, diarrhea,
constipation, orthopnea, ___ edema. She denies any recent travel
or surgeries.
- In the ED, patient was afebrile, hypertensive to
160s-190s/50s-70s, HR ___, SpO2 high ___ on 3L.
- Exam was notable for: tachypnea, decreased breath sounds at
bases
- Labs were notable for: normal WBC, Cr 1.2, trop 0.02, BNP
2176,
VBG 7.39/47
- EKG: NSR, normal axis, normal intervals, STD V2-V4 <1mm
- CXR: no edema, effusions, or consolidations
- Bedside echo with normal EF. B-lines appreciated bilaterally.
- The patient was given:
___ 00:36SLNitroglycerin SL .4 mg
___ 02:39IHIpratropium-Albuterol Neb 1 NEB
___ 02:39IVFurosemide 40 mg
___:38IV DRIPNitroglycerin Started 0.1 mcg/kg/min
___ 03:38PO/NGAspirin 325 mg
___ 04:13IV DRIPNitroglycerin Rate Changed to 0.5
mcg/kg/min
___ 04:16IV DRIPNitroglycerin Rate Changed to 1
mcg/kg/min
___ 04:42IV DRIPNitroglycerin Rate Changed to 1.5
mcg/kg/min
___ 04:57IV DRIPNitroglycerin Rate Changed to 2
mcg/kg/min
___ 06:34IV DRIPNitroglycerin Rate Changed to 2.5
mcg/kg/min
___ 09:04IV DRIPNitroglycerinConfirmed Rate Changed to
3 mcg/kg/min
___ 09:50PO/NGAspirin 325 ___ 09:50SC
Insulin 4 Units
___ 11:19PO/NGOxyCODONE--Acetaminophen (5mg-325mg) 1
___ 11:19PO/NGGabapentin 600 mg
___ 12:35IV DRIPNitroglycerinConfirmed No Change in
Rate, rate continued at 3 mcg/kg/min
___ 14:30SCInsulin 10 Units
___ 18:32IV DRIPNitroglycerinConfirmed Rate Changed to
2 mcg/kg/min
___ 20:00SCInsulin 8 Units
___ 20:20PO/NGAtorvastatin 80 mg
___ 20:20PO/NGOxyCODONE--Acetaminophen (5mg-325mg) 1
TAB
___ 20:20PO/NGHydrALAZINE 25 mg
___ 20:20POIsosorbide Mononitrate (Extended Release)
120
mg
___ 20:20POMetoprolol Succinate XL 100 mg
___ 20:25IV DRIPNitroglycerinConfirmed Rate Changed to
1 mcg/kg/min
___ 20:54IV DRIPNitroglycerinConfirmed Rate Changed to
0.5 mcg/kg/min
___ 21:18IV DRIPNitroglycerinConfirmed Rate Changed to
0 mcg/kg/min
___ 21:30IV DRIPNitroglycerinStopped in Other Location
On arrival to the floor, the patient states she is feeling well
with no symptoms. She denies any chest pain or shortness of
breath. She is unclear at which point her symptoms improved.
Past Medical History:
CAD
Carotid stenosis status post CEA on the left
Significant PVD s/p multiple interventions
DMII
Back Pain
Depression
Hypercholesterolemia
HTN
PAST SURGICAL HISTORY:
___: Right external iliac artery to profunda femoral artery
bypass graft with 6 mm ringed PTFE.
___: Right ___ toe debridement of skin, subcutaneous tissue and
nail. Second toe debridement of skin, subcutaneous tissue and
bone.
___: Ileofemoral/profunda femoral endarterectomy with Saphenous
vein patch angioplasty. Right profunda femoral to peroneal
artery
bypass graft using non reverse greater saphenous vein
___: Revision of left femoral to peroneal artery bypass graft
with jump graft using reversed left arm cephalic vein.
___: Left common femoral to peroneal artery bypass with non
reversed saphenous vein graft
___: Left carotid endarterectomy
Social History:
___
Family History:
Mother deceased at ___. Father deceased at ___ of myocardial
infarction. Sister deceased at ___, pancreatic cancer. Brother
deceased at ___, GI tract cancer. All other siblings are deceased
secondary to complications of diabetes and high blood pressure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 0048 BP: 152/68 HR: 79
___ 0022 Temp: 97.4 PO BP: 173/59 HR: 64 RR: 18 O2 sat: 95%
O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVD to mid neck at 45
degrees.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ SEM
best heard at ___
LUNGS: Faint crackles at lung bases bilaterally. No wheezes,
rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: trace pedal edema bilaterally, 1+ DP pulses b/l,
s/p
toe amputations, no visible ulcers
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout.
DISCHARGE PHYSICAL EXAM
=========================
VITALS: 24 HR Data (last updated ___ @ 1127)
Temp: 98.3 (Tm 98.4), BP: 116/60 (116-179/59-74), HR: 74
(65-77), RR: 20 (___), O2 sat: 94% (92-94), O2 delivery: RA,
Wt: 177.47 lb/80.5 kg
GENERAL: In NAD
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM
NECK: JVP ~10 cm
CARDIAC: RRR, ___ systolic murmur best heard at ___
LUNGS: CTAB
EXTREMITIES: Warm, no ___ edema bilaterally, s/p toe amputations,
no visible ulcers
SKIN: No visible rashes
NEUROLOGIC: A&Ox3, motor and sensation grossly intact.
Pertinent Results:
___ 01:22AM BLOOD WBC-9.0 RBC-3.44* Hgb-10.2* Hct-33.3*
MCV-97 MCH-29.7 MCHC-30.6* RDW-13.1 RDWSD-46.1 Plt ___
___ 01:22AM BLOOD ___ PTT-32.8 ___
___ 01:22AM BLOOD Glucose-208* UreaN-31* Creat-1.2* Na-140
K-4.7 Cl-104 HCO3-25 AnGap-11
___ 01:22AM BLOOD CK(CPK)-388*
___ 01:22AM BLOOD CK-MB-11* MB Indx-2.8 proBNP-2176*
___ 01:22AM BLOOD cTropnT-0.02*
___ 06:55AM BLOOD cTropnT-0.05*
___ 03:53PM BLOOD cTropnT-0.05*
___ 07:45AM BLOOD CK-MB-4 cTropnT-0.02*
___ 10:21AM BLOOD CK-MB-9 cTropnT-0.07*
___ 05:11PM BLOOD cTropnT-0.87*
___ 11:10PM BLOOD cTropnT-1.16*
___ 07:15AM BLOOD cTropnT-1.30*
___ 07:45AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.6
___ 03:22PM BLOOD %HbA1c-7.9* eAG-180*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO DAILY
2. Gabapentin 600 mg PO QPM
3. Gabapentin 900 mg PO QHS
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, chest tightness
5. amLODIPine 10 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. BuPROPion 75 mg PO BID
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. HydrALAZINE 25 mg PO TID
10. NPH 28 Units Breakfast
NPH 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM back pain
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain -
Moderate
16. Rivaroxaban 2.5 mg PO BID
17. Aspirin 81 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. HydrALAZINE 50 mg PO TID
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. NPH 28 Units Breakfast
NPH 5 Units Bedtime
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, chest tightness
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. BuPROPion 75 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Gabapentin 300 mg PO DAILY
12. Gabapentin 900 mg PO QHS
13. Gabapentin 600 mg PO QPM
14. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM back pain
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain
- Moderate
18. Rivaroxaban 2.5 mg PO BID
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypertensive Emergency
Secondary: CAD, DM2, CKD, PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with possible flash pulmonary edema// eval for pulmonary
edema
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___
FINDINGS:
There is no focal consolidation, pleural effusion, or pneumothorax. Compared
to the prior chest radiograph right basilar atelectasis has mildly improved.
Heart size is top-normal. Chronic elevation of the right hemidiaphragm,
unchanged, accounts for vascular crowding and mild atelectasis at the right
lung base. Aorta, with dense degenerative calcifications in the knob, has an
otherwise normal contour.
IMPRESSION:
No acute cardiopulmonary process, specifically no pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CAD w/ new onset CP, dyspnea// ? pulm
edema
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with subsegmental atelectasis in the right lung base.
The patient is rotated to the left. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 97.5
heartrate: 66.0
resprate: 16.0
o2sat: 97.0
sbp: 185.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ year old woman w/ ___ CAD (70% mid LAD,
80% Diagonal, 100% occlusion of the LCx, mid RC 50-60%), PVD,
DM2, CKD who presented with dyspnea and chest pain, found to be
in a hypertensive emergency with demand ischemia and flash
pulmonary edema.
TRANSITIONAL ISSUE:
=========================
[ ] Follow up blood pressure and basic metabolic panel at
post-hospitalization visit
ACTIVE ISSUES:
=========================
#HYPERTENSIVE EMERGENCY:
#ACUTE HYPOXEMIC RESPIRATORY FAILURE ___ FLASH PULMONARY EDEMA:
#NSTEMI, TYPE II:
#CORONARY ARTERY DISEASE:
Felt to be secondary to recently held losartan/hctz given
concern for progressive CKD outpatient. First felt dyspneic on
___ ___, worse on ___, and then presented to the ___ ED. Did
well in the ED on a nitro gtt and was diuresed, weaned from O2
to room air. Overnight, minimal events, until the first day of
her admission when she triggered for acute hypoxemic respiratory
failure and severe hypertension to 220s/120s. It appeared that
she still needed further diuresis and titration of her blood
pressure medications while on a nitro gtt. Nitro gtt was
re-started, and blood pressure medications rapidly titrated up
along with diuresis. The patient's blood pressure quickly
dropped to a much safer level within the hour, and was soon back
on room air, and was stable over the next two days. Please see
below for her final antihypertensive regimen at discharge.
Additionally, she had chest pain that resolved with her blood
pressure and diuresis. Trops were trended and did increase, but
not trended further despite further increase because she was
completely asymptomatic. All of this was felt to be demand
ischemia from her hypertensive emergency. Additionally, she did
not require any further diuresis once her blood pressure was
under better control.
CHRONIC/STABLE ISSUES:
=========================
#PVD:
- Continued home antiplatelets
#CKD:
- Monitored closely in the hospital. Did not restart hctz but
did restart losartan due to uncontrolled blood pressure.
#NEUROPATHY:
- Continued home pain medications
#DM2:
- Continued home insulin. No changes made.
#DEPRESSION:
- Continued home bupropion |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
PICC insertion, left upper extremity
attach
Pertinent Results:
DISCHARGE LABS:
___ 06:57AM BLOOD WBC-2.7* RBC-3.51* Hgb-11.1* Hct-33.5*
MCV-95 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.2 Plt ___
___ 06:57AM BLOOD Neuts-45.0 ___ Monos-13.1*
Eos-4.1 Baso-0.7 Im ___ AbsNeut-1.20* AbsLymp-0.98*
AbsMono-0.35 AbsEos-0.11 AbsBaso-0.02
___ 06:57AM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-143
K-3.3* Cl-105 HCO3-26 AnGap-12
___ 06:57AM BLOOD ALT-5 AST-12 LD(LDH)-146 AlkPhos-59
TotBili-0.2
___ 06:57AM BLOOD Mg-1.7
MICRO:
___: ___ MSSA, ___ Acenitobacter radioresistens
___: NGTD
___: NGTD
___: NGTD
MRI:
1. Unchanged configuration of a T12 compression fracture, with
persistent high signal on water ideal images. Retropulsion
results in mild canal narrowing, but no cord compression or
signal abnormality.
2. There is no evidence of vertebral discitis/osteomyelitis, or
epidural
abscess.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diphenoxylate-Atropine 1 TAB PO Q6H
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
4. Escitalopram Oxalate 30 mg PO DAILY
5. Fludrocortisone Acetate 0.2 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. LOPERamide 4 mg PO QID diarrhea
9. Midodrine 2.5 mg PO TID
10. Montelukast 10 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Rivaroxaban 20 mg PO QPM
13. Simvastatin 20 mg PO QPM
14. Thiamine 100 mg PO DAILY
15. Omeprazole 40 mg PO BID
16. Potassium Chloride 20 mEq PO DAILY
17. Prochlorperazine 5 mg IV Q8H:PRN Nausea/Vomiting - First
Line
Reason for PRN duplicate override: Not tolerating PO
18. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
19. dutasteride 0.5 mg oral QHS
20. LORazepam 0.5 mg PO Q6H:PRN nausea
21. Promethazine 25 mg PO Q6H:PRN nausea
22. Niacin SR 1000 mg PO BID
Discharge Medications:
1. CeFAZolin 2 g IV Q8H Duration: 23 Days
last day ___ (4 weeks from first negative culture, ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every
eight (8) hours Disp #*60 Intravenous Bag Refills:*0
2. Ciprofloxacin HCl 500 mg PO BID Duration: 8 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*17 Tablet Refills:*0
3. Lidocaine Jelly 2% 1 Appl TP ONCE Duration: 1 Dose
apply to lower back for back pain
RX *lidocaine 5 % apply thin film twice daily as needed
Refills:*0
4. sodium chloride 0.9 % injection 6X/WEEK for orthostatic
hypotension
NS 1L IV with MVI-13 added, 6 days per week PRN
RX *sodium chloride 0.9 % 1 Liter IV 6 days per week, PRN Disp
#*24 Cartridge Refills:*0
5. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
6. Diphenoxylate-Atropine 1 TAB PO Q6H
7. Dolutegravir 50 mg PO DAILY
8. dutasteride 0.5 mg oral QHS
9. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
10. Escitalopram Oxalate 30 mg PO DAILY
11. Fludrocortisone Acetate 0.2 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. LevETIRAcetam 1000 mg PO BID
14. LOPERamide 4 mg PO QID diarrhea
15. LORazepam 0.5 mg PO Q6H:PRN nausea
16. Midodrine 2.5 mg PO TID
17. Montelukast 10 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Niacin SR 1000 mg PO BID
20. Omeprazole 40 mg PO BID
21. Potassium Chloride 20 mEq PO DAILY
22. Prochlorperazine 5 mg IV Q8H:PRN Nausea/Vomiting - First
Line
Reason for PRN duplicate override: Not tolerating PO
23. Promethazine 25 mg PO Q6H:PRN nausea
24. Rivaroxaban 20 mg PO QPM
25. Simvastatin 20 mg PO QPM
26. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Staph aureus (methicillin-susceptible) bacteremia
Acenitobacter bacteremia
Acute right upper extremity Deep vein thrombosis associated with
PICC line
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with PICC // PICC position
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided PICC terminates in the low SVC, without evidence of pneumothorax.
1.3 cm nodular opacity projects over the right upper chest with associated
fiducial marker, similar to prior, compared to today's measurement of the
prior study measuring the same size. No new focal consolidation is seen.
There is no pleural effusion or pneumothorax. Cardiac silhouette size is
borderline to mildly enlarged. Mediastinal contours are unremarkable..
IMPRESSION:
Right-sided PICC terminates in the low SVC.
Redemonstrated right upper lung nodular opacity with fiducial marker, similar
to prior. No new focal consolidation.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with diarrhea, now no BM. n/v. Hx of
anal Ca s/p radiationNO_PO contrast // bowel obstruction
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 13.4 mGy (Body) DLP = 678.8
mGy-cm.
Total DLP (Body) = 691 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Calcification is noted of the
mitral annulus.
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 not visualized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Left renal
cysts measure up to 2.5 cm. There left cortical and parapelvic cysts. There
is no perinephric abnormality.
GASTROINTESTINAL: Moderate hiatal hernia. The stomach is unremarkable. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Diverticulosis of the sigmoid colon is noted, without evidence of
wall thickening or fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Severe T12 compression deformity appears increased when compared to the
study from ___, but similar compared to ___. There
is no significant change in alignment.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal process. Diverticulosis without evidence of acute
diverticulitis.
2. Moderate hiatal hernia.
3. Severe T12 compression deformity appears increased when compared to the
study from ___, but similar compared to ___. There
is no significant change in alignment.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ w/ PICC in right UE, now with staph bacteremia, eval for clot
// please include RUE and right neck for evidence of thrombus
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
There is a nonocclusive DVT in the right axillary vein. Also seen is a
nonocclusive thrombus in the right basilic vein.
The right internal jugular and brachial veins are patent, show normal color
flow, spectral doppler, and compressibility. The right cephalic vein is
patent, compressible and show normal color flow.
IMPRESSION:
Nonocclusive DVT in the right axillary vein and basilic vein.
NOTIFICATION: Findings were communicated via telephone with ___, MD
on ___ at 15:20, 15 minutes after discovery of findings.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ w/ MSSA bacteremia, back pain // ?vertebral osteo
?vertebral osteo
please include T and L-spine, eval for osteo/abscess
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: CT abdomen and pelvis dated ___
and ___.
FINDINGS:
THORACIC:
There is exaggerated thoracic kyphosis centered at T9. Alignment is otherwise
normal. There is a compression fracture of the T12 vertebral body with
increased STIR and decreased T1 signal. The vertebral body enhances after
contrast administration. Overall the degree of compression is more severe in
comparison with ___, but comparable to the ___
suggesting that this is subacute. Vertebral body signal intensity is
otherwise preserved. There is loss of disc height and disc desiccation signal
throughout the thoracic spine.
There is no canal or neural foraminal narrowing from T1-T2 through T9-10.
Ligamentum flavum thickening/facet osteophytes at T9-10 results in mild canal
narrowing. At T11-12, there is mild canal narrowing due to retropulsion of
the superior T12 vertebral body. There is also mild bilateral neural
foraminal narrowing. At T12-L1, there is no canal narrowing. Mild bilateral
neural foraminal narrowing is noted.
LUMBAR:
Alignment is normal.Vertebral body signal intensity is normal. There is mild
disc desiccation signal throughout the lumbar spine.The conus medullaris
terminates at L1.There is no evidence of infection or neoplasm. There is no
abnormal enhancement after contrast administration.
At L1-2 and L2-3, there is no canal or neural foraminal narrowing.
At L3-4, small broad disc bulge in combination with facet hypertrophy and
ligamentum flavum thickening results in mild canal narrowing. There is mild
left greater than right neural foraminal narrowing.
At L4-5, a disc bulge with superimposed central protrusion in combination with
mild facet hypertrophy and ligamentum flavum thickening results in mild canal
narrowing. No neural foraminal narrowing.
At L5-S1, minimal disc bulge is present without canal narrowing. No neural
foraminal narrowing.
OTHER: Numerous left peripelvic T2 hyperintense renal cysts and a cortical
cysts are noted.
IMPRESSION:
1. Unchanged configuration of a T12 compression fracture, with persistent high
signal on water ideal images. Retropulsion results in mild canal narrowing,
but no cord compression or signal abnormality.
2. There is no evidence of vertebral discitis/osteomyelitis, or epidural
abscess.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Vomiting, unspecified, Diarrhea, unspecified, Left upper quadrant pain, Tachycardia, unspecified
temperature: 98.4
heartrate: 124.0
resprate: 24.0
o2sat: 100.0
sbp: 163.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
PCP:
- please assess clinical resolution of bacteremia
- please discontinue PICC following full course of antibiotics
- Determine need for DEXA scan to evaluate for osteoporosis in
setting of T12 compression fracture in a male.
- CT chest ___ with bilateral pulmonary nodules, the majority
of which are stable however there is a slightly larger 4 mm
nodule which is seen along the course of prior biopsy tract.
Three to six-month follow-up chest CT is suggested.
- ___ year follow-up from ___ renal ultrasound to assess
interval change of the 3.6 cm right upper pole cyst
HOSPITAL COURSE:
#Staph bacteremia:
#Acenitobacter bacteremia:
#low back pain: MSSA bacteremia ___ bottles) + 1 Acenitobacter
___ bottles on initial set; of less clear clinical
significance), associated with PICC placed for daily hydration
at home. Working up any metastatic infection unrevealing. TTE
showing RA density, but nothing apparent on TEE. MRI not
suggesting osteo. Initially on Vanc/CTX. Cleared culture x72+
hours. Transitioned to Cefazolin 2g Q8 and Cipro 500 BID with
plans for 4 weeks (given the presence of a DVT) and 14 days,
respectively. In the meantime, while pt is to have his PICC in
place, continued the daily PRN saline boluses, though this plan
will be evaluated by PCP ___ 4 week treatment, given the
risk of complication long term.
#PEs:
#acute DVT: R First incident of clot per chart was ___.
Segmental and Subsegmental diagnosed in ___ and now confirmed
PICC-related DVT in right axillary vein as of pm of ___ pt
endorsing rivaroxaban adherence at home. Heme feeling that low
burden PE I/s/o PICC does not represent treatment failure and
may continue Rivaroxaban.
#niacin flushing reaction: Patient with an acute onset of upper
chest, bilateral UE flushing on day 6 of admission, with
pruritus, resolved in 2 hours without intervention. No evidence
of other drug rash. No recurrence. Most consistent with a niacin
reaction. Pt endorses generally not taking at home. He is on
Niacin per Dr. ___ oncologist, due to low niacin
levels, attributed to his ___
(which reportedly can cause pellagra). Unclear whether there was
some issue with his SR formulation releasing immediately; it was
restarted on a trial basis as of ___ with the plan to discontinue
if subsequent reaction occurred.
#RECURRENT ACUTE ON CHRONIC NAUSEA AND VOMITING, LACTIC ACIDOSIS
(RESOLVED): Multiple workups unrevealing. Patient reports
symptoms worsened following his chemotherapy, so GI thinks this
is possibly cisplatin-induced gastroparesis. He has previously
had an extensive work-up of his diarrhea during inpatient
hospitalizations, which has been notable for an elevated fecal
calprotectin, colonoscopy ___ without active mucosal
inflammation, normal MRE aside from known hepatic steatosis, and
stool cultures negative for c diff, campylobacter, salmonella or
shigella. Last hospitalization team attributed symptoms to
alcoholic hepatitis/gastritis in setting of AST>>ALT. This
dmission transaminases and lipase are normal, making alcoholic
hepatitis/gastritis less likely. During his stay, intermittently
with nausea Sx seemingly without specific prompt, but resolved
with PRN. Most effective agent appears to have been Compazine
IV. No nausea over the 2 days prior to ___. Returned on regular
home regimen.
#CHRONIC DIARRHEA: Has been worked up extensively both as
inpatient and outpatient in past and workup has been largely
negative. Per GI, they suspect diarrhea is related to past
radiation from anal cancer treatment as well as dysmotility from
his cisplatin treatment. Loperamide dose increased on last
discharge. Gets standing K supplementation. On the floor,
diarrhea is improved somewhat.
#CHRONIC ORTHOSTATIC HYPOTENSION: Likely ___ chronic diarrhea
and autonomic neuropathy, possibly from chronic alcohol, at home
on midodrine and fludrocortisone 0.2 and per pt gets 1L fluid
through PICC every day. BP generally stable this admission
though did have +orhtostatics responsive to NS bolusing
#ANEMIA: Stable, normocytic. No evidence of hemolysis on prior
admissions. Had normal B12, folate. Ferritin > 100, making iron
deficiency less likely, but with iron sat <20% need to consider
iron supplementation. Would repeat iron studies as outpatient.
# GERD, ___ ESOPHAGUS: Omeprazole increased to 40mg BID
last hospitalization. Will continue.
# THORACIC COMPRESSION FRACTURE: Severe T12 compression
deformity, new in ___. MRI was repeated given his staph
bacteremia without e/o diskitis but with disc retropulsion,
accounting for his pain. Partial response to Tylenol and lido;
but pt tolerating ambulation as of ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L arm and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of IDDM,
HTN, and asthma but no known history of CAD or chest pain who
presented to ___ with L arm and chest pain and was
found to have lateral TWI and trop-I 0.33 concerning for NSTEMI.
He was transferred to ___ for further management.
Patient reports he was in his usual state of health until ~9pm
evening before presentation, when he noticed dull left arm pain.
He works as a ___, often lifting, and didn't think much of
the pain. He did check his blood pressure and noted it to be
220/100. His wife suggested he go to the ED but he declined.
Around ___ pain woke him up and he took an extra dose of
clonidine and returned to bed. He woke up again at 0500 with
dizziness. He called out of work. He was able to sleep until
0900 when he awoke with persistent L arm pain that now extended
into L lateral chest. Pain is dull, pressure like, and got worse
with exertion.
At ___, patient received SLNTG with improvement in pain. He
was started on a heparin gtt and received a full-strength ASA.
He was noted to be hyperglycemic, with f/s 400. Cr was 1.7
(denies known history of kidney disease, though has had
refractory HTN and baseline Cr 1.1-1.3).
He was transferred to our ED, where initial vitals were 6 98.4
85 141/95 18 98% . Trop-T was 0.08 --> 0.10 and Cr had improved
to 1.4. EKG showed LVH, TWI in V4-V6 and II, III, and aVF, and
J-point elevation in V1-V2. He was continued on a heparin gtt,
which was decreased from 1090 units/hr to 590 units/hr for
unknown reason (possibly high PTT at OSH? First PTT here 86). He
had returning CP and was put on NTG gtt starting at 0.14mcg;
this was briefly increased to 0.44 for ongoing CP. He was
admitted to the ___ service for medical management and
consideration of catheterization. Vitals prior to transfer were
5 98.7 70 158/93 18 99% RA.
On arrival to the floor, patient is sitting comfortably in bed.
He reports ongoing ___ CP that is dull and constant, radiating
down L arm. No associated SOB, dizziness, lightheadedness,
abdominal pain, tearing pain. Morphine was ordered but when RN
went to administer, patient had fallen asleep.
Of note, patient's wife reports that his HTN is refractory and
he has been seen by a HTN specialist, who told them patient's
kidneys are fine. He underwent ETT in ___ that was negative for
ischemia. She reports he is so used to running high that he
feels dizzy with SBP's in 120's. He recently ran out of
amlodipine due to a refill problem and has been off of that for
several days. She also reports his blood sugars are poorly
controlled.
Also of note, patient is on furosemide for an unclear
indication. He says it is to "help me pee," and denies a history
of CHF or edema. He denies CAD, prior MI's, prior CP, orthopnea,
PND, or palpitations. His mother died suddenly at age ___ of
unknown causes but there is no known family history of early
CAD.
On reassessment, patient continues to sleep comfortably.
Past Medical History:
- IDDM: poorly controlled per report
- Asthma
- HTN: poorly controlled ___ medication non-compliance
- HL
- Seasonal allergies
Social History:
___
Family History:
- Mother died suddenly at age ___ (cause unknown)
- Father died of old age at ___
- No family history of CAD, MI, or CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: 98 160/104 66 16 100 RA 91.4 kg
GENERAL: NAD, very comfortable-appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. PMI
nondisplaced. Chest wall non-tender.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing or edema
PULSES: 2+ ___ pulses bilaterally
NEURO: CN II-XII intact, A+O x 3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
===========================
Vitals: 98.1, 140/80, 72, 18, 98% on RA
GENERAL: NAD, very comfortable-appearing
HEENT: NCAT, EOMI, injected conjunctiva, patent nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. PMI
nondisplaced. Chest wall non-tender.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing or edema
PULSES: 2+ ___ pulses bilaterally
Pertinent Results:
ADMISSION LABS
=================
___ 04:10PM BLOOD WBC-4.4 RBC-3.32* Hgb-10.8* Hct-31.3*
MCV-94 MCH-32.6* MCHC-34.6 RDW-12.1 Plt ___
___ 04:10PM BLOOD Neuts-40.4* Lymphs-46.2* Monos-8.2
Eos-4.6* Baso-0.6
___ 04:10PM BLOOD ___ PTT-86.6* ___
___ 04:10PM BLOOD Glucose-300* UreaN-22* Creat-1.4* Na-138
K-3.9 Cl-103 HCO3-33* AnGap-6*
___ 10:57PM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1
NOTABLE LABS
===============
___ 08:00AM BLOOD Glucose-123* UreaN-16 Creat-1.4* Na-138
K-3.9 Cl-102 HCO3-31 AnGap-9
___ 07:10AM BLOOD Glucose-130* UreaN-19 Creat-1.5* Na-140
K-3.9 Cl-101 HCO3-30 AnGap-13
___ 04:10PM BLOOD CK-MB-6
___ 04:10PM BLOOD cTropnT-0.08*
___ 10:45PM BLOOD cTropnT-0.10*
___ 10:57PM BLOOD CK-MB-7
___ 08:00AM BLOOD CK-MB-11* cTropnT-0.30*
___ 06:46PM BLOOD CK-MB-7 cTropnT-0.24*
___ 10:57PM BLOOD ___ PTT-34.0 ___
___ 08:00AM BLOOD ___ PTT-49.0* ___
___ 09:45AM BLOOD ___ PTT-72.9* ___
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:30PM URINE Color-Straw Appear-Clear Sp ___
___ 02:21PM URINE Color-Straw Appear-Clear Sp ___
___ 04:56AM URINE Hours-RANDOM UreaN-304 Creat-43 Na-113
K-10 Cl-95
___ 04:56AM URINE Osmolal-347
DISCHARGE LABS
================
___ 07:55AM BLOOD WBC-3.8* RBC-3.37* Hgb-10.8* Hct-32.0*
MCV-95 MCH-32.1* MCHC-33.9 RDW-12.2 Plt ___
___ 07:55AM BLOOD Glucose-148* UreaN-23* Creat-1.5* Na-138
K-3.8 Cl-100 HCO3-28 AnGap-14
___ 07:55AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.0
STUDIES
===========
ECG (___): Sinus rhythm with marked first degree A-V delay.
Left ventricular hypertrophy. Secondary ST-T wave inversions in
the lateral leads, probably due to left ventricular hypertrophy.
Cannot exclude ischemia. No significant change compared to three
previous tracings of ___.
CT HEAD W/O CONTRAST (___): IMPRESSION: No acute
intracranial process
RENAL ULTRASOUND WITH DOPPLERS (___): The right kidney
measures 10.7 cm and is normal morphology. The cortex is normal
in thickness and echogenicity. There is no hydronephrosis or
perinephric fluid collection. The left kidney measures 9.9 cm
with normal echotexture, no perinephric fluid collections, and
normal morphology. There is no hydronephrosis. In the right
kidney, the resistive indices of the intrarenal arteries ranges
from 0.66 is 0.7, within the normal range. In the left kidney,
the resistive indices of the intrarenal arteries ranges from
0.64-0.73, within the normal range. Acceleration times and peak
systolic velocities of the main renal artery are normal.
Appropriate flow and waveforms are seen in the main renal veins
bilaterally. No evidence of tardus parvus waveforms. The
bladder is filled with fluid and is normal.
IMPRESSION: Normal bilateral renal ultrasound with appropriate
arterial resistive indices.
STRESS TEST (___): RESTING DATA
EKG: NSR, 1ST DEGREE AVD, LVH W/ REPOL ABN
HEART RATE: ___ PRESSURE: 170/98
PROTOCOL ___ - TREADMILL
STAGETIMESPEEDELEVATIONHEARTBLOODRPP
(MIN)(MPH)(%)RATEPRESSURE
___
___
___
TOTAL EXERCISE TIME: 9.5% MAX HRT RATE ACHIEVED: 81
SYMPTOMS:NONE
INTERPRETATION: This was an active ___ year old DM2 man with HTN
and
HLD, who was referred to the lab from the inpatient floor for an
evaluation of chest discomfort in the setting of recent NSTEMI
(___). He exercised for 9.5 minutes of ___ protocol
___ METs)
and stopped due to fatigue. This represents an average
functional
capacity for his age. He denied any chest, arm, neck or back
discomforts, inappropriate shortness of breath, palpitations or
symptoms
of exercise intolerance throughout the study. In the setting of
diffuse
ST T wave abnormalities on baseline ECG due to LVH with strain,
the ECG
was uninterpretable for evaluating ischemic changes. However,
the ST
segment and T wave morphologies did not change from baseline
during
exercise or in recovery. The rhythm was sinus with rare isolated
APB's
seen during exercise. There was marked hypertension at rest with
an
exaggerated hypertensive blood pressure response to exercise.
The heart
rate responded appropriately to both exercise and recovery.
IMPRESSION: ECG uninterpretable for ischemia evaluation in the
setting
of LVH w/ strain. No anginal type symptoms. Resting hypertension
with
exaggerated hypertensive response to exercise. Average
functional
capacity demonstrated. Echo report sent separately.
STRESS TTE (___): LVEF >55%. The patient exercised for 9
minutes30 seconds according to ___ treadmill protocol (10.6
METS) reaching a peak heart rate of 130 bpm and a peak blood
pressure of 220/90 mmHg. The test was stopped because of
fatigue. This level of exercise represents an average exercise
tolerance for age. The exercise ECG was uninterpretable due to
resting ST-T wave changes (see exercise report for details). The
blood pressure response to stress was abnormal/mildly
hypertensive.
Resting images were acquired at a heart rate of 62 bpm and a
blood pressure of 170/98 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Echo
images were acquired within 98 seconds after peak stress at
heart rates of 120 - 85 bpm. These demonstrated appropriate
augmentation of all left ventricular segments with slight
decrease in cavity size.
IMPRESSION: Average functional exercise capacity with baseline
hypertension and hypertensive BP response to exercise. ECG not
interpretable for ischemia in the presence of baseline
abnormalities. No 2D echocardiographic evidence of inducible
ischemia to achieved workload.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Amlodipine 10 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4-6h prn SOB, wheezing
6. Metoprolol Succinate XL 200 mg PO DAILY
7. CloniDINE 0.3 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
5. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
7. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4-6h prn SOB, wheezing
9. Outpatient Lab Work
Please have chemistry-10 panel drawn on ___
DX: Unspecified essential hypertension ICD-9 Code: ___.
Please Fax Results To: ___. Fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
# Type II Non-ST Elevation Myocardial Infarction
# Hypertensive Emergency
# Acute Kidney Injury
CHRONIC ISSUES
===============
# Insulin Dependent Diabetes Mellitus
# Asthma
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with headaches, hypertensive urgency // bleed or
mass, mass effect
TECHNIQUE: Contiguous axial images CT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 891.93 mGy-cm
CTDI: 54.63 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction. The
ventricles and sulci are normal in size and configuration. The basal cisterns
appear patent and there is preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Uncontrolled hypertension, elevated creatinine and elevated
microalbumin to creatinine ratio.
Technique: Grayscale, color, and spectral Doppler evaluation of the kidneys.
COMPARISON: None
FINDINGS:
The right kidney measures 10.7 cm and is normal morphology. The cortex is
normal in thickness and echogenicity. There is no hydronephrosis or
perinephric fluid collection. The left kidney measures 9.9 cm with normal
echotexture, no perinephric fluid collections, and normal morphology. There
is no hydronephrosis.
In the right kidney, the resistive indices of the intrarenal arteries ranges
from 0.66 is 0.7, within the normal range.
In the left kidney, the resistive indices of the intrarenal arteries ranges
from 0.64-0.73, within the normal range.
Acceleration times and peak systolic velocities of the main renal artery are
normal. Appropriate flow and waveforms are seen in the main renal veins
bilaterally. No evidence of tardus parvus waveforms.
The bladder is filled with fluid and is normal.
IMPRESSION:
Normal bilateral renal ultrasound with appropriate arterial resistive indices.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: NSTEMI
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 98.4
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 95.0
level of pain: 6
level of acuity: 2.0 | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ gentleman
with a history of difficult-to-manage HTN and IDDM who presented
with 1 day of L arm and chest pain and was found to have cardiac
enzyme elevation and EKG changes consistent with NSTEMI.
Initially, pt's NSTEMI managed for ACS with heparin gtt.
Following evaluation, pt's NSTEMI was thought to be type 2
demand ischemia in the setting of hypertensive emergency. As his
BP improved on a nitro gtt, pt's chest pain and arm pain
resolved. Exercise stress test was done and returned within
normal limits. He was started on a modified anti-hypertensive
regimen with success. BPs on day of discharge 130-150s/70-90s.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with left arm and chest pain. He was
found to have elevated cardiac enzymes and t-wave inversions in
inferior leads consistent with NSTEMI. Pt was found to be in
hypertensive emergency which was thought to be the likely cause
of his symptoms resulting in demand ischemia and a type II
NSTEMI. Pt. was initially medically managed with heparin gtt
which was later discontinued following improvement of his
symptoms with improvement of his blood pressures (arguing
against a coronary event). Pt. was maintained on heparin gtt
for 24 hours and d/c'ed when coronary event was thought to be
unlikely. Given significant risk factors of age, HTN, DM and
NSTEMI, pt. had a stress TTE which was without wall motion
abnormalities at rest and without ischemic changes with exercise
supporting more of a demand ischemia event. He was discharged
on ASA 81mg, atorvastatin 80mg, beta blockade, and ace
inhibitor.
# Hypertensive emergency: Per PCP, ___. has had difficult to
treat hypertension most likely ___ non-compliance. Pt. was
noted to be with SBP at home in 220s and on admission in 180s.
He was initially managed with nitro gtt and later transitioned
to a 4 drug oral regimen including amlodipine, chlorthalidone,
carvedilol, and lisinopril which he tolerated well. Pt. had a
significant headache, following admission in addition to blurry
vision in the setting of anti-plt therapy. For concern of an
intracranial bleed, pt. had a NCHCT which was negative for an
acute intracranial process. His neuro exam remained non-focal
and his vision returned to baseline shortly following improved
blood pressure control. We had extensive discussion with pt.
regarding the long-term effects of hypertension. It seems that
pt. has been non-compliant because he sometimes feels that his
BP meds make him lightheaded especially when he is at work (his
job is strenuous as he is a ___).
# ___: Pt. with ___ above his known baseline creatinine of
1.1-1.3 (in ___ records, verified by PCP). His creatinine
was elevated on admission consistent with ___. His urine lytes
return with evidence of intrinsic injury with FeNa 2.8%, FeUrea
55.8% consistent with ___ ___ hypertensive emergency. His
creatinine remained stable. He was instructed to have repeat
chemistry in approximately 7 days as an outpatient.
CHRONIC ISSUES
=================
# IDDM: Stable. Continued on home regimen of glargine 34 units
qAM and Humalog ISS
# Asthma: Continued Albuterol nebs prn
# Hyperlipidemia. Continued Atorvastatin 80mg daily
TRANSITIONAL ISSUES
===================
# Type 2 NSTEMI: Pt. continued on atorvastatin 80, asa 81,
carvedilol, and lisinopril at discharge.
# Hypertensive emergency: Pt. managed initially on nitro gtt
transitioned to PO regimen consisting of lisinopril,
chlorthalidone, carvedilol, and amlodipine.
# Outpatient Labs: Pt. should have repeat chemistries drawn one
week after discharge (sometime after ___.
# Code: Full Code
# Emergency Contact: Wife ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefepime / Ragweed
Attending: ___.
Chief Complaint:
cough, congestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with a history of
lymphoblastic blast crisis of CML day ___ after a double cord
transplant who presented to the ED with productive cough,
headache, sinus and ear congestion. Patient reports acute onset
of symptoms x4 d ago, since then little relief with flonase,
sudafed 30mg bid, allegra. Patient has a history of sinus
infections in the past, previously seen by ENT, intermittently
treated with Augmentin. Pt went to ENT today for appt, but was
told that her insurance expired, and was referred here to the ER
for eval.
In the ED, initial vitals were: 96.5 118 115/68 20 95%. Labs
were significant for WBC 17, Cr 1.7 (baseline 1.3-1.5), lactate
2.1. CXR was concerning for multifocal PNA. Patient was given
750mg po levoflox, Zofran, 650mg acetaminophen, an albuterol
neb, and Tesselon pearles as well as 1L NS. Case was discussed
with Dr. ___ recommended admission. Vitals prior to
transfer were 98.1 104 134/69 18 97%
Review of Systems:
(+) Endorses congestion, nose bleeds, nausea, and vomiting
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin
breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
BREAST CANCER ___: L infiltrating ductal ca dx ___ and tx
lumpectomy, axillary node dissection, chemo and XRT. Followed by
___. Has declined Tamoxifen. s/p prophylactic BSO in
___.
.
CML
1. CML diagnosed ___, started on imatinib on ___,
went into CHR and had a partial cytogenetic and major molecular
response.
2. Noticed to have blasts on peripheral blood smear on ___ -
bone marrow biopsy ___ showed lymphoblastic blast phase of
chronic myelogenous leukemia. The blast count was 43% on the
aspirate and 60-70% on the core biopsy.
3. Part A of hyper-CVAD from ___, part B of hyper-CVAD on
___.
4. Bone marrow biopsy on ___ showed no evidence of leukemia
involvement. Cytogenetics were negative for ___
chromosome.
5. High dose cyclophosphamide on ___ as conditioning for
allogenic bone marrow transplant, transplant aborted because her
stem cell donor refused to have his stem cell collected. She was
discharged home and restarted on dasatinib.
6. Allogenic double cord HSCT on ___, conditioning with
Cyclophosphamide/TBI/Fludarabine. Hospitalized ___.
Her hospital stay was complicated by fever on
day -5 and, in the post-transplant setting by HHV-6 viremia and
BK viruria. HHV-6 viremia cleared.
7. Hospitalization with severe sinusitis ___.
8. Hospitalization for shortness of breath ___.
9. Hospitalization after a seizure episode between ___ and
___.
10. Maintenance Dasatinib started end ___ - stopped
___.
Other PMH:
CERVICAL SPONDYLOSIS
CHRONIC RENAL FAILURE (baseline Cr ~1.5)
GLAUCOMA
INSOMNIA
OSTEOPOROSIS
EAR, NOSE & THROAT
SEIZURES
BASAL CELL CARCINOMA
SINUSITIS, chronic rhinitis
Social History:
___
Family History:
Patient's mother died ___ years old, had a history of melanoma.
Patient's father is alive. A maternal grandmother died from
ovarian cancer at the age of ___. ___ had 2 brothers and one
died in a car accident. One brother is alive and well. She has a
son and a daughter.
Physical Exam:
ADMISSION EXAM
PHYSICAL EXAM:
VS: 98.6, 131/77, 106, 18, 97% on RA
GENERAL: NAD
HEENT: Mucous membranes moist
NECK: No cervical, submandibular, or supraclavicular LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTA bilaterally, dullness at bases
ABDOMEN: +BS, non-tender, non-distended, no rebounding or
guarding
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS: 98.4 114/62 105 18 100RA
GENERAL: NAD
HEENT: Mucous membranes moist
NECK: No cervical, submandibular, or supraclavicular LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTA bilaterally, dullness at bases
ABDOMEN: +BS, non-tender, non-distended, no rebounding or
guarding
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-17.0*# RBC-3.37* Hgb-10.1* Hct-31.4*
MCV-93 MCH-29.9 MCHC-32.1 RDW-13.9 Plt ___
___ 04:18PM BLOOD Glucose-125* UreaN-29* Creat-1.7* Na-133
K-4.1 Cl-97 HCO3-25 AnGap-15
___ 04:23PM BLOOD Lactate-2.1*
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-12.9* RBC-3.09* Hgb-9.3* Hct-28.6*
MCV-93 MCH-30.2 MCHC-32.6 RDW-13.8 Plt ___
___ 07:55AM BLOOD Neuts-82.6* Lymphs-10.6* Monos-6.2
Eos-0.5 Baso-0.1
___ 07:55AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9
CXR ___
FINDINGS:
Patchy bilateral lower lobe opacities are seen, worrisome for
multifocal
pneumonia. No pleural effusion is seen. The cardiac and
mediastinal
silhouettes are unremarkable. No evidence of pneumothorax is
seen.
IMPRESSION:
Patchy bilateral lower lobe opacities worrisome for multifocal
pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Astelin *NF* (azelastine) 137 mcg NU QD
3. Estring *NF* (estradiol) 2mg Vaginal Every 3 months
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
6. Venlafaxine XR 150 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID
8. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Astelin *NF* (azelastine) 137 mcg NU QD
2. Calcium Carbonate 500 mg PO QID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
5. Venlafaxine XR 150 mg PO DAILY
6. Vitamin D 800 UNIT PO DAILY
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth q6
Disp #*200 Milliliter Refills:*0
8. Levofloxacin 250 mg PO Q24H Duration: 5 Days
RX *levofloxacin 250 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
9. Alendronate Sodium 70 mg PO QMON
10. Estring *NF* (estradiol) 2mg Vaginal Every 3 months
11. Oseltamivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*6 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Productive cough with sputum, chills.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Patchy bilateral lower lobe opacities are seen, worrisome for multifocal
pneumonia. No pleural effusion is seen. The cardiac and mediastinal
silhouettes are unremarkable. No evidence of pneumothorax is seen.
IMPRESSION:
Patchy bilateral lower lobe opacities worrisome for multifocal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SINUS INFECTION
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 96.5
heartrate: 118.0
resprate: 20.0
o2sat: 95.0
sbp: 115.0
dbp: 68.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ is a ___ with Hx of Lymphoblastic blast crisis of
CML day ___ after a double cord transplant who presented to the
ED with productive cough, headache, sinus and ear congestion,
found to have possible multifocal PNA on CXR.
# PNA: Patient with multifocal pneumonia, leukocytosis, though
no documented fevers. She endorses a history of congestion and
cough prior to this episode as well as nausea/vomiting;
possible that she had a viral URI and now has a super-imposed
PNA. Although do not need to treat with Tamiflu (as has had
symptoms for more than 48 hours), a nasal swab was performed but
did not have adequate cells for evaluation. She was discharged
on levofloxacin to finish a ___nd a 5 day course of
tamiflu.
# CML: In remission. Continue follow-up with outpatient
providers.
# TACHYCARDIA: likely secondary to acute inflammatory response
to pneumonia. Resolved with fluid resuscitation.
# ACUTE ON CHRONIC KIDNEY INJURY: Basline 1.1-1.3, Unclear
etiology of CKD. Patient has been encouraged to see nephrology
in the past, but is does not appear as if she has gone. Her
medications were renally dosed and her ___ improved back to its
baseline with fluids.
# INURANCE: Patient lost her insurance prior to this visit and
was notified in ___ clinic. Case management and social work
consults performed, and she obtained her insurance again. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Jaundice, confusion
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is an ___ gentleman with a pmhx. significant for DM
II, HTN, AAA repair, and ?TIAs who is admitted from ___
___ with elevated LFTs, jaundice, and change in mental
status.
History is obtained from patient's wife and HCP as patient is
confused and unable to details events leading up to admission.
Apparently patient was in his usual state of health until about
2 weeks ago when he began feeling unwell and with decreased
appetite. He also noticed darkened urine around that time.
However, about 3 days prior to admission, urine became much
darker and patient's wife noticed that the whites of his eyes
were turning yellow. Patient's family brought him to ___
___ on ___ where he was found to have elevated LFTs and a
RUQ concerning for biliary dilation and ?pancreatic mass.
Patient was transferred to ___ for ERCP and further work-up.
In the ___ ED, initial vitals were: 87 181/66 16 99%.
Patient was not given any medications. RUQ ultrasound showed:
"comparison OSH ultrasound performed earlier today. s/p
cholecystectomy. Intrahepatic biliary dilatation, no prior s/p
ccy for comparison. distal CBD/panc duct dilated to 1 cm. ?
echogenic mass measuring 3.5 cm along panc head. rec further
eval with CTA panc/MRCP and/or ERCP. AAA s/p repair." Upon
transfer to the floor, vitals were: 88 160/57 18 98%.
A full review of systems is unable to be obtained due to patient
delirium.
Past Medical History:
--DM II
--TIAs
--Hypertension
--BPH
--AAA repair
Social History:
___
Family History:
Patient's mother had DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7, 146/91, 85, 18, 99% on RA
GENERAL: Lying in bed, no acute distress, foley in place, knows
name and that he is in the hospital, thinks there is another
person at foot of the bed when there is not
HEENT: Mucous membranes very dry
CHEST: Patient does not cooperate with exam, no obvious wheezes
or rhonchi
CARDIAC: Irregularly irregular, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
NEURO: Patient is moving all 4 extremities, but a thorough
neurologic exam is difficult due to confusional state
DISCHARGE EXAM:
GENERAL: Alert, NAD
CV: RRR, no m/r/g
RESP: CTA bilaterally
ABD: S/NT/ND, BS present
NEURO: non-focal, oriented x 3
Pertinent Results:
Admission Labs:
___ 06:45PM BLOOD WBC-8.3 RBC-4.41* Hgb-14.4 Hct-41.3
MCV-94# MCH-32.6* MCHC-34.8 RDW-14.7 Plt ___
___ 06:45PM BLOOD Neuts-80.8* Lymphs-11.5* Monos-5.0
Eos-1.8 Baso-0.8
___ 06:45PM BLOOD ___ PTT-30.9 ___
___ 06:45PM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-141
K-3.6 Cl-105 HCO3-23 AnGap-17
___ 06:45PM BLOOD ALT-423* AST-270* AlkPhos-538*
TotBili-8.4* DirBili-6.7* IndBili-1.7
___ 06:45PM BLOOD Albumin-3.5 Calcium-9.1 Phos-2.6* Mg-1.9
Discharge Labs:
___ 06:40AM BLOOD WBC-7.6 RBC-3.93* Hgb-12.3* Hct-37.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-15.6* Plt ___
___ 06:40AM BLOOD Glucose-127* UreaN-12 Creat-0.6 Na-137
K-3.6 Cl-106 HCO3-19* AnGap-16
___ 06:40AM BLOOD ALT-195* AST-87* AlkPhos-435*
TotBili-6.4*
___ 07:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7
___ 08:24PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:24PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-4* pH-6.5 Leuks-SM
___ 08:24PM URINE RBC-1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-0
___ 08:24PM URINE Mucous-RARE
RUQ US - FINDINGS: There is intrahepatic biliary dilatation.
No discrete intrahepatic lesion is seen. The patient is status
post cholecystectomy. The main portal vein is patent with
hepatopetal flow. The common bile duct measures 0.8 cm in its
mid portion and up to 1 cm distally. The distal CBD versus the
pancreatic duct measures 1.0 cm. In the region of the
pancreatic head, there is an echogenic area measuring 3.0 x 3.5
cm, which could represent a mass. Recommend further evaluation
with CTA pancreas, MRC, and/or ERCP. Patient is status post AAA
repair with the full size of the mid aorta measuring 7.3 x 8.4 x
7.3 cm and with the lumen of the stent patent.
IMPRESSION: Intra- and extra-hepatic biliary dilatation.
Status post cholecystectomy without prior imaging since the
cholecystectomy prior to today. Query echogenic lesion in the
region of the pancreatic head. Recommend further evaluation
with CTA pancreas, MRCP, and/or ERCP.
ERCP
- Normal major papilla
- Cannulation of the biliary duct was successful and deep with a
sphincterotome
- A 1 cm stricture was seen in the mid-CBD. The proximal CBD was
dilated.
- A sphincterotomy was performed
- Cytology samples were obtained using a brush from the CBD
stricture
- A 7cm by ___ plastic biliary stent was placed successfully
across the CBD stricture
- Otherwise normal ercp to third part of the duodenum
CTA Abdomen - FINDINGS:
FINDINGS:
The visualized lung bases show trace bilateral pleural fluid on
the left
greater than the right. There is mild associated compressive
atelectasis of the left lung base. Subtle air trapping is noted
in the left lung base. Limited imaging of the heart shows
extensive coronary calcifications. No pericardial effusion is
present. The distal esophagus shows circumferential thickening
of the wall, which is a nonspecific finding but may represent
esophagitis in the appropriate clinical setting.
The liver demonstrates several hypo enhancing areas in the right
posterior segment measuring 1.0 cm (6: 142), 1.5 cm (series 6:
128), 1.5 cm (6: 125) compatible with hepatic metastases. There
is moderate intrahepatic biliary dilation in the right posterior
segment, which may be related to local obstruction from hepatic
metastases. There is centralized pneumobilia predominantly in
the left lobe of the liver, which is an expected finding after
ERCP. Small amount ___ hepatic ascites is present. A
biliary stent is in place extending from the proximal common
bile duct into the ___ portion of the duodenum. Gallbladder is
surgically absent.
The pancreas is heterogeneously enhancing with multiple
hypoattenuating areas in the body and tail and extensive
dilatation of the pancreatic duct and most prominent upstream
measuring up to 12 mm in the head of the pancreas. There is an
abrupt cut off of the pancreatic duct within the head of the
pancreas at the level of a large hypo attenuating mass measuring
2.9 x 2.8 cm on coronal imaging series 109, image 24. There is
stranding about the head of the pancreas. The adjacent
abdominal vasculature is patent with no apparent encasement of
the vessels. There are multiple enhancing peripancreatic lymph
nodes measuring up to 10 mm in short axis (6: 47).
Both kidneys enhance symmetrically and excrete contrast
normally. There are multiple subcentimeter hypodensities in the
bilateral kidneys which are too small to fully characterize but
most likely represent renal cysts. The right adrenal gland is
unremarkable. The left adrenal gland shows nodular contours.
The stomach demonstrates an enhancing exophytic soft tissue mass
measuring 2.5 x 1.9 cm (6b:119), which is concerning for a
gastrointestinal stromal tumor. The intra-abdominal loops of
small and large bowel are normal in caliber. There is a soft
tissue nodule adjacent to the transverse colon (6b: 174), which
is concerning for spread of disease. A few colonic diverticula
are noted without inflammatory changes to suggest
diverticulitis. No free air or ascites is present.
There are extensive vascular calcifications. The patient is
status post
endovascular repair of a large infrarenal abdominal aortic
aneurysm measuring 8.0 x 7.7 x 7.8 cm with a stent extending
from chest below the level of the renal veins to the bilateral
common iliac arteries.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions
are detected. Multilevel degenerative changes are noted
throughout the visualized thoracolumbar spine.
IMPRESSION:
1. Metastatic pancreatic neoplasm: Hypo attenuating 2.9 cm mass
in the head of the pancreas at the level of abrupt cutoff of the
dilated pancreatic duct concerning for primary pancreatic
neoplasm with hypoattenuating lesions in the right posterior
segment of the liver concerning for hepatic metastases.
Prominent peripancreatic lymph nodes and multiple
hypoattenuating, likely cystic lesions throughout the body and
tail of the pancreas.
2. Biliary: Moderate intrahepatic biliary dilation in the
right posterior segment may be related to local obstruction from
hepatic metastases. Mild centralized intrahepatic biliary
dilation status post ERCP with biliary stent in appropriate
position.
3. Patent vasculature with conventional anatomy.
4. Exophytic gastric mass: Enhancing 2.5 cm mass from the
gastric fundus concerning for gastrointestinal stromal tumor.
Endoscopic ultrasound could be considered for further
evaluation.
5. Circumferential thickening of the distal esophageal wall may
represent esophagitis in the appropriate clinical setting.
6. Large infrarenal abdominal aortic aneurysm status post
endovascular aortic repair.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Atenolol 50 mg PO DAILY
Please hold for SBP <100 or HR <55.
3. Cyanocobalamin 1000 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
Please hold for SBP <100.
5. Aspirin 81 mg PO DAILY
6. Glargine 14 Units Dinner
Discharge Medications:
1. Atenolol 50 mg PO DAILY
Please hold for SBP <100 or HR <55.
2. Cyanocobalamin 1000 mcg PO DAILY
3. Glargine 14 Units Dinner
4. Lisinopril 20 mg PO DAILY
Please hold for SBP <100.
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Magnesium Oxide 0 PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Pancreatic Neoplasm
Stomach Mass
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
EXAM: Right upper quadrant ultrasound.
CLINICAL INFORMATION: ___ male with jaundice.
COMPARISON: Outside hospital ultrasound performed earlier the same date,
___.
FINDINGS: There is intrahepatic biliary dilatation. No discrete intrahepatic
lesion is seen. The patient is status post cholecystectomy. The main portal
vein is patent with hepatopetal flow. The common bile duct measures 0.8 cm in
its mid portion and up to 1 cm distally. The distal CBD versus the pancreatic
duct measures 1.0 cm. In the region of the pancreatic head, there is an
echogenic area measuring 3.0 x 3.5 cm, which could represent a mass.
Recommend further evaluation with CTA pancreas, MRC, and/or ERCP. Patient is
status post AAA repair with the full size of the mid aorta measuring 7.3 x 8.4
x 7.3 cm and with the lumen of the stent patent.
IMPRESSION: Intra- and extra-hepatic biliary dilatation. Status post
cholecystectomy without prior imaging since the cholecystectomy prior to
today. Query echogenic lesion in the region of the pancreatic head.
Recommend further evaluation with CTA pancreas, MRCP, and/or ERCP.
Radiology Report
HISTORY: Elevated liver enzymes and recent ultrasound concerning for
pancreatic mass, here to evaluate for pancreatic and hepatobiliary pathology.
TECHNIQUE: Multi detector CT imaging was performed of the abdomen prior to
and during the dynamic injection of 200 cc Omnipaque intravenous contrast per
CTA pancreas protocol. The initial scan was suboptimal due to failure of the
patient's IV. A repeat scan was performed after the IV was replaced.
Multiplanar reformats were generated and reviewed.
DLP: ___ mGy-cm.
COMPARISON: Right upper quadrant sonogram dated ___.
FINDINGS:
The visualized lung bases show trace bilateral pleural fluid on the left
greater than the right. There is mild associated compressive atelectasis of
the left lung base. Subtle air trapping is noted in the left lung base.
Limited imaging of the heart shows extensive coronary calcifications. No
pericardial effusion is present. The distal esophagus shows circumferential
thickening of the wall, which is a nonspecific finding but may represent
esophagitis in the appropriate clinical setting.
The liver demonstrates several hypo enhancing areas in the right posterior
segment measuring 1.0 cm (6: 142), 1.5 cm (series 6: 128), 1.5 cm (6: 125)
compatible with hepatic metastases. There is moderate intrahepatic biliary
dilation in the right posterior segment, which may be related to local
obstruction from hepatic metastases. There is centralized pneumobilia
predominantly in the left lobe of the liver, which is an expected finding
after ERCP. Small amount ___ hepatic ascites is present. A biliary stent
is in place extending from the proximal common bile duct into the ___ portion
of the duodenum. Gallbladder is surgically absent.
The pancreas is heterogeneously enhancing with multiple hypoattenuating areas
in the body and tail and extensive dilatation of the pancreatic duct and most
prominent upstream measuring up to 12 mm in the head of the pancreas. There
is an abrupt cut off of the pancreatic duct within the head of the pancreas at
the level of a large hypo attenuating mass measuring 2.9 x 2.8 cm on coronal
imaging series 109, image 24. There is stranding about the head of the
pancreas. The adjacent abdominal vasculature is patent with no apparent
encasement of the vessels. There are multiple enhancing peripancreatic lymph
nodes measuring up to 10 mm in short axis (6: 47).
Both kidneys enhance symmetrically and excrete contrast normally. There are
multiple subcentimeter hypodensities in the bilateral kidneys which are too
small to fully characterize but most likely represent renal cysts. The right
adrenal gland is unremarkable. The left adrenal gland shows nodular contours.
The stomach demonstrates an enhancing exophytic soft tissue mass measuring 2.5
x 1.9 cm (6b:119), which is concerning for a gastrointestinal stromal tumor.
The intra-abdominal loops of small and large bowel are normal in caliber.
There is a soft tissue nodule adjacent to the transverse colon (6b: 174),
which is concerning for spread of disease. A few colonic diverticula are
noted without inflammatory changes to suggest diverticulitis. No free air or
ascites is present.
There are extensive vascular calcifications. The patient is status post
endovascular repair of a large infrarenal abdominal aortic aneurysm measuring
8.0 x 7.7 x 7.8 cm with a stent extending from chest below the level of the
renal veins to the bilateral common iliac arteries.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are detected.
Multilevel degenerative changes are noted throughout the visualized
thoracolumbar spine.
IMPRESSION:
1. Metastatic pancreatic neoplasm: Hypo attenuating 2.9 cm mass in the head
of the pancreas at the level of abrupt cutoff of the dilated pancreatic duct
concerning for primary pancreatic neoplasm with hypoattenuating lesions in the
right posterior segment of the liver concerning for hepatic metastases.
Prominent peripancreatic lymph nodes and multiple hypoattenuating, likely
cystic lesions throughout the body and tail of the pancreas.
2. Biliary: Moderate intrahepatic biliary dilation in the right posterior
segment may be related to local obstruction from hepatic metastases. Mild
centralized intrahepatic biliary dilation status post ERCP with biliary stent
in appropriate position.
3. Patent vasculature with conventional anatomy.
4. Exophytic gastric mass: Enhancing 2.5 cm mass from the gastric fundus
concerning for gastrointestinal stromal tumor. Endoscopic ultrasound could be
considered for further evaluation.
5. Circumferential thickening of the distal esophageal wall may represent
esophagitis in the appropriate clinical setting.
6. Large infrarenal abdominal aortic aneurysm status post endovascular aortic
repair.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: JAUNDICE
Diagnosed with OBSTRUCTION OF BILE DUCT, JAUNDICE NOS, HYPERTENSION NOS
temperature: 97.6
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 172.0
dbp: 52.0
level of pain: 13
level of acuity: 2.0 | This is an ___ gentleman with a PMHx significant for
HTN, TIA, and AAA repair who is admitted with jaundice, elevated
LFTs, and RUQ concerning for mass.
# BILIARY OBSTRUCTION, ELEVATED LFTS, JAUNDICE: RUQ performed
on admission revealing echogenic lesion in the region of the
pancreatic head. Given concern for mass obstructing CBD, the
patient underwent ERCP with stent placement. With this therapy,
bilirubin and LFT's trended down. Biopsies were taken during
ERCP and were pending at the time of discharge. After ERCP, the
patient underwent CTA abdomen, which confirmed a pancreatic
lesion concerning for malignancy with evidence of likely liver
metastases. Given these findings, oncology f/u was recommended.
After discussion with the patient's PCP's office, it was decided
to refer the patient to Dr. ___. Unfortunately,
appointment was not able to be scheduled prior to discharge
because pathology had not yet returned. Dr. ___ office will
be in contact to arrange a follow-up appointment with the
patient after pathology has returned. Pt will need repeat ERCP
in approximately 6 weeks. ERCP office will contact him to
arrange this appointment.
# Stomach Lesion: Seen on CTA abdomen, concerning for potential
GIST. Given slow growth of GIST tumors and relatively rapid
growth of patient's pancreatic malignancy, further evaluation of
this stomach lesion was deferred to patient's PCP and
oncologist.
# Delirium: Likely toxic-metabolic encephalopathy in the setting
of biliary obstruction. Patient's mental status improved to
baseline after biliary stent was placed.
# Hypokalemia: Pt noted to have low potassium on the day of
discharge (3.0). Was repleted with 60 meq. Potassium will be
closely monitored at his rehab.
# HTN, BENIGN: Continued atenolol and lisinopril
# DMII WITHOUT COMPLICATIONS: Continued lantus. Held metformin
during admission, restarted on discharge.
# HISTORY OF TIA: Aspirin and aggrenox held for 5 days after
ERCP with sphincterotomy, can be restarted on ___.
# B12 DEFICIENCY: Continued B12 supplementation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L sided weakness/numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed F w/o significant PMH who
presents with L sided weakness and numbness. Hx obtained from pt
and family at bedside.
Pt reports that early this morning, she woke up with
excruciating
pain in her L calf. She later went to her mom's house and at
approximately 8:30am acutely developed numbness in her LUE/LLE
in
a downward spreading fashion. Denies associated burning,
tingling, headache or back pain. Around the same time, she also
noted weakness in L hemibody, typified by feeling herself slouch
in kitchen chair. She also endorses proceeding "fogginess" and
breathing difficulties, with her family reporting she seemed
confused. They also said she displayed some slurred speech. Pt
reports she had difficulty "getting her words out", although
denied any clear word finding difficulties. Due to this
constellation of sx, she was urgently brought to ___ for
evaluation.
Within an hour at OSH ED, mental status and language improved.
Since that time, numbness and weakness have been improving in
gradual fashion. Continues to have sharp pain in L calf, which
with palpation radiates up to proximal thigh. She states she has
had this intermittently over the last 3 weeks and for which she
was planning to undergo ___ Dopplers per her PCP. Of note, pt
reports taking one line of cocaine last night (she says she has
taken a few times in past without issues). Denies prior hx of
migraines, sz, or strokes.
On neuro ROS, the pt endorses headache in posterior occiput over
last hour, pressure-like in quality and mild in severity.
Otherwise ROS negative except as noted above.
Past Medical History:
None
Social History:
___
Family History:
PGF-stroke in ___
Physical Exam:
ADMISSION PHYSICAL EXAM
Physical Exam:
Vitals: T: 98 P: 69 BP: 121/67 RR: 16 O2sat: 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Discomfort to palpation over L calf, 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. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1.5mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 3 ___ ___ 2 5- 4+ 4+ 5- 5- 5-
R 5 ___ ___ 5 5 5 5 5 5 5
*pt displayed giveway throughout LUE/LLE during confrontational
exam
-Sensory: Decreased LT over LUE/LLE 9(70-80% of normal).
Initially endorsed decreased PP over L hemibody but later stated
normal and then hyperesthesias. Intact to temperature sensation
b/l. Proprioception intact at great toes b/l. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF on R, none on HKS bilaterally.
-Gait: Deferred
=======================================
DISCHARCHE PHYSICAL EXAM
L deltoid ___ and pain limited, otherwise exam is non focal.
Sensation and strength intact. Able to ambulate on her own
without assistance.
Pertinent Results:
LABS
___ 07:20AM BLOOD WBC-6.5# RBC-3.99 Hgb-13.0 Hct-38.4
MCV-96 MCH-32.6* MCHC-33.9 RDW-12.3 RDWSD-43.3 Plt ___
___ 04:10PM BLOOD WBC-14.0* RBC-4.17 Hgb-13.5 Hct-39.5
MCV-95 MCH-32.4* MCHC-34.2 RDW-12.3 RDWSD-43.0 Plt ___
___ 04:10PM BLOOD Neuts-61.6 ___ Monos-7.7 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-8.64* AbsLymp-4.07* AbsMono-1.08*
AbsEos-0.13 AbsBaso-0.05
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-32.1 ___
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD ___ PTT-29.8 ___
___ 07:20AM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-22 AnGap-16
___ 04:10PM BLOOD Glucose-93 UreaN-8 Creat-0.7 Na-137 K-3.4
Cl-101 HCO3-19* AnGap-20
___ 07:20AM BLOOD CK(CPK)-38
___ 12:45PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:20AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0 Cholest-142
___ 04:10PM BLOOD Albumin-4.4 Calcium-9.2 Phos-3.8 Mg-1.8
___ 07:20AM BLOOD %HbA1c-4.8 eAG-91
___ 07:20AM BLOOD Triglyc-111 HDL-65 CHOL/HD-2.2 LDLcalc-55
___ 07:20AM BLOOD TSH-1.7
___ 07:20AM BLOOD CRP-3.1
___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:20AM BLOOD SED RATE-PND
IMAGING
MRI BRAIN: No evidence of acute territorial infarction,
intracranial hemorrhage, mass, or abnormal enhancement.
Medications on Admission:
NONE
Discharge Medications:
NONE
Discharge Disposition:
Home
Discharge Diagnosis:
Transient headache, confusion, LT sided weakness, and chest
tightness in the setting of severe anxiety after cocaine use.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (upright AP AND LAT)
INDICATION: ___ with Left sided weakness// PNA? Consolidation?
COMPARISON: None
FINDINGS:
AP upright and lateral views of the chest provided. Hyperdense nodule
projecting over the left apex could represent a calcified granuloma. AAThere
is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact. No free air below
the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with hx of recent cocaine use who presented
with left-sided weakness and numbness, resolving. Evaluate for intracranial
pathology.
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: Prior outside CT head dated ___.
FINDINGS:
There is no evidence of acute infarction or intracranial hemorrhage. The
ventricles are normal in size without mass effect or midline shift. The
visualized arterial vascular flow voids are preserved. There is no enhancing
mass or abnormal enhancement. The dural venous sinuses appear patent on the
postcontrast images. There is mild mucosal thickening of the bilateral
ethmoid and maxillary sinuses. There is trace nonspecific opacification of
the bilateral mastoid air cells. The orbits appear unremarkable.
IMPRESSION:
1. No evidence of acute territorial infarction, intracranial hemorrhage, mass,
or abnormal enhancement.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with left calf pain// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Calf pain, L Weakness, Transfer
Diagnosed with Weakness
temperature: 98.0
heartrate: 69.0
resprate: 16.0
o2sat: 99.0
sbp: 121.0
dbp: 67.0
level of pain: 8
level of acuity: 2.0 | ___ yo woman with no significant medical history presenting with
an episode of headache, confusion, LT sided weakness, and chest
tightness in the setting of severe anxiety after cocaine use.
Imaging with brain MRI and CTA head/neck unremarkable (without
vessel reformats to rule out small vasospasm read as normal by
both outside hospital radiologists and ___ radiologists). Lyme
serum sent and is pending. Orthostatics negative. Cardiac
enzymes normal. She was monitored on telemetry, given IVF
repletion, evaluated by ___. Symptoms improved spontaneously.
Gabapentin was trialed, however it made patient sleepy so this
medication was discontinued. Likely this could have represented
a transient vasospasm from cocaine that has resolved, as well as
a functional disorder given her significant anxiety.
Transitional Issues
- Follow serum Lyme
- Close PCP follow up
-___ with neurology x1 in ___ ___ at 3:30 ___
-outpatient echocardiogram to complete the stroke work up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rash, abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with a
history of rheumatoid arthiritis (previously on anti-TNF;
stopped
___, prior alcohol abuse complicated by chronic portal vein
thrombosis in the setting of pancreatitis, portal hypertension
with varices s/p band ligation presenting for evaluation of rash
and abnormal labs.
The patient reports that he had a mechanical fall on ___. He
presented to ___, and was found to have
traumatic right humeral fracture and rib fractures requiring
chest tube placements c/b Infuenza Pneumonia and MSSA
bacteremia/empyema s/p thoracocentesis and decortication. He was
discharged on IV cefazolin for an intended 4-week course, but
subsequently developed a purpuric rash on his knees, per notes
around ___. He was seen by ID, and his antibiotics were
switched from cefazolin to vancomycin. He subsequently presented
to ___ in ___ for persistent rash, and vancomycin was
switched to Linezolid, although vancomycin was not thought to be
the cause of his rash. He underwent skin biopsy on ___, with
pathology consistent with leukocytoclastic vasculitis, although
numerous eosinophils in the biopsy raises consideration for a
hypersensitivity etiology. The differential diagnosis includes
vasculitis associated with autoimmune disease (rheumatoid
arthritis).
Overall, the thinking was that this rash was possibly triggered
by an infection, and was thought to be less likely secondary to
his rheumatoid arthritis or an antibiotic or drug exposure.
Immunosuppression and prednisone was considered but was not
initiated. Per ___ notes, it appears that the plan was for
the
patient to see rheumatology as an outpatient to discuss
re-initiating Humira.
In the interim, the patient reports that the rash has
progressed,
and spread to his arms just recently. The rash is not pruritic
or
painful. He saw his gastroenterologist on the day of admission,
who referred him to the hospital for further evaluation.
On arrival to the floor, patient reports that he has severe pain
in his right shoulder, which has been present since his accident
in ___. No other joint pain or swelling. He denies any other
complaints. No fever/chills, weight loss. No cough, shortness of
breath, chest pain, palpitations. He has been told that he has
hematuria, but he has not noticed this himself. No melena or
hematochezia. No nausea, vomiting, diarrhea. No unintentional
weight loss. Of note, the patient localizing the worsening of
his
symptoms to the same time that he started iron supplementation.
Past Medical History:
- Alcohol abuse
- Pancreatitis
- Pancreatic pseudocyst x2
- Chronic cholecystitis
- Hepatic, portal and splenic vein thromboses; not on
anticoagulation due to hemorrhagic pancreatic pseudocyts
- Portal hypertension
- Esophageal varices s/p banding
- HLD
- Rheumatoid arthritis, previously on anti-TNF
- s/p bilateral hernia repair in ___
- left eye strabismus, s/p corrective surgery good success
without complication in ___
Social History:
___
Family History:
Mother w/ emphysema. Father w/ CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 145/73 81 18 98 Ra
GENERAL: Lying in bed, in NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM, no oral lesions
NECK: No JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: BS+, soft, NTND
EXTREMITIES: No peripheral edema; TTP over right glenuohumeral
joint
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Nonblanching purpuric rash on bilateral lower extremities
with blistering of bilateral heels; rash also present on dorsum
of hands up to mid-arm bilaterally; sparing of trunk and face
DISCHARGE PHYSICAL EXAM
VS: 97.9F, 112/59, HR 81, RR 16, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: rrr, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: trace edema ___, non-tender
Skin: dozens of erythematous macules on legs and arms, sparing
chest/abdomen/back/face. Rash improving. Left heel bulla.
Neuro: A&Ox3, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS
___ 09:30AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.2* Hct-26.6*
MCV-94 MCH-28.9 MCHC-30.8* RDW-15.7* RDWSD-53.9* Plt ___
___ 09:30AM BLOOD Neuts-82.8* Lymphs-8.7* Monos-4.6*
Eos-3.2 Baso-0.4 Im ___ AbsNeut-8.24* AbsLymp-0.87*
AbsMono-0.46 AbsEos-0.32 AbsBaso-0.04
___ 09:30AM BLOOD ___ PTT-36.2 ___
___ 09:30AM BLOOD Plt ___
___ 05:30AM BLOOD Ret Aut-1.9 Abs Ret-0.04
___ 05:30AM BLOOD ___ Thrombn-18.6*
___ 05:30AM BLOOD FactVII-93
___ 09:30AM BLOOD TotProt-7.6 Albumin-2.6* Globuln-5.0*
Phos-2.9 Mg-2.0 Iron-31*
___ 09:30AM BLOOD calTIBC-176* VitB12-1256* Folate-15
Ferritn-699* TRF-135*
___ 05:30AM BLOOD Hapto-171
___ 09:30AM BLOOD TSH-0.93
___ 05:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 05:30AM BLOOD ANCA-NEGATIVE B
___ 05:30AM BLOOD CRP-94.6* dsDNA-NEGATIVE
___ 09:30AM BLOOD RheuFac-18* ___
___ 09:30AM BLOOD PEP-NO MONOCLO FreeKap-239.5*
FreeLam-314.8* Fr K/L-0.76 IgG-2368* IgA-1347* IFE-NO MONOCLO
___ 05:30AM BLOOD C3-102 C4-14
___ 07:20PM BLOOD HBV VL-NOT DETECT
___ 05:30AM BLOOD HCV Ab-NEG
DISCHARGE LABS
___ 01:00PM BLOOD WBC-5.0 RBC-2.54* Hgb-7.3* Hct-23.7*
MCV-93 MCH-28.7 MCHC-30.8* RDW-15.9* RDWSD-54.4* Plt ___
___ 01:00PM BLOOD Plt ___
___ 07:21AM BLOOD ___ PTT-32.9 ___
___ 07:21AM BLOOD Glucose-82 UreaN-27* Creat-1.7* Na-140
K-5.0 Cl-104 HCO3-24 AnGap-12
___ 07:21AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9
___ 01:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
IMAGING
Renal US ___
1. Cavernous transformation of the main portal vein consistent
with chronic portal vein thrombosis. A small amount of
hepatopetal flow was identified within the right portal vein.
2. No hydronephrosis identified.
CXR ___
No previous images. The cardiac silhouette is at the upper
limits of normal. Indistinctness of pulmonary vessels suggests
some elevated pulmonary venous pressure. Opacification at the
left base silhouetting hemidiaphragm most likely represents a
combination of atelectasis and pleural fluid. However, there is
suggestion of mild coalescence of opacification just above and
lateral to the lower cardiac border. In the appropriate
clinical setting, this would be worrisome for superimposed
aspiration/pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 10 mg PO QHS
2. LORazepam 1 mg PO Q8H:PRN Anxiety
3. Nadolol 20 mg PO DAILY
4. Lovastatin 20 mg oral QHS
5. Ferrous Sulfate 325 mg PO DAILY
6. Magnesium Oxide 280 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO QHS:PRN Pain -
Severe
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth q6h PRN Disp #*28 Tablet
Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. Levothyroxine Sodium 25 mcg PO DAILY
5. LORazepam 1 mg PO Q8H:PRN Anxiety
6. Lovastatin 20 mg oral QHS
7. Magnesium Oxide 280 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Vitamin B Complex 1 CAP PO DAILY
10. Zolpidem Tartrate 10 mg PO QHS
11. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until you follow up with your PCP
12.Outpatient Lab Work
Lab: Na,K,Cl,HCO3,BUN,Cr,Glu Date: ___
Dx: Acute kidney failure (ICD9:___.9)
___: ___ (Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Leukocytoclastic Vasculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man with recent pneumonia presenting with
leukocytoclastic vasculitis// Pneumonia? Pulmonary edema? Pulmonary
hemorrhage?
IMPRESSION:
No previous images. The cardiac silhouette is at the upper limits of normal.
Indistinctness of pulmonary vessels suggests some elevated pulmonary venous
pressure. Opacification at the left base silhouetting hemidiaphragm most
likely represents a combination of atelectasis and pleural fluid. However,
there is suggestion of mild coalescence of opacification just above and
lateral to the lower cardiac border. In the appropriate clinical setting,
this would be worrisome for superimposed aspiration/pneumonia.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with history of portal vein thrombosis, here with
___ and leukocytoclastic vasculitis// Doppler evaluation of portal vein;
hydronephrosis?
TECHNIQUE: Grey scale, color and spectral doppler ultrasound images of the
abdomen were obtained.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LIVER: Note is made the left hepatic lobe could not be identified due to
overlying bowel gas and limited sonographic windows. Within that limitation
the hepatic parenchyma appears within normal limits. The contour of the liver
is smooth. There is no focal liver mass. The region of the main portal vein
was evaluated with color and spectral Doppler imaging. The region where the
main portal vein usually lies is replaced with multiple tortuous vessels which
demonstrate arterial flow on spectral Doppler imaging, consistent with
cavernous transformation and chronic portal vein thrombosis. Within the
region of the right portal vein, a small amount of hepatopetal portal venous
flow is identified. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 12.4 cm.
KIDNEYS: The right kidney measures 10.4 cm. The left kidney measures 12.9 cm.
Views of the bilateral kidneys show no hydronephrosis. A simple cyst is seen
arising from the lower pole of the left kidney measuring 1.1 cm
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cavernous transformation of the main portal vein consistent with chronic
portal vein thrombosis. A small amount of hepatopetal flow was identified
within the right portal vein.
2. No hydronephrosis identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Encntr for obs for oth suspected diseases and cond ruled out
temperature: 97.2
heartrate: 76.0
resprate: 16.0
o2sat: 97.0
sbp: 150.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT:
Mr. ___ is a ___ y/o man with a history of rheumatoid
arthiritis (previously on anti-TNF; stopped ___,
prior alcohol abuse complicated by chronic portal vein
thrombosis in the setting of pancreatitis, portal hypertension
with varices s/p band ligation who presented with worsening rash
and ___.
ACUTE ISSUES
============
# Rash
# Leukocytoclastic Vasculitis:
Patient with several month history of rash, with biopsy in ___
consistent with LCV vs hypersensitivity (eosinophils). ___ be
secondary to Influenza/pneumonia in ___, although this does
not explain progression of rash recently. ___ be related to
antibiotic use. Felt unrelated to rheumatoid arthritis by
rheumatology despite patient being off Humira. Autoimmune panel
was sent with most studies negative except for positive RF and
HBcAb. Hepatitis B viral load not detected. Resent HBcAb for
possible false positive, but results still pending at discharge.
Patient also had elevated IgA, concerning for IgA
nephropathy/henoch-schonlein purpura, though patient denied
abdominal pain and arthralgias. Per dermatology, patient did not
need treatment for rash itself as it was asymptomatic. Patient
also evaluated by wound nurse for blisters on feet and heels.
# Acute kidney injury:
Baseline creatinine 1.0, elevated to 1.7 on admission. Concern
for possible glomerulonephritis in setting of
LCV as above. Renal US showed no hydronephrosis. Patient had low
protein/Cr ratio and sediment showed few RBC casts. His Cr
remained stable, discharge Cr 1.7. Per renal, given patient's
recent NSAID use, his ___ could be NSAID induced ATN. Discharged
with close follow-up with nephrology for outpatient renal biopsy
if Cr remains elevated.
# Acute on chronic anemia:
No evidence of bleeding. Iron studies suggest anemia of chronic
disease. Haptoglobin, t. bili, fibrinogen argue against
hemolysis. Patient has a history of esophageal varices, but he
did not have changes in his bowel movements. The patient
received one unit RBC, and hemoglobin remained stable. Patient
had been taking OTC iron supplement which was held for concern
that it was related to rash. Evaluated by hematology who
reviewed his smear and did not see evidence of MDS. ___
consider outpatient hematology work-up if anemia persistent.
# History of portal vein thrombosis:
RUQ US showed stable chronic portal vein thrombosis.
# Right humeral fracture:
Patient with traumatic right humeral fracture on ___ of this
year, awaiting arthroplasty in ___. Patient had ongoing shoulder
pain not well controlled on home oxycodone regimen, so frequency
was increased to oxycodone 5 mg q4h PRN.
CHRONIC ISSUES
==============
# Rheumatoid Arthritis:
Diagnosed about ___ years ago. Previously on methotrexate, and
then started on Humira about ___ years ago.
Humira has been on hold since ___ and he has not had any flares
since then.
# Portal hypertension
# Esophageal varices s/p banding:
Held nadolol in setting of renal failure
# BPH:
Continued home tamsulosin
# Hypothyroidism:
Continued home levothyroxine
# Anxiety:
Continued home lorazapam as needed
# Insomnia:
Held zolpidem during this admission
TI:
[ ] Patient needs close follow-up with nephrology for possible
renal biopsy
[ ] Patient should have his Cr drawn on ___ with results
sent to PCP
[ ] Held home nadolol in setting ___
[ ] Patient found to be HBcAb positive, hepatitis B viral load
negative. Repeat HBV serology pending, to be followed up by
hepatologist, Dr. ___
[ ] Patient's anemia should be monitored. Consider outpatient
hematology work-up if does not improve with
[ ] Started on folic acid and thiamine for history of alcohol
use
[ ] Oxycodone increased for severe shoulder pain to 5 mg q6h PRN
on discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Macrodantin /
hydrochlorothiazide / Reglan / cephalexin / rifampin /
nitrofurantoin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman w/hx AS s/p TAVR (___), afib on coumadin,
HFpEF (EF 60-65%), BiV ICD (___), TIA presenting with
subacute dyspnea on exertion and chest pain.
Patient presented to the ___ ED as she noted chest
pressure at rest as well as ongoing dyspnea on exertion. There
was no associated nausea or diaphoresis. At ___, patient
had
negative troponin, normal BNP. CXR was without abnormality and
EKG was without ischemic changes. Patient was transferred here
for further evaluation.
Patient has noted ongoing dyspnea on exertion which did not
improve after her TAVR in ___. She states that her shortness of
breath on exertion has been subjectively worsening over the past
3 weeks though has been stably present since prior to TAVR. She
has not been able to walk more than a few steps without
significant dyspnea for at least ___ year. She uses a walker at
home and notes that knee and back pain are the first limiting
factor for exertion though dyspnea has been an issue as well. No
chest pain or tightness with activity. Notes intermittent
substernal sensation of tightness at rest that resolves
spontaneously and has no associated triggers. No concurrent
nausea or dyspnea. The sensation of chest tightness is new over
the past few weeks and remains stable. She has had gradual
weight
gain over the past few years given significant back and knee
pain
and DOE. No ___ swelling. No new PND or orthopnea though hard to
assess as sleeps in recliner at baseline over the past ___ years
for back pain. Uses CPAP at night for OSA.
She otherwise denies any fevers, nausea, vomiting, diarrhea,
dysuria, hematuria.
Of note, she did sustain a fall a few days prior to presentation
with residual pain in her neck and bilateral shoulders. She
notes
falling while playing with her grandchildren without any
prodromal symptoms. She reported to an urgent care after the
fall
with normal x-ray.
In the ED initial vitals were:
T 97 HR 88 BP 121/78 RR 16 SpO2 94% RA
Labs/studies notable for:
WBC 12.5 Hgb 14.3 Plt ___
-------------
4.9/24/1.0
INR 3.4
pBNP 355, trop <0.01 x2
UA: neg nit, 123 WBC, 6 RBC, 30 prot, 10 epi
Patient was given:
___ 81mg
Lisinopril 5mg
Spirolocatone 75mg
Metoprolol succinate 75mg
Insulin 80
Oxycodone 2.5mg
Insulin 160mg
Warfarin 13mg
Atorvastatin 40mg
Oxycodone 2.5mg
Vitals on transfer: T 98.5 HR 75 BP 149/52 RR 18 SpO2 92% RA
EKG: paced rhythm, biventricular pacing, underlying Afib, no new
ST changes
CXR: Left chest wall dual lead pacing device as well as a
replaced valve are again noted. The lungs are clear without
focal
consolidation. No pleural effusion or pneumothorax is seen.
Enlarged cardiomediastinal silhouette is unchanged.
On the floor, patient confirms the history above and denies
chest
pain or shortness of breath. She has very limited mobility with
transfer from bed to chair due to pain.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes mellitus type II
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- ___ LMCA clear, LAD with mild plaquing. LCx with mild
plaquing, RCA with 40% stenosis at origin.
- HFpEF (EF 60%)
- Aortic stenosis s/p TAVR ___
- Recurrent Atrial Fibrillation, S/P multiple cardioversions
and
ultimately AVJ ablation ___
- S/p biventricular pacer/ICD implant ___ at ___
3. OTHER PAST MEDICAL HISTORY
- Amaurosis fugax while on xarelto
- Obesity
- Cervical plate surgery
- Torn meniscus bilateral knee
- OSA - CPAP
- Chronic back pain
- S/p failed left total knee replacement
- Right anterior mid-calf ulcer, followed by ___ for dressing
changes
Social History:
___
Family History:
Mother- atrial fibrillation
Father - MI at age ___.
Sons: 3 with mitochondrial disease of varying degrees
Physical Exam:
ADMISSION PHYSICAL EXAM
=============================
T 98.4 BP 140/60 HR 81 RR 17 Sat 93% RA
Gen: Sitting up in chair comfortably, significant pain with
movement from bed to chair, gait appears unstable without cane
HEENT: No icterus. MMM. OP clear.
NECK: Supple, unable to assess JVP with body habitus.
CV: RRR. no m/r/g
LUNGS: CTAB though very distant breath sounds No wheezes, rales,
or rhonchi.
ABD: NABS. Obese Soft, NT, ND.
EXT/skin: significant bilateral venous stasis changes shins down
to feet, no evidence of cellulitis or warmth, feet warm though
unable to palpate pulses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout. Gait assessment deferred
DISCHARGE PHYSICAL EXAM
==============================
24 HR Data (last updated ___ @ 512)
Temp: 97.9 (Tm 98.4), BP: 138/84 (111-154/53-84), HR: 75
(75-78), RR: 18 (___), O2 sat: 96% (93-96), O2 delivery: Ra,
Wt: 364.42 lb/165.3 kg
Fluid Balance (last updated ___ @ 244)
Last 8 hours Total cumulative -1400ml
IN: Total 0ml
OUT: Total 1400ml, Urine Amt 1400ml
Last 24 hours Total cumulative -1640ml
IN: Total 1260ml, PO Amt 1260ml
OUT: Total 2900ml, Urine Amt 2900ml
Gen: Morbidly obese woman sitting up in chair comfortably
HEENT: No icterus. MMM. OP clear.
NECK: Supple, unable to assess JVP with body habitus.
CV: RRR. no m/r/g
LUNGS: CTAB though very distant breath sounds, expiratory
wheezes, rales, or rhonchi.
ABD: NABS. Obese Soft, NT, ND.
EXT/skin: significant bilateral venous stasis changes shins down
to feet, no evidence of cellulitis or warmth, feet warm though
unable to palpate pulses. Raised dermatomal rash on L back with
vesicle formation. Intertrigo of the breasts
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout. Unsteady gait
Pertinent Results:
ADMISSION LABS
===================
___ 02:45AM BLOOD WBC-12.5* RBC-4.58 Hgb-14.3 Hct-44.9
MCV-98 MCH-31.2 MCHC-31.8* RDW-14.6 RDWSD-52.9* Plt ___
___ 02:45AM BLOOD Neuts-72.8* Lymphs-15.0* Monos-8.9
Eos-2.2 Baso-0.6 Im ___ AbsNeut-9.13* AbsLymp-1.88
AbsMono-1.11* AbsEos-0.27 AbsBaso-0.08
___ 02:45AM BLOOD ___ PTT-36.6* ___
___ 02:45AM BLOOD Glucose-85 UreaN-23* Creat-1.0 Na-138
K-4.9 Cl-100 HCO3-24 AnGap-14
___ 06:54AM BLOOD ALT-26 AST-23 AlkPhos-82 TotBili-0.7
___ 02:45AM BLOOD proBNP-355
___ 02:45AM BLOOD cTropnT-0.01
___ 09:45AM BLOOD cTropnT-<0.01
___ 06:54AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.8
PERTINENT LABS
====================
___ 05:43AM BLOOD WBC-14.0* RBC-4.39 Hgb-13.5 Hct-42.9
MCV-98 MCH-30.8 MCHC-31.5* RDW-14.2 RDWSD-50.9* Plt ___
___ 06:05AM BLOOD WBC-12.7* RBC-4.53 Hgb-14.1 Hct-43.8
MCV-97 MCH-31.1 MCHC-32.2 RDW-14.0 RDWSD-49.7* Plt ___
___ 06:05AM BLOOD Glucose-58* UreaN-26* Creat-0.8 Na-137
K-4.1 Cl-97 HCO3-26 AnGap-14
___ 06:05AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.0
IMAGING
======================
TTE ___
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. The estimated right atrial
pressure is ___ mmHg. The left ventricle has a normal cavity
size. There is suboptimal image quality to assess
regional left ventricular function. The visually estimated left
ventricular ejection fraction is >=60%.
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Tissue Doppler
suggests a normal left ventricular filling pressure (PCWP less
than 12mmHg). The right ventricle was not well
seen with uninterpretable free wall motion assessment. The
aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending
aorta diameter. A ___ 3 aortic valve bioprosthesis is
present. The prosthesis is well seated with normal
gradient. There is no aortic valve stenosis. There is an
eccentric, anterior mitral leaflet directed jet of trace
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is
moderate mitral annular calcification. There is trivial mitral
regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Likely preserved global
left ventricular systolic function.
Cannot comment on right ventricular function. Well-seated,
normally functioning aortic valve
___ ___ortic regurgitation (no
paravalvular leak). Mild pulmonary
hypertension.
Compared with the prior TTE ___, suboptimal image quality
precludes definititve comparison
CTA CORONARY ARTERIES ___
FINDINGS:
Image Quality: The overall quality of the CT angiographic
examination is poor
and is limited by poor arterial opacification and patient
motion.
AGATSTON SCORE: The total (aggregate) calcium score using the AJ
130 method is
1476. Total volume score is 1352. 90% of similar patients have
less coronary
artery calcium.
Individual major vessel AJ 130 scores are: LM: 117; LAD: 572;
LCX: 320; RCA:
467.
CORONARY CTA: Dominance of the coronary artery system: right
with normal
origins and course.
There is atherosclerotic disease noted in the LAD, LCx and RCA.
No major
plaques are seen, though evaluation is very limited and
narrowing within 50%
cannot be excluded.
CARDIAC MORPHOLOGY: The right atrium is normal. The right
ventricle is
normal. The left atrium is normal. The left ventricle is
normal. The
pericardium is normal and there is no pericardial effusion. The
patient is
status post aortic valve replacement. No plaques are seen
associated with the
replaced aortic valve. There are mitral annular calcifications.
A
biventricular pacing devices is seen.
EXTRACARDIAC FINDINGS:
No suspicious pulmonary nodules. There is mild left basilar
atelectasis and
mild bilateral dependent atelectasis. There are moderate
multilevel
degenerative changes of the thoracic spine.
IMPRESSION AND RECOMMENDATIONS: Very limited study due to
patient body
habitus, motion artifact, poor arterial opacification. Please
note coronary
CTA is not the preferred modality due to patient body habitus.
Total calcium score of 1476.
CAC-DRS ___ A3/N3
CAC Score risk: CAC-DRS 3 (>300): moderately to severely
increased risk- high
intensity statin + 81mg ___ recommended
(A - risk category based on Agatston score / N - number of
coronary arteries
containing calcifications)
CAD-RADS N- Non-diagnostic study, obstructive CAD cannot be
excluded.
Additional or alternative evaluation may be needed. There is
disease noted in
the LAD, LCx and RCA, and while no major plaques are seen,
evaluation is very
limited and narrowing within 50% cannot be excluded.
CT CHEST ___
No evidence of pulmonary edema or pneumonia.
ANKLE XRAY ___
FINDINGS:
No acute fractures or dislocations are seen.There is mild
periosteal reaction
about the medial and inferior medial aspect of the medial
malleolus with
subtle lucency of the medial malleolus tip. There is moderate
soft tissue
edema about the ankle most pronounced medially.There is a healed
distal
fibular fracture. Prominent plantar and Achilles related
enthesophytes.
There are vascular calcifications. There are mild degenerative
changes about
the tibiotalar joint. Possible small ankle joint effusion.
IMPRESSION:
Mild periosteal reaction about the medial aspect of the ankle
with
questionable small osseous erosion of the distal tip of the
medial malleolus,
may represent early osteomyelitis in the correct clinical
context, with other
etiologies including inflammatory arthropathy not excluded.
Note that MRI is
more sensitive for detection of osteomyelitis.
Moderate soft tissue edema about the ankle, most pronounced
medially.
MRI ___
IMPRESSION:
1. No bone marrow signal abnormality to suggest osteomyelitis.
2. Diffuse subcutaneous edema of the left ankle without rim
enhancing fluid
collection.
3. Mid substance Achilles tendinopathy with edema in ___
fat pad. No
Achilles tendon tear.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Venlafaxine XR 225 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Warfarin 13 mg PO DAILY16
9. ClonazePAM 2 mg PO QHS:PRN sleep
10. U-500 Conc 160 Units Breakfast
U-500 Conc 160 Units Bedtime
Discharge Medications:
1. Advair HFA (fluticasone propion-salmeterol) 115-21
mcg/actuation inhalation BID
2 puffs twice a day
RX *fluticasone propion-salmeterol [Advair HFA] 115 mcg-21
mcg/actuation 2 puffs IH twice a day Disp #*1 Inhaler Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H cough, wheeze, shortness
of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH every six
(6) hours Disp #*1 Inhaler Refills:*0
3. Cephalexin 500 mg PO QID Duration: 7 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp
#*28 Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
2 puffs daily
RX *tiotropium bromide [Spiriva Respimat] 2.5 mcg/actuation 2
puffs IH once a day Disp #*1 Inhaler Refills:*0
6. TraMADol 25 mg PO Q6H:PRN BREAKTHROUGH PAIN Duration: 2 Days
RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth
every six (6) hours Disp #*6 Tablet Refills:*0
7. ValACYclovir 1000 mg PO TID Duration: 7 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day
Disp #*4 Tablet Refills:*0
8. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
9. U-500 Conc 160 Units Breakfast
U-500 Conc 160 Units Bedtime
10. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Aspirin 81 mg PO DAILY
13. ClonazePAM 2 mg PO QHS:PRN sleep
14. Spironolactone 25 mg PO DAILY
15. Venlafaxine XR 225 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
17. Warfarin 13 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
COPD
Cellulitis of Left Lower Extremity
Varicella Zoster
SECONDARY DIAGNOSIS
========================
ATRIAL FIBRILLATION
HEART FAILURE WITH PRESERVED EJECTION FRACTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with shortness of breath// pneumonia, pulmonary
edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Left chest wall dual lead pacing device as well as a replaced valve are again
noted.The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. Enlarged cardiomediastinal silhouette is unchanged.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CORONARY ARTERIES W/3D W/FUNCTION
INDICATION: ___ is a ___ year old woman w/hx AS s/p ___,
afib, HFpEF (EF 60-65%), BiV ICD (___), TIApresenting with subacute
dyspnea on exertion and chest pain.// eval for coronary artery stenosis
TECHNIQUE: A 320-slice multidetector CTA ___) of the coronary
arteries was obtained using prospective ECG gating with Omnipaque contrast
administered intravenously. To provide better evaluation of the anatomy and
disease process, advanced 3D post-processing techniques, including multiplanar
reconstruction, maximal intensity projections, curved reconstructions, and
volume rendering were performed on a separate workstation.
Calcium score was calculated using Vitrea V-Score software. No intravenous
contrast material was administered for this portion of the exam.
Medications: None. Nitroglycerin could not be given due to patient's aortic
stenosis.
Vital Signs: The patient's heart rate was continuously monitored by a nurse.
Prior to this study, the heart rate was 80 beats per min and the blood
pressure was 134/48 mm Hg.
Procedure complications/allergic reactions: none
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.6 s, 23.5 cm; CTDIvol = 7.3 mGy (Body) DLP =
170.7 mGy-cm.
2) Stationary Acquisition 0.5 s, 14.0 cm; CTDIvol = 12.5 mGy (Body) DLP =
175.1 mGy-cm.
3) Stationary Acquisition 0.3 s, 0.5 cm; CTDIvol = 1.6 mGy (Body) DLP = 0.8
mGy-cm.
4) Stationary Acquisition 3.7 s, 0.5 cm; CTDIvol = 20.3 mGy (Body) DLP =
10.1 mGy-cm.
Total DLP (Body) = 357 mGy-cm.
COMPARISON: None available.
FINDINGS:
Image Quality: The overall quality of the CT angiographic examination is poor
and is limited by poor arterial opacification and patient motion.
AGATSTON SCORE: The total (aggregate) calcium score using the AJ 130 method is
1476. Total volume score is 1352. 90% of similar patients have less coronary
artery calcium.
Individual major vessel AJ 130 scores are: LM: 117; LAD: 572; LCX: 320; RCA:
467.
CORONARY CTA: Dominance of the coronary artery system: right with normal
origins and course.
There is atherosclerotic disease noted in the LAD, LCx and RCA. No major
plaques are seen, though evaluation is very limited and narrowing within 50%
cannot be excluded.
CARDIAC MORPHOLOGY: The right atrium is normal. The right ventricle is
normal. The left atrium is normal. The left ventricle is normal. The
pericardium is normal and there is no pericardial effusion. The patient is
status post aortic valve replacement. No plaques are seen associated with the
replaced aortic valve. There are mitral annular calcifications. A
biventricular pacing devices is seen.
EXTRACARDIAC FINDINGS:
No suspicious pulmonary nodules. There is mild left basilar atelectasis and
mild bilateral dependent atelectasis. There are moderate multilevel
degenerative changes of the thoracic spine.
IMPRESSION AND RECOMMENDATIONS: Very limited study due to patient body
habitus, motion artifact, poor arterial opacification. Please note coronary
CTA is not the preferred modality due to patient body habitus.
Total calcium score of 1476.
CAC-DRS ___ A3/N3
CAC Score risk: CAC-DRS 3 (>300): moderately to severely increased risk- high
intensity statin + 81mg ASA recommended
(A - risk category based on Agatston score / N - number of coronary arteries
containing calcifications)
CAD-RADS N- Non-diagnostic study, obstructive CAD cannot be excluded.
Additional or alternative evaluation may be needed. There is disease noted in
the LAD, LCx and RCA, and while no major plaques are seen, evaluation is very
limited and narrowing within 50% cannot be excluded.
REFERENCES: Calcium Scoring is reported using the interactive ___ form
(___) and graded using the CAC-DRS
___ (J Cardiovasc Comput Tomogr ___.
CAC-DRS 0 (A0) - Agaston score 0: Very low risk (statin generally not
recommended)
CAC-DRS 1 (A1) - Agaston score between ___: Mildly increased risk (moderate
intensity statin recommended)
CAC-DRS 2 (A2) - Agaston score between 100-299: Moderately increased risk
(moderate to high intensity statin + 81 mg ASA recommended)
CAC-DRS 3 (A3) - Agaston score between >300: Moderately to severely increased
risk (high intensity statin + 81 mg ASA recommended)
Coronary stenoses are reported as maximum percentage diameter stenosis and
graded using the CAD-RADS classification (___ Cardiovasc Imaging ___
Sep;9(9):1099-113).
CAD-RADS 0: 0%, no stenosis
CAD-RADS 1: ___, minimal stenosis or plaque with no stenosis
CAD-RADS 2: ___, mild stenosis
CAD-RADS 3: 50-69%, moderate stenosis
CAD-RADS 4A: 70-99%, severe stenosis
CAD-RADS 4B: >50% stenosis of the left main or >=70% stenosis of the left
anterior descending, the left circumflex, and the right coronary, severe
stenosis
CAD-RADS 5: 100%, total occlusion
CAD-RADS N: Non-diagnostic study, obstructive CAD cannot be excluded
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:08 pm, 50 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST WITHOUT CONTRAST
INDICATION: ___ year old woman with significant dyspnea on exertion// eval
lung parenchyma
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.6 s, 33.1 cm; CTDIvol = 22.9 mGy (Body) DLP = 720.9
mGy-cm.
Total DLP (Body) = 735 mGy-cm.
COMPARISON: CTA torso from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities on the chest wall. Mild atherosclerotic
calcifications in the head and neck arteries. Left anterior wall AICD with
leads in the right atrium and right ventricle.
HEART AND VASCULATURE:
The heart is enlarged with a dilated right atrium. Status post aortic valve
replacement. Coarse calcifications are noted surrounding the mitral annulus..
No pericardial effusion. Moderate atherosclerotic calcifications in the aorta
and in the coronary arteries. The aorta and pulmonary arteries are normal in
caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria. No hilar lymphadenopathy.
PLEURA:
No pleural effusions. Mild bilateral apical scarring.
LUNGS:
Respiratory motion artifacts limits evaluation of the lung parenchyma. The
airways are patent to the subsegmental levels. No bronchial wall thickening,
bronchiectasis or mucus plugging. No grossly large suspicious lung nodules.
Small linear consolidation in the left lower lobe, likely atelectasis.
CHEST CAGE:
No acute fractures. Moderate thoracic spondylosis. No suspicious lytic or
sclerotic lesions. Anterior cervical fusion hardware. Healed fracture
through the posterior aspect of the left fifth rib.
UPPER ABDOMEN:
Limited evaluation of the upper abdomen show mild diffuse low-attenuation of
the liver, likely representing hepatic steatosis. Unchanged thickened left
adrenal gland with no evident nodules.
IMPRESSION:
No evidence of pulmonary edema or pneumonia.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ year old woman with significant pain to palpation of L ankle
with overlying cellulitis// eval for osteo
TECHNIQUE: Three views of the left ankle.
COMPARISON: None available.
FINDINGS:
No acute fractures or dislocations are seen.There is mild periosteal reaction
about the medial and inferior medial aspect of the medial malleolus with
subtle lucency of the medial malleolus tip. There is moderate soft tissue
edema about the ankle most pronounced medially.There is a healed distal
fibular fracture. Prominent plantar and Achilles related enthesophytes.
There are vascular calcifications. There are mild degenerative changes about
the tibiotalar joint. Possible small ankle joint effusion.
IMPRESSION:
Mild periosteal reaction about the medial aspect of the ankle with
questionable small osseous erosion of the distal tip of the medial malleolus,
may represent early osteomyelitis in the correct clinical context, with other
etiologies including inflammatory arthropathy not excluded. Note that MRI is
more sensitive for detection of osteomyelitis.
Moderate soft tissue edema about the ankle, most pronounced medially.
NOTIFICATION: The impression above was entered by Dr. ___ on ___
at 11:48 into the Department of Radiology critical communications system for
direct communication to the referring provider.
Radiology Report
EXAMINATION: MR ANKLE ___ LEFT
INDICATION: ___ F with HFpEF, Afib s/p AVJ ablation with biV pacemaker
presenting with cellulitis and erosive changes on xray c/f osteo. Patient with
clearance for MRI as per OMR.// eval for osteo
TECHNIQUE: Multiplanar images of the left ankle were performed with and
without intravenous contrast using a routine MR ankle protocol.
COMPARISON: Left ankle radiograph dated ___.
FINDINGS:
Achilles tendon: There is mid substance tendinopathy of the Achilles tendon
without discrete tear. There is edema in the ___ fat pat.
Posterior tibial tendon: Normal.
Flexor digitorum tendon: Normal.
Flexor hallucis tendon: Normal.
Peroneal tendons: Normal.
Anterior tibialis tendon: Normal.
Extensor digitorum tendon: Normal.
Extensor hallucis longus: Normal.
The study is not tailored for evaluation ligamentous injury in the ankle.
Given the limitation the syndesmotic ligaments, lateral collateral ligament,
and medial collateral ligament are grossly intact.
Sinus tarsi: Normal.
Plantar fascia: Normal.
Tibiotalar joint space: There is no joint effusion or osteochondral lesions.
Marrow signal: There is no bone marrow signal abnormality to suggest
osteomyelitis..
Other findings: There is diffuse subcutaneous edema. No rim enhancing fluid
collection identified.
IMPRESSION:
1. No bone marrow signal abnormality to suggest osteomyelitis.
2. Diffuse subcutaneous edema of the left ankle without rim enhancing fluid
collection.
3. Mid substance Achilles tendinopathy with edema in ___ fat pad. No
Achilles tendon tear.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea on exertion
Diagnosed with Dyspnea, unspecified
temperature: 97.0
heartrate: 88.0
resprate: 16.0
o2sat: 94.0
sbp: 121.0
dbp: 78.0
level of pain: 3
level of acuity: 2.0 | SUMMARY
===================
___ is a ___ year old woman w/hx AS s/p TAVR
(___), afib, HFpEF (EF 60-65%), BiV ICD (___), TIA
presenting with subacute dyspnea on exertion and chest pain.
Patient underwent a battery of tests and it was thought her
symptoms were likely due to COPD and deconditioning and
therefore she was started on a prednisone taper. Her hospital
course was complicated by both shingles outbreak and cellulitis
for which she was treated.
TRANSITIONAL ISSUES
=======================
[] Patient provided with albuterol, Spiriva and advair at
discharge
[] Should have cardiology follow up for HFpEF.
[] Should have pulmonary follow up for COPD as well as sleep
medicine for OSA.
[] increased Lisinopril to 10 mg qd for BP control. consider
further uptitration
[] if suspicion for angina, consider amlodipine 5 mg qd vs Imdur
30 mg qd for microvascular angina
[] Patient developed cellulitis of the left lower extremity
while inpatient and was instructed to complete a 10 day course
of Keflex. Patient should be evaluated for resolution of
cellulitis after completing the antibiotic course.
[] Next INR should be checked on ___.
Discharge Weight: 365 lbs
Discharge Cr: 0.8
ACUTE ISSUES
===================
# Subacute Dyspnea on Exertion:
Ongoing dyspnea on exertion in pre and post TAVR with similar
symptoms noted at last Cardiology visit in ___. Given the
large differential, patient underwent a battery of tests. Her
PFTs showed mild to moderate obstructive pattern with normal
DLCO. Pulmonary was consulted and thought that her symptoms were
unlikely due to pHTN despite her prior TTE (___) showing
elevated pressures because it was thought these pressures were
reflective of her pre-TAVR stenotic valve. Unfortunately, her
body habitus precluded nuclear imaging and TTEs have suboptimal
quality which precluded dobutamine/pacemaker-mediated stress
testing. However she did have a CTA Coronary which showed a
total Ca score of 1476. Given the elevated calcium score her
atorvastatin was increased. After reviewing her cath from
___, it was thought her symptoms were unlikely cardiac. She
was treated for a COPD exacerbation for 5 days which improved
her dyspnea.
#Cellulitis of the L ankle
Patient noted to have significant erythema and warmth of the L
ankle on ___. Denies fevers or chills. Per patient, she has
frequent episodes of cellulitis. Significant pain of palpation
of the ankle. Xray showing concern for erosive changes and
unable to rule out osteomyelitis. MRI was ordered and showed no
evidence of osteomyelitis. ID was consulted and recommended
treating for cellulitis. Patient was discharged to complete a 10
day course of Keflex.
# Atypical angina:
Symptoms occurring at rest without correlation to activity.
Troponin negative x2, no ischemic EKG changes. Given duration of
symptoms, and relatively clear cath in ___, low suspicion for
active ACS. Patient was trialed on amlodipine 2.5mg for
antinginal effects without relief in symptoms so this was
discontinued.
#VZV
Patient evaluated by dermatology on ___ for new rash consistent
with shingles. Treated with Valcyclovir 1g TID x7 days (start
___, end ___.
# AS s/p TAVR
TTE from ___ showing peak gradient 14mmHg, mean gradient 7mmHg,
valve area 2.8cm, EKG without ischemic changes. TTE on ___
showed valve was well seated.
# Afib
# Coagulopathy
On warfarin as had TIA/amaurosis fugax while on xarelto INR
supratherapeutic on admission. Rate control with metop succinate
100mg daily.
# HFpEF (EF 60-65%)
No evidence of volume overload on exam. BNP low though ___ be
falsely low iso obesity. Continued ___,
atorvastatin, and increased lisinopril.
#Asymptomatic pyuria
No symptoms of UTI. UA with 10 epis and likely contamination. No
indication for treatment of asymptomatic UTI and as such will
not repeat UA.
# IDDM
- decreased home Insulin U-500 160mg qAM and 120mg qdinner while
in house given change in eating habits while inpatient (carb
consistent, low fat diet).
#Coping
Patient taking care of two sons at home as well as herself.
Recently lost husband ___ years ago). SW consulted for coping.
================
CHRONIC ISSUES:
================
#Back/knee pain
Significant back and knee pain with activity and only on Tylenol
at home
- Tylenol PRN
# CAD
- Continued ___ 81mg
- Continued Atorvastatin 80mg
- Continued metoprolol XL 50mg daily
# HTN
- Continued lisinopril 10mg daily and metoprolol as above
# Depression
- Continued home Venlafaxine XR 225mg DAILY
- Continued home ClonazePAM 2mg QHS:PRN sleep
# OSA
- Continued CPAP
# Vitamin D deficiency
- Continued home vitamin D
=====================================
# CODE STATUS: Full confirmed
# CONTACT: ___ ___
Greater than 30 minutes spent on discharge planning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
opioids
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with stage IIB Hodgkin lymphoma s/p 2 cycles of
ABVD c/b pneumonitis with subsequent PET-CT ___ showing
progression of disease who is now C3D6 ICE chemotherapy and
recently D/C on ___ (stayed for 3 days) who developed fever to
102.2 at home, with fatigue and new cough. Pt received his first
dose of neuopogen ___ morning prior to presentation to ED
but pt denies previous febrile reaction. Pt states that he
usually feels the peak effects of ICE chemo on day 5. He has
been laying in bed since his discharge, recovering from the
chemo. He states that on ___ ___, he began to experience
fevers/chills (denies rigors) and his T was checked which was
102.2. He states that he has developed a mild cough, productive
but unable to describe color, that started that day as well. No
SOB, CP, palpitations. He denies other infectious ROS including
HA, neck pain, nasal congestion, sore throat, odynophagia, ear
pain, n/v, abd pain, d/c, dysuria, rashes, or any other pains.
.
In the ED, initial VS were 98.2 104 107/65 16 99%. Labs notable
for WBC of 33 (up from 8; neupogen x1). UA unrevealing. Lactate
1.7. CXR did not show PNA. No antibiotics given. At time of
transfer to the ___ floors, VS were 97.9 91 109/65 16 97%. No
fever while in the ED.
.
Review of Systems:
Per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY
___ presented to PCP with week of fevers to 102, drenching
night sweats, cough and enlarged lymph node of the neck. CXR was
performed that was concerning for lymphoma
___ CXR: bilateral mediastinal masses with marked enlargement
of the mid and superior mediastinal structures surrounding the
lower portion of the trachea without evidence of significant
constriction
___iopsy consistent with classic
HL
___ C1D1 ABVD
___ C2D1 ABVD
___ Repeat PFT showed drop in DLCO and started on low dose
prednisone at 20mg
___ PET scan showed marked regression in mediastinal mass,
but some progression in some areas and one new area of avidity,
but in setting of possible lung inflammation was difficult to
interpret and plan to continue ABVD and repeat
___ C3D1 ABVD
___ Repeat PFT on prednisone showed resolution of DLCO
___ Repeat PET scan showed clear progression of his disease
___ After meeting with Dr. ___ for elective
admission on ___ for salvage ICE therapy.
___ ICE cycle 1
___ ICE cycle 2
___ ICE cycle 3
.
PAST MEDICAL HISTORY:
Depression/anxiety
GERD
superficial venous thrombosis: L Cephalic vein in forearm
.
PAST SURGICAL HISTORY:
Vasectomy in ___
Social History:
___
Family History:
Mother died of breast cancer at age ___ in ___.
Maternal grandmother w/ breast cancer.
Father w/ blood DO, but was a heavy drinker and died @ age ___.
No family history lymphomas or leukemias in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99 124/54 91 18 96%RA
General: NAD, comfortable, no signs of resp distress
HEENT: NCAT, MMM, pink conj, anicteric, no thrush or oral
lesions
Neck: Supple, no JVD
CV: S1S2 RRR no m/g/c/r
Lungs: CTAB
Abdomen: NABS soft, NT/ND, no organomegaly, no r/g
GU: No foley
Ext: 2+ pulses, no c/c/e
Neuro: CN ___ intact, motor/sensation in tact, normal
ambulation
Skin: No rash, salmon colored patch on occiput
.
DISCHARGE PHYSICAL EXAM: similar to admission.
Pertinent Results:
ADMISSION LABS:
___ 11:55PM BLOOD WBC-33.1*# RBC-3.47* Hgb-10.8* Hct-31.5*
MCV-91 MCH-31.3 MCHC-34.4 RDW-16.9* Plt ___
___ 11:55PM BLOOD Neuts-96.1* Lymphs-3.0* Monos-0.4*
Eos-0.5 Baso-0
___ 11:55PM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-132*
K-3.7 Cl-96 HCO3-22 AnGap-18
___ 11:55PM BLOOD ALT-26 AST-17 AlkPhos-114 TotBili-1.1
___ 11:55PM BLOOD LD(LDH)-223
___ 11:55PM BLOOD Albumin-4.1
___ 12:09AM BLOOD Lactate-1.7
___ 12:57AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 12:57AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
.
DISCHARGE LABS:
.
MICRO:
Blood and Urine Cxs Pending
.
IMAGING:
CXR ___
IMPRESSION: Hyperinflated but clear lungs. Mediastinal and
hilar enlargement consistent with the patient's lymphoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO TID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q6H:PRN nausea
4. Ondansetron ___ mg PO Q8H:PRN nausea
5. Prochlorperazine ___ mg PO Q8H:PRN nausea
6. Ranitidine 150 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Filgrastim 480 mcg SC Q24H
Please resume on ___ and use as directed
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q6H:PRN nausea
4. Ondansetron ___ mg PO Q8H:PRN nausea
5. Prochlorperazine ___ mg PO Q8H:PRN nausea
6. Ranitidine 150 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Filgrastim 480 mcg SC Q24H
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Fever
Secondary: Hodgkin's Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Refractory Hodgkin's lymphoma and ongoing fever.
COMPARISON: ___.
Mediastinal bulky mass is unchanged, bilateral. Lungs are clear. There is no
pleural effusion or pneumothorax. The Port-A-Cath catheter tip terminates at
the level of low SVC.
Gender: M
Race: UNKNOWN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, HODGKINS DIS NOS UNSPEC
temperature: 98.2
heartrate: 104.0
resprate: 16.0
o2sat: 99.0
sbp: 107.0
dbp: 65.0
level of pain: 2
level of acuity: 2.0 | ___ year old man with stage IIB Hodgkin lymphoma s/p 2 cycles of
ABVD c/b pneumonitis with subsequent PET-CT ___ showing
progression of disease who is currently receiving ICE
chemotherapy, p/w fever. Likely non-infectious but continued on
flagyl/cipro at time of dc. Cultures pending at dc but ngtd.
# Fever: T 102 at home with main localizing sign being a mild
productive cough. CXR in the ED showed no evidence of an
infiltrate or PNA. No antibiotics were started in ED. Exam on
admission did not suggest PNA. As a result, fever was thought to
be 2/t Neupogen and/or recent chemo. Pt was monitored while on
the ___ floor while not on antibiotics and Tmax was 101 after
the first day of admission. Neupogen was held on admission and
given the following day, at a lower dose of 300mcg QD, after he
did not have evidence of a fever. Cultures showed no growth to
date at time of dc. Was low grade in ___ at time of dc so
cipro/flagyl was continued. patient had close followup with
outpatient hem onc attending.
# Stage IIB Hodgkins Lymphoma: S/p 3 cycles of ABVD c/b
decreased DLCO that resolved with prednisone. Currently on ICE
(ifosfamide, carboplatin, etoposide) salvage chemotherapy since
___ after PET scan on ___ showed disease progression.
Repeat PET-CT ___ after cycle 2 ICE showed decreased LN size
and decreased FDG avidity. Recieved cycle 3 without incident
(c3d1 ___. Continued ppx with Acyclovir/Bactrim.
Transfusion scales in place for hct <21, plts <10.
# Depression/Anxiety: Continued Citaloparm, Zolpidem. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Toradol / Wellbutrin / Ambien / Benadryl / Celebrex / Zyprexa /
torsemide / BuSpar / clonidine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of systolic CHF, etoh abuse, b/l ___ edema,
personality disorder, HL, and history of TBI who presents with
shortness of breath and lower extremity pain and swelling. Says
that he has been at rehab for the past four weeks and that he's
being "neglected and abused" by staff. He has multiple rambling
complaints and is at times difficult to redirect. His biggest
complaint is his leg, his right leg has a new ulcer and he
believes the legs are not being dressed properly. His shortness
of breath feels worse. He refused in the ED to take Lasix, and
also refuses on the floor. He states that Lasix cause his body
to shut down. On previous admissions he has been found cutting
the IV on a Lasix drip. He has vague complaints of chest pain,
and is unable, or unwilling, to describe his symptoms, but does
not have chest pain currently. Of note he is poorly compliant
with diuretics and diet.
In the ED initial vitals were: 98.1 ___ 18 96% RA
EKG: sinus rate of 98, prolonged QTC, otherwise normal
intervals, poor R wave progression with q-waves in V1-V3,
diffuse ST flattening
Labs/studies notable for: WBC 8.1 with 79% PMNs, H/H 9.8/32.2,
normal Chem7, BNP 2796, troponin < 0.01. UA with large leuks,
many WBCs, moderate bacteria, 19 RBCs. Chest xray showed stable
cardiomegaly and mild hilar congestion.
Patient was given: PO cipro
Vitals on transfer: 98.1 95 104/60 18 99% RA
On the floor, patient refused Lasix, he states he will improve
his volume overload by taking "his own nutrients". He was
screaming at staff. He was demanding pain medications.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- sHF (EF 20%)
- Hyponatremia
- MI at age ___, states he "lost 15% of his heart muscle" and
had
an "enlarged heart" thereafter. Formerly followed by a
cardiologist at ___
- "internal bleeding" several months ago, with hematuria,
resolved
- Ortho-spine issues after being attacked (several times) in
muggings; s/p anterior fusion of C3-C7. Followed by orthopedic
surgery and neurosurgery at ___
- DJD
- PTSD after being attacked
- Anxiety
- Personality or mood disorder (schizoid), he has been
hospitalized at ___ at least once within the past
year, for two months, states this was for "exhaustion and
depression." Pt refers team to Dr. ___ at ___
___
- Alcohol abuse
- Tobacco abuse
- Homelessness (recently housed)
Social History:
- Born/raised, childhood: Grew up in ___, with
mother, father, and 4 siblings.
- Education: Completed high school, took some college courses
- Employment/Source of income: Worked many jobs in the past,
including ___, worked at a ___ clinic, and
several volunteer jobs. Currently unemployed, on ___
- Housing: lives alone, in current apartment x 6 months, prior
to that was homeless
- Exposure to violence: attacked and mugged many times
SUBSTANCE ABUSE HISTORY:
As per Dr. ___ ___ note:
"- EtOH: ___ year of sobriety with AA meetings. Denies history
of
WD. Review of OMR reveals ___ detox program. EtOH
levels as high as 340 previously. Past three EtOH levels
___, and ___ were negative."
- Tobacco: 1.5 ppd
- Marijuana: denies
- Opiates, including heroin: only opioid use is morphine
prescribed for back pain
- Benzodiazepines: denies
- Cocaine/Crack: denies (although has admitted to use per the
record)
- Amphetamines: denies
- LSD/PCP/Ecstasy/Mushrooms: denies"
Family History:
Mother died of breast CA
Father and brother died of ___ disease
Physical Exam:
===================
Admission Exam:
===================
GENERAL - NAD
HEENT - no scleral icterus, OP clear, poor dentition
NECK - supple, JVP elevated
CARDIAC - regular, pronounced PMI, no m/r/g appreciated
PULMONARY - bilateral crackles
ABDOMEN - +BS, soft, non-distended, non-tender
EXTREMITIES - edematous, 2+ pitting edema, bilateral erythema
but no warmth, superficial ulcers on right leg, wrapped left
leg, refuse taking off bandage,
NEUROLOGIC - Moves all 4 extremities
LABS: reviewed, see below
MICRO: reviewed, see below
EKG: sinus rate of 98, prolonged QTC, otherwise normal
intervals, poor R wave progression with q-waves in V1-V3,
diffuse ST flattening
======================
Discharge Exam: ***LEFT AMA***
======================
VS: T=98.0 BP=113/65 HR=83 (running high 90's, low 100's) RR=18
O2 sat=96RA
I/O: 24hr: 1480/3700 8hr: ___
Wt:
8
3
.
1
k
g
-
>
8
2
.
4
kg->82.5->81.6->79.3->79.2->76.7->76.0->73.3kg->74.4->73.3->71.8
GENERAL: disheveled, poorly shaven, NAD
HEENT: EOMI, no scleral icterus
NECK: Supple with JVP of 3cm above collarbone at 45 degrees
CARDIAC: RRR, no MRG
LUNGS: On RA, good air exchange, no increased work of breathing,
mild crackles at bases standing up, no rales or ronchi.
ABDOMEN: Soft, NTND. +BS
EXTREMITIES: 2+ edema to knees b/l with 2cm round ulceration on
ventral aspect of R shin, about 5cm above the ankle, can see
fatty tissue but no purulence
SKIN: chronic skin changes of b/l shins/calves
Pertinent Results:
=================
Admission Labs:
==================
___ 07:09PM BLOOD WBC-8.1 RBC-3.80* Hgb-9.8* Hct-32.2*
MCV-85 MCH-25.8* MCHC-30.4* RDW-19.5* RDWSD-60.1* Plt ___
___ 04:54AM BLOOD ___ PTT-32.9 ___
___ 07:09PM BLOOD Glucose-112* UreaN-17 Creat-1.0 Na-133
K-5.1 Cl-98 HCO3-23 AnGap-17
___ 04:54AM BLOOD ALT-14 AST-23 AlkPhos-253* TotBili-1.0
___ 07:09PM BLOOD proBNP-2796*
___ 07:09PM BLOOD cTropnT-<0.01
___ 04:54AM BLOOD cTropnT-<0.01
___ 04:54AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
==============
CARDIAC LABS:
==============
___ 07:09PM BLOOD proBNP-2796*
___ 07:09PM BLOOD cTropnT-<0.01
___ 04:54AM BLOOD cTropnT-<0.01
=========================
PERTINENT IMAGING/STUDIES
=========================
CT HEAD W/O CONTRAST (___):
Chronic findings as discussed above. No evidence of fracture,
hemorrhage or infarction
CT C- SPINE (___):
No evidence of fracture. Minimal anterior subluxation of C7 on
T1 due to degenerative disease.
Anterior fusion of C3 through C7 appears intact with no evidence
of hardware failure.
Degenerative disc disease with canal and foraminal narrowing at
multiple levels.
CXR PA/LAT (___)
FINDINGS:
AP upright and lateral views of the chest provided.
The heart remains mildly enlarged. Lung volumes are low
limiting assessment. No convincing signs of pneumonia or edema.
There may be mild hilar congestion. No large effusion or
pneumothorax. Mediastinal contour is normal. Bony structures
are intact. Bilateral AC joint arthropathy noted. Fusion
hardware projects over the C-spine.
IMPRESSION:
Stable mild cardiomegaly with mild hilar congestion.
======
MICRO:
======
Urine Culture:
URINE CULTURE (Final ___:
___ MD (___) REQUESTS FOSFOMYCIN SENSITIVITIES
___.
ENTEROCOCCUS FAECIUM. >100,000 ORGANISMS/ML..
Sensitivity testing per ___ ___.
ZONE SIZE FOR FOSFOMYCIN IS 15 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
Fosfomycin sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>64 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
===============
Discharge Labs: ***LEFT AMA***
===============
___ 07:00AM BLOOD WBC-5.1 RBC-3.86* Hgb-9.8* Hct-31.2*
MCV-81* MCH-25.4* MCHC-31.4* RDW-18.0* RDWSD-52.9* Plt ___
___ 07:00AM BLOOD Plt ___
___ 03:04PM BLOOD Glucose-157* UreaN-22* Creat-1.2 Na-130*
K-3.6 Cl-86* HCO3-31 AnGap-17
___ 03:04PM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bengay Cream 1 Appl TP TID:PRN pain
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. QUEtiapine Fumarate 200 mg PO QHS
10. QUEtiapine Fumarate 50 mg PO QAM
11. QUEtiapine Fumarate ___ mg PO Q6H:PRN anxiety, agitation,
insomnia
12. Thiamine 250 mg PO DAILY
13. Furosemide 100 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*90 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
4. Bengay Cream 1 Appl TP TID:PRN pain
RX *menthol [BenGay Vanishing Scent] 2.5 % apply three times a
day Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
9. QUEtiapine Fumarate 200 mg PO QHS
RX *quetiapine 200 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. QUEtiapine Fumarate 50 mg PO QAM
RX *quetiapine 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Thiamine 250 mg PO DAILY
RX *thiamine HCl (vitamin B1) 250 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
12. Furosemide 100 mg PO BID
RX *furosemide [Lasix] 80 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
RX *furosemide 20 mg 5 tablet(s) by mouth twice a day Disp #*300
Tablet Refills:*0
13. QUEtiapine Fumarate ___ mg PO Q6H:PRN anxiety, agitation,
insomnia
14. Potassium Chloride (Powder) 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 packet(s) by mouth daily Disp
#*100 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
acute on chronic systolic heart failure
Urinary tract infection
Secondary diagnoses:
Leg ulcers
Mood disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with cough sob
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided.
The heart remains mildly enlarged. Lung volumes are low limiting assessment.
No convincing signs of pneumonia or edema. There may be mild hilar
congestion. No large effusion or pneumothorax. Mediastinal contour is
normal. Bony structures are intact. Bilateral AC joint arthropathy noted.
Fusion hardware projects over the C-spine.
IMPRESSION:
Stable mild cardiomegaly with mild hilar congestion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man who fell and hit hit, no LOC. // eval for
hemorrhage after headstrike
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, 17.1 cm; CTDIvol = 47.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Prominence of
the ventricles and sulci is suggestive of atrophy.
No fracture seen. There is moderate mucosal thickening in the ethmoid air
cells. The imaged portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are otherwise clear. The imaged portion of the orbits are
unremarkable.
IMPRESSION:
Chronic findings as discussed above. No evidence of fracture, hemorrhage or
infarction.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old man who fell and hit hit, no LOC. eval for
hemorrhage. cervical spine tenderness // eval for cervical spine tenderness
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.4 s, 24.8 cm; CTDIvol = 37.3 mGy (Body) DLP = 926.2
mGy-cm.
Total DLP (Body) = 926 mGy-cm.
COMPARISON: CT C-spine ___
FINDINGS:
Evaluation at the level of the dental hardware is somewhat limited due to
artifact. Anterior fusion hardware from C3-C7 appears similar to prior.
There is no perihardware lucency or other complication identified.
Alignment is not significantly changed since prior, with minimal C7 on T1
anterolisthesis similar to prior. No fractures are identified.
There are changes of degenerative disc disease with a small bulge of the disc
at C2-3 narrowing the spinal canal but not contacting the spinal cord. The
neural foramina appear normal.
At C3-4, prominent intervertebral osteophytes encroach on the spinal canal,
greater on the left than right. These appear to flatten the anterior surface
of the spinal cord. In addition, uncovertebral and facet osteophytes produce
moderate -severe left neural foraminal narrowing.
At C4-5, intervertebral osteophytes narrow the spinal canal and flatten the
anterior surface of the spinal cord. Facet and uncovertebral osteophytes
produce moderate right neural foraminal narrowing.
At C5-6, small intervertebral osteophytes narrow the spinal canal and contact
the anterior surface of the spinal cord. The neural foramen appears normal.
At C6-7, intervertebral osteophytes narrow the spinal canal and slightly
flatten the anterior surface of the spinal cord. Uncovertebral osteophytes
produce mild right and moderate left neural foraminal narrowing.
There is mild canal narrowing at C7-T1 due to subluxation. However, this does
not appear sufficient to contact the spinal cord. The neural foramina appear
normal.
There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No evidence of fracture. Minimal anterior subluxation of C7 on T1 due to
degenerative disease.
Anterior fusion of C3 through C7 appears intact with no evidence of hardware
failure.
Degenerative disc disease with canal and foraminal narrowing at multiple
levels.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Leg swelling, Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 98.1
heartrate: 104.0
resprate: 18.0
o2sat: 96.0
sbp: 98.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | ****LEFT AMA******
Mr. ___ was admitted ___ with acute systolic heart failure
exacerbation in setting of refusing diuresis at rehab. He was
treated with Lasix gtt at 20/hr with intermittent boluses of
80mg IV. He diuresed well but was refusing dietary restrictions.
He was maintained on a regular diet but was successfully losing
___ kgs per day. On the morning of ___, he became upset with
the ongoing diuresis and leg wounds in the middle of the night
and he left AMA. He was encouraged to stay but refused because
he didn't like the treatment which he felt was "experimental."
He understood the risks of leaving without adequate diuresis
including worsening heart failure and even sudden death. He
planned to seek care at a different hospital. He was also
treated for a UTI while admitted and finished his antibiotic
course while at ___.
#Acute on chronic systolic CHF exacerbation: EF 20% per ECHO
from ___. Patient presenting in setting of significant
systolic CHF but personality limits adherence to medications.
Currently refuses Lasix and torsemide as outpatient. Eventually
agreed to 60-80mg IV Lasix doses on condition of staying in the
hospital. Also continued on metoprolol. Did not obtain TTE as
exacerbation clearly related to non-compliance with medications.
He was attempted to be diuresed ultimately with a Lasix drip at
20mg/hr with some good effect (losing ___ per day) but this
was limited by his behavioral issues as mentioned above. He also
refused a fluid restriction.
#UTI: Found to have VRE UTI for which he was treated with
Fosfomycin.
#Leg ulcers: Do not look actively infected. Likely secondary to
venous stasis, seen by wound care and clean dressings were
maintained.
#Personality or mood disorder: very combative at baseline. On
Seroquel 50qAM and 100qPM Psychiatry consulted and recommended
behavioral interventions consistent with a prior social work
note. See recommendations:
For staff
Behavioral plan for ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / Tetanus /
Tuberculin,Purif.Prot.Deriv. / metoprolol
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L
hemiplegia), and schizophrenia, now presenting with altered
mental status.
He was noted by ___ to have confusion and disorientation, which
appeared to be new as of ___. He was unable to provide further
history given altered mental status. Per outpatient notes, he
has been gaining weight due to dietary indiscretion.
In the ED, initial VS notable for
97.8 88 136/51 18 100% RA
Exam was notable for soft abdomen, 2+ bilateral pitting edema,
guaiac positive stool, mild asterixis, no accessible ascites
seen on ultrasound.
He was given:
___ 18:44 IV Dextrose 50% 12.5 gm
___ 19:01 IVF 1000 mL NS 1000 mL
___ 21:55 PO/NG Lactulose 30 mL
___ 00:09 PO/NG Lactulose 30 mL
He was admitted to medicine for further management.
On arrival he had large bowel movement. Denies pain or
discomfort.
Past Medical History:
- EtOH abuse
- EtOH cirrhosis
- Variceal bleeds
- Erosive esophagitis and gastic varicies
- CVA and left hemiplegia
- IDDM
- Schizophrenia
- Anemia
- Hypothyroidism
- Obesity
- HTN
- HL
- Migranes
- COPD
Social History:
___
Family History:
No family history of liver disease
Physical Exam:
ADMISSION
VS: 98.3 123/56 97 22 100RA
General: Obese man in NAD
HEENT: NCAT, pupils equal, MMM
Neck: Supple
CV: RRR, S1/S2 no m/r/g
Lungs: CTAB anterior fields
Abdomen: Soft, nontender, nondistended NABS
GU: Incontinent of urine.
Ext: Tender ___ pitting edema bilaterally to knees
Neuro: A/O to name only, not to location or year.
Skin: No rashes noted.
DISCHARGE
VS: 98.9 120s/50-70s 80-90s ___ 100RA
General: Obese man in NAD
HEENT: NCAT, pupils equal, MMM
Neck: Supple
CV: RRR, S1/S2 no m/r/g
Lungs: CTAB anterior fields
Abdomen: Soft, nontender, nondistended NABS
GU: Incontinent of urine.
Ext: Tender ___ pitting edema bilaterally to knees
Neuro: A/O x 3, no asterixis
Skin: No rashes noted.
Pertinent Results:
ADMISSION LABS
___ 06:48PM BLOOD WBC-4.7 RBC-3.65* Hgb-11.7* Hct-33.5*
MCV-92 MCH-32.1* MCHC-34.9 RDW-13.0 RDWSD-43.6 Plt Ct-53*
___ 06:48PM BLOOD Neuts-77.3* Lymphs-9.0* Monos-10.5
Eos-2.6 Baso-0.2 Im ___ AbsNeut-3.60# AbsLymp-0.42*
AbsMono-0.49 AbsEos-0.12 AbsBaso-0.01
___ 06:48PM BLOOD ___ PTT-36.4 ___
___ 06:48PM BLOOD Plt Ct-53*
___ 06:48PM BLOOD Glucose-74 UreaN-22* Creat-0.9 Na-136
K-3.8 Cl-102 HCO3-22 AnGap-16
___ 06:48PM BLOOD ALT-28 AST-54* AlkPhos-77 TotBili-1.1
___ 05:00AM BLOOD Albumin-3.2* Calcium-8.7 Phos-4.2 Mg-2.3
___ 02:02AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:02AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:02AM URINE RBC-3* WBC-3 Bacteri-MOD Yeast-NONE
Epi-<1
___ 02:02AM URINE CastHy-5*
DISCHARGE LABS
___ 05:00AM BLOOD WBC-1.8* RBC-3.23* Hgb-10.1* Hct-30.2*
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 RDWSD-43.9 Plt Ct-48*
___ 05:00AM BLOOD Plt Ct-48*
___ 05:00AM BLOOD Glucose-143* UreaN-20 Creat-0.8 Na-138
K-3.6 Cl-107 HCO3-21* AnGap-14
___ 05:00AM BLOOD ALT-30 AST-51* AlkPhos-76 TotBili-0.7
___ 05:00AM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.1 Mg-2.0
MICROBIOLOGY
___ BLOOD CULTURE, URINE CULTURE NEGATIVE
IMAGING
-Chest x-ray ___:
Mild pulmonary vascular congestion. No focal consolidation to
suggest pneumonia.
-RUQUS ___:
1. Cirrhotic liver with no focal hepatic lesions identified in
this limited examination.
2. Patent main portal vein.
3. Splenomegaly.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with altered mental status
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The aorta is unfolded.
There is mild pulmonary vascular congestion. No focal consolidation, pleural
effusion or pneumothorax is present. Mild multilevel degenerative changes are
seen in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion. No focal consolidation to suggest
pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with cirrhosis and altered mental status
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal CT from ___.
FINDINGS:
Study is slightly limited due to patient's inability to comply with breathing
instructions.
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
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 18.4 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with no focal hepatic lesions identified in this limited
examination.
2. Patent main portal vein.
3. Splenomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status, question of fall today,
tenderness to palpation within the midline cervical spine
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.
2) Sequenced Acquisition 6.4 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: None.
FINDINGS:
The exam is somewhat limited by motion despite attempts to repeat sequences.
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is slight leftward angulation of the nasal bone, likely chronic. There
is no evidence of acute fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ M with altered mental status, possible fall today,
tenderness to palpation within the midline cervical spine.
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 5.9 s, 22.8 cm; CTDIvol = 37.2 mGy (Body) DLP = 850.4
mGy-cm.
Total DLP (Body) = 850 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel mild degenerative
changes are noted with loss of disc height and anterior and posterior
osteophytes, worse at C3-4 C5-6 and C6-7. A disc bulge and posterior
osteophytes at C3-4 and C6-7 indent the thecal sac anteriorly. Mild
multilevel neural foraminal narrowing is most pronounced bilaterally at C5-6
and C6-7. There is no prevertebral soft tissue swelling. There is no
evidence of infection or neoplasm.
IMPRESSION:
No evidence of fracture or traumatic malalignment.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 97.8
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 51.0
level of pain: unable
level of acuity: 2.0 | ___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L
hemiplegia), and schizophrenia, now presenting with altered
mental status.
# HEPATIC ENCEPHALOPATHY:
History of encephalopathy on lactulose maintenance, now with
acute encephalopathy and asterixis. Infectious workup negative
including bland UA, urine culture NGTD, blood culture NGTD,
negative CXR. No ascites. No portal vein thrombosis on RUQUS.
Patients home lactulose increased to 30mL po/pr q2h until he
cleared, then discharged on 30mL four times daily. Please
titrate to 3BM-5BM daily. Rifaximin 550 BID was started given
decompensated encephalopathy. Lactulose also written PRN for
additional orders if he becomes encephalopathic. If this is used
as a PRN order, please notify the staff MD.
# NASH / ETOH Cirrhosis: MELD 11 on admission, stable from
prior. Decompensated by encephalopathy as above. Last EGD in
___. History of variceal banding, but did not tolerate beta
blockers. No ascites currently. He was continued on his home
medications: pantoprazole, spironolactone, and furosemide.
# COAGULOPATHY: No evidence of active bleeding
CHRONIC ISSUES:
# Type 2 Diabetes: Continued insulin.
# Hypertension: Continued Lisinopril 10 mg daily.
# Schizophrenia: Continued Topiramate 100 mg PO BID, risperidone
briefly held but then restarted.
# COPD: Continued Fluticasone-Salmeterol Diskus (250/50) BID.
# Chronic pain: Held HYDROcodone-Acetaminophen while acutely
encephalopathic.
# Eye drops: Continued Latanoprost 0.005% Ophth. Soln. QHS.
# Hypothyroidism: Continued Levothyroxine Sodium 200 mcg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Bactrim / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
increasing h/a's and lower extremity weakness (L>R)
Major Surgical or Invasive Procedure:
___: Right craniotomy and evacuation of subdural hematoma
History of Present Illness:
This is a ___ y.o. female known to service with chronic R SDH
after a syncopal fall. She was followed by Dr. ___ in the
___ clinic. She reports that for the past ___ days she
has had increasing headaches and gait instability. She has
tried OTC without much relief. She went to the ED and after
evaluation surgical planning was initiated.
Past Medical History:
asymptomatic PE and DVT off coumadin since ___
CAD s/p stent ___
HTN
thoracic aneurysm, with mural thrombus in the descending aortic
artery ___
lupus anticoagulant upper limit normal
diverticular disease
hyperlipidemia
GERD
anxiety
osteoarthritis s/p total-knee replacement
carpal tunnel s/p release surgeries and prior hysterectomy
3 lumbar spine surgeries
Social History:
___
Family History:
No FH of clotting, PE, stroke, or known autoimmune illness.
Positive FH of CABG in 6 siblings, M/I in father.
Physical Exam:
On admission:
Mental status: Awake and alert x2.5 knew day and year cofused
with month, cooperative with examination;
normal affect.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
II-XII intact, pupils ___ b/l, EOM intact, no nystagmus
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ in UEs, slight generalized
weakness in LLE ___. + slight left pronator drift; no clonus,
toes upgoing on left, downgoing on right
PHYSICAL EXAM UPON DISCHARGE:
Alert and Oriented x2, somewhat confused about place on and off
CN ___ grossly intact
L grip 5-, LLE IP 5-, Q5, H4, AT5, EHL3, G5
Pertinent Results:
___ CT Head: IMPRESSION:
1. Interval increase in size of right hemispheric convexity
subdural hematoma with associated increase in leftward shift of
the normally midline structures.
2. No acute large vascular territorial infarction.
___ CXR: IMPRESSION: No acute cardiopulmonary process.
CT HEAD W/O CONTRAST Study Date of ___ 7:46 ___
IMPRESSION: Interval right craniotomy and placement of a right
subdural drain with decrease in size of the right subdural fluid
collection, which now measures 14-mm, but persistent right
sulcal and lateral ventricle effacement and 8 mm leftward shift
of normally midline structures. Large right subdural air,
likely post-procedural.
CT HEAD W/O CONTRAST Study Date of ___ 7:46 AM
IMPRESSION: Expected post-surgical changes in right subdural
hematoma drain with decrease in pneumocephalus. Stable 8 mm
leftward shift of midline structures.
CT Head ___:
Since the previous CT examination, the subdural drain has been
removed. The size of the residual subdural has not
significantly changed. No definite new hemorrhage seen
LENS ___:
No evidence of deep vein thrombosis in either leg
Medications on Admission:
Atenolol; Fluoxetine; Nifedipine; Nitroglycerine; Omeprazole.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, HA, fever
2. Atenolol 50 mg PO DAILY
3. Codeine Sulfate ___ mg PO Q4H:PRN pain
RX *codeine sulfate 15 mg ___ tablet(s) by mouth Q4hrs Disp #*60
Tablet Refills:*0
4. Fluoxetine 20 mg PO DAILY
5. Heparin 5000 UNIT SC TID
may start at 2200 ___
6. LeVETiracetam 1000 mg PO BID Duration: 6 Days
Last dose on ___
7. NIFEdipine CR 60 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Xopenex Neb *NF* 1 NEB IH Q6H wheezing Reason for Ordering:
Wheezing, albuterol may induce A. Fib
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID constipation
13. Bisacodyl 10 mg PO/PR DAILY constipation
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Subdural Hematoma
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: Known subdural hematoma, now with worsening lower extremity
weakness over the past three days. Evaluate for progression of subdural
hematoma.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
COMPARISON: CT head from ___.
FINDINGS: There has been an interval increase in size of the known subdural
hematoma overlying the right cerebral hemisphere, with the maximal width of
the extra-axial collection now measuring 2.4 cm compared to 1.7 cm previously
(2:17). The degree of associated leftward shift of the normally midline
structures is also increased, now measuring 11 mm compared to 8 mm previously
(2:13). Marked sulcal effacement throughout the right hemisphere is
redemonstrated, as is marked compression of the right lateral ventricle.
There is no entrapment of the left lateral ventricle or transtentorial
herniation.
There is no acute large vascular territorial infarction. Calcifications are
seen of the bilateral cavernous carotid arteries. The imaged portions of the
orbits are unremarkable. The visualized portions of the paranasal sinuses and
mastoid air cells are well aerated.
IMPRESSION:
1. Interval increase in size of right hemispheric convexity subdural hematoma
with associated increase in leftward shift of the normally midline structures.
2. No acute large vascular territorial infarction.
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with subdural hematoma which is worsening. Preop
chest x-ray.
FINDINGS: Frontal and lateral views of the chest are compared to previous
exam from ___. The lungs remain clear of focal consolidation or
effusion. Cardiac silhouette is slightly enlarged and there is a tortuous
aorta, unchanged from prior. The descending thoracic aorta is enlarged,
aneurysmal, measuring 5.8 cm AP and lateral view. Osseous structures notable
for left shoulder arthroplasty.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with coronary artery disease and history of
pulmonary embolus, now with subdural hematoma.
___.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
reviewed.
FINDINGS: There has been interval right frontal craniotomy with placement of
a subdural catheter. Large right frontal subdural air is likely
post-procedural. There has been interval decrease in size of the right
subdural collection, which now measures 14 mm in greatest width. There is
decreased but persistent leftward shift of normally midline structures, now
measuring 8 mm. The basal cisterns appear patent. There is persistent
effacement of the sulci along the right cerebral convexity and of the right
lateral ventricle. Soft tissue swelling and subgaleal air overlie the
craniotomy site. Craniotomy hardware and scalp surgical staples are seen. The
visualized portions of the paranasal sinuses and mastoid air cells appear well
aerated.
IMPRESSION: Interval right craniotomy and placement of a right subdural drain
with decrease in size of the right subdural fluid collection, which now
measures 14-mm, but persistent right sulcal and lateral ventricle effacement
and 8 mm leftward shift of normally midline structures. Large right subdural
air, likely post-procedural.
Radiology Report
INDICATION: Chronic subdural hematoma with craniotomy performed. Evaluation
for interval changes after evacuation.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast.
COMPARISON: Multiple prior NECTs of the head from ___ to ___.
FINDINGS: Comparison to NECT of the head from ___, there is little
interval change. Again noted is a large right frontoparietal fluid collection
with recent evacuation and external drain in place. There is unchanged 8 mm
leftward subfalcine herniation. The basal cisterns are patent, however.
Pneumocephalus has decreased. The subdural fluid collection is unchanged in
size. Persistent effacement of the right lateral ventricle and right
frontoparietal cerebral convexities is unchanged. Post-surgical changes from
craniotomy are noted. There is no new area of hemorrhage. The visualized
paranasal sinuses, mastoid air cells, middle ear cavities are clear.
IMPRESSION: Expected post-surgical changes in right subdural hematoma drain
with decrease in pneumocephalus. Stable 8 mm leftward shift of midline
structures.
Radiology Report
EXAM: CT of the head.
CLINICAL INFORMATION: Patient with subdural hematoma status post evacuation.
TECHNIQUE: Axial images of the head were obtained without contrast and
compared with prior CT of ___.
FINDINGS: Since the previous study, the subdural drain has been removed.
Residual subdural with high and low density measuring approximately 14 mm is
again identified, not significantly changed since the prior study. Mild
indentation on the adjacent sulci and slight indentation on the right lateral
ventricle are again noted without significant midline shift. Basal cisterns
remain patent.
IMPRESSION: Since the previous CT examination, the subdural drain has been
removed. The size of the residual subdural has not significantly changed. No
definite new hemorrhage seen.
Radiology Report
HISTORY: ___ female with extended bed rest, evaluate legs for DVT.
COMPARISON: No previous exam for comparison.
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.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY WEAKNESS
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 97.6
heartrate: 61.0
resprate: 18.0
o2sat: 96.0
sbp: 99.0
dbp: 53.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted to the Neurosurgery service. Pre-op
work up was initiated for plans for surgery on ___. Aspirin was
held and platelets were ordered on call to the OR. SBP was
controlled for a goal of less than 140. Consent was obtained for
the OR.
On ___ she was neurologically unchanged, (left drift, and LLE
weakness). She was taken to the OR in the afternoon, she
underwent a right frontal temporal craniotomy for ___
evacuation. A subdural drain was left in. She was extubated and
transferred to the ICU where she stayed over night.
On ___, the patients subdural drain was electively discontinued
and the insertion site was closed with staples. A physical
therapy consult was placed and the patient was mobilized out of
bed to the chair with assistance. The patient tolerated a
regular diet well. In the morning the patient went into atrial
fibrillation and had low urine output. The patient was given a
250cc bolus and the patient converted back into normal sinus
rhythm spontaneously. The urine output increased to over 30 cc
an hour. Given the patient low urine output and atrial
fibrillation the patient was kept in the intensive care unit for
one more day. In the evening the Foley catheter was
discontinued. On exam, the patient was alert and oriented to
person, place and time. Strength was full. There was no
pronator drift. The patient's incision was well approximated
and clean without drainage.
On ___ she was seen and evaluated and felt to be appropriate
for transfer to the floor with telemetry. She awaited a floor
bed, however none became available. On ___ she was stable and
underwent a head CT prior to discharge. There was no increase in
hemorrhage. She was on the floor on ___ and was stable. ___ was
following. Screening LENS were ordered and there was no blood
clot in either leg. She was transferred to rehab on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, back pain
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
___ yo. w/history of severe migraines, now here with 2 weeks
of headache and 1 week of low back pain. First symptom was
headache similar to previous migraines but unrelenting for the
last couple of weeks, which she has not had since high school.
It
is left-sided, frontal, throbbing, associated with phonophobia,
nausea, and extreme light sensitivity: she wears her sunglasses
at night.
Also has sensation of floaters or tracers in eyes, and pain on
eye movements when looking to the side of the headache. She
thinks these visual symptoms may be related to her extreme
photophobia as they are improved with the sunglasses.
She has been taking ibuprofen 600 ___ x daily as well as
Fioricet, without relief, and just got prescriptions for
tramadol
and sumatriptan as well but was unable to tolerate these as they
made her feel trippy and woozy.
Over the last week, she also developed low back pain that
radiates down her entire right leg. The last couple of days has
had neck stiffness on the left side. No history of neck trauma
At the time of evaluation, pt had received morphine 5 mg IV
twice
and ondansetron, without relief.
ROS: Complains of urinary frequency but not urgency or
incontinence, and has good bowel control. Feels unable to
ambulate due to severe pain.
On neurologic ROS, no
lightheadedness/confusion/syncope/seizures/difficulty with
producing or comprehending speech/amnesia/concentration
problems;
no loss of vision/amaurosis/diplopia/vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia.
On general ROS, no fevers/chills/rigors/night
sweats/anorexia/weight loss. No chest
pain/palpitations/dyspnea/exercise intolerance/cough. No
vomiting/diarrhea/constipation/abdominal pain. No
dysuria/hematuria.
Past Medical History:
- Migraine without aura, with previous ED visits and
hospitalizations as teenager
- ruptured ovarian cyst
- lactose intolerance
Social History:
___
Family History:
Parents: mother with migraines
___: grandmother with ___
Uncle with epilepsy
Physical Exam:
Admission exam:
VS T:97.6 HR:75 BP:102/66 RR:18 SaO2:99%RA
General: NAD, lying in bed in moderate distress due to headache,
back pain and photophobia, wearing dark sunglasses
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Neck: Negative Brudzinski and Kernig signs but has
paracervical
muscle spasm on left. No lymphadenopathy or thyromegaly.
- Neurovascular: No carotid, vertebral or subclavian bruits.
- Cardiovascular: carotids with normal volume & upstroke; RRR,
no
M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding, no hepatosplenomegaly to palpation
and percussion
- Extremities: Warm, no cyanosis/clubbing/edema.
- Back: no tenderness to percussion of spine. Negative straight
leg raise when sitting on edge of bed, although pt was unable to
tolerate it lying flat; negative crossed straight leg raise.
Internal rotation of hip elicits pain, as does compression of
pelvis.
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3.
Attention: Recalls a coherent history; thought process coherent
and linear without circumstantiality and tangentiality.
Concentration maintained when recalling months backwards.
Language: fluent without dysarthria and with intact repetition
and verbal comprehension. No paraphasic errors. Follows two-step
commands, midline and appendicular and crossing the midline.
High- and low-frequency naming intact. Normal reading. Normal
prosody.
Memory: Registration ___ and recall ___, improving to ___ with
category cueing.
Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object
or
spacing errors.
Executive function tests: Luria hand sequencing learned without
verbal reinforcement.
Cranial Nerves:
[II] Pupils: equal in size, small ~ 1 mm and reactive on taking
off sunglasse, unable to tolerate flashlight or fundoscopic
exam.
[III, IV, VI] EOM intact, only physiologic end-gaze nystagmus.
[V] V1-V3 with symmetrical sensation to light touch/pin/cold.
Pterygoids contract normally.
[VII] No facial asymmetry.
[VIII] Hearing grossly intact.
[IX, X] Palate elevation symmetric.
[XI] SCM strength ___ bilaterally.
[XII] Tongue shows no atrophy, emerges in midline and moves
facilely.
Motor: Normal bulk and tone. No pronation or drift. No tremor or
asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Extensor Digitorum Brevis [R 5] [L 5]
Flexor Digitorum Brevis [R 5] [L 5]
Sensory:
Intact proprioception at halluces bilaterally.
No deficits to pinprick testing on extremities and trunk. Has
patches of hypersensitivity on left face & neck & shoulder, low
back pain, stretch over right groin, inside of left thigh,
entire
right leg.
Cortical sensation: No extinction to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 2 2
R ___ 2 2
Babinski testing impossible due to withdrawal.
Coordination: No rebound. No past-pointing when touching own
nose
with finger, with eyes closed. No dysmetria on finger-to-nose
and
heel-knee-shin testing. No dysdiadochokinesia. Forearm orbiting
symmetric. Finger tapping on crease of thumb symmetric.
Gait& station:
Antalgic gait.
.
.
DISCHARGE EXAM: Unchanged.
Pertinent Results:
___ 08:28PM BLOOD WBC-5.1 RBC-4.55 Hgb-13.4 Hct-40.0 MCV-88
MCH-29.5 MCHC-33.6 RDW-12.5 Plt ___
___ 08:28PM BLOOD Neuts-59.0 ___ Monos-5.1 Eos-0.4
Baso-0.9
___ 08:28PM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-139 K-4.3
Cl-100 HCO3-25 AnGap-18
___ 11:55AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-8
___ ___ 11:55AM CEREBROSPINAL FLUID (CSF) TotProt-26 Glucose-62
___ 11:55 am CSF;SPINAL FLUID Source: LP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 9:20 am SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
.
.
CT HEAD NON-CONTRAST
IMPRESSION: No evidence of an acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN headache
2. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
3. Sumatriptan Succinate 50 mg PO DAILY:PRN headache
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H:PRN headache
2. Sumatriptan Succinate 50 mg PO DAILY:PRN headache
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological Exam: Non-focal
Followup Instructions:
___
Radiology Report
HISTORY: Two weeks of headaches and neck pain.
TECHNIQUE: Continuous axial sections were acquired through the brain without
the administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
DLP: 897.50 mGy/cm.
COMPARISON: None.
FINDINGS: There is no acute intracranial hemorrhage, edema or mass effect. The
ventricles, cisterns and sulci are normal in size and configuration. The
gray-white matter differentiation is preserved. The imaged paranasal sinuses
and mastoid air cells are well aerated. The bones are unremarkable.
IMPRESSION: No evidence of an acute intracranial process.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Neck pain, Back pain
Diagnosed with HEADACHE, LUMBAGO
temperature: nan
heartrate: 75.0
resprate: 18.0
o2sat: 99.0
sbp: 102.0
dbp: 66.0
level of pain: 9
level of acuity: 3.0 | A/P: ___ h/o migraines p/w severe headache with bland LP and
unremarkable NCHCT. Her headaches improved with toradol and
sleep and were ascribed to migraine.
.
ACTIVE ISSUES
# Headache: The patient had a normal non-contrast head CT and
lumbar puncture. Her symptoms were likely migraine- related. She
responded well to Zofran and Toradol; she was discharged the day
after admission with unchanged exam.
.
INACTIVE ISSUES
# ruptured ovarian cyst
# lactose intolerance
.
TRANSITIONAL ISSUES
# MIGRAINE: Follow for prophylaxis needs |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Multiple complaints
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History is somewhat hampered by the patient's inability to
relate a coherent history.
Mr ___ is a ___ with Hodgkin lymphoma s/p chemo and
mantle-XRT ___, thymic carcinoma s/p resection ___ with
recurrence ___, stable until ___ when lost to followup in our
center, CAD s/p IPMI and PCI with "3 stents", HTN, HL, COPD,
active smoking, BPH, GERD, depression/anxiety, chronic left
shoulder pain, who presents with fairly nebulous complaints.
He relates a history that has no particular start point and no
obvious milestones.
- He says that over the past year he has noticed a clicking
sensation, not really a pain, that occurs when he breathes. It
comes and goes, but it has been more frequent recently and he
has started to worry about it. He thinks it could represent
progression/recurrence of his cancer.
- He says that he has had shoulder issues for years. He was
enrolled in a pain clinic for ___ years, trial of injections and
Percocet, but was unhappy because they "didn't try to find the
answer" and so he stopped going. He was referred to orthopedist
Dr ___ performed MRI that showed "tears" and reportedly
performed a procedure on his shoulder, that didn't work. Dr
___ told him "there wasn't anything more he
could do for him." Over the past few weeks, he has noted
increasing pain in the shoulder, some in his neck on that side,
with radiation down his arm. Pain is sharp, worsened with ROM,
but it is present all the time.
- He has had fluctuations in his blood pressure, at times as
high as high 180s/110s. This has been happening for the past few
weeks. He denies symptoms, but said his daughter checks his BP
frequently.
- He is anxious and feels he needs a PET scan to determine the
source of his underlying issues.
According to Mr ___, his daughter became concerned about his
shoulder pain with the radiation down the arm, along with the
higher blood pressure. She brought him into ___
___. He endorses a negative experience, where they "focused
only on my heart and said things were fine." We do not have
those records.
His PCP apparently recommended he go back to see Dr ___ from
Thoracics given his concerns. For unclear reasons, they decided
to come to our ED rather than making an appointment. In the ED
here, he had stable vital signs, mild tachycardia. Labs were
performed and were unremarkable. Imaging was uploaded but there
is no comment on the reads and he was not sent to us with copies
of records. Admission was requested.
He currently complains only of shoulder pain. It is as described
above. He notably denies any increase in pain with ambulation.
He tells me he is able to walk to the store and back without
dyspnea and has continued to be able to do. He experiences
chronic dyspnea with exertion when going up 1 flight of stairs,
but denies chest pain. He endorsed sweats, but no f/c, n/v/d/c,
cough, leg swelling, rashes.
ROS is negative in 10 points except as noted above
Past Medical History:
Hodgkin lymphoma s/p chemo and mantle-XRT ___, thymic carcinoma
s/p resection ___ with recurrence ___, stable until ___ when
lost to followup in our center, CAD s/p IPMI and PCI with "3
stents", HTN, HL, COPD, active smoking, BPH, GERD,
depression/anxiety, chronic left shoulder pain
Social History:
___
Family History:
Mother died in ___ of pancreatic cancer
Father died in ___ of COPD and prostate cancer
Sister died in ___ of cancer (cannot remember type)
Physical Exam:
Vitals AVSS
Gen NAD, pleasant
Abd soft, NT, ND, bs+
CV RRR, soft systolic murmur, no rubs ___
Lungs CTA ___, few rhonchi at bases
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
MSK pain with flexion, abduction, and internal and external
rotations of the left shoulder
Psych flat affect
Discharge Physical Exam:
Exam:
Vitals AVSS, SBP 100s-130s.
Gen NAD, pleasant, sitting up in bed eating lunch.
Abd soft, NT, ND, bs+
CV RRR, soft systolic murmur
Lungs CTA ___, few rhonchi at bases
Ext WWP, no edema
Skin no rash, anicteric
Neuro nonfocal, moves all extremities, steady gait
MSK pain with flexion, abduction, and internal and external
rotations of the left shoulder
Psych flat affect
Pertinent Results:
Labs on admission:
Heme
___ 08:10PM BLOOD WBC-7.5 RBC-4.82 Hgb-14.3 Hct-42.0 MCV-87
MCH-29.7 MCHC-34.0 RDW-14.6 RDWSD-46.8* Plt ___
___ 08:10PM BLOOD Neuts-72.1* ___ Monos-5.5 Eos-1.1
Baso-0.4 Im ___ AbsNeut-5.43 AbsLymp-1.55 AbsMono-0.41
AbsEos-0.08 AbsBaso-0.03
___ 08:10PM BLOOD ___ PTT-31.7 ___
Chem
___ 08:10PM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-139
K-3.9 Cl-102 HCO3-24 AnGap-17
___ 08:10PM BLOOD ALT-20 AST-25 CK(CPK)-57 AlkPhos-94
TotBili-0.2
___ 08:10PM BLOOD Lipase-22
___ 08:10PM BLOOD cTropnT-<0.01 proBNP-116
___ 08:10PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.8 Mg-2.2
Imaging:
CT Chest:
New 2.5 cm paramediastinal mass, adjacent to the aortic arch.
Recurrence of
disease is likely. Severe pulmonary emphysema with multiple
small areas of
nodularity and scarring, with a morphology unlikely to reflect
metastatic
disease.
Ultrasound Sniff Test:
There is normal, expected downward movement of the diaphragm
upon rapid nasal
inspiration bilaterally.
Discharge Labs:
___ 07:49AM BLOOD WBC-7.7 RBC-4.73 Hgb-14.1 Hct-43.0 MCV-91
MCH-29.8 MCHC-32.8 RDW-15.4 RDWSD-50.6* Plt ___
___ 07:49AM BLOOD Glucose-100 UreaN-15 Creat-0.9 Na-142
K-4.2 Cl-102 HCO3-26 AnGap-18
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. meloxicam 15 mg oral DAILY
2. Citalopram 20 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. TraMADol 50 mg PO BID:PRN Pain - Moderate
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Cyclobenzaprine 5 mg PO TID
8. HydrALAZINE 50 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 6 hours Disp
#*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Please take for the next ___ days then stop.
RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 8 hours Disp
#*20 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe Duration: 5 Days
Reason for PRN duplicate override: Alternating agents for
similar severity
Please taper off this medication over the next 5 days.
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*25 Tablet Refills:*0
6. Senna 17.2 mg PO BID
RX *sennosides [Senexon] 8.6 mg 2 Tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
Daily Disp #*60 Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
10. amLODIPine 10 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Citalopram 20 mg PO DAILY
13. Cyclobenzaprine 5 mg PO TID
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. Furosemide 20 mg PO DAILY
16. HydrALAZINE 50 mg PO DAILY
17. Loratadine 10 mg PO DAILY
18. LORazepam 1 mg PO QHS:PRN extreem anxiety
19. Metoprolol Tartrate 50 mg PO BID
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. Omeprazole 20 mg PO DAILY
22. Tamsulosin 0.4 mg PO QHS
23. Tiotropium Bromide 1 CAP IH DAILY
24. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Arthritis pain
Likely recurrence of Thymic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with history of Hodgkin's lymphoma status post
chemotherapy and mantle field distribution radiotherapy in ___ with interval
development of a mediastinal mass consistent with thymic carcinoma. Thepatient
is status post resection in ___ and a biopsy of a recurrence in ___. Lost to follow up for ___ years now with left shoulder pain.// ?
Recurrance of cancer
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: 219 mGy-cm
COMPARISON: ___.
FINDINGS:
Status post sternotomy. No abnormalities at the level of the thyroid. Saber
sheath trachea. 25 x 20 mm soft tissue density mass in the anterior
mediastinum, adjacent to the aortic arch (3, 15). No hilar lymphadenopathy.
Borderline sized lymph nodes in the posterior mediastinum (3, 25). No
incidental pulmonary embolism. No pericardial effusion. Right kidney cyst
(3, 57). Mild degenerative vertebral disease. No vertebral compression
fractures. No osteolytic lesions at the level of the ribs, the sternum, or
the vertebral bodies. Mild bilateral apical scarring. Moderate respiratory
motion. Severe pulmonary emphysema. The masslike lesion in the mediastinum
shows extension into the lung parenchyma, with accompanying interstitial
thickening (5, 78). Several mostly subpleural micronodules and areas of
parenchymal scarring (5, 139). Mild atelectasis at the left lung basis. Mild
mucous plugging. No pleural effusions.
IMPRESSION:
New 2.5 cm paramediastinal mass, adjacent to the aortic arch. Recurrence of
disease is likely. Severe pulmonary emphysema with multiple small areas of
nodularity and scarring, with a morphology unlikely to reflect metastatic
disease.
Radiology Report
EXAMINATION: Ultrasound sniff test
INDICATION: ___ year old man with PMHx Hodgkin lymphoma s/p chemo and
mantle-XRT ___, thymic carcinoma s/p resection ___ with recurrence ___,
stable until ___ when lost to follow-up in our center. CT scan now with 2-3cm
anterior mediastinal mass likely near the vagus nerve. Discussed with Thoracic
surgery who requests sniff test to check diaphragm function (U/S)// sniff test
to check diaphragm function (U/S)
TECHNIQUE: Grey scale Doppler ultrasound images of the abdomen were obtained
of the right and left hemidiaphragm while at skin the patient to rapidly
inspired through the nose.
COMPARISON: CT chest ___
FINDINGS:
There is normal, expected downward movement of the diaphragm upon rapid nasal
inspiration bilaterally.
IMPRESSION:
No paradoxical diaphragmatic motion with rapid nasal inspiration.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal CT, L Shoulder pain
Diagnosed with Adult failure to thrive, Weakness
temperature: 97.3
heartrate: 108.0
resprate: 16.0
o2sat: 99.0
sbp: 142.0
dbp: 94.0
level of pain: 10
level of acuity: 3.0 | This is a ___ with Hodgkin lymphoma s/p chemo and mantle-XRT
___, thymic carcinoma s/p resection ___ with recurrence ___,
stable until ___ when lost to followup in our center, CAD s/p
IPMI and PCI with "3 stents", HTN, HL, COPD, active smoking,
BPH, GERD, depression/anxiety, chronic left shoulder pain, who
presents with fairly nebulous complaints.
# Multiple longstanding complaints in setting of known diagnosis
of recurrent thymic carcinoma: He has multiple complaints that
sound very chronic in nature. It is not entirely clear the
extent of his workup, also not unclear how closely he has been
followed for his thymic carcinoma. He has not been seen since
___ when the plan was for yearly CT scan and follow up with
Thoracic Surgery and Oncology. At the time he was lost to f/u
here he had fairly stable imaging. It is not clear if he has had
imaging in the last ___ years. CT imaging done at ___ here shows
a new 2-3cm lesion in the anterior medistiumum that is
concerning for recurrence. The case was discussed with thoracic
surgery who recommended ___ guided biopsy (if possible). The
patient declined this biopsy and requested outpatient evaluation
including a PET CT prior to discussion with Dr. ___. He
declined the inpatient ___ guided biopsy. He will have na
outpatient PET-CT and PFTs prior to his appointment with Dr.
___. Onc follow up as an outpatient. PCP has ___ to
Dr ___ (___)
# Acute on chronic pain,
# Shoulder and arm pain: Given longstanding history, report of
MRI shoulder, this sounds most likely due to
arthritis/capsulitis/tendinitis. Could have neuropathic/cervical
radiculopathy component (cervical arthritis, less likely
metastatic disease). Brachial plexopathy in context of expanding
intrathoracic mass is possible but not seen on imaging. Pain
better controlled in the hospital. Discussed with Patient and
family that will need long term follow up as appears arthritis
and that narcotics have no role in long term therapy for
arthritis pain. He will follow up with his PCP.
# HTN: Report of labile and elevated BPs PTA, but currently BPs
are reasonable here in spite of pain SBP 100-130 on home
medication while pain was well controlled. Continued home
regimen with pain control.
# HL
# CAD s/p MI
# Chest "clicking": Unlikely to be cardiac/ischemic etiology of
his symptoms given his ability to walk on level ground upwards
of ___ mile and his report of stable dyspnea when taking stairs.
Chest clicking is not an anginal type of pain. He is clear that
he does not have any chest pain. Troponin x1 here on admission,
many many hours (days per patient) out from onset of his
arm/shoulder pain. BNP negative. Pain improved with therapy for
MSK pain. Follow up with PCP as an outpatient.
# COPD: Stable. He says he takes Advair, Spiriva, and albuterol
- Continued inhalers
# GERD: Stable
- Continued omeprazole
# Depression/anxiety: Stable
- Continued citalopram
# BPH: Stable
- Continued Flomax |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
propranolol
Attending: ___.
Chief Complaint:
right stump infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ year old male patient with uncontrolled DM
type 2 who is status post right below knee amputation with c/b
surgical site infection and bone cyst, who presets to the ED
after having discharge from surgical site associated with
subjective fever and chills. condition started approximately
last
___ after visiting Dr. ___ in the clinic and sutures
were removed at that time. over the week, he experienced mild
shooting pain that comes and goes associated with some
malodorous
discharge. He states that these are similar symptoms as when he
had wound infection. He endorsed chills and subjective fever,
but
no anorexia, nausea/vomiting, chest pain, shortness of breath or
any other complaints.
Past Medical History:
PMH: DM1, HTN, HLD, CKD stage 3 (Baseline Cr 1.9), PVD, R heel
osteomyelitis
PSH:
- Right L4-5 discectomy ___ ___
- R THR
- RLE angiogram for nonhealing heel ulcer - single vessel ___
runoff to foot ___ ___
- Split-thickness skin graft to the right heel ___
___
- Right BKA ___ ___
- Left AT and peroneal angioplasty ___ ___
- Left below knee popliteal to anterior tibial arterial bypass
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: afebrile,
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: no Right stump erythema, hotness. mild tenderness at the
distal anterior part of the stump, open wound at the tip of the
stump, with malodorous discharge.
Pulses: R: P/D/BKA L: P/D/D/D
Pertinent Results:
___ 07:10AM BLOOD WBC-4.7 RBC-3.40* Hgb-9.2* Hct-29.3*
MCV-86 MCH-27.1 MCHC-31.4* RDW-13.8 RDWSD-43.1 Plt ___
___ 11:45PM BLOOD Neuts-85.9* Lymphs-6.0* Monos-5.9 Eos-1.4
Baso-0.4 Im ___ AbsNeut-13.80* AbsLymp-0.96* AbsMono-0.94*
AbsEos-0.22 AbsBaso-0.06
___ 01:05PM BLOOD Glucose-149* UreaN-35* Creat-2.3* Na-135
K-5.0 Cl-103 HCO3-24 AnGap-13
___ 01:05PM BLOOD Calcium-8.1* Phos-4.1 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO QHS
2. Atorvastatin 10 mg PO QPM
3. CloNIDine 0.2 mg PO TID
4. Gabapentin 800 mg PO TID
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Glargine 45 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
hold for ___ stool
3. Metoprolol Succinate XL 50 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H PRN Disp #*18 Tablet
Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0
6. Glargine 45 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
7. Amitriptyline 25 mg PO QHS
8. amLODIPine 10 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. CloNIDine 0.2 mg PO TID
11. Gabapentin 800 mg PO TID
12. Lisinopril 10 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Rt Bellow Knee stump infection
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: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with BKA with concern for wound infection. Assess for
subcutaneous gas.
TECHNIQUE: Frontal and cross-table lateral radiographs of the right knee.
COMPARISON: None.
FINDINGS:
Status post below right knee amputation. Of note distal most aspect of tibia
and fibula was not fully evaluated. No acute fracture or dislocation. No
joint effusion. Subtle rounded lucency seen along the edge of film may
represent a locule of gas projecting over the mid tibia/fibula. Mild
degenerative changes of the right knee predominantly involve the medial
compartment. No periosteal reaction or cortical irregularity. No suspicious
lytic or sclerotic lesion is identified. No soft tissue calcification or
radio-opaque foreign body is detected.
IMPRESSION:
1. Status post below right knee amputation. Of note distal most aspect of
tibia and fibula WAS EVALUATED ON A SUBSEQUENT STUDY.
2. Subtle rounded lucency along the distal tibia may represent a locule of
gas projecting over the mid tibia/ fibula, suspicious for infectious
subcutaneous emphysema.
RECOMMENDATION(S): Clinical correlation recommended to assess for infection
and necrotizing fasciitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:32 AM, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with cough and fever. Assess for pneumonia.
TECHNIQUE: Single portable upright frontal chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
The lungs are well inflated and clear. No pleural effusion or pneumothorax.
Heart size, mediastinal contour, and hila are unremarkable.
IMPRESSION:
No acute cardiopulmonary process. Specifically, no pneumonia.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ with right BKA stump site inefection. Assess distal stump
for subcutaneous emphysema.
TECHNIQUE: Frontal and lateral view radiographs of right knee.
COMPARISON: Right knee radiograph ___.
FINDINGS:
Patient is status post below right knee amputation with associated
postsurgical changes. Subtle rounded radiolucencies within the distal lateral
posterior stump may represent subcutaneous emphysema. No cortical
irregularity or periosteal new bone formation. Scattered soft tissue
calcifications are likely postsurgical.
No right knee joint effusion. Mild degenerative changes of the medial right
knee with subchondral sclerosis and small osteophytes.
IMPRESSION:
1. Subtle rounded radiolucencies along distal lateral posterior stump may be
subcutaneous emphysema.
2. No radiographic evidence of osteomyelitis.
3. Status post right below-knee amputation with associated postsurgical
changes.
RECOMMENDATION(S): If persistent concern for osteomyelitis consider MR for
further evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fevers // ___ year old man with fevers
___ year old man with fevers
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___ AND
___ AT 00:44.
LUNGS CLEAR. HEART SIZE NORMAL. NO PLEURAL ABNORMALITY. CONFIGURATION TO
THE UPPER MEDIASTINUM, WIDENED TO THE LEFT, COULD BE DUE TO FAT DEPOSITION OR
THE CONGENITAL ANATOMIC ANOMALY, PERSISTENT LEFT SUPERIOR VENA CAVA.
Radiology Report
INDICATION: ___ year old man with nausea, vomiting // ___ year old man with
nausea, vomiting
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative changes in the lumbar spine
and left hip. There is a right-sided total hip arthroplasty.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of bowel obstruction.
Radiology Report
EXAMINATION: CT LOWER EXT W/C RIGHT
INDICATION: ___ year old man with febrile illness susp. bacteremia with Rt BKA
stump wound ulcer. His Cr is ___ since ___. we hydrated him before an will
hydrate after the CT will be done. Thank you. Evaluate for source of
infection in RLE.
TECHNIQUE: ___ MD CT images of the right lower extremity were obtained
after the administration of IV contrast and reformatted in bone and soft
tissue algorithm. Coronal and sagittal reformations were also obtained and
used in evaluation.
DOSE: Acquisition sequence:
1) Spiral Acquisition 24.8 s, 75.9 cm; CTDIvol = 34.6 mGy (Body) DLP =
2,585.9 mGy-cm.
Total DLP (Body) = 2,603 mGy-cm.
COMPARISON: Right tib-fib radiograph of ___.
FINDINGS:
There is diffuse soft tissue swelling and edema at the right below-the-knee
amputation stump, extending up to the tibial tuberosity. Of note, there is an
irregular 2.7 x 1.6 x 0.9 cm fluid collection in the soft tissues of the stump
(4:351, 603A:66). Multiple small calcifications are identified in the soft
tissues at the stump, likely postsurgical in nature. There is no subcutaneous
emphysema. No evidence of cortical irregularity or periosteal reaction
involving the underlying tibia and fibula. Of note, multiple enlarged, likely
reactive, right inguinal lymph nodes are present (4:93, 604A:22).
Incidental note is made of extensive atherosclerotic disease involving the
right common, superficial, and deep formal artery, extending into the right
popliteal artery. There also small bilateral fat containing inguinal hernias.
There is no joint effusion. Patient is post right will hip arthroplasty.
Degenerative changes of the medial patellofemoral compartment are mild.
IMPRESSION:
1. Soft tissue swelling and edema involving the right below-the-knee
amputation distal tissues, extending up to the level of the tibial tuberosity.
Multiple enlarged, reactive right inguinal lymph nodes.
2. There is a 2.7 x 1.6 x 0.9 cm peripherally enhancing fluid collection in
the soft tissues at the stump, concerning for a small abscess.
3. No evidence of underlying tibial or fibular cortical irregularity or
periosteal reaction. However, as noted on the prior radiograph, MRI is more
sensitive for evaluation of osteomyelitis.
4. There is no subcutaneous emphysema.
This preliminary report was reviewed with Dr. ___
radiologist.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 17:15 on ___, 5 min after discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval, Fever, Hyperglycemia
Diagnosed with Infection of amputation stump, right lower extremity, Amputation of limb(s) cause abn react/compl, w/o misadvnt
temperature: 98.1
heartrate: 99.0
resprate: 16.0
o2sat: 99.0
sbp: 158.0
dbp: 85.0
level of pain: 8
level of acuity: 2.0 | Mr ___ is a ___ year old male with poorly controlled DM2,
who had BKA c/b surgical site infection who necessitated
revision and cyst excision one month prior to his current
admission, . The patient presented with wound discharge and
chills concerning for another episodes of right stump infection.
The patient presented with fever to 102.3 shacking chills with
no apparent source of infection other the Hx of mild discharge
from a tiny wound in the stump which on physical examination was
not apparent. Blood and urine culture were taken and the
patient was put on vanco cypro flagyl IV. He underwent CT of his
lower extremities which revealed a small fluid collection at the
tip of the stump ant. and distal to the tibia. a conservative
treatment was decided upon.
The patient presented with high levels of blood glucose that
were first hard to manage but as his infection was controlled so
as his glucose levels.
3 days before discharge the tiny crack in the stump was open and
an offensive smell purulent material was discharged with an
immediate relief. The fever did nor reoccurred. He was put back
on his home meds and tolerated diet well. Of note that the
patient suffers from CRF with Cr in the range of 1.7-3.3. His Cr
level during admission was 1.9 which went up as high as 2.8 and
now trending down to 2.3 on the day of his discharge. He has an
appointment with his nephrologist on the ___ and will be
trend his Cr level for this encounter on the beginning of the
week.
Mr ___ wound culture grew mixed bacteria, blood culture
had no growth. He was switched to Bactrim and was discharged
home with dry dressing and Po Abx. He was instructed not to wear
his prosthesis until he will be followed by Dr ___ in his
office within 10 days. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Latex / Penicillins / Bactrim
Attending: ___
Chief Complaint:
Right Foot Infection
Major Surgical or Invasive Procedure:
1. Excisional debridement of bone, ___ metatarsal, right
foot.
2. Ulcer excision with primary closure, right foot.
History of Present Illness:
Mr. ___ is a ___ with PMHx significant for CMT, COPD, HTN. He
underwent a reconstruction of the R foot ___. He has
had a lateral foot ulcer on the right foot since surgery. The
size of the ulcer improved after the surgery. He also has a L
___ toe amputation at ___ last month and is
still healing from that. He reports over the last 5 days he was
having fevers / chills and also decreased appetite. He then
noticed increased redness and swelling to the Right Foot with
increased bloody and clear drainage from the lateral foot ulcer.
He has been doing daily dressing changes. Per the patient Dr.
___ has been treating him, mentioned that he might need
to go back to the OR to take some bone out around the ulcer
which could be causing the wound to remain open. He then decided
to present to the ED for further evaluation. He denies any
recent chest pain, shortness of breath, nausea, diarrhea,
constipation. He has not noticed any purulent drainage coming
from the R foot wound. He does not have sensation to the ___ and
does not report any pain ___ either foot.
Past Medical History:
PMH: Charcot ___ disease, COPD, HTN
PSH: R triple arthrodesis, TAL (___), L tibial and fibular
sesamoidectomy (___), L ___ MTC and hallux IPJ fusion (___),
R ___, midfoot osteotomy, TAL (___), L Pan met, Keller, TAL
(___), L hallux amp (___) Right Foot cavus Recon (___)
Social History:
___
Family History:
n/c
Physical Exam:
Discharge Physical Exam:
AVSS
Gen - NAD
Cardiac - RRR
Pulm - no respiratory distress
Abd - soft, nontender
VASC: ___ pulses palpable bilaterally, cap refill < 3 sec to
the digits.
Right Lower extremity - ___ normal and palpable b/l. Lateral
and plantar midfoot T incision sutures intact, incision well
copated, no signs of dehisence, mild serous drainage. No
surrounding erythema or edema. No TTP
Left Lower Extremity - s/p hallux amputation and recent ___ toe
amputation. The second toe amputation site that has completely
healed.
Neuro: light touch sensation absent to the ___ bilaterally.
Pertinent Results:
MICRO:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 06:09AM BLOOD WBC-8.0 RBC-4.72 Hgb-14.8 Hct-43.8 MCV-93
MCH-31.4 MCHC-33.8 RDW-14.1 RDWSD-47.8* Plt ___
___ 07:10AM BLOOD WBC-6.0 RBC-4.65 Hgb-14.5 Hct-42.8 MCV-92
MCH-31.2 MCHC-33.9 RDW-14.4 RDWSD-48.4* Plt ___
___ 07:00AM BLOOD WBC-6.2 RBC-4.77 Hgb-14.9 Hct-44.3 MCV-93
MCH-31.2 MCHC-33.6 RDW-13.9 RDWSD-47.7* Plt ___
___ 08:10AM BLOOD WBC-6.8 RBC-4.50* Hgb-14.2 Hct-41.8
MCV-93 MCH-31.6 MCHC-34.0 RDW-13.9 RDWSD-47.8* Plt ___
___ 06:04AM BLOOD WBC-8.1 RBC-4.60 Hgb-14.2 Hct-42.6 MCV-93
MCH-30.9 MCHC-33.3 RDW-14.0 RDWSD-47.8* Plt ___
___ 06:09AM BLOOD Neuts-83.5* Lymphs-5.8* Monos-9.2
Eos-0.1* Baso-0.4 Im ___ AbsNeut-6.71* AbsLymp-0.47*
AbsMono-0.74 AbsEos-0.01* AbsBaso-0.03
___ 06:09AM BLOOD Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-30.1 ___
___ 07:00AM BLOOD Plt ___
___ 08:10AM BLOOD Plt ___
___ 06:04AM BLOOD Plt ___
___ 06:09AM BLOOD Glucose-169* UreaN-21* Creat-1.5* Na-130*
K-3.9 Cl-95* HCO3-21* AnGap-18
___ 07:10AM BLOOD Glucose-139* UreaN-18 Creat-0.9 Na-136
K-3.8 Cl-101 HCO3-21* AnGap-18
___ 07:00AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-24 AnGap-17
___ 08:10AM BLOOD Glucose-160* UreaN-14 Creat-0.7 Na-138
K-3.7 Cl-103 HCO3-26 AnGap-13
___ 06:04AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-25 AnGap-15
___ 07:10AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.9
___ 07:00AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.9
___ 08:10AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.6
___ 06:04AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
___ 07:10AM BLOOD CRP-172.2*
___ 06:51AM BLOOD Vanco-15.9
___ 04:18PM BLOOD Lactate-2.5*
Medications on Admission:
sotalol 80", diltiazem 240', ASA 81', lisinopril 20'
Discharge Medications:
1. CeFAZolin 2 g IV Q8H Duration: 6 Weeks
RX *cefazolin ___ dextrose (iso-os) 2 gram/50 mL 2 Grams IV every
eight (8) hours Disp #*126 Intravenous Bag Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*84 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*126 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Sotalol 80 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Foot Infection with osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Non-weightbearing to right foot
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: History: ___ with CMT and extensive podiatric history presents
with redness, swelling and worsening plantar ulcer// evaluate for fracture,
osteo
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of right foot
COMPARISON: Right foot radiographs from ___
FINDINGS:
Calcaneal osteotomy and screw fixation appears unchanged. Postoperative
changes with resection of the fourth and fifth metatarsals appears stable.
Foci of subcutaneous emphysema are present along the lateral soft tissues
adjacent to the fifth metatarsal base. There is no definite underlying
osteolysis. Soft tissue edema noted. Linear radiopaque 8mm structure seen on
the lateral view plantar to the proximal to the metatarsals may represent a
foreign body.
IMPRESSION:
1. Foci of subcutaneous emphysema along the lateral soft tissues adjacent to
the fifth metatarsal base which are concerning for infection and/or
ulceration. No definite underlying osteolysis to suggest acute osteomyelitis
radiographically.
2. Stable post operative changes.
3. Possible plantar foreign body.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p right foot bony debridement lateral midfoot//
post op eval
TECHNIQUE: Right foot three views
COMPARISON: ___
FINDINGS:
There has been interval debridement of lateral midfoot. Previously seen soft
tissue gas is decreased, remaining components may be postsurgical or from
infection. More prominent plantar surface soft tissue swelling.
Postoperative changes resection of distal fourth, fifth metatarsals.
Calcaneal osteotomy. Hindfoot fusion with 2 screws in place. Advanced
degenerative, hypertrophic changes midfoot, with abundant hypertrophic
changes, subchondral cystic changes, are stable, may be degenerative, or from
neuropathic arthropathy. Normal midfoot alignment. Stable lucency at the
proximal first metatarsal. Degenerative changes interphalangeal joint great
toe, first MTP joint, stable. Distal phalanx of second toe is suboptimally
seen, may be secondary to its position, or postoperative, resorptive change,
stable. Calcaneal plantar, Achilles bone spurs.
IMPRESSION:
Interval postoperative changes, more prominent plantar surface soft tissue
swelling. Residual soft tissue air the surgical bed, may be postoperative or
from infection.. Otherwise as above
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// R SL Power PICC 44cm ___
___ Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Right PICC line tip is difficult to see, is likely in the low SVC, it overlies
spine. Shallow inspiration. Normal heart size, pulmonary vascularity.
Linear atelectasis at the left base. Right lung is clear. No sizable
effusion. No pneumothorax.
IMPRESSION:
Right PICC line
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Wound eval
Diagnosed with Cellulitis of left lower limb
temperature: 101.7
heartrate: 86.0
resprate: 18.0
o2sat: 96.0
sbp: 135.0
dbp: 75.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the podiatric surgery service from
the emergency room on ___ for a R foot infection. On
admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for Right foot debridement. Pt was evaluated by anesthesia and
taken
to the operating room on ___ for bone debridement and
primary closure. There were no adverse events ___ the operating
room; specimens were sent for micro and patholgy. please see the
operative note for details. Afterwards, pt was taken to the PACU
___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized. The
infectious disease team consulted post operatively for
antibiotic recommendation for possible osteomyelitis. Per ___
Infectious Disease, Patient was discharged with IV cefazolin, PO
flagyl and PO Cipro based on sensitivities for 6 weeks. His
intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged.
The patient was subsequently discharged to home on ___ with
antibiotics x 6 weeks and follow up with OSH infectious disease
___ ___. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with
the discharge plan. Patient is to be NON-WEIGHTBEARING to R
foot. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
- Orthopedic surgery to repair R femur fracture on ___
History of Present Illness:
___ y/o demented F presenting from nursing home where she had is
thought to have had a mechanical fall. Fall was unwitnessed, was
found down in bathroom. Sent to ___ for
initial evaluation with subsequent transfer to ___. Head CT
and CT cervical spine at ___ negative. No PNA was seen there.
although rib fracture noted. ___.
.
In the ED, initial VS: Tc: 98.2 HR: 106 BP: 122/80 02 sat 99%
RA. In the ED she became hypotensive to 74/50 with altered
mental status, had elevated white count, thus she received
empiric antibiotic coverage with IV ceftriaxone and vancomycin.
No clear source was noted. An XR and CT showed fracture right
femur. She was found to be hypokalemic.
.
She received morphine 4mg IV, zofran 2mg, ceftriaxone 1g,
vancomycin 1g, potassium IV.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Dementia
Hyperlipidemia
Urinary incontenence
Depression
Anemia
Social History:
___
Family History:
Unable to obtain from patient due to dementia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp: 96.9 HR: 95% BP:142/78 02: 96% 4LNC
___ - unable to follow commands, responds to voice, touch
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, holosystolic murmur, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), external rotation right hip.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, CNs II-XII grossly intact, muscle strength ___
throughout.
DISCHARGE PHYSICAL EXAM:
VSS WNL
GEN: Resting in bed in NAD.
HEENT: NCAT, MMM.
COR: +S1S2, RRR, ___ SEM heard throughout precordium
PULM: Bibasilar crackles, no coarse breath sounds.
___: +NABS in 4Q. Soft, NTND.
EXT: WWP, edema improved in R ___. 1+ hand edema.
NEURO: Oriented to "hospital".
Pertinent Results:
ADMISSION LAB RESULTS:
___ 09:45PM BLOOD WBC-13.8* RBC-3.96* Hgb-11.6* Hct-33.8*
MCV-85 MCH-29.2 MCHC-34.2 RDW-14.3 Plt ___
___ 09:45PM BLOOD Neuts-88.3* Lymphs-8.7* Monos-2.6 Eos-0.1
Baso-0.4
___ 09:45PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-139
K-4.0 Cl-93* HCO3-33* AnGap-17
___ 04:45PM BLOOD CK(CPK)-272*
___ 01:00AM BLOOD cTropnT-<0.01
___ 01:00AM BLOOD Albumin-2.8* Calcium-6.8* Phos-4.9*
Mg-1.7
___ 01:24AM BLOOD Lactate-3.4*
PLAN FILMS OF R LEG:
FINDINGS: There is complete fracture through the distal shaft of
the femur
with displacement of the distal fragment by a full shaft width
with
foreshortening and there is also a comminution fragment. The
bones appear
demineralized. Patchy vascular calcifications are present. The
fracture
approaches the metaphysis but does not appear to enter the knee
joint itself.
.
IMPRESSION: Complete oblique displaced distal right femur
fracture.
.
DISCHARGE LABS:
.
___ 06:45AM BLOOD WBC-9.2 RBC-3.60* Hgb-10.9* Hct-31.6*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.6* Plt ___
___ 06:45AM BLOOD Glucose-104* UreaN-36* Creat-0.7 Na-138
K-3.2* Cl-104 HCO3-21* AnGap-16
CT Abdomen, Chest, Pelvis with Contrast (___):
FINDINGS: A calcified thyroid nodule is noted within the right
lobe of the
thyroid gland (series 2, image 30) measuring 20 x 16 mm. This
can be further evaluated with a thyroid ultrasound on a
non-emergent basis. A 16-mm nodule is noted within the right
upper lobe of the lung (series 2, image 22) which is suspicious
for malignancy. Bibasilar atelectasis is noted. Mediastinal,
axillary and hilar lymph nodes do not meet size criteria for
pathologic enlargement. The ascending aorta measures 5.5 cm
consistent with ascending aortic aneurysm.
.
Complex mixed fusiform abdominal aneurysm is noted with a
suprarenal component measuring 6.3cm and component at and below
the level of the renal arteries measuring 6cm in max diameter.
There is an aortobifemoral graft with occluded native common
iliac arteries. Extensive atherosclerotic calcifications are
noted throughout the abdominal aorta.
.
Two hyperdense foci may be due to enhancing polyps or
potentially stones,
although the former is more likely. Particularly regarding the
fundal lesion, focal adenomyomatosis could also be considered. A
19 x 12 mm hypodensity at the head of the pancreas may represent
IPMN and may be further evaluated with MRCP.
.
The liver, spleen, bilateral adrenal glands appear unremarkable.
Both kidneys appear mildly lobulated with minimal scarring of
the cortex, particularly in the left kidney, but there is no
evidence of hydronephrosis or renal calculi. There is no free
air or free fluid within the abdomen. Retroperitoneal and
mesenteric lymph nodes do not meet size criteria for pathologic
enlargement. Intra-abdominal loops of large and small bowel are
unremarkable.
.
There is a Foley catheter within the bladder. Pelvic lymph nodes
do not meet size criteria for pathologic enlargement. The uterus
appears unremarkable. The rectum and sigmoid colon are within
normal limits.
.
There is extensive demineralization of the bones. A right sixth
rib deformity is of indeterminate chronicity, correlate with
point tenderness (2,35).
.
Multilevel degenerative changes are noted within the
thoracolumbar spine.
.
IMPRESSION:
1. 16 mm right upper ___ pulmonary nodule, suspicious for
malignancy.
2. Ascending aorta aneurysm measuring 5.5cm in max diameter.
Complex mixed
fusiform abdominal aneurysm with a suprarenal component
measuring 6.3cm and component at and below the level of the
renal arteries measuring 6cm in max diameter. Aortic bifem with
occluded native common iliac arteries.
3. Right 6th rib deformity is of indeterminate chronicity,
correlate with
point tenderness.
4. Calcified thyroid nodule measuring 20 mm, may be further
evaluated with an US on a nonemergent basis.
5. Hyperdense foci in the gallbladder suggesting polyps or
potentially stones, probably less likely; unless MRCP is
pursued, gallbladder ultrasound could be considered clinically
indicated to evaluate further.
6. Sigmoid diverticulosis.
7. A 19 x 12 mm hypodensity at the head of the pancreas may
represent IPMN and may be further evaluated with MRCP.
.
CXR (___): FINDINGS: The mediastinum is widened secondary to
known ascending aortic aneurysm, but is unchanged from prior
exams. There is no new mediastinal widening. The cardiac
silhouette is stably enlarged. Bilateral moderate pleural
effusions are unchanged with associated bibasilar atelectasis.
There are no new consolidations. There is no pneumothorax.
.
IMPRESSION:
1. Unchanged appearance of the mediastinum.
2. Bilateral moderate pleural effusions.
3. Bibasilar atelectasis.
Medications on Admission:
Lovastatin 20mg daily
Paxil 20mg daily
HCTZ 25mg daily
potassium chloride 20mEQ BID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for Pain.
2. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 1 months.
3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. potassium chloride 20 mEq Packet Sig: One (1) PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- R Distal Femur fracture s/p fall
- Delirium
SECONDARY DIAGNOSES:
- Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with new hypotension and tachypnea status post
trauma.
COMPARISON: Outside hospital chest radiograph dated ___ at approximately
5 p.m. and CT chest dated ___ at approximately 9:00 p.m.
TECHNIQUE: Single frontal chest radiograph was obtained portably. Per
technologist's report, the patient was unable to cooperate for the exam and
was stabilized by the ED resident, who approved the image.
FINDINGS: Very limited view of the chest without obvious pneumothorax or
edema. The patient is rotated, limiting evaluation of the cardiomediastinal
silhouette, but an enlarged calcified aorta is again noted. Right lower lung
nodule is obscured. Note is made of a large right calcified thyroid nodule.
IMPRESSION: Very limited study due to patient rotation without evidence for
large pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Open reduction and internal fixation of the femur.
Note is made that the radiologist was not attending the procedure.
Total fluoroscopy time of 169.4 seconds was documented. The eleven
fluoroscopic spot images were brought to our review and demonstrate the
process of open reduction and internal fixation.
For precise details, please review procedure report.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after femur fracture, with
pulmonary edema.
AP radiograph of the chest was compared to ___.
Bilateral consolidations appear to be increased as well as there is increase
in bilateral pleural effusion. On the other hand, there is no evidence of
pulmonary edema on the current examination. Enlarged aorta is consistent with
thoracic ascending aortic aneurysm, better appreciated on the CT chest from
___. No pneumothorax is seen. The right upper lobe nodule is
better appreciated on the CT torso not well seen on the chest radiograph.
Radiology Report
INDICATION: Postoperative hypotension with thoracic aneurysm on Lovenox.
Evaluate for mediastinal changes.
COMPARISONS: Chest radiograph ___. Chest radiograph ___.
FINDINGS: The mediastinum is widened secondary to known ascending aortic
aneurysm, but is unchanged from prior exams. There is no new mediastinal
widening. The cardiac silhouette is stably enlarged. Bilateral moderate
pleural effusions are unchanged with associated bibasilar atelectasis. There
are no new consolidations. There is no pneumothorax.
IMPRESSION:
1. Unchanged appearance of the mediastinum.
2. Bilateral moderate pleural effusions.
3. Bibasilar atelectasis.
Gender: F
Race: HISPANIC OR LATINO
Arrive by AMBULANCE
Chief complaint: FEMUR FX
Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 98.2
heartrate: 106.0
resprate: 16.0
o2sat: 99.0
sbp: 122.0
dbp: 280.0
level of pain: 13
level of acuity: 2.0 | PRIMARY REASON FOR HOSPITALIZATION:
___ F w dementia presents s/p fall presumed to be mechanical,
found to have R femur fracture. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ year old year old male with no significant PMHx, p/w RLQ pain
starting ___ after lunch, associated w/ mild nausea, no
emesis. Patient reports anorexia but otherwise denies
fevers/chills. Patient denies migration or radiation of pain
anywhere. Upon evaluation in ED, patient appeared comfortable.
Abdomen significant for focal RLQ TTP, no rebound/guarding.
Past Medical History:
Anxiety
Social History:
___
Family History:
Father with hematologic malignancy
Physical Exam:
Physical Exam on admission ___:
Vitals - T 98.3 / HR 68 / BP 118/74 / RR 16 / O2sat 100% RA
General - comfortable, NAD
HEENT - moist mucous membranes, PERRLA, EOMI
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, nondistended, focal TTP in RLQ, no
rebound/guarding
Extremities - warm and well-perfused
Neuro - A&OX3
Physical Exam on discharge ___:
Vitals - T 98.2 HR 74 BP 119/75, RR 16 O2 sat 97% on RA.
General: NAD
Neuro: Alert and oriented x 3, follows commands
Cardiac: Regular rate and rhythm
Pulmonary: Lung sounds clear bil
Abdomen: +bs, soft, non-distended, slightly tender to touch, no
erythema or exudate at port sites.
Extremities: No edema, no calf pain
Skin: Warm, dry
Pertinent Results:
___ 11:30AM BLOOD WBC-7.4 RBC-4.65 Hgb-14.2 Hct-41.5 MCV-89
MCH-30.5 MCHC-34.2 RDW-12.3 RDWSD-39.6 Plt ___
___ 11:30AM BLOOD Neuts-69.6 Lymphs-16.1* Monos-13.5*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-1.19*
AbsMono-1.00* AbsEos-0.01* AbsBaso-0.02
___ 04:00PM BLOOD ___ PTT-29.1 ___
___ 11:30AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-25 AnGap-13
___ 11:30AM BLOOD ALT-22 AST-17 AlkPhos-61 TotBili-0.3
___ 11:30AM BLOOD Albumin-4.4
___ 11:56AM BLOOD Lactate-1.2
Abd/Pelvis CT with contrast on ___:
IMPRESSION:
Early acute uncomplicated appendicitis.
Medications on Admission:
Sertraline 50mg PO twice daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID constipation
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
do not drive while on this medication, may cause drowsiness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Sertraline 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with right lower quadrant abdominal pain// ? appendicitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 5.3 s, 57.9 cm; CTDIvol = 16.4 mGy (Body) DLP = 949.5
mGy-cm.
Total DLP (Body) = 960 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.
Portal venous system is 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.
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. Colon and rectum
are within normal limits. The base of the appendix is mildly enlarged,
measuring up to 8 mm, with thickened walls. Together with mucosal hyperemia
and periappendiceal fat stranding, findings are compatible with early acute
appendicitis. No abscess or perforation.
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 lymphadenopathy. A few prominent
mesenteric lymph nodes measuring up to 9 mm in the right lower quadrant are
likely reactive. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Early aacute uncomplicated appendicitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 99.3
heartrate: 92.0
resprate: 16.0
o2sat: 99.0
sbp: 133.0
dbp: 84.0
level of pain: 4
level of acuity: 3.0 | ___ year old male, admitted for RLQ abdominal pain,
abdomen/pelvis CT showed acute uncomplicated appendicitis. The
patient was made NPO and given intravenous fluids. Subsequently
went to the OR on ___ for a laparoscopic appendectomy. No
complications. He has been tolerating a regular diet and has no
issues voiding. His pain has been well controlled on
analgesics. He has been ambulatory. Follow up appointment was
made with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
PCP: ___. ___
CC: Leg pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of HTN who presented to the ED with
LLE swelling and pain for a few weeks. She reports that about 3
weeks prior to admission she was at her daughter's house when
she tripped over the threshold entering her house and she fell
to the ground landing on both her knees. She developed a
laceration and presented to ___ for evaluation. Per ___ records
x-rays were negative and no evidence of infection so she was
discharged home. Approximately one week prior to admit, two
weeks after initial fall, she was walking off the T in the ___
station when her foot caught a "spike" sticking up out of the
bricks, she tripped and landed on her left knee. The wound
reopened and it started bleeding a lot. She again presented to
___ where x-rays were negative and she was discharged without
antibiotics given no concern for infection. Over the next week,
several days prior to presentation to the ED she reports
increased redness, swelling and pain of LLE. She reports ongoing
bleeding from wound with severe pain, she has been applying
bacitracin to the wound and she has not seen any purulence or
other drainage from the wound. More recently she developed
tingling sensation in 3 of her toes. She saw her PCP for
evaluation this morning who referred her to the ED for work up.
In the ED, initial vitals were: ___ pain 97.8 87 136/88 18 100%
RA. Labs were notable for leukocytosis. Because extent of
swelling, pain and new paresthesias ortho was consulted for
potential compartment syndrome. Ortho was less concerned for
compartment syndrome or necrotizing fasciitis after evaluation,
they recommend plain films and ultrasound. ___ was negative for
DVT, x-ray negative for fracture and soft tissue US showing
edema consistent with cellulitis without abscess. Ortho final
evaluation was consistent with severe cellulitis and recommended
conservative therapy and strict LLE elevation at all times. She
was started on IV Vancomycin and admitted to medicine.
On the floor, she appears well and is in no acute distress. Her
pain is well controlled, currently ___ in severity and she
denies fevers. She reports subjective chills but otherwise feels
well.
Incidentally, her daughter presented to ___ ED at the same time
as her index ED visit and remains hospitalized for "kidney
problems"
Review of systems:
(+) Per HPI
(-) Denies fever, 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. Otherwise ROS is negative.
I reviewed records from ___ which arrived with the patient
Past Medical History:
Hypertension
Gout
Hyperlipidemia
Glaucoma
Morbid Obesity BMI >40
Social History:
___
Family History:
Daughter with "kidney problems"
Son with MI at ___
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.1 PO 148 / 80 104 18 94 RA
Pain Scale: ___
General: Patient appears well, she is awake, interactive,
pleasant, fully alert, oriented and linear. She appears in no
acute distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: Obese abdomen, soft, non-tender, non-distended,
normoactive bowel sounds throughout, no rebound or guarding
Ext: Her LLE is warm to touch, predominantly around wound which
is marked, the skin is mildly erythematous and blanched with
palpation. Anteriorly there is a There is also a 2cm, oval
shaped, open wound overlying tibial head inferior to patella.
The sounds is actively bleeding with dark red blood, there is no
purulent drainage even with massaging wound. There is a soft,
fluctuant, pocket inferor to the wound with surrounding
induration more distally, superiorly and lateral to wound. There
is no pain with active or passive range of motion of foot or
ankle. 2+ DP pulses and her foot is warm. There is preserved
sensation. Calf is swollen on left compared to right but is soft
and compressible, not tense.
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
Exam on discharge:
97.6 BP:111/69 HR: 86 R: 18 98 Ra
Gen: NAD, lying in bed, well appearing
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Ext: Anterior L shin with oval shaped 3x3cm wound with packing
in
place. Laterally- 2x3cm wound also with packing. +sanguenous
drainage
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
Admission Labs:
___ 04:30PM BLOOD WBC-10.5* RBC-3.99 Hgb-11.4 Hct-36.6
MCV-92 MCH-28.6 MCHC-31.1* RDW-15.5 RDWSD-51.4* Plt ___
___ 04:30PM BLOOD Neuts-72.0* ___ Monos-5.6 Eos-1.7
Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-2.06 AbsMono-0.59
AbsEos-0.18 AbsBaso-0.05
___ 04:30PM BLOOD ___ PTT-31.3 ___
___ 04:30PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-139
K-3.5 Cl-101 HCO3-25 AnGap-17
___ 05:04PM BLOOD Lactate-1.2
Imaging:
Knee Tib/Fib: No fracture. No focal erosion.
___: No evidence of deep venous thrombosis in the left lower
extremity veins.
Soft Tissue US of leg:
IMPRESSION:
Edema and complex fluid collection fluid is seen in the
subcutaneous tissues of the left shin, with some extension into
the adjacent musculature.
Infection could certainly be possible in the proper clinical
setting.
MRI Leg: ___
IMPRESSION:
8.5 x 1.8 x 7 collection within the subcutaneous tissue of the
anterior aspect
of the left leg could represent an organized hematoma, however
superimposed
infection cannot be excluded. No evidence of muscle or bony
involvement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Simvastatin 10 mg PO QPM
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. clotrimazole-betamethasone ___ % topical BID:PRN
7. Aspirin 81 mg PO DAILY
8. Glucosamine Chondroitin PLUS (gluc-condr-om3-dha-epa-___-st)
375-100-36-54 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth Q6hrs Disp #*18
Capsule Refills:*0
3. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. clotrimazole-betamethasone ___ % topical BID:PRN
7. Glucosamine Chondroitin PLUS
(gluc-condr-om3-dha-epa-___-st) 375-100-36-54 mg oral DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lisinopril 5 mg PO DAILY
11. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hematoma with concern for infection
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with left leg lesion, swelling// dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT
INDICATION: ___ year old woman with wound// please evaluate marked area for
abscess
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left shin.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left shin. There is edema and a well-defined complex fluid collection seen in
the subcutaneous tissues of the left shin, with some extension into the
adjacent musculature. The discrete area of complex fluid measures
approximately 4.8 cm cc by 4.1 cm TRV by 2.3 cm deep.
IMPRESSION:
Edema and complex fluid collection fluid is seen in the subcutaneous tissues
of the left shin, with some extension into the adjacent musculature.
Infection could certainly be possible in the proper clinical setting.
NOTIFICATION: Updated wording of wet read was discussed by ___ with Dr.
___.
Radiology Report
EXAMINATION: MRI of the left calf.
INDICATION: ___ year old woman with history of repeat trauma to her left shin
with open wound and ultrasound showing fluid collection. Orthopedics
requesting MRI to better evaluate abscess vs. hematoma and extent of muscle
involvement// ? hematoma vs. abscess, question muscle involvement. Wound is
anterior shin/tibia
TECHNIQUE: Multiplanar images of the left calf was performed with the
administration of 10 CC of Gadavist using a routine MR calf protocol.
COMPARISON: Ultrasound from ___.
FINDINGS:
Soft tissue: There is a mildly T1 hyperintense STIR hyperintense rim enhancing
collection within the anterior aspect of the left leg measuring approximately
8.5 x 1.8 x 7.7 cm within its maximal dimension that could represent an
organized hematoma, however superimposed infection cannot be excluded. A skin
defect is noted within the anterior aspect of the midportion of the leg, which
is contiguous with the collection.
Muscles: Fatty atrophy of the medial gastrocnemius muscle is likely from old
injury. Otherwise, normal signal intensity.
Bone marrow: No signal abnormality to suggest osteomyelitis. Mild subchondral
edema is noted within the bilateral tibial plateau secondary to degenerative
changes.
IMPRESSION:
8.5 x 1.8 x 7 collection within the subcutaneous tissue of the anterior aspect
of the left leg could represent an organized hematoma, however superimposed
infection cannot be excluded. No evidence of muscle or bony involvement.
Radiology Report
INDICATION: ___ with recent fall, concern for infection of left calf/knee//
soft tissue, fracture
TECHNIQUE: Three views of the left knee. Two views of the left tibia and
fibula.
COMPARISON: None.
FINDINGS:
Tricompartmental degenerative changes are noted with joint space loss,
particularly at the medial femorotibial compartment, and spurring. There is
no fracture. There is no suprapatellar effusion.
Distally, the left tibia and fibula are intact without fracture or focal
osseous abnormality. Plantar and posterior calcaneal spurs are noted.
IMPRESSION:
No fracture. No focal erosion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg swelling, Wound eval
Diagnosed with Cellulitis of left lower limb
temperature: 97.8
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 88.0
level of pain: 4
level of acuity: 3.0 | ___ woman with history of hypertension who presented to
the ED with left leg pain, swelling and redness for the past 3
weeks since two falls with an open pretibial wound.
# Cellulitis
# Left Leg hematoma
The patient presented with extensive edema of LLE with open
pre-tibial wound. She was seen by orthopedics given concern for
compartment syndrome which was felt to be unlikely. She had a
___ which ruled out DVT and an ultrasound which showed a fluid
collection. She was started on IV vancomycin and subsequently
underwent an MRI of her calf which confirmed a hematoma,
infection can not be ruled out. She was seen by plastic surgery
who performed a bedside I and D and hematoma evacuation. They
also made a second incision to drain the hematoma. The patient
remained afebrile without systemic signs of infection. She was
transitioned to oral Bactrim/Keflex to complete a 7 day course.
She will continue daily dressing changes with packing and kerlix
and follow up with plastic surgery next week. She was advised
to keep her leg elevated and to discuss returning to work at her
PCP follow up.
# Hypertension
Chronic, stable continued home medications: Lisinopril, HCTZ,
ASA
# HLD
- Continued statin
# Gout
Chronic, stable, no flares for "years" per patient
- Continued Allopurinol
# Glaucoma
Chronic, stable
- Continued Latanoprost eye drops |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, LLE fracture
Major Surgical or Invasive Procedure:
Left lower leg ORIF
History of Present Illness:
___ y.o. M with myotonic dystrophy and mild mental ___
transferred from ___ s/p fall presents
with L lower extremity fracture.
The patient's guardian reports that the patient was walking from
the bathroom when he felt sudden onset weakness of his L leg.
The patient reportedly tripped over a rug and subsequently fell
scraping his head and landing on his shoulder. There were no
reported prodromal symptoms (syncope, changes in vision,
palpitations, convulsions) or lost of consciousness. After his
fall, the patient denied any headaches, mental status changes,
nausea, or vomiting.
The patient initially presented to ___
where initial head/spine CT was unremarkable. Radiographs of the
LLE revealed comminuted fractures of the distal tibia and
fibula. The patient was subsequently transferred to the ___
for further evaluation and management. In the ED, his initial
vitals were: 98.4 92 141/91 24 100%. He received 10 mg IV
morphine and IV Cefazolin. Ortho was consulted and recommended
ORIF today.
His vitals prior to transfer to the floor were 90 137/83 20
100%. Initial labs were most notable for Na 148.
The patient and his guardian denies any recent illnesses but
does endorse cough and diarrhea for the past several months.
Currently, the patient is anxious but overall denies any
headaches, pain, nausea, vomiting, or confusion.
Past Medical History:
1. Myotonic dysptrophy since birth
2. Oropharyngeal dysphagia
3. Left bundle branch block (LBBB)
4. Blepharitis
Social History:
___
Family History:
Mother and brother had myotonic dystrophy. Father died of
cancer.
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAM:
VS: 98.1, 82, 135/71, 24, 99% RA
___: NAD.
HEENT:Head: Superfical scalp laceration on anterior surface. No
active bleeding, no hematomas. No tenderness on palpation of
sinuses. No periorbital or mastoid ecchymoses. Sclera appear
slightly injected. Tympanic membranes clear on otoscopy. Mild
erythema of ear canal bilaterally. Moist mucous membranes with
white material. No pharyngeal lesions.
Neck: Poor control. No lymphadenopathy.
CV: Marked pectus excavatum. RRR, normal S1 and S2. No m,r,g
Lungs: CTAB
Abdomen: Soft, NT, ND. +BS. No masses or hepatosplenomegaly. No
rebound or guarding.
Back: Marked
GU: Exam deferred.
MSK: Flaccid muscle tone throughout. No focal tenderness at
shoulder joints bilaterally. Left leg in cast.
Ext: Full lower extremity pulses, no cyanosis or clubbing. No
appreciate edema.
Neuro: AOx3. CN II-XII grossly intact. No focal deficits.
Discharge Physical Exam:
VS: 98.6 98.5 61-108 (118/43- 157/75) ___ 95-100% RA
I/O: MN: NR/700, 24h: 1450/600 BMx3
___: NAD.
HEENT: Superfical scalp laceration on anterior surface. No
active bleeding, no hematomas. No tenderness on palpation of
sinuses. No periorbital or mastoid ecchymoses. Sclera appear
slightly injected. Tympanic membranes clear on otoscopy. Moist
mucous membranes with white material. No pharyngeal lesions.
Neck: Poor control. No lymphadenopathy.
CV: Marked pectus excavatum. RRR, normal S1 and S2. No m,r,g
Lungs: CTAB
Abdomen: Soft, NT, ND. +BS. No masses or hepatosplenomegaly. No
rebound or guarding.
Back: Marked
GU: Exam deferred.
MSK: Flaccid muscle tone throughout. No focal tenderness at
shoulder joints bilaterally. Left leg stabilized with splint.
Ext: Full lower extremity pulses, no cyanosis or clubbing. No
appreciate edema.
Neuro: AOx3. CN II-XII grossly intact. No focal deficits.
Labs: Reviewed, please see below
Pertinent Results:
Admission Labs
----------------
___ 07:00AM BLOOD WBC-9.3 RBC-4.69 Hgb-15.2 Hct-43.1 MCV-92
MCH-32.4* MCHC-35.3* RDW-12.6 Plt ___
___ 07:00AM BLOOD Neuts-79.2* Lymphs-14.0* Monos-5.4
Eos-0.4 Baso-1.1
___ 07:00AM BLOOD ___ PTT-20.9* ___
___ 07:00AM BLOOD Glucose-95 UreaN-17 Creat-0.5 Na-148*
K-4.1 Cl-113* HCO3-18* AnGap-21*
___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 08:00AM URINE Color-Straw Appear-Clear Sp ___
Discharge Labs
----------------
___ 07:25AM BLOOD WBC-7.3 RBC-3.99* Hgb-12.6* Hct-37.5*
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.0 Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-113* UreaN-7 Creat-0.4* Na-146*
K-4.0 Cl-113* HCO3-23 AnGap-14
Imaging
----------------
CXR ___:
A semi-erect frontal view of the chest shows no displaced rib
fracture. There is a marked dextroscoliosis of the thoracic
spine. There is no pleural effusion, pneumothorax focal
airspace consolidation. The cardiac silhouette is difficult to
assess given the spinal abnormality. However, mild cardiomegaly
is present. Air-filled loops of large bowel are seen.
CT C-SPINE W/O CONTRAST ___: No C-spine fracture.
CT HEAD W/O CONTRAST ___: No acute intracranial process.
ANKLE (AP, MORTISE & LA) ___:
3 views of the knee demonstrate normal alignment without
fracture or
dislocation. There are mild degenerative changes.
3 views of the left ankle demonstrate a comminuted distal tibial
and fibular fractures overlying plaster which somewhat limits
evaluation . There is a minimal impaction and angulation at the
fracture site, with the largest area of distration measuring 5
mm in the anterior cortex of the tibia with posterior angulation
at the fracture site.
Microbiology
----------------
Blood cultures ___ pending
Medications on Admission:
This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Senna 2 TAB PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L Comminuted Tib-Fib Fracture
Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent (at baseline mental status)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Myotonic dystrophy after fall this morning. Evaluate for fracture.
COMPARISON: None.
FINDINGS: A semi-erect frontal view of the chest shows no displaced rib
fracture. There is a marked dextroscoliosis of the thoracic spine. There is
no pleural effusion, pneumothorax focal airspace consolidation. The cardiac
silhouette is difficult to assess given the spinal abnormality. However, mild
cardiomegaly is present. Air-filled loops of large bowel are seen.
Radiology Report
INDICATION: Myotonic dystrophy, status post fall this morning with head
trauma. Evaluate for head bleed.
COMPARISON: None.
TECHNIQUE: Contiguous axial slices were acquired through the brain without
administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
DLP: 1025.72 mGy-cm.
FINDINGS: There is no evidence of infarction, hemorrhage, edema, or shift of
the normally midline structures. The ventricles and sulci are of normal size
and configuration for age. There is periventricular white matter hypodensity
suggesting chronic small vessel ischemia. The basal cisterns remain patent. A
small osteoma is seen along the right parietal bone. The imaged paranasal
sinuses and mastoid air cells are well aerated. There is no fracture.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: Myotonic dystrophy with fall this morning and head trauma.
Evaluate for spinal fracture.
COMPARISON: None.
TECHNIQUE: MDCT axial images were acquired through the cervical spine without
administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
DLP: 804.82 mGy-cm.
FINDINGS: There is no evidence of fracture or subluxation. There is no
prevertebral soft tissue swelling. Minimal degenerative changes are seen at
C5-C6 with anterior osteophytes. Small posterior osteophytes at this location
minimally encroach on the spinal canal, but do not appear to contact the
spinal cord. Soft tissues of the neck and lung apices are unremarkable. The
thyroid is normal. Small amount of debris is seen within the trachea.
IMPRESSION: No evidence of fracture or subluxation.
Radiology Report
HISTORY: Status post fall with open left ankle fracture.
COMPARISON: Outside films from ___ at 0 200.
FINDINGS:
3 views of the knee demonstrate normal alignment without fracture or
dislocation. There are mild degenerative changes.
3 views of the left ankle demonstrate a comminuted distal tibial and fibular
fractures overlying plaster which somewhat limits evaluation . There is a
minimal impaction and angulation at the fracture site, with the largest area
of distration measuring 5 mm in the anterior cortex of the tibia with
posterior angulation at the fracture site..
Radiology Report
HISTORY: ORIF.
Fluoroscopic assistance provided to surgeon in the O.R. without the
radiologist present. Four spot views obtained. Fluoro time recorded as 19.3
seconds on the electronic requisition. Correlation with real-time findings
and when appropriate conventional radiographs are recommended for full
assessment.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX ANKLE NOS-OPEN, UNSPECIFIED FALL, MYOTONIC MUSCULAR DYSTROPHY
temperature: 98.4
heartrate: 92.0
resprate: 24.0
o2sat: 100.0
sbp: 141.0
dbp: 91.0
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 left open distal tibial shaft fracture and
hyponatremia and was initially admitted to the medicine service.
He was found to have hypovolemic hyponatremia, and when this was
corrected by oral intake, the patient was transferred to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left distal tibia I&D and ORIF,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to either rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the left lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fatigue and new PE/port-associated right atrial clot on CT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with history of metastatic bladder
cancer with no evidence of disease after 9 cycles of
pembrolizumab, pembro-induced COOP and atrial thrombus on
apixaban, who presents with increased fatigue and new PE +
port-associated right atrial clot noted on CT Torso.
Ms ___ states she has been generally well, apart from 2 weeks
of
worsening fatigue, where she notices decreased energy by the end
of the day after going about her daily activities.
She saw Dr ___ in follow up today and after the appointment,
her routine CT Torso incidentally noted segmental LLL PE and
port-associated RA thrombus, for which she was referred to ED.
She states that she otherwise is completely asymptomatic. Denies
chest pain, palpitations, extremity edema. She has had ongoing
dyspnea on exertion for months with the diagnosis of her pembro
pneumonitis, which is unchanged. She estimates she can walk
about
___ minutes before stopping for dyspnea. She has not had
headache, dizziness, subjective fevers, night sweats, change in
appetite, bleeding in stool or urine, abd discomfort, N/V. She
has not missed any doses of apixaban.
Past Medical History:
PAST MEDICAL HISTORY:
-Asymptomatic sinus bradycardia, Adapta pacemaker placed in
___
-bilateral intraocular lens replaced in ___.
-Single oophorectomy in the ___.
-TURBT ___
-Radical cystectomy and urostomy ___.
Social History:
___
Family History:
Mother deceased at ___, had diabetes. Father
deceased at ___, had history of kidney cancer. One sister had
colon cancer and another sister had breast cancer.
Physical Exam:
VITALS:
___ 1335 Temp: 98.5 PO BP: 154/71 R Sitting HR: 64 RR: 16
O2 sat: 97% O2 delivery: RA
EXAMINATION
General: Well appearing pleasant elderly woman, ambulating from
bed to chair. In no acute distress. Not dyspneic on short
ambulation.
Neuro: Alert, oriented, provides clear history, PERRL, moving
all four extremities.
HEENT: No scleral icterus. Oropharynx moist without lesions.
Cardiovascular: Regular rate and rhythm without murmur. Radial
and DP pulses present.
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended. Bowel sounds present.
Surgical deformity and umbilical hernia that is reducible.
Urostomy in RLQ is c/d/i with clear yellow urine with some
sediment.
Extr/MSK: Thin, no peripheral edema
Skin: No acute rashes noted, but areas of ecchymosis related to
venipuncture.
Access: PIV. POC not accessed.
Pertinent Results:
___ 06:50AM BLOOD WBC-7.2 RBC-2.90* Hgb-8.3* Hct-28.3*
MCV-98 MCH-28.6 MCHC-29.3* RDW-20.4* RDWSD-73.6* Plt ___
___ 11:35AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.5* Hct-28.6*
MCV-97 MCH-28.9 MCHC-29.7* RDW-20.6* RDWSD-73.0* Plt ___
___ 06:50PM BLOOD Neuts-76.2* Lymphs-14.0* Monos-8.8
Eos-0.2* Baso-0.6 Im ___ AbsNeut-6.61* AbsLymp-1.21
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.05
___ 06:50PM BLOOD ___ PTT-27.9 ___
___ 06:50AM BLOOD Creat-0.8 Na-145 K-4.4 Cl-111* HCO3-25
AnGap-9*
___ 11:35AM BLOOD UreaN-23* Creat-0.9 Na-142 K-4.3 Cl-106
HCO3-25 AnGap-11
___ 10:15AM BLOOD ALT-10 AST-16 AlkPhos-48 TotBili-<0.2
___ 06:50PM BLOOD cTropnT-<0.01 proBNP-181
___ 06:50AM BLOOD Phos-3.7 Mg-2.3
___ 06:50AM BLOOD TSH-40*
___ 10:15AM BLOOD TSH-38*
___ 06:50AM BLOOD T3-80 Free T4-0.4*
ECHOCARDIOGRAM ___
IMPRESSION: Small, ill-defined, probable, mass attached to the
right atrial catheter (better
visualized by transesophageal echocardiography). Mild symmetric
left ventricular hypertrophy
with normal cavity size and hyperdynamic regional/global
systolic function. Mild to moderate
tricuspid regurgitation. Normal estimated pulmonary artery
systolic pressure.
Right upper extremity ultrasound ___
IMPRESSION: No evidence of deep vein thrombosis in the right
upper extremity.
CT Chest ___
IMPRESSION:
Filling defect in the left posterior basal segmental branch of
the left lower lobe pulmonary artery concerning for pulmonary
embolism. Additional filling defect in the distal SVC
surrounding the distal tip of the Port-A-Cath and within the
right atrium also most likely represents thrombus. Correlation
with echocardiography is recommended.
No evidence of infarction.
Stable right middle lobe pulmonary nodule measuring 2 mm. No
new pulmonary nodules.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Ranitidine 150 mg PO BID
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
5. Gabapentin 100 mg PO TID
6. Apixaban 5 mg PO BID
7. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
8. Lidocaine 5% Patch 1 PTCH TD QAM knee pain
9. Docusate Sodium 240 mg PO BID
10. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin [Lovenox] 60 mg/0.6 mL 60 mg Subcutaneous every
twelve (12) hours Disp #*60 Syringe Refills:*0
2. Levothyroxine Sodium 12.5 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
4. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
5. Docusate Sodium 240 mg PO BID
6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
7. Gabapentin 100 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM knee pain
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO BID
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism and port-associated RA thrombus
Constipation
Metastatic bladder cancer
Pembrolizumab associated COOP
Fatigue
Hypothyroidism
Normocytic anemia
L3 compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ with history of metastatic bladder cancer with no evidence of
disease after 9 cycles of pembrolizumab, pembro-induced COOP and atrial
thrombus on apixaban, who presents with increased fatigue and new PE +
port-associated right atrial clot noted on CT Torso.// evaluate for RUE port
associated clot burden
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: CT chest from ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Intracardiac thrombosis, not elsewhere classified, Dyspnea, unspecified
temperature: 97.3
heartrate: 69.0
resprate: 18.0
o2sat: 99.0
sbp: 147.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | ___ with history of metastatic bladder cancer with no evidence
of disease after 9 cycles of pembrolizumab, pembro-induced COOP
and atrial thrombus on apixaban, who presents with increased
fatigue and new pulmonary embolism and port-associated right
atrial clot on CT Torso.
# Pulmonary embolism and port-associated RA thrombus. This may
be explained by apixaban failure as clot seemed to decrease
previously on enoxaparin. Workup included Trop/EKG/BNP that is
reassuring against heart strain. TTE suggests new atrial lead
thrombus, but poor quality. TEE was recommended for further
characterization, but this would not change management and was
not pursued as discussed with outpatient hematologist. Pacer
remains functional and treatment would be anticoagulation. Close
cardiology follow up would be valuable to monitor pacer
function. Interventional radiology was consulted for
consideration of port removal. Per ___, the removal of port would
only be performed after a minimum of ___ days of effective
anticoagulation with lovenox or coumadin (per protocol). Per ___,
the port only needs to be removed if malfunctioning. No need to
access port at this time. Patient was treated with heparin
infusion and transitioned to 1 mg/kg enoxaparin without
incident. RUE Doppler did not reveal RUE DVT.
# Fatigue. Hypothyroidism.
Fatigue is likely caused by hypothryroidism (related to steroid
use versus late pembrolizumab effects). Less likely due to clot
burden and inflammatory state.
Fatigue may also be due to steroid taper. TSH elevated and FT4
low. Initiating levothyroxine therapy as discussed with
outpatient provider who will monitor response.
# Constipation: Treated with bowel regimen.
# Metastatic bladder cancer, in remission. s/p radical
cystectomy and ileal conduit, ___. Solitary L parietal lobe
metastasis s/p resection ___ followed by CK to surgical bed
___. Received 9 cycles of Pembrolizumab (last ___ and
developed
COOP 6 months off pembrolizumab. Will update primary oncologist.
# Pembrolizumab associated COOP
Developed COOP 6 months off pembro. Treated with steroids; most
recently restarted on tmt dose steroid ___ for worsening
pneumonitis, but now tapered down to 5 mg daily. CT yesterday w/
stable 2mm nodules, no evidence of worsening pneumonitis.
Patient is continued on prednisone 5 mg daily.
# Normocytic anemia, stable. This is a combination of ACD and
iron deficiency. Continued on iron supplement.
#L3 Compression fracture: likely in setting of underlying
osteoporosis and prolonged steroid use. s/p denosumab on ___.
- Cont home Ca/vit D
Hospital course, assessments, and discharge plans discussed with
patient and family who express understanding and agree with
discharge. The above was discussed with outpatient oncologist
who also agreed with plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: ___ is a ___ year-old
woman with recent history of copious diarrhea presented to OSH
with right sided numbness and paresthesia, and is transferred
after syncope, bradycardia, hypotension for further evaluation
Patient endorses chronic diarrhea since ___ (constant since
___, notable for watery diarrhea ___. Outpatient workup
in
___ negative C diff, and upcoming colonoscopy scheduled
___.
She recently went to ___ for LUE numbness and
paresthesia on ___. She had LUE numbness and heaviness of the
entirety of her LUE lasting for ___ hours. She was admitted for
workup. Per OSH records, her workup included negative MRI,
CTA/MRA, TTE with bubble. A1c 5.3%, LDL 114. She initially
received ASA 81 mg and Lipitor 10 mg while awaiting results of
her hypercoagulable workup, but these were held due to concern
for overtreatment. B12 was 305, and B12 supplementation was
recommended.
She was discharged home. ___ as she worked out she became
lightheaded and nauseous, and was generally fatigued for the
following days. She woke from sleep at 4 am on ___. with
right arm numbness / heaviness and tingling in fingers and hand
heaviness. She also experienced "head heaviness" and trouble
finding words.
In the ED, she had jaw tightness and a syncopal event. Per OSH
report, her HR dropped to 32 and BP 52/40. Her BG was 67. She
was
given atropine and D50. The patient was lying down at the time,
reports her "head felt heavy" and "jaw felt tight," and she was
nauseated with a headache. She did not feel the room spinning or
darkness closing in. Reportedly she passed out for 10 seconds,
no
head strike, and awoke feeling sick, nauseous and still with a
HA. Her EKG was concerning for TWI, so OSH ED referred her to
___ for further evaluation
In the ED, initial vital signs were: T 98.6 P 64 BP 99/62 R 18
O2
sat. 100 on RA
- Exam unremarkable
- Studies performed include CXR
- Vitals on transfer: T 98.2 P 59 BP 98/57 R 17 O2 sat. 100 on
RA
Upon arrival to the floor, the patient in no acute distress. The
numbness and tingling she reported earlier has resolved. She
feels intermittently lightheaded and dizzy but only when she
stands up, no further syncope episodes. She does report a ___
bilateral frontal squeezing headache without radiation similar
in
character to previous headaches. Notably, the patient reports
dyspnea and chest tightness after ___ crossfit workout,
resolved with rest, slight recurrence while walking on ___
but otherwise has not recurred.
ROS otherwise negative in remaining systems.
Past Medical History:
None.
Social History:
___
Family History:
Notable for MI at age ___ in grandfather and in
___ in maternal aunt. ___ and HTN on mother's side but not
in mother. Sister with ___ disease and ___ cousin with UC.
No history sudden cardiac death or unexplained death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 98.6PO 98/54 56 18 99 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. No dysmetria, disdiadochokinesia. Gait is normal.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tm: 98.6 Tc: 97.9 BP: 95-106/52-66 HR: 56-64 RR: ___
O2%: 99-100
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. No dysmetria, disdiadochokinesia. Gait is normal.
Pertinent Results:
ADMISSION LABS
==============
___ 11:30AM BLOOD WBC-5.1 RBC-3.89* Hgb-12.1 Hct-36.9
MCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt ___
___ 11:30AM BLOOD Neuts-71.1* ___ Monos-6.5
Eos-0.8* Baso-0.6 Im ___ AbsNeut-3.62 AbsLymp-1.05*
AbsMono-0.33 AbsEos-0.04 AbsBaso-0.03
___ 11:30AM BLOOD ___ PTT-25.6 ___
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-110* HCO3-20* AnGap-15
___ 11:30AM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:47AM BLOOD Lactate-1.3
MICROBIOLOGY
==============
___ CULTURE-FINALEMERGENCY WARD
IMAGING/STUDIES
==============
___ EKG
Sinus bradycardia. Compared to the previous tracing of ___
there are no significant changes.
___ CXR
IMPRESSION:
No evidence of acute cardiopulmonary process.
DISCHARGE LABS
==============
___ 07:40AM BLOOD WBC-4.5 RBC-3.70* Hgb-11.4 Hct-34.7
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.4 RDWSD-43.0 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-21* AnGap-15
___ 07:40AM BLOOD ALT-11 AST-16 AlkPhos-38 TotBili-0.3
___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
___ 07:40AM BLOOD Cortsol-10.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-Vasovagal syncope
Secondary diagnosis
-Diarrhea, unexplained etiology
-Unspecified disturbances of skin sensation
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 no sig PMHx syncopal episode given atropine
doing an infectious work up. // Eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside facility Chest radiograph ___ at 07:46
FINDINGS:
Lung volumes are normal. There is no consolidation, pleural effusion or
pneumothorax. Cardiomediastinal contours are normal. There is no
subdiaphragmatic free air. No acute osseous abnormalities are identified.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Syncope, Transfer
Diagnosed with Syncope and collapse
temperature: 98.6
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 99.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year-old woman with a month-long
history of copious diarrhea presenting to ___ with
right-sided numbness and paresthesia, and was transferred to
___ after an episode of syncope, bradycardia, and
hypotension for further evaluation. Notably, the patient
recently underwent extensive workup for possible stroke/TIA and
infectious causes of diarrhea at BID-P, with no etiology found.
At ___ the patient's ED course was notable for negative
tropsx2 and non-specific t-wave inversions on several EKGs (no
baseline comparison available), AM cortisol 10.4 (nl). She was
monitored on telemetry overnight with no arrhythmias identified,
and had no further parasthesias or syncopal episodes, though she
had one short episode of dizziness. Low concern for cardiac
etiology, presumed vasovagal exacerbated by stress of recent
diarrhea, patient discharged to follow up with planned
outpatient colonoscopy on ___ in ___.
ACTIVE PROBLEMS
===============
# Syncope: Syncope in the setting of bradycardia and
hypotension, EKG with T-wave inversions of varying depths.
Differential diagnosis initially bradyarrhythmia vs. vasovagal
vs. hypocortisolism as primary causes. Ischemia seemed unlikely
in setting of negative trops and minimal chest discomfort in a
woman with high exercise tolerance. Seemed very likely vasovagal
and less likely cardiac, AM cortisol within normal limits. Safe
for discharge with outpatient follow-up
# Chest heaviness: Patient with chest heaviness and dyspnea
after crossfit workout on ___, resolved with rest, though
patient had repeat, milder chest heaviness and slight dyspnea on
___ while walking. Patient also with T-wave changes, DDx
vasospasm vs. MSK vs. anxiety. Determined low risk and possible
___ anxiety in setting of diarrhea, can ___ with PCP outpatient
for cardiology referral if deemed necessary
# Diarrhea: Voluminous, loose, non-bloody diarrhea ___ times
daily since ___. DDx infectious vs. autoimmune vs. IBS. Has had
extensive infectious workup at BID-P, all negative. Patient w/
colonoscopy schedule ___, should complete for most diagnostic
utility.
# Transient weakness/numbness extremities: Patient with
extensive workup at BID-P, no cause seen for stroke/TIA (MRI,
CTA/MRA, TTE w/ bubble), also no sign of MS on MRI. PCP should
___ hypercoag labs and Lyme studies from BID-P.
CHRONIC PROBLEMS
================
# Borderline B12 deficiency: Continue B12 PO as outpatient.
TRANSITIONAL ISSUES
===================
Transitional issues
[] Follow up with Dr. ___, ___
[] Complete scheduled colonoscopy on ___ with prep the night
before
[] Talk to your PCP about their perspective on starting a statin
and on the need for further cardiac workup of the T-wave changes
on your EKGs |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Ultram / tramadol / Oxycodone / Alleve /
chlorine / bee venom (honey bee) / bee pollen
Attending: ___.
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ long hx of spinal fractures and pelvic
instability/dislocations, who now p/w lower back/R hip pain w/
sudden onset 2 days ago. Crossed legs while sitting, then pain
began when she tried to stand. Since then has been unable to put
pressure on R side, has vomited once ___ pain. Denies
numbness/weakness/paresthesias. Called orthopedist/PCP who told
her to come to ED for evaluation.
In the ED, imaging was obtained:
- Pelvic/R hip x-ray: Degenerative disease at the hips is mild.
No acute fracture or dislocation.
- LS spine x-ray: No fracture or malalignment
- CT pelvis: No acute fracture or dislocation
- CT L spine: No acute fracture or spinal subluxation
Pr was seen by ___ in ED whose report is below:
Pt is limited by pain. She is able to ambulate short distances
independently with RW and perform basic bed mobility
independently. She was not able to progress to stairs assessment
on 2 attempts ___ pain. Pt was provided ice which she reports
subjectively improved the pain. Anticipate once pain control is
optimized she will be able to functionally return home and
should f/u with her outpatient ___. RN is going to medicate pt
and assess ambulation and will page ___ if there are any
additional issues. Also pt has RW and B AC's at home already.
Also seen by orthopedics whose report is below:
Patient seen and examined with Dr ___. Patient well known to
Dr ___ several joint related issues. After discussion w
patient and her husband, we recommend:
1) Warm and form back brace. Nopco paged by ___
2) ___ for mobility/stair training. Has walker at home
3) DC on short course of po dilaudid and valium
4) Dr ___ to arrange injection with Dr ___
for patient
On the floor, before the physician has seen the patient, nursing
reports that the patient has been very difficult to manage due
to certain requests. Patient would like to stay in the stretcher
while in room because she needs a hard mattress. She refuses to
transfer to the hospital bed, which is against hospital policy
because of lack of safety features on the stretcher. Finally a
compromise is reached where the stretcher mattress is placed on
the bed. Husband was also caught taking pictures of staff for
litigous purposes, which is also against policy. security
alerted and husband confronted that if he does takes another
picture of staff he will be escorted from the hospital.
Throughout this situration, there multiple threats to leave AMA.
Once Examining the patient, she is very pleasant and recounts
the history of her illness. She is currently not in pain while
immobile and seated in the decubitus position. She will not
however allow me to do a full exam due to pain.
Past Medical History:
1.Spinal Problems
2.vaginal lichen planus
3.hypertension
4.osteopenia ___ BMD)
5.GERD
6. Mitral Valve Prolapse
7. C. Diff colitis
8. Raynaud's
9. Tibial Plateau Fracture
10. Right meniscal tear s/p meniscectemy
11. Uterine fibroid
Social History:
___
Family History:
Hypertension (Mother)
___ (Father)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97 167/67 63 18 100%RA
General: Alert, oriented, no acute distress, lying comfortably
in lateral decubitus position
HEENT: NC/AT
Neck: supple
Lungs: No respiratory distress, no increased work of breathing
CV: No pedal edema
Abdomen: non-distended, soft
Ext: TTP right sacroilliac joint; rest of joint and leg exam is
limited by pain
Neuro: AO x 3
DISCHARGE PHYSICAL EXAM
Vitals: Refused morning vital signs
General: Alert, oriented, no acute distress; lying supine
initially; she is able to sit up to side of bed without
assistance. No distress while performing these maneuvers.
Lungs: No respiratory distress, no increased work of breathing
CV: No pedal edema
Abdomen: non-distended, soft
Ext: TTP right sacroilliac joint; did not allow physician to
move the lower extremities in order to perform a full joint
exam.
Neuro: AO x 3; moves all extremities without difficulty
Pertinent Results:
CT L-SPINE: No acute fracture or malalignment in the lumbar
spine
CT PELVIS:
1. No acute fracture or dislocation.
2. Trace amount of simple pelvic free fluid, which is not a
normal finding in a postmenopausal patient though nonspecific.
PELVIS PLAIN FILM
Degenerative disease at the hips is mild. No acute fracture or
dislocation.
LUMBAR PLAIN FILM: No fracture or malalignment in the lumbar
spine.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Enalapril Maleate 5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Estradiol 1 mg PO DAILY
Discharge Medications:
1. Enalapril Maleate 5 mg PO DAILY
2. Estradiol 1 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Outpatient Physical Therapy
Please evaluate and provide home physical therapy.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Low Back Pain
Secondary:
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: ___ with hx of pelvic instability now w/ new R hip pain // eval
for new lower back/hip pain
COMPARISON: Prior CT abdomen pelvis from ___.
FINDINGS:
AP pelvis and two views of the right hip were provided. The bony pelvic ring
is intact. SI joints are symmetric and normal. Both hips align normally with
mild loss of joint space and mild subchondral sclerosis. The femoral heads
maintain their normal rounded contour. No soft tissue abnormalities. Mild
spurring is seen along the inferior femoral acetabular joint.
IMPRESSION:
Degenerative disease at the hips is mild. No acute fracture or dislocation.
Radiology Report
INDICATION: ___ with hx of pelvic instability now w/ new R hip pain // eval
for new lower back/hip pain
COMPARISON: ___, CT abdomen pelvis from ___.
FINDINGS:
AP and lateral views of lumbar spine were provided. There are 5
non-rib-bearing lumbar type vertebral bodies. Rudimentary ribs are noted at
T12. There is no compression fracture or malalignment. Disc spaces are
preserved. No significant spur formation. SI joints appear normal. Hip joints
align normally with mild subchondral sclerosis noted. The imaged bowel gas
pattern is unremarkable.
IMPRESSION:
No fracture or malalignment in the lumbar spine.
Radiology Report
INDICATION: ___ female with history of pelvic instability and spinal
fractures now with lumbosacral pain. Evaluate for fracture.
TECHNIQUE: Helical axial MDCT sections through the lumbar spine. Reformatted
images in sagittal and coronal axis were obtained. No IV contrast was
administered.
DOSE: DLP: 882 mGy-cm.
CTDIvol: 31 mGy.
COMPARISON: Radiographs from ___ and CT from ___.
FINDINGS:
There are 5 lumbar-type vertebral bodies with preserved vertebral body height.
No acute fracture or malalignment is seen, and there is no prevertebral soft
tissue swelling or hematoma. Mild facet arthropathy is noted throughout the
lumbar spine. Mild disc height loss is seen at L5-S1. While CT is unable to
provide intrathecal detail compared with MRI, the visualized outline of the
thecal sac is normal.
The visualized small and large bowel loops are normal without signs of
obstruction or wall thickening. Parapelvic cysts are noted in the left
kidney. The other visualized abdominal organs are within normal limits.
IMPRESSION:
No acute fracture or malalignment in the lumbar spine.
Radiology Report
INDICATION: ___ female with history of pelvic instability and spinal
fractures, now with new pain in the lumbosacral spine, right hip and pelvis.
TECHNIQUE: Axial MDCT images were obtained through pelvis without IV contrast
material or oral contrast material. Sagittal and coronal reformatted images
were obtained. DOSE DLP: 745 mGy-cm.
COMPARISON: Radiograph from ___ and ___.
FINDINGS:
OSSEOUS STRUCTURES: The bony pelvic ring is intact. SI joints are symmetric
without significant degenerative disease. Both hips align normally with mild
degenerative disease including small marginal osteophytosis and mild loss of
joint space noted at both hips.
The imaged small and large bowel loops appear normal without wall thickening
or signs of obstruction. The appendix is normal. Uterus and adnexal regions
appear grossly unremarkable. The urinary bladder is partially distended. Trace
free pelvic fluid is noted of unclear etiology.
IMPRESSION:
1. No acute fracture or dislocation.
2. Mild degenerative disease at both hips.
3. Trace amount of simple pelvic free fluid.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with LUMBAGO, FEM GENITAL SYMPTOMS NOS
temperature: 98.9
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 170.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | ___ yo F with long history of pelvic joint disease who is
admitted for pain control.
#Acute Pain: Patient has a long history of pelvic joint disease.
CT scan of the pelvis and lumbar spine showed no acute changes
in the applicable joints. She was seen in the ED by her
orthopedist Dr. ___ recommended an sacro-illiac joint
injection as an outpatient the following day. Physical Therapy
also saw the patient in the ED and cleared her to go home with
outpatient pain control and her walker at home. However, given
her reported pain in the ED in the setting of multiple drug
allergies she was admitted for pain control. She was given 10mg
oxycodone, 5mg valium, and standing Tylenol for pain relief. She
was also given Zofran for her nausea. The following morning, she
stated that she was ready for discharge and that her pain was
controlled for the time being and that she was planning on
attending her outpatient appointment for injection of the SI
joint. On day of discharge, she was able to walk to the bathroom
without difficulty, sit up unassisted, and shower unassisted.
#History of anaphylaxis: Multiple allergies (including
oxycodone) listed after anaphylactic reaction post surgery 2
weeks ago. Causative agent was not found. Oxycodone given in ED
without issue. An epipen was ordered for immediate use if she
began to have symptoms of
#HTN: continued enalapril and HCTZ
#Postmenopausal: continued estradiol
#Important Hospital Events:
1. Upon admission to medical floor, patient refused to transfer
to the hospital bed because she needed a harder mattress such as
the one on the stretcher. Fortunately, a compromise was found to
place the stretcher mattress on the hospital bed.
2. Her husband was seen taking pictures of Emergency room staff
citing litigous purposes and security was called to warn him
that he would be escorted off the premises if did so again.
3. Patient complained of a migrain headache the morning of
discharge and before the physician could respond to the
complaint and prescribe medication, the husband was seen by
patient sitter to provide the patient with outside pills after
very clear instructions that this was against hospital policy.
He refused inspection of the bottle
4. The patient insisted on ambulance transfer out of hospital,
and refused to pay for it out of pocket when informed that she
did not meet criteria for insurance coverage.
#Transitional Issues:
-Pt provided a Rx for home ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / Lactulose
Attending: ___.
Chief Complaint:
S/p seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a pmhx. significant for
metastatic RCC with mets to skull on pazopanib, HTN,
hyperlipidemia and depression, who is admitted from the ED with
change in mental status and ___ activity.
Patient states that for the last 3 days she has felt slightly
off: she has noticed ___ difficulty and that sometimes
she "moves her lips and no words come out." She also reports
myoclonic jerkings in her extremities, which subside on their
own. On day of admission to the hospital, patient's social
worker was visitng. Ms. ___ lost consciousness and apparently
had a seizure (unknown duration or clinical manifestations).
Social worker called ___, and the next thing patient remembers
was waking up in the back of an ambulance. She was taken to
___ where a CT scan showed: in comparison to
study in ___, stable L craiotomy changes presnet w/
underlying encephalomalacia of the L frontal and parietal lobe.
inc CSF is noted at the surgical site. no evidence of acute ICH.
no midline shift. no masses. no evidence of acute territorial
infarct. bony calvarium is otherwise intact."
Patient was transferred to ___ for further evaluation. In
___ ED, initial vitals were: 98.1 68 109/66 21 96%. Neuro
oncology was contacted who recommended Keppra load of 1000mg and
admit to OMED. On admission, vitals were: 68 108/68 20 97%.
ROS: Patient endorses ___ difficulties. Says memory
has gotten worse over the past ___ days. Has chills but no
documented fevers. Nausea, which she relates to anxiety.
Denies vision change, shortness of breath, chest pain, change in
stools, dysuria, or other concerning signs or symptoms.
Past Medical History:
--Metastatic renal cancer
--Hypertension
--Hyperlipidemia
--Ostomy for incontinence
--Depression
--COPD
Social History:
___
Family History:
No family history of malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 68 108/68 20 97%
GENERAL: No acute distress, lying in bed, pale
HEENT: Mucous membranes slightly dry
NECK: No cervical, submandibular, or supraclavicular LAD
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, light brown stool in ostomy, ___,
___
EXTREMITIES: No edema bilaterally
NEURO: Alert and oriented, forgetful about some parts of her
medical history (she says this is not normal), CN ___ grossly
intact, strength ___ in upper and lower extremities, cerebellar
signs not done, gait deferred
Pertinent Results:
___ 05:45PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 05:45PM ___ this
___ 05:45PM ALT(SGPT)-23 AST(SGOT)-36 ALK ___ TOT
___
___ 05:45PM ___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM PLT ___
___ 05:45PM ___ ___
CXR ___: FINDINGS: Frontal and lateral views of the chest
were obtained. There is persistent blunting of the costophrenic
angles and possible minimal pleural thickening bilaterally,
which is unchanged in appearance since the prior study. Chain
sutures are again seen overlying the right ___
hemithorax. Slight upper lobe patchy opacity are seen which
could be due to aspiration or infection and are of indeterminate
acuity. No pleural effusion is seen. There is no evidence of
pneumothorax. The cardiac and mediastinal silhouettes are
stable. Surgical clips are partially seen in the upper
abdomen.
.
___ read:
Preliminary ReportNo infarct or hemorrhage. No evidence of
abnormal enhancement or masses
Preliminary Reportwithin the confines of the study.
.
Head CT:
IMPRESSION:
Interval development of a small ___ hemorrhage at the
cranioplasty site, without mass effect on the adjacent brain.
.
Micro
___ flora
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath
2. Atenolol 100 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
Please hold for SBP <100.
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Hydrocortisone 15 mg PO BID
6. Mirtazapine 15 mg PO HS
7. Sertraline 200 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. pazopanib *NF* 400 mg Oral QD
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN Headache
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Fludrocortisone Acetate 0.05 mg PO DAILY
4. Hydrocortisone 15 mg PO QAM
5. Hydrocortisone 10 mg PO QPM
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Mirtazapine 15 mg PO HS
8. Sertraline 200 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. pazopanib *NF* 400 mg Oral QD
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Acetaminophen 1000 mg PO Q8H:PRN headache
available over the counter
13. Divalproex (DELayed Release) 750 mg PO BID
RX *divalproex [Depakote] 250 mg 3 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*0
14. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN severe
pain
RX *oxycodone 5 mg ___ to1 tablet(s) by mouth q6hr; prn Disp
#*60 Tablet Refills:*0
15. Outpatient Lab Work
Dx = Convulsive Seizure ICD 345.10. Please draw "depakote"
level on ___ and fax result to Dr. ___
and Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure w/ fall, small head bleed
metastatic renal cell carcinoma
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: For seizure.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
persistent blunting of the costophrenic angles and possible minimal pleural
thickening bilaterally, which is unchanged in appearance since the prior
study. Chain sutures are again seen overlying the right mid-to-lower
hemithorax. Slight upper lobe patchy opacity are seen which could be due to
aspiration or infection and are of indeterminate acuity. No pleural effusion
is seen. There is no evidence of pneumothorax. The cardiac and mediastinal
silhouettes are stable. Surgical clips are partially seen in the upper
abdomen.
Radiology Report
HISTORY: Metastatic renal cell carcinoma, now with new onset of seizures.
TECHNIQUE: Multiplanar multisequence MRI of the brain was obtained before and
after the administration of IV gadolinium. The patient became agitated and a
code purple was called. The patient was sedated and brought back to the MRI,
however he continued to move, and the scan was aborted as the MPRAGE images
were non diagnostic due to motion, and the T2 and FLAIR sequences were not
completed.
COMPARISON: CT head noncontrast of ___ and MRI of ___.
FINDINGS:
Please note that the T2, FLAIR and MPRAGE sequences were not acquired and the
axial T1 post-contrast is limited due to motion, therefore the sensitivity of
this study is decreased.
There is no infarct or hemorrhage. There is no midline shift, masses, or
abnormal enhancement.
There is mild mucosal thickening of the ethmoid air cells.
There is a left frontal cranioplasty.
IMPRESSION:
No infarct or hemorrhage. No evidence of abnormal enhancement or masses
within the confines of the study.
Radiology Report
HISTORY: ___ woman with metastatic renal cell carcinoma, history of
left frontal bone metastasis resection and cranioplasty, now status post fall
and seizure, with progressive worsening left frontal headache.
COMPARISON: CT from ___ dated ___, and multiple prior head CTs and MRIs performed here.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Coronal, sagittal, and thin-section
bone-algorithm reconstructed images were obtained.
DLP: 1040 mGy-cm
CTDIvol: 64 mGy
FINDINGS:
Left frontal cranioplasty is again seen. There is interval development of a
small extra-axial hemorrhage overlying the brain at the cranioplasty site, not
seen on the ___ CT one day earlier. There is no associated mass effect
on the adjacent brain parenchyma. There is no parenchymal hemorrhage or edema.
A small rounded hypodensity in the region of the right lentiform nucleus
corresponds to a prominent perivascular space seen on prior MRIs. The
ventricles and sulci are unchanged in size, within normal limits for age.
Basal cisterns are patent. There is preservation of gray-white matter
differentiation.
No acute fracture is identified. Partial opacification of bilateral mastoid
air cells and mild mucosal thickening within the right sphenoid sinus are
unchanged from one day earlier.
IMPRESSION:
Interval development of a small extra-axial hemorrhage at the cranioplasty
site, without mass effect on the adjacent brain.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at 15:50
on ___ via telephone, 5 minutes following discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NEW SEIZURE
Diagnosed with SEC MAL NEO BRAIN/SPINE
temperature: 97.5
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 78.0
level of pain: 3
level of acuity: 2.0 | Pt is a ___ y.o female with h.o metastatic RCC to the skull s/p
cyberknife on chemo, HTN, HL, s/p ostomy for incontinence,
depression, COPD who was admitted with suspicion of new seizure,
c/b possible encephalopathy.
.
#Seizure, convulsive: No clear suggestion of infection or
metabolic cause. Pt was on tramadol as an outpatient which can
decrease the seizure threshold. This was discontinued. Primary
concern remained for metastasis. OSH CT was without acute
findings. However, CT at ___ concern for small hemorrhage near
craniotomy site. Unclear if this could precipitate seizure. The
patient was loaded on keppra and started on this medication.
Given, no fever, leukocytosis, or signs of meningitis, there was
no current indication for LP. Given, pt's history of depression,
there was some consideration of changing keppra to an
alternative AED and it was decided on ___ to transition over to
depakote. Pt was given a final dose of keppra on ___ and a
depakote load of 1500mg. Depakote was started at 750mg BID on
___. Neurosurgical did not think there was anything to do
regarding the possible small intracranial hemorrhage. ___
recommended transitioning to depakote and checking a level on
___ AM, and the ___ will draw this and fax to Dr. ___
(___) and Dr. ___. She has follow up with oncology
at ___, ___ in 2 weeks. She is discharged home with a
walker.
.
#chronic headache/intracranial ___ has a h.o
headaches. She is s/p cyberknife therapy for frontal skull vs.
frontal lobe metastasis, details unclear. Headache and possible
small bleed were felt to be due to fall after seizure. As
above, initial OSH CT unrevealing for acute process. No fever or
leukocytosis or signs of meningitis. However, CT at ___
revealed small extraaxial hemorrhage which was very small and
possibly related to trauma from fall. The neurosurgical service
was consulted and did not have further recommendations. The
neurooncology service recommended transition to depakote for
seizure prophylaxis. Her tramadol was discontinued and she was
started on PO oxycodone and acetaminophen therapy.
-headache is semiacute, on chronic (was taking meds at home)
.
#Encephalopathy, NOS vs. mood ___ exhibited some frontal
disinhibition as well as mood lability during admission. Per her
home SW, and PCP she has exhibited lability in the past and has
had some cognitive impairments after her prior surgery. Seemed
as though disinhibition and emotional lability were increased
during this admission, though decreased prior to discharge. It
is theoretical that this could be atypical manifestation of
concussion, or from keppra (was discontinued), vs. acute
exacerbation of her depression/stress related to her current
medical and social condition (finances, divorce). Social work
was consulted as well as ___ and OT who recommended rehab, but
patient refused, so will go home with increased services. Pt was
given PO ativan with good effect. Pt has ___ TIWK, home health
aids who help her clean weekly and help with her finances, and
home Soc worker. She will get ___ services too.. She has a
friend who helps with her cat. Her husband according to SW,
appears agreeable by phone, but patient reports he's not that
helpful to the patient. Pt does have a therapist, but stated
that she has been unable to see her therapist due to financial
concerns (of note, it appears that her finances are helped by
social worker, but pt has some cognitive deficits and forgets
her PINs and then reports having difficulty with fiances. She
has insurance. She is discharged to home with increased
services and will follow up with neurooncology ___.
.
#metastatic ___ on pazopanib as outpt, held during admission.
OK to restart upon discharge. follow up with oncologist ___
.
#adrenal ___ hydrocortisone and
fludricortisone at home doses.
.
#HTN, ___ home meds
.
#depression- Continued outpt sertraline and remeron. Social work
was consulted. Pt expressed that she has a therapist in the
outpatient setting and that financial concerns have been a
barrier in the outpatient setting. She will benefit from
continued support by social work and therapist.
.
DVT PPx:hep SC TID
.
CODE: DNR/DNI
.
Transitional (external):
-continued SW and therapist support for ongoing depression and
social situation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / aspirin
Attending: ___.
Chief Complaint:
foul smelling drainage from umbilicus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with extensive PMH, hospitalized ___ for sepsis and
RP hematoma after a fall, course complicated by acute
cholecystitis managed with percutaneous cholecystostomy, also
c/b acute-on-chronic renal failure and acute-on-chronic CHF. He
was discharged to an extended care facility, and was again
hospitalized ___ due to concern for stroke. He has been
recovering well at rehab, though his cholecystostomy tube did
fall out on ___, without recurrence of his RUQ pain. He
presented to the ED tonight after noticing foul-smelling brown
fluid coming from his umbilicus. He has not been having pain or
obstructive symptoms, and has no history of abdominal surgery.
He denies fever, chills, nausea, vomiting, diarrhea, or
constipation.
Past Medical History:
Atrial fibrillation
Chronic Kidney Disease
Morbid obesity
Sleep apnea
Nephrolithiasis
s/p extended hospitalization for pneumonia
s/p removal of right arm benign tumor one year ago
Diabetes Mellitus Type 2
Hypothyroidism
Diastolic CHF
Hypertension
Hyperlipidemia
s/p lithotripsy
Ulcer -- many years ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: T 99.1, HR 97, BP 126/79, RR 24, O2 96ra
Gen: a&o x3, nad, morbidly obese
CV: rrr, no murmur
Resp: decreased at bilateral bases
Abd: morbidly obese, mild erythema of lower pannus, ostomy
appliance over umbilicus with stool in bag
Extr: chronic venous stasis changes, warm
DRE: unable to perform due to patient habitus
.
On discharge:
Vitals: T 98.1, HR 91, BP 106/59, RR 2, O2 97% ra
Gen: a&o x3, nad, morbidly obese
CV: rrr, no murmur
Resp: decreased at bilateral bases
Abd: morbidly obese, mild erythema of lower pannus improved from
prior assessment, ostomy appliance over umbilicus with formed
light brown stool in bag, abdomen nontender, no rebound/guarding
Extr: chronic venous stasis changes, warm
Pertinent Results:
___ Ultrasound of abdomen:
No drainable fluid collections identified
___ 03:30AM WBC-8.1 RBC-3.21* HGB-8.7* HCT-26.7* MCV-83
MCH-27.1 MCHC-32.5 RDW-16.5*
___ 03:30AM NEUTS-70.1* ___ MONOS-7.7 EOS-2.6
BASOS-0.4
___ 03:30AM PLT COUNT-322
___ 03:30AM ___ PTT-33.4 ___
___ 03:30AM GLUCOSE-121* UREA N-22* CREAT-1.0 SODIUM-136
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
___ 03:30AM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.6
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 06:45 6.2 3.26* 8.9* 27.5* 84 27.1 32.2 16.5* 320
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
___ 03:30 70.1* 19.1 7.7 2.6 0.4
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 07:35 23.0*1 2.2*
Medications on Admission:
tylenol prn, milk of mag prn, ___ prn, dulcolax prn, lasix
60", KCl 40", toprol 100', folic acid, synthroid ___, zocor
20', omeprazole 20', multivitamin, advair 250-50", augmentin
500-125" through ___, guaifenesin 100 prn, coumadin
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. insulin regular human 100 unit/mL Solution Sig: One (1) inj
Injection ASDIR (AS DIRECTED): per attached sliding scale.
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Start ___. Adjust for goal INR ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. colocutaneous fistula
2. cellulitis
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: Colocutaneous fistula through an umbilical hernia with possible
associated abscess. Assess for drainable collection.
COMPARISON: Reference CT available from ___.
TECHNIQUE: Ultrasonography of the umbilical region.
FINDINGS: Mixed echogenic material is seen within the paraumbilical region,
subjacent to a stoma bag filled with colonic fluid and stool. No drainable
fluid collections are seen. An area of nonvascular echogenic material may
represent phlegmon; however, this is difficult to distinguish from neighboring
tissues, which includes mental fat within a known paraumbilical hernia, better
seen on the reference CT examination.
IMPRESSION: No drainable collection seen. Mixed echogenic material subjacent
to the stoma bag may represent phlegmonous material; however, it is difficult
to distinguish this from neighboring omental fat from known paraumbilical
hernia. Infection cannot be excluded by US. This area is better visualized on
the reference CT examination from ___.
Radiology Report
LIMITED ABDOMINAL ULTRASOUND
CLINICAL INDICATION: Erythema and query fluctuance on left pannus, evaluate
for fluid collections.
Scanning was performed over the area of skin erythema in the left lower
abdomen pannus. No fluid collections could be identified in any portion of
this region.
CONCLUSION: No drainable fluid collections identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SURGICAL EVAL
Diagnosed with INTESTINAL FISTULA
temperature: 99.1
heartrate: 97.0
resprate: 24.0
o2sat: 96.0
sbp: 126.0
dbp: 79.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ was admitted on ___ under the Acute Care Surgery
Service for management of his colocutaneous fistula. Given his
extensive past medical history, he was deemed not a surgical
candidate for repair of the fistula. The wound/ostomy nurse was
consulted who applied an appropriate pouching appliance to the
fistula. Errythema was noted near the site of the fistula, and
an ultrasound was obtained to rule out a drainable fluid
collection, which was negative. He was initially started on
empiric antibiotic treatment with
vancomycin/ciprofloxacin/flagyl on admission, however, after the
negative ultrasound, the errythema was attributed to cellulitis
and his antibiotics were changed to keflex for a total course of
2 weeks. His coumadin was held on admission given the initial
consideration of surgery as well as its possible interaction
with ciprofloxacin. The patient's INR remained therapeutic
during his hospitalization between 2.3 and 2.4. At discharge,
plan to restart coumadin at prior dose on ___.
.
His vital signs were monitored throughout his hospitalization
and he remained afebrile and hemodynamicaly stable. His home
cpap therapy was continued. He wasm encouraged to mobilize out
of bed as tolerated. He was initially kept NPO and given IV
fluids, but was restarted on a regular diet on ___, which he
tolerated without abdominal symptoms. His intake and output were
monitored. His blood glucose levels were monitored QID and
covered with an insulin sliding scale as needed. His home
medications were continued while in the hospital, with the
exception of the coumadin as noted above.
.
At discharge he is feeling well, afebrile and hemodynamically
stable, tolerating a regular diet and is at his baseline
functional status. His cellulitis is improving on exam and his
fistula is well contained in a colostomy pouch. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck/Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w HTN s/p TEVAR & L renal artery stent ___ for type B
aortic dissection, discharged 2 days prior to presentation,
returns w focal neck pain. Pt has focal, non-radiating, midline
lower neck pain that began 2
days ago on the morning of discharge. Was felt to be
musculoskeletal at that time due to the presence of tenderness
and improvement with tylenol and heat packs. Pt states that
after he went home it persisted. Last night it increased in
severity and kept him up most of the night. Early this AM it
became so
unbearable that he could not move his neck so he went to ___
___. Since receiving IV pain meds, pt's pain has improved. On
arrival to ___ pt has full range of motion of his neck and
___ pain. He is admitted for further evaluation given resent
TEVAR.
Past Medical History:
PMH: type B aortic dissection diagnosed ___, HTN
PSH: back surgery x2, L wrist surgery
Physical Exam:
Alert and oriented x 3. His neurological exam normal, upper back
is now ony slightly tender to palpation.
VS:BP 118/71 HR 70 RR 18
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: all palp.
Feet warm, well perfused. No open areas.
Pertinent Results:
___ 05:01AM BLOOD WBC-12.2* RBC-4.37* Hgb-12.8* Hct-37.9*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.0 RDWSD-41.2 Plt ___
___ 06:55AM BLOOD Glucose-123* UreaN-16 Creat-1.3* Na-136
K-4.2 Cl-100 HCO3-24 AnGap-16
___ 06:55AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
CT cervical spine
1. No evidence of epidural collection.
2. Multilevel degenerative changes most pronounced at C5-C6
and C6-C7 where there is cord remodeling without abnormal cord
signal.
Medications on Admission:
-Amlodipine 10 mg daily
-Diltiazem 90 mg QID
-Hydralazine 100 mg Q6H
-Lisinopril 40 mg daily
-Carvedilol 25 mg BID
-Chlorthalidone 50 mg daily
-Spironolactone 50 mg daily
-Aspirin 81 mg daily
-Acetaminophen ___ mg Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Chlorthalidone 50 mg PO DAILY
6. Cyclobenzaprine 10 mg PO QID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
7. Diltiazem 90 mg PO QID
8. HydrALAzine 100 mg PO Q6H
9. Lisinopril 40 mg PO DAILY
10. Ibuprofen 600 mg PO Q8H:PRN pain
11. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Back/Neck Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: History: ___ with neck pain with recent dissection // eval for
dissection
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest,
abdomen and pelvis after administration of 100 cc of Omnipaque IV contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 1798 mGy-cm
COMPARISON: CTA torso ___
FINDINGS:
CTA TORSO:
Patient is status post type B aortic dissection repair with endovascular graft
extending from just proximal to the left subclavian artery to the distal
thoracic aorta. The left subclavian artery is excluded and not opacified
proximally but reconstitutes approximately 3 cm distal with the remainder of
the subclavian artery appearing opacified.
Beyond the stent the dissection flap remains visible with grossly stable size
of the false and true lumens. The celiac trunk, right and left renal arteries
originating from the true lumen and are patent. There has been interval
placement of a left proximal renal artery stent which appears patent (2:161).
The patent ___ from the true lumen. The dissection flap ends
approximately 8 cm from the aortic bifurcation.
Tiny amount of thrombus adherent to the wall of the right jugular and
brachiocephalic vein is noted not extending to the SVC (02:39).
CT CHEST WITH CONTRAST:
Thyroid is unremarkable. No lymphadenopathy. Scattered mediastinal lymph
nodes are similar to prior not pathologically enlarged by CT size criteria.
Heart size is normal without pericardial effusion. The main pulmonary
arteries are enlarged up to 4.3 cm as before. There is atherosclerotic
calcification of the coronary arteries most notably the LAD.
The tracheobronchial tree is patent to the subsegmental level. There is no
bronchial wall thickening. Lungs are clear without pleural effusion or
pneumothorax. There is no worrisome pulmonary nodule or opacity.
CT ABDOMEN WITH CONTRAST:
The liver enhances normally without focal lesions. The gallbladder, spleen
and pancreas are unremarkable. 1.2 cm hypodense nodule in the right adrenal
gland is incompletely characterize but is statistically most likely a benign
adrenal adenoma, unchanged since the prior study.
The stomach, small and large bowel are normal in caliber without obstruction.
There is no mesenteric retroperitoneal lymphadenopathy. There is no free air
or free fluid. There is a small fat containing paraumbilical hernia.
CT PELVIS WITH CONTRAST:
Small fat containing bilateral inguinal hernias. The urinary bladder, seminal
vesicles and prostate are unremarkable. There is no pelvic wall or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No worrisome blastic or lytic lesions.
IMPRESSION:
1. Expected postoperative appearance following repair of type B aortic
dissection.
2. The proximal neck vessels appear normal without evidence of dissection.
The excluded left subclavian artery is occluded proximally but reconstitutes
after approximately 3 cm.
3. The main arterial structures of the abdomen and pelvis are patent.
Notably, the left renal stent is patent and both kidneys enhance
symmetrically.
4. Tiny amount of thrombus adherent to the wall of the right brachiocephalic
and jugular veins is noted (02:39) but does not extend to the SVC possibly
secondary to previous central venous catheter.
5. Stable enlargement of the main pulmonary artery suggesting component of
pulmonary hypertension.
6. 1.2 cm hypodense nodule in the right adrenal gland is incompletely
characterized but is statistically most likely an adrenal adenoma. Attention
can be paid on follow up imaging.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ w HTN s/p TEVAR L renal artery stent ___ for type B
aortic dissection, discharged 2 days ago, returns w focal neck pain. // focal
tenderness focal tenderness
TECHNIQUE: Patient was unable to tolerate a full examination examination.
Only sagittal images of the cervical spine without contrast could be obtained
COMPARISON: None
FINDINGS:
Limited exam as patient could not tolerate the full exam. Only sagittal
sequences could be obtained.
Alignment is normal. Vertebral body marrow signal is mildly heterogeneous
likely reflecting degenerative change. There is mild loss of normal
intervertebral disc signal. There is loss of normal intervertebral disc
height at C6-C7. The spinal cord appears normal in caliber and configuration.
There is a broad-based disc protrusion at C3-C4 with resulting mild spinal
canal narrowing and broad-based disc protrusions at C5-C6 and C6-C7 with
resulting moderate spinal canal narrowing. There is no abnormal cord signal
detected but evaluation on inversion recovery images is limited due to
artifacts. Increased signal in the interspinous region in the C7-T1 level
appears artifactual. Mild increased signal between the spinous processes of
C1 and C2 on inversion recovery images are nonspecific and may indicate mild
ligamentous injury without disruption. .
IMPRESSION:
Limited examination. Multilevel degenerative changes most pronounced at C5-C6
and C6-C7. No abnormal cord signal detected. Increased signal between the
spinous processes of C1 and C2 on inversion recovery images is nonspecific and
may indicate mild ligamentous injury without disruption. Given the limited
nature of examination, this could not be fully evaluated.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST
INDICATION: ___ w HTN s/p TEVAR L renal artery stent ___ for type B
aortic dissection, discharged 2 days ago, returns w focal neck pain. //
Please evaluate for focal tenderness, needs gadolinium
TECHNIQUE: Routine MRI of the cervical spine using sagittal and axial T1, T2
and STIR images. Postcontrast imaging was performed.
COMPARISON: Prior limited MRI of the cervical spine dated ___.
FINDINGS:
Examination limited by artifact from aortic stent as well as motion.
On the sagittal images, there is no malalignment or loss of vertebral body
height. No suspect marrow lesions are seen. There is mild diffuse loss of
normal intervertebral disc signal and loss of normal intervertebral disc
height at C6-C7. The craniovertebral junction is unremarkable. The cord is
normal in signal intensity and morphology.
At C1-C2, there is no significant disc herniation or spinal canal stenosis.
There is right greater than left uncovertebral facet joint arthropathy
resulting in mild right neural foraminal narrowing.
At C3-C4, there is no significant disc herniation or spinal canal stenosis.
There is right greater than left uncovertebral facet joint arthropathy
resulting in moderate to severe right neural foraminal narrowing and mild left
neural foraminal narrowing.
At C4-C5, there is no disc herniation or spinal canal stenosis. There is
bilateral uncovertebral facet joint arthropathy resulting in moderate left and
mild right neural foraminal narrowing.
At C5-C6, there is a left paracentral/foraminal disc protrusion which is
moderately narrowing the spinal canal and remodeling the cord without
resulting in abnormal cord signal. There is bilateral uncovertebral facet
joint arthropathy resulting in mild right and moderate to severe left neural
foraminal narrowing.
At C6-C7, there is a broad-based disc protrusion moderately narrowing the
spinal canal and flattening the ventral aspect of the cord. There is
bilateral uncovertebral facet joint arthropathy resulting in moderate to
severe bilateral neural foraminal narrowing.
At C7-T1, there is no significant disc herniation, spinal canal stenosis or
neural foraminal narrowing.
There is no abnormal enhancement on post-contrast images.
The visualized soft tissues of the neck are unremarkable.
IMPRESSION:
1. No evidence of epidural collection.
2. Multilevel degenerative changes as detailed above most pronounced at C5-C6
and C6-C7 where there is cord remodeling without abnormal cord signal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with CERVICALGIA, POSTSURGICAL STATES NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | Mr. ___ was admitted to the hospital with severe upper
back/neck pain. Given his recent TEVAR he was admitted to the
hospital for full evaluation. THe pain team was consulted who
felt the pain was musculoskeletal and recommended muscle
relaxers and pain medications. The neurology team also
evaluated and did a MRI of the cervical spine which was
basically unremarkable. The pain improved with time and
medication. We have arranged for follow up with the PCP ___ 2
days to discuss ___ or other therapies for the discomfort. A
prescription for a muscle relaxer to take if needed was also
given.
During the hopitalization, BP was in excellent control,
130-110/80s. All BP medications were continued in the hospital.
He will follow up with his PCP further titration. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / lisinopril / Pravachol / Indocin / Zocor
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of CAD s/p attempted PCI of CTO of RCA
___ with plan for recanalization ___ who presented ___ with
CP this evening.
The patient reports central chest pressure last evening at 7pm
that occurred when he was watching TV. It was ___ non-radiating
sharp pain. It lasted 45 minutes; resolved 30 minutes after
taking nitroglycerin x2 by EMS. He was also given a full dose
aspirin. He denies nausea, vomiting, diaphoresis, ripping or
tearing pain. Prior episodes of chest pain occurred with
exertion.
He was brought to ___ troponin x1 was <0.015. EKG was unchanged
without any signs of ischemia. He was given 1 inch of
nitropaste.
Reports that the chest pain that started overnight was different
than previous episodes. This pain was described as chest pain
that was substernal and came on with rest. Previous episodes
were associated with chest pressure. Yesterday's chest pain
resolved 40 minute after taking sublingual nitro.
Other labs were unremarkable. He was then transferred to ___
for further care.
In the ED initial vitals were: 98.0 70 162/66 16 95% RA
- Labs in the ED unremarkable. No cardiac enzymes were drawn.
- EKG: NSR, nl axis, early R wave progression, LVH, STD/E/I
- Patient was given: nothing
On the floor the patient denies chest pain. He is feeling well.
Past Medical History:
- CAD w/attempted RCA with attempted PCI of CTO in ___
- Paroxysmal atrial fibrillation
- Hypertension
- Hyperlipidemia
- Peripheral vascular disease s/p bilateral iliac and femoral
artery stents
- Gout
- BPH
- HLD
Social History:
___
Family History:
Mother with angina in her ___, a paternal uncle who underwent
coronary bypass at age ___, and a paternal grandmother with a CVA
in her ___. There is no family history of sudden cardiac death
or arrhythmia.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
=====================================
VS: 97.8 157/52 58 16 95% RA wt 68.8kg
GENERAL: Well appearing gentleman
HEENT: Drooping of right eyelid. PERRL. MMM
NECK: Supple, no JVD
CARDIAC: Bradycardic, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: +1 pitting edema b/l
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PHYSICAL EXAM ON DISCHARGE
======================================
T= 97.8 BP= 140/54 HR= 57 RR=16 O2 sat= 95% RA
Wt: 68.8 kg
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No elevated JVP
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. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: + 1 pitting edema up to mid shin bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+
Left: Radial 2+
Pertinent Results:
LABS ON ADMISSION
===================================
___ 06:45AM GLUCOSE-89 UREA N-26* CREAT-1.1 SODIUM-142
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14
___ 06:45AM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.2
___ 06:45AM WBC-6.7 RBC-3.32* HGB-11.4* HCT-33.8*
MCV-102* MCH-34.3* MCHC-33.7 RDW-12.3 RDWSD-45.9
___ 02:25AM NEUTS-73.0* LYMPHS-16.4* MONOS-7.7 EOS-2.1
BASOS-0.5 IM ___ AbsNeut-4.54 AbsLymp-1.02* AbsMono-0.48
AbsEos-0.13 AbsBaso-0.03
___ 03:37AM ___ PTT-25.1 ___
___ 01:25PM CK-MB-5 cTropnT-<0.01
___ 01:25PM BLOOD CK-MB-5 cTropnT-<0.01
LABS ON DISHCARGE
===================================
___ 06:45AM BLOOD WBC-6.7 RBC-3.32* Hgb-11.4* Hct-33.8*
MCV-102* MCH-34.3* MCHC-33.7 RDW-12.3 RDWSD-45.9 Plt ___
___ 06:45AM PLT COUNT-127*
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-142
K-4.5 Cl-108 HCO3-25 AnGap-14
___ 06:45AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.2
___ 06:45AM CK(CPK)-237
___ 06:45AM ___ PTT-29.2 ___
___ 06:45AM BLOOD CK-MB-5 cTropnT-<0.01
EKG ___: Sinus bradycardia. Vent rate: 56 bpm. PR
interval: 172 ms. ___: 82 ms QTc: 425. No signs of ST segment
elevation or depression. No TWI.
ADMISSION EKG ___: Sinus rate 55, normal axis and
intervals, LVH, no TWI or ST changes
STRESS TEST ___: He exercised for 9 mins and achieved 10.1
METS with evidence of inducible ischemia with the development of
2mm downsloping ST depressions in V4-6 during the recovery
phase.
CARDIAC CATH ___: Single vessel CAD of the RCA with
attempted PCI of CTO of RCA, unable to pass wire, plan to return
in late ___ for planned CTO recanalization.
CXR ___: No acute cardiopulmonary processes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO QPM
2. Multivitamins 1 TAB PO DAILY
3. Fish Oil (Omega 3) 2400 mg PO BID
4. Niacin SR 1000 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Amlodipine 5 mg PO DAILY
11. Doxazosin 2 mg PO HS
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Doxazosin 2 mg PO HS
5. Fish Oil (Omega 3) 2400 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pravastatin 20 mg PO QPM
10. Niacin SR 1000 mg PO DAILY
11. Aspirin 325 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest Pain
Secondary:
CAD s/p attempted PCI of RCA ___ with plan re-canalization on
___
Paroxysmal Atrial Fibrillation
Hypertension
Hyperlipidemia
PVD s/p ___ iliac and femoral stents.
Gout
BPH
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The cardiomediastinal silhouette and pulmonary vasculature are unremarkable.
The lungs are clear aside from volume loss in the right lower lobe. There is
no pleural effusion or pneumothorax.
IMPRESSION:
No acute abnormality.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Cardiomyopathy, unspecified
temperature: 98.0
heartrate: 70.0
resprate: 16.0
o2sat: 95.0
sbp: 162.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with history of CAD s/p attempted PCI of CTO of RCA
___ with plan for re-canalization ___ who presented to the
ED with CP concerning for ACS.
# Coronary artery disease:
Patient presented with chest pain at rest and given underlying
CAD, the pain was concerning for unstable angina. He had known
total occlusion of RCA s/p failed PCI in ___ with planned
recanalization procedure on ___. Initial chest pain was
sub-sternal and resolved about 40 minutes after taking
sublingual nitroglycerin.
Throughout hospital stay EKG's were normal and troponin x3 were
negative. He did not have any chest pain throughout this
hospital course. Dr. ___ was informed of the patient's
condition and hospitalization. In discussion with him and
cardiology team, it was determined that the patient could return
for planned RCA recanalization procedure on ___. Patient
was continued on his home dose of 325 mg Aspirin, Plavix,
metoprolol, and Pravastatin throughout his hospital stay.
# Paroxysmal Atrial fibrillation (___: 3):
Patient was in normal sinus rhythm throughout hospitalization.
Patient has never been on anticoagulation. He was previously
taking Flecainide, but this was recently stopped given abnormal
stress test and he was started on Metoprolol. Further discussion
regarding anticoagulation of atrial fibrillation at time of
follow up should be considered. He was continued on home dose of
Metoprolol and aspirin.
# PVD s/p stenting:
Patient was continued on high dose aspirin and Plavix. Aspirin
325 mg continued as patient on this previously per
recommendation for PVD.
# HTN: Patient was continued on home losartan and amlodipine. He
remained normotensive throughout hospital stay.
# HLD: Patient was continued on pravastatin, fish oil.
# BPH: Patient was continued on home doxazosin
# Gout: Patient was continued on home dose of allopurinol |
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, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man w/ PMH anemia, DVT/PE on
Coumadin, glaucoma, CKD, NSTEMI ___, depression,
thrombocytopenia who presented with confusion and left shoulder
pain s/p fall.
Per ED note: Patient has 3 days of progressive weakness and
altered mental status, followed by unwitnessed fall last night.
Patient's son heard him fall, immediately entered room, denies
that he had loss of consciousness. Approximately 1 week ago he
began having cough with yellow/brown sputum production, started
by PCP on azithromycin following CXR without focal pneumonia.
Interval improvement in cough. No hemoptysis.
Exam noted right pupil larger than left s/p cataract surgery.
AAOX3, with ___ strength in upper and lower extremities. DTRs
intact. Gait testing was deferred.
Per PCP note the day prior, the patient started having delirium
___. He developed a "cold" ___ days ago and has had a
cough of thick yellow-green sputum. Some dyspnea on exertion but
no SOB at rest. Had no fevers but did not have chills and
sweats.
Had been exposed to sick contacts with flu and URIs. On the ___
he started hearing people and seeing people that weren't there.
At that time a CXR was done which was felt to show increased
interstitial markings and the PCP diagnosed the patient with
bronchitis and started him on Azithromycin.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Anemia, B12 deficiency
BPH
Bladder cancer hx
Carpal tunnel syndrome
Cataract
Chronic low back pain
DVT/PE on Coumadin
Glaucoma
HLD
OA
CKD
Vocal cord polyps
Eczematous dermatitis
NSTEMI ___
Depression
Thrombocytopenia
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission Physical:
====================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge physical
====================
General: Well appearing, comfortable, NAD, hoarse voice
HEENT: Anicteric, eyes conjugate, MM dry, no JVD, right pupil
dilated from prior surgery
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields with some rhonchi at bases otherwise
clear
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, oriented to
place and year as ___
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
================
___ 12:32PM BLOOD WBC-6.7 RBC-3.20* Hgb-10.2* Hct-31.4*
MCV-98 MCH-31.9 MCHC-32.5 RDW-14.2 RDWSD-50.9* Plt ___
___ 12:32PM BLOOD Neuts-52.8 ___ Monos-10.2 Eos-3.3
Baso-0.8 Im ___ AbsNeut-3.52 AbsLymp-2.16 AbsMono-0.68
AbsEos-0.22 AbsBaso-0.05
___ 09:17AM BLOOD ___ PTT-44.4* ___
___ 12:32PM BLOOD UreaN-33* Creat-2.0* Na-142 K-5.0 Cl-107
HCO3-25 AnGap-10
___ 09:17AM BLOOD ALT-28 AST-37 AlkPhos-133* TotBili-0.6
___ 12:32PM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1
Discharge
Creatinine 2.1
Hgb 9.5, platelet 116
INR 4.2-->3.9-->4.1-->2.5
CXR ___
IMPRESSION:
1. No evidence of pneumonia.
2. Unchanged diffuse interstitial disease, better described on
prior CT.
XR hip ___
IMPRESSION:
No fracture or dislocation.
CT c-spine ___
IMPRESSION:
Study is moderately limited due to motion.
No evidence of traumatic malalignment. No acute fracture.
CT head ___
IMPRESSION:
The study is severely limited due to patient motion. Within the
limitations,
there is no evidence of large intracranial hemorrhage, no
evidence of midline
shift. There is no evidence of acute large territory infarction,
however
detection is significantly limited due to motion.
EKG
NSR 62, QT 487
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Terazosin 2 mg PO QHS
3. Acetaminophen 1000 mg PO Q8H
4. QUEtiapine Fumarate 25 mg PO QHS
5. ammonium lactate ___ % topical BID:PRN
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Docusate Sodium 100 mg PO BID
8. Warfarin 7.5 mg PO DAILY16
9. Atorvastatin 40 mg PO QPM
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. melatonin 6 mg oral QHS
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Aspirin 81 mg PO DAILY
15. FLUoxetine 40 mg PO DAILY
16. Cyanocobalamin 1000 mcg IM/SC MONTHLY
17. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. ammonium lactate ___ % topical BID:PRN
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Cyanocobalamin 1000 mcg IM/SC MONTHLY
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. FLUoxetine 40 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. melatonin 6 mg oral QHS
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. QUEtiapine Fumarate 25 mg PO QHS
14. Terazosin 2 mg PO QHS
15. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
16. Vitamin E 400 UNIT PO DAILY
17. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
metabolic encephalopathy
fall
weakness
supratherapeutic INR
Discharge Condition:
fair
Ambulatory with 1 person assist
Followup Instructions:
___
Radiology Report
INDICATION: ___ with AMS// eval for pneumonia
TECHNIQUE: Single supine view of the chest.
COMPARISON: Chest x-rays from ___ and ___.
FINDINGS:
The lungs are clear. There is no consolidation. No obvious effusion or
pneumothorax based on a supine film. The cardiomediastinal silhouette is
stable. No displaced fractures identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ s/p fall with weakness and right hip tenderness.// Fracture?
Dislocation
TECHNIQUE: AP view of the pelvis. AP and frogleg lateral views of the right
hip.
COMPARISON: Correlation made to CT abdomen pelvis from ___.
FINDINGS:
There is no fracture. No focal osseous abnormality. Mild degenerative
changes noted at the femoroacetabular joints bilaterally. There is no
dislocation. Surgical material projects over the right pelvis as well as an
IVC filter partially visualized over the lower abdomen.
IMPRESSION:
No fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with closed head inj// eval for bleed/fx
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 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.6 cm; CTDIvol = 45.7 mGy (Head) DLP =
301.0 mGy-cm.
3) Sequenced Acquisition 8.0 s, 16.8 cm; CTDIvol = 74.4 mGy (Head) DLP =
1,248.7 mGy-cm.
Total DLP (Head) = 1,650 mGy-cm.
COMPARISON: ___ CT head
FINDINGS:
The study is severely limited due to patient motion, despite repeat imaging.
Within the limitations, there is no evidence of large intracranial hemorrhage,
no evidence of midline shift. There is no evidence of acute large territory
infarction, however detection is significantly limited due to motion. There
is prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular white matter hypodensities are nonspecific, but likely reflect
sequelae 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:
The study is severely limited due to patient motion. Within the limitations,
there is no evidence of large intracranial hemorrhage, no evidence of midline
shift. There is no evidence of acute large territory infarction, however
detection is significantly limited due to motion.
RECOMMENDATION(S): If there is deterioration in exam or other concern, repeat
imaging may be obtained as clinically indicated.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:05 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with closed head inj// eval for bleed/fx
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 518.1
mGy-cm.
Total DLP (Body) = 518 mGy-cm.
COMPARISON: ___ CT cervical spine
FINDINGS:
Study is limited due to motion at the C3-C4 level and at C7.
There no malalignment. No fractures are identified. There is multilevel
scratch uncovertebral hypertrophy and facet osteophytes with resulting
multilevel mild-to-moderate neural foraminal stenosis, most significant at
C3-C4. There are posterior vertebral body osteophytes with resulting mild
spinal canal narrowing most significant at C3-C4 and C5-C6. There is no
prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
Study is moderately limited due to motion.
No evidence of traumatic malalignment. No acute fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, L Shoulder pain, s/p Fall
Diagnosed with Altered mental status, unspecified, Weakness, Abnormal coagulation profile, Long QT syndrome
temperature: 98.9
heartrate: 72.0
resprate: 18.0
o2sat: 96.0
sbp: 144.0
dbp: 75.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old man w/ PMH anemia, DVT/PE on Coumadin,
glaucoma, CKD, NSTEMI ___, depression, thrombocytopenia who
presented with delirium and left shoulder pain s/p fall.
#Toxic metabolic encephalopathy: Per family, several days of
hallucinations and weakness prior to admission consistent with
delirium. Felt to be most likely related to recent URI with poor
sleep due to cough, ultimately leading to delirium. Initially on
azithromycin for ? bronchitis which was stopped due to lack of
evidence of bacterial infection. Treated with cough suppressant
and bowel regimen as well as delirium precautions with
improvement in delirium.
#Fall/Weakness: Trauma eval in ED negative. Seen by ___ with plan
for rehab.
#Supratherapeutic INR
#H/o DVT/PE: On warfarin at home with INR elevated on admission,
possibly related to azithromycin. Warfarin was held until ___,
on which his home dose of 7.5mg is resumed given INR of 2.5 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Oxycodone
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
___ w/Necrotizing gallstone pancreatitis requiring multiple
hospitalizations (most recently dc ___. Pt presents with
fever to 101.4. She denies localizing symptoms, specifically
denies abdominal pain, nausea, vomiting, shortness of breath,
chest pain, open wounds.
In ED pt had CT scan, unchanged from prior. GI notified. Given
vanc/cipro/flagyl and zofran. Bolused 2L and blood cultures
drawn.
On arrival to floor pt reports that she currently has no pain or
nausea. +Cough for 3 days, spitting up clear sputum with
associated nausea. Also with left ear pain. No hearing loss. No
history of recurrent ear infections.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Hyperlipidemia
Necrotizing gallstone pancreatitis; hospitalization
___
Pleural effusion, d/t pancreatitis
Hyperglycemia, d/t pancreatitis
Pancreatic insufficiency, d/t pancreatitis
Anemia, chronic disease
Social History:
___
Family History:
Unknown. Pt adopted.
Physical Exam:
Vitals: T:100.1 BP:130/74 P:110 R:18 O2:96%ra
PAIN: 0
General: nad
HEENT: DBT in place with bridle, op clear, unable to visualize
posterior pharynx
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Physical exam on discharge:
Vitals: 98.7 BP: 126/75 P: 90 R: 18 O2: 98% RA
Pain: O
Laying in bed in NAD
HEENT: NGT in place with bridle, op clear, unable to visualize
posterior pharynx
Lungs: decreased air entry at left base
CV:RRR, no m/r/g
Abdomen: Soft, non tender, non distended bowel sounds present
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 09:45PM GLUCOSE-132* UREA N-14 CREAT-0.4 SODIUM-135
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-26 ANION GAP-18
___ 09:45PM ALT(SGPT)-59* AST(SGOT)-47* ALK PHOS-503* TOT
BILI-0.3
___ 09:45PM LIPASE-62*
___ 09:45PM ALBUMIN-3.4*
___ 09:45PM WBC-24.3*# RBC-3.57* HGB-9.7* HCT-31.2*
MCV-87 MCH-27.3 MCHC-31.2 RDW-14.2
___ 09:45PM NEUTS-81.7* LYMPHS-11.5* MONOS-5.5 EOS-0.6
BASOS-0.7
___ 09:45PM PLT COUNT-1099*
___ 12:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-MOD
___ 12:20AM URINE RBC-3* WBC-15* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:20AM URINE MUCOUS-OCC
Pleural fluid:
ATYPICAL.
Atypical cells - favor reactive mesothelial cells; inflammatory
cells
and histiocytes.
CT ABD/PEL ___ Wetread: Moderate-sized left pleural
effusion is relatively unchanged since ___.
Multiple multiloculated pseudocysts are decreased in size since
___. No ascites.
CXR ___ Preliminary Report IMPRESSION: A moderate-sized
left pleural effusion with underlying atelectasis has decreased
since ___. No focal opacity suggestive of pneumonia is
seen.
CT abd/chest ___
IMPRESSION:
1. Roughly 20 cm stretch of transverse colon beginning at the
hepatic flexure
with prominent wall thickening, edema and surrounding marked
inflammatory
change. This degree of findings with phlegmonous change with
decreased size
of an uncinate pancreatic pseudocyst is most suggestive of
partial cyst
rupture with leak of pancreatic enzyme contents across the
mesocolon causing
secondary inflammation. No frank abscess. Diverticulitis is
hard to exclude
but seems much likely as the etiology to describe the overall
findings.
2. Transgastric catheter continues to drain the pancreatic tail
pseudocyst,
which is decreased in size compared to prior examination; a
superior
subphrenic extension, including an air-fluid level, persists but
has also
decreased. An uncinate process pseudocyst is also decreased in
size; however,
the now largest pancreatic head pseudocyst has intervally
increased in size,
and it may exert focal mass effect on the adjacent traversing
duodenum.
3. Trace ascites likely secondary to inflammation.
4. Simple renal cyst.
CT chest ___
Left greater than right bibasilar consolidations are similar to
prior
examination and could represent atelectasis; however, their
pattern of
hypoenhancement particularly at the left base is worrisome for
pneumonia. A
small to moderate left sided simple density pleural effusion has
decreased in
volume compared to prior study.
CT abdomen: ___
IMPRESSION:
1. Increased organization of a phlegmon surrounding the proximal
tranverse
colon consistent with walled off fat necrosis. No discrete
drainable abscess
in this region. Known transverse colitis within this fat
necrosis is
unchanged. No free intraperitoneal air or pneumotosis.
2. Mild decrease in a subdiaphragmatic abcess. Drainage of this
abscess would
be difficult given its location and risk of infecting overlying
pleural
effusion.
3. Mild increase in a nonhemorragic left pleural effusion.
4. Mild decrease in size of the pancreatic head and uncinate
pseudocysts.
Increase in pancreatic body pseudocyst and stable pancreatic
tail pseudocyst
with a drainage catheter.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. FoLIC Acid 1 mg PO DAILY
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
4. Lorazepam 0.5 mg PO Q8H:PRN nausea/anxiety
5. Senna 1 TAB PO BID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Glargine 18 Units Breakfast
Discharge Medications:
1. Aztreonam ___ mg IV Q8H
Last day ___
RX *aztreonam in dextrose(iso-osm) [Azactam in dextrose
(iso-osm)] 2 gram/50 mL 2 gm IV Q8hrs Disp #*240 Vial Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
5. Glargine 12 Units Bedtime
6. Lorazepam 0.5 mg PO Q8H:PRN nausea/anxiety
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Senna 1 TAB PO BID
9. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Take until ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Q8hrs
Disp #*90 Tablet Refills:*0
11. Outpatient Lab Work
Please check weekly CBC, Chem 7, BUN/CR and AST/ALT and have
results faxed to ___
R.N.s at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Diverticulitis/Transverse Colitis
Pleural effusion
Secondary:
Pancreatitis with pseudocysts
Secondary diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever and recent pseudocyst drainage. Evaluation of pseudocyst
size.
TECHNIQUE: Multi detector CT scan through the abdomen and pelvis was
performed after the administration of 130 cc Omnipaque IV contrast. Coronal
and sagittal reformatted images were obtained.
DLP: 480.31 mGy-cm.
COMPARISON: CT abdomen and pelvis ___ at ___.
FINDINGS:
There is bibasilar, left greater than right atelectasis. A moderate-sized
left pleural effusion is relatively unchanged since ___.
The liver enhances homogeneously without focal lesions. The portal vein is
patent. There are multiple calcified gallstones within the gallbladder.
The previously seen multiloculated pancreatic pseudocyst in the body and tail
continues to decrease in size now measuring 4.1 x 5.4 cm (02:24) and
previously measuring 5. 6 x 7.2 cm. The cyst contains air and multiple
pigtail catheters are seen within the cyst communicating with the stomach. An
additional portion of the pseudocyst located superior to the spleen has also
has decreased in size, now measuring 1.1 x 5.4 cm (601B: 50) and previously
measuring 3 x 7.8 cm. A bilobed pseudocyst adjacent to the pancreatic head is
stable in size measuring 4.2 x 2.8 cm (02:31) and previously measured 4.3 x 3
cm. The smaller component of this pseudocyst measures 2.3 x 3 .8 cm (02:40)
and previously measured 2.8 x 3.9 cm. These two cysts do not contain
catheters. The remainder of the pancreas enhances homogeneously without focal
areas of necrosis.
The spleen appears normal. The the adrenal glands are unremarkable. A 2.6 cm
left renal cyst (02:31) is unchanged. The kidneys demonstrate symmetric
nephrograms and excretion of contrast. There is no hydronephrosis.
The stomach contains multiple pigtail catheters. An upper enteric tube
terminates in the small bowel. The small and large bowel are normal without
evidence of wall thickening or obstruction. The appendix appears normal.
The bladder, uterus and adnexa appear normal. There is no free fluid, free
air or lymphadenopathy. The aorta is normal in caliber.
Osseous structures: No concerning osteoblastic or osteolytic lesions.
IMPRESSION:
1. Moderate-sized left pleural effusion is relatively unchanged since
___.
2. Multiple multiloculated pseudocysts in the left upper quadrant with drains
in place are decreased in size since ___ however, a collection within
the head of the pancreas is not significantly changed and does not contain a
drainage catheter.
3. No free fluid or signs of pancreatitis or pancreatic necrosis.
Radiology Report
HISTORY: Patient with prolonged dobhoff tube due to pancreatitis now with
fever, left sided neck and ear pain, please eval for abscess, mastoiditis.
COMPARISON: None available.
TECHNIQUE: MDCT all of the neck was performed with 2.5 mm axial sections
obtained from the aorticopulmonary window through the orbital level, during
the dynamic administration of IV contrast. Reformatted coronal and sagittal
images were generated and reviewed.
CTDIvol: 111.70mGy.
DLP: 1317.10 mGy-cm
FINDINGS:
Visualized portions of the intracranial structures are unremarkable. The
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. A
nasal gastric tube is seen within the left nasal cavity.
Evaluation of the aerodigestive tract demonstrates no exophytic mucosal mass,
nor areas of focal mass-effect. Evaluation of the cervical lymph node chains
demonstrate no pathologic lymphadenopathy by imaging criteria. The thyroid
gland is normal. The salivary glands are unremarkable in appearance. The
neck vessels enhance bilaterally without significant stenosis. No abnormal
fluid collections or mass is identified in the neck.
Partially visualized lung apices demonstrate a large left-sided pleural
effusion with adjacent compressive atelectasis.
IMPRESSION:
1. No evidence of abnormal fluid collection or mass seen in the neck. The
mastoid air cells are clear.
2. Partially visualized large left-sided pleural effusion with compressive
atelectasis.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pleural effusion after
chest tube placement.
AP radiograph of the chest was compared to ___.
The left pigtail catheter is in place. There is a substantial interval
decrease in pleural effusion. Heart size and mediastinum are stable. Upper
lungs are clear. Right lung is unremarkable.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with left pleural effusion.
AP radiograph of the chest was reviewed in comparison to ___.
The Dobbhoff tube passes below the diaphragm with its tip not included in the
field of view. Left pigtail catheter is in place. There is interval decrease
in left pleural effusion. Still present right pleural effusion are most
likely small to moderate. There is no pneumothorax. No pulmonary edema
demonstrated.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after chest tube removal.
AP radiograph of the chest was reviewed in comparison to ___
obtained at 09:37 a.m.
The left pigtail catheter has been removed. There is no interval development
of pneumothorax and there is no interval increase in pleural effusion. Basal
consolidation and atelectasis are noted. The heart size and mediastinum are
stable. Lungs are essentially clear with only mild vascular congestion.
Radiology Report
HISTORY: Pancreatitis, rising white count with concern for abscess.
COMPARISON: CT abdomen and pelvis ___.
TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and
pelvis after the administration of IV and oral contrast. Additional images
through the abdomen were obtained prior to contrast. Chest images were
archived to a separate clip. Multiplanar reformatted images were generated in
the coronal and sagittal planes.
DLP: 1756.00 mGy-cm.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously without focal
lesion, intra- or extra-hepatic biliary ductal dilatation. The portal vein is
patent. Numerous gallstones are contained within an otherwise thin-walled
gallbladder. The spleen and adrenal glands are grossly unremarkable in
appearance. There is a simple density 2.6 cm left interpolar renal cyst. The
kidneys otherwise present symmetric nephrograms and excretion of contrast
without focal solid lesion, pelvicaliceal dilatation or perinephric
abnormality.
There remains mild peripancreatic fat stranding with numerous pseudocysts.
Transgastric drainage catheters remain in the collection adjacent to the
pancreatic tail with only a minimal amount of fluid with locules of gas,
appearing mildly improved compared to prior examination, at the site of
catheter placements. A air-fluid containing left subphrenic extension of the
collection persists but also appears somewhat decreased.
The largest remaining collection is within the pancreatic head and measures
5.3 x 3.7 cm (3:60), mildly increased in size compared to prior study where it
measured 4.2 x 2.9 cm. An additional cystic collection suggesting a
pseudocyst adjacent to the uncinate process measures 2.7 x 2.1 cm, decreased
in size compared to a prior study (3:70), where it measured 3.2 x 2.8 cm. The
remainder of the pancreatic parenchyma enhances homogeneously without evidence
of necrosis. The mid splenic vein is again probably occluded or at least with
markedly attenuated flow as it passes through a region of severe inflammatory
changees, also noting omental collateral flow pathways. The IMV is minimally
attenuated adjacent to the large pancreatic head pseudocyst, but appears
patent.
There is a roughly 20 cm stretch of transverse colon beginning at the hepatic
flexure demonstrating prominent wall thickening with mural edema and diffuse
surrounding area of marked expansile fat stranding measuring roughly 14.9 x
9.5 cm without distinct fluid collection. Fat stranding extends superiorly up
to a suspected pseudocyst that has decreased in size over the short interval.
There are a few colonic diverticula including in the region of affected mid
transverse colon. A small portion of an adjacent ileal loop is mildly
thickened, likely reactive. The distal large bowel is grossly unremarkable.
There is no evidence of bowel obstruction.
An upper enteric post-pyloric tube terminates in the proximal jejunum.
The abdominal aorta is normal in caliber with grossly patent celiac axis, SMA,
bilateral renal arteries and ___. There is no mesenteric or retroperitoneal
lymphadenopathy. There is a small fat-containing umbilical hernia.
CT PELVIS WITH CONTRAST: A small amount of fluid layering within the pelvis
likely is tracking from above. The uterus, adnexa, bladder and rectum are
grossly unremarkable. There is no inguinal or pelvic wall lymphadenopathy by
CT size criterion.
BONE WINDOWS: There are no suspicious focal blastic or lytic lesions.
IMPRESSION:
1. Roughly 20 cm stretch of transverse colon beginning at the hepatic flexure
with prominent wall thickening, edema and surrounding marked inflammatory
change. This degree of findings with phlegmonous change with decreased size
of an uncinate pancreatic pseudocyst is most suggestive of partial cyst
rupture with leak of pancreatic enzyme contents across the mesocolon causing
secondary inflammation. No frank abscess. Diverticulitis is hard to exclude
but seems much likely as the etiology to describe the overall findings.
2. Transgastric catheter continues to drain the pancreatic tail pseudocyst,
which is decreased in size compared to prior examination; a superior
subphrenic extension, including an air-fluid level, persists but has also
decreased. An uncinate process pseudocyst is also decreased in size; however,
the now largest pancreatic head pseudocyst has intervally increased in size,
and it may exert focal mass effect on the adjacent traversing duodenum.
3. Trace ascites likely secondary to inflammation.
4. Simple renal cyst.
Results were discussed over the telephone with Dr. ___ by Dr. ___
___ at 3:20 p.m. on ___, five minutes after discovery.
Radiology Report
HISTORY: Pancreatitis with rising leukocytosis and cough with suspicion for
abscess.
COMPARISON: Numerous CT abdomen and pelvis studies dating from ___ through ___.
TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and
pelvis after the administration of IV and oral contrast. Abdomen and pelvis
images were archived to a separate clip. Multiplanar reformatted images were
generated in the coronal and sagittal planes as well as axial maximum
intensity projection images.
DLP for the total of chest, abdomen and pelvis acquisition is recorded on the
separate abdomen and pelvis report.
FINDINGS:
CT CHEST WITH CONTRAST:
The thyroid gland is unremarkable. The trachea is midline, and the airways
are patent to the subsegmental level.
Heart size is normal without significant pericardial effusion. The thoracic
aortic arch and main pulmonary artery are normal in caliber. There is no
central pulmonary embolus. There are no pathologically enlarged
supraclavicular, axillary, hilar or mediastinal lymph nodes.
Bibasilar left greater than right basal consolidations are similar compared to
___ however, the pattern of relative ___ is concerning
for pneumonia. The small layering left-sided simple density pleural effusion
has improved compared to a prior study. Motion artifact limits evaluation for
a small nodularity. A 3 mm nodule in the lingula is unchanged compared to
prior examination (4:126). This nodule has no concerning features and does
not require further surveillance. No new nodule is identified. There is no
pneumothorax.
BONE WINDOWS: The thoracic cage is unremarkable without suspicious blastic or
lytic lesion.
IMPRESSION:
1. Left greater than right bibasilar consolidations are similar to prior
examination and could represent atelectasis; however, their pattern of
___ particularly at the left base is worrisome for pneumonia. A
small to moderate left sided simple density pleural effusion has decreased in
volume compared to prior study.
2. Abdomen and pelvis findings are included on a separate report.
Results were discussed over the telephone with Dr. ___ by Dr. ___
___ at 3:20 p.m. on ___, five minutes after discovery.
Radiology Report
CHEST RADIOGRAPH
HISTORY: PICC line placement.
COMPARISONS: ___ radiograph and CT from ___.
TECHNIQUE: Chest, semi-upright AP portable.
FINDINGS: A new left-sided PICC line terminates in the mid superior vena
cava. A feeding tube courses into the stomach. There are at least three
double pigtail catheters in the left upper quadrant. A moderate left-sided
pleural effusion is probably unchanged in size with patchy associated opacity
suggesting minor atelectasis. There is no pneumothorax.
IMPRESSION: New PICC line terminating in the superior vena cava.
Radiology Report
HISTORY: Pancreatitis and pseudocyst presents with fever found to have
transverse colitis. Assess for developing abscess.
COMPARISON: CT abdomen/ pelvis ___. ___
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the pubic symphysis after administration of IV and oral contrast.
Multiplanar reformatted images in coronal and sagittal axis were generated
FINDINGS:
Heart and lungs: Limited assessment of the lung bases demonstrate no focal
opacity. Again seen is a large nonhemorrhagic left pleural effusion which has
mildly increased in size. Mild decrease in the subdiaphragmatic fluid
collection with a peripheral enhancing irregular rim and locules of air which
is consistent for an abscess. No pericardial effusion.
Liver: The liver is homogeneous without focal opacity. No portal venous air
or pneumobilia. No intrahepatic biliary duct dilatation. The gallbladder is
thin walled with multiple calcified gallstones which are unchanged from prior
study. The main portal vein and its major branches are patent.
Pancreas: Again seen are multiple pseudocysts. There has been interval
decrease in the pancreatic head pseudocyst which now measures 4.1 x 3.4 cm
(previously 5.3 x 3.7 cm)(4:33) as well as a 2.5 x 2.1 cm (previously 2.7 x
2.1 cm) (4: 42) pseudocyst in the uncinate. The pseudocyst in the pancreatic
body has slightly increased in size now measuring 1.8 x 1.0 cm (previously 1.3
x 0.5cm. Again seen is a drainage ___ is seen is tail pseudocyst which is
unchanged in size and measures 2.7 x 1.2 cm (previously 2.9 x 1.2 cm)(4:27).
No new focal solid or cystic lesions. No peripancreatic fat stranding.
Adrenal gland: The adrenal glands are unremarkable.
Spleen: The spleen is homogeneous and normal in size. The subdiaphragmatic
abscess is superior and distinct from the spleen.
Kidney: Again seen is a 2.7 x 2.3 cm (previously 2.8 x 2.3 when measured in a
similar fashion) lobulated cyst in the left mid kidney. No additional focal
cystic or solid lesions. Symmetric nephrograms and excretion of contrast.
The proximal ureters are normal in caliber. No pelvocaliceal dilatation or
perinephric stranding.
GI: A feeding tube courses through the esophagus with the tip in the mid
jejunum. The stomach is non distended. The duodenum, small bowel are normal
in caliber without focal wall thickening or obstruction. Few diverticula
without diverticulitis are noted in the sigmoid colon. The rectum, descending
and distal transverse colon are normal in caliber without focal wall
thickening, fat stranding, or mass lesion. Again seen is thickening of the
proximal transverse colon bowel wall which is unchanged from prior study with
preserved passage of contrast distally. Previously identified inflammation
surrounding the proximal transverse colon is now more organized with enhancing
internal vessels suggestive of walled off fat necrosis. No pneumatosis.
Vascular: The descending aorta and its major branches are normal in caliber
and patent. No aneurysmal dilatation of the descending aorta. The IVC,
hepatic veins, splenic vein, SMV and renal veins are patent.
Retroperitoneum and abdomen: No retroperitoneal or mesenteric lymph node
enlargement by CT criteria. No ascites, free intraperitoneal air or abdominal
wall hernia.
Osseous structures: Mild degenerative changes of the lumbar spine is noted.
No focal lytic or blastic lesions suspicious for malignancy.
CT pelvis: Air is seen in the vagina. The bladder is decompressed and the
terminal ureters are not visualized. No inguinal or pelvic wall lymph node
enlargement. No pelvic free fluid.
IMPRESSION:
1. Increased organization of a phlegmon surrounding the proximal tranverse
colon consistent with walled off fat necrosis. No discrete drainable abscess
in this region. Known transverse colitis within this fat necrosis is
unchanged. No free intraperitoneal air or pneumotosis.
2. Mild decrease in a subdiaphragmatic abcess. Drainage of this abscess would
be difficult given its location and risk of infecting overlying pleural
effusion.
3. Mild increase in a nonhemorragic left pleural effusion.
4. Mild decrease in size of the pancreatic head and uncinate pseudocysts.
Increase in pancreatic body pseudocyst and stable pancreatic tail pseudocyst
with a drainage catheter.
Results were conveyed via telephone by Dr. ___ to ___
at 16:00 on ___ within 10 minutes of observation of findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, HYPERLIPIDEMIA NEC/NOS
temperature: 99.4
heartrate: 126.0
resprate: 18.0
o2sat: 94.0
sbp: 128.0
dbp: 83.0
level of pain: 7
level of acuity: 3.0 | ___ w/Necrotizing gallstone pancreatitis requiring multiple
hospitalizations presents with fever, found to have transverse
colitis, managed conservatively with antibiotics.
#Transverse colitis, diverticulitis
The patient presented with fevers and was initially started on
cipro and flagyl, suspecting a GI source. She continued to
have fever and rising WBC. A CT neck to eval for mastoiditis or
neck abscess was obtained as the pt had a dobhoff and mild neck
pain which did not show signs of infection. Antibiotics were
broadened to include vanc and aztreonam. Repeat CT abd then
revealed transcolonic inflammation and colitis/diverticulitis
with possible mircoperforation that may have been due to
longstanding inflammation from pancreatitis. The patient was
followed by infectious diseases who recommended continuing
Cipro/flagyl/aztreonam. The patient improved clinically but
platelets continued to rise despite dropping WBC count. The
patient therefore underwent repeat abdominal CT scan on ___
which showed an area of fat necrosis and a sub diaphragmatic
abscess. Radiology felt there was no approach to safely drain
this abscess via ___ guided drainage. The case was also discussed
with surgery who have been following the patient who felt
operative intervention was not indicated. The decision was made
with infectious disease to discharge the patient on a prolonged
course of PO flagy and IV aztreonam. She will follow up in the
___ clinic at which point a decision will be made regarding
repeat imaging and duration of antibiotic therapy.
#Pleural Effusion:
The patient has had a recurrent left pleural effusion. She
underwent thoracentesis to evaluate for infection. Studies were
not consistent with infection but cytology did show atypical
cells - favor reactive mesothelial cells; inflammatory cells and
histiocytes. The patient will need repeat imaging to asses for
underlying malignancy once her acute illness and pleural
effusion have resolved.
#Pancreatitis with pseudocyst
The patient remained on tube feeds and was tolerating clear
liquids. She is followed by the ___ team/Dr. ___
follow up at the beginning of ___ as scheduled.
#Diabetes: ___ pancreatic insufficiency
The patient's lantus was decreased to 12 units with good glucose
control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive / Plaquenil / omeprazole / Prozac / quinacrine /
metformin / varenicline / vancomycin
Attending: ___
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Hepatic abscess aspiration
Bilateral percutaneous transhepatic biliary srain placement
R chest tube placement
History of Present Illness:
Ms. ___ is a pleasant ___ w/ Stage IV adenocarcinoma of
the
appendix on cetuximab, s/p R hemicolectomy with diverting
ileostomy, complicated by chronic partial SBO on TPN, bilateral
hydronephrosis s/p b/l ureteral stents and percutaneous
nephrostomy tubes, recent polymicrobial bacteremia and liver
abscesses s/p 6 weeks of IV antibiotics, who presents with
fevers
of ___.
She states she saw her oncologist on ___. She had a CT done
which revealed possible reaccumulation of her hepatic abscess.
The plan was to continue monitor and have it drained. ___ the
weekend she felt fatigued, with nausea, no vomiting and
decreased
appetite (albeit she does not eat). She has also been having
decreased output from her ostomy bag. She also had a fever of
___. She called ___. She went to ___ where she had a CT
scan which revealed concern for recurrent hepatic abscess. She
is
actually already scheduled for a transhepatic cholangiogram for
possible drainage of the abscess. Images were uploaded.
Pt oncologist at ___ recommended transfer to ___ for further
management due to concern for possible recurrent infection. Pt
received IV Zozyn PTA at 7pm this evening. She also received
Dilaudid for pain. She was AF in ED and mildy tachy in ___ with
otherwise stable VS.
Past Medical History:
Oncologic History and Complications:
-Stage 4 adenocarcinoma of the appendix (peritoneal implants,
pulmonary nodules) s/p:
- R hemicolectomy w/end ileostomy (___)
- debulking surgery with hyperthermic intraperitoneal
mitomycin-C chemo ___, ___
- Neoadjuvant and adjuvant FOLFOX chemo (? to ___ ___ - ?)
- Currently on cetuximab (___)
-Chronic partial SBO on TPN
-Bilateral hydronephrosis s/p b/l ureteral stents and
percutaneous nephrostomy tubes (s/p multiple exchanges)
-Biliary obstruction s/p stents & drains
-GERD
Other Medical History:
-SLE
-HTN
-Dyslipidemia
-Fibromyalgia
___ procedures:
___: R PCN exchange
___: bilateral PCN exchange
___: bilateral PCN exchange
___: biliary drain removal.
___: cholangiogram with tri-lateral stent placement.
___: PTBD placement
___: PCN placement
Social History:
___
Family History:
Father with multiple MIs, first in ___. Multiple cancers. Mother
with lung cancer. Counsin with leukemia.
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
VITAL SIGNS: ___ 130/78 91 93% RA
General: NAD, Resting in bed comfortably, chronically ill,
fatigued
HEENT: MM very dry
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, tender to deep palpation, ostomy bag w/ liquid
brown stool, b/l PCN dressings c/d/i w/ clear yellow urine
draining.
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
===========================
DISCHARGE PHYSICAL EXAM
===========================
VS: 98.4 140/70 99 18 95%RA
GEN: NAD, lying in bed
HEENT: scleral icterus, scar on R cheek and forehead that
patient reports are from lupus
Cards: RRR no murmurs/gallops/rubs.
Pulm: diffuse rhonchorous breath sounds throughout
GU: nephrostomies draining clear yellow urine
Abd: erythema around ostomy site, colostomy draining brown
liquid with blood tinged stool; no melena; +BS, soft, PTBDs
capped, no rebound or guarding, distended but not firm
Neuro: AOx3, moving all 4 extremities
Pertinent Results:
=========================
ADMISSION LABS
=========================
___ 12:00AM BLOOD WBC-11.2*# RBC-3.23* Hgb-8.4* Hct-26.9*
MCV-83 MCH-26.0 MCHC-31.2* RDW-16.2* RDWSD-49.1* Plt ___
___ 12:00AM BLOOD Neuts-85.2* Lymphs-7.0* Monos-5.7 Eos-1.6
Baso-0.2 Im ___ AbsNeut-9.52* AbsLymp-0.78* AbsMono-0.64
AbsEos-0.18 AbsBaso-0.02
___ 12:00AM BLOOD Plt ___
___ 06:32AM BLOOD ___ PTT-28.6 ___
___ 12:00AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-134
K-3.5 Cl-101 HCO3-22 AnGap-15
___ 12:00AM BLOOD ALT-114* AST-110* AlkPhos-457*
TotBili-5.2* DirBili-4.3* IndBili-0.9
___ 12:00AM BLOOD Albumin-2.7*
___ 06:32AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.3
Mg-1.4*
___ 12:25AM BLOOD Lactate-0.9
====================
MICRO
====================
___ 12:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:11 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
YEAST. 10,000-100,000 CFU/mL.
___ 6:32 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PORT.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 3:15 pm ABSCESS Source: Liver Abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
2:40PM.
___ ALBICANS. SPARSE GROWTH. Yeast
Susceptibility:.
Fluconazole = 0.5 MCG/ML = SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines. Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
CEFTAZIDIME AND Piperacillin/Tazobactam sensitivity
testing
performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:21 pm PLEURAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 7:33 pm BLOOD CULTURE Source: Line-port.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:41 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:04 pm URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
=========================
IMAGING
=========================
___ HEPATIC ABSCESS ASPIRATION
Successful US-guided aspiration of a right hepatic lobe fluid
collection.
Sample was sent for microbiology evaluation.
___ CXR
Interval placement of a right chest tube which projects over the
right mid to lower hemithorax. No significant interval change
in the moderate right
pleural effusion.
___ CT A/P
1. Again seen are four common bile duct metal stents. Compared
to ___, there is decreased intrahepatic biliary
ductal dilatation in the portion of the hepatic parenchyma
drained by the left biliary stent. There is also new
pneumobilia in this region. Mild hyperenhancement of the
hepatic parenchymal in this region is favored to represent
either cholestatic hepatitis or cholangitis.
2. There is persistent intrahepatic biliary ductal dilatation in
the segments drained by the right anterior stent. Again seen in
this region is a resolving biloma/abscess which is similar in
size compared to ___.
3. No significant intrahepatic biliary ductal dilatation is
noted in the areas drained by the other 2 right-sided biliary
stents.
4. Similar to mildly decreased size of a segment 8 hypodensity,
compatible
with resolving abscess. No new hepatic lesion is seen.
5. Mild persistent right hydronephrosis is slightly decreased
compared to
prior studies. There is no left hydronephrosis. The bilateral
percutaneous nephrostomy tubes are in appropriate position.
6. Similar appearance of multiple splenic hypodensities,
compatible with
infarcts.
7. Diffusely thickened bladder wall may be related to under
distension and
tumor involvement, however clinical correlation to exclude
cystitis is
recommended.
8. Similar appearance of persistent posterior bladder mass with
loss of rectal fat plane worrisome for metastatic involvement.
9. Similar appearance of retroperitoneal lymphadenopathy.
10. Bilateral pleural effusions and patchy nodular airspace
opacity in the
lung bases, right middle lobe, and lingula were better evaluated
on the
dedicated CT of the chest from ___. Please see
that report for further details.
___ PTBD
1) Successful balloon sweeps of the right anterior metallic
stent
2) Successful ___ PTBD placement through the right anterior stent
3) Successful balloon sweeps of the left biliary stent
4) Successful placement of a left 10 ___ internal external
biliary drain through the interstices of the existing left
internal metal stent.
___ CXR
In comparison with study of ___, there is little overall
change.
Again there is a small apical pneumothorax. Little change in
the atelectatic streaks at the right base with residual
effusion. Mild atelectatic changes are seen at the left base
and the central catheters are stable.
================
DISCHARGE LABS
================
___ 06:00AM BLOOD WBC-11.3* RBC-3.12* Hgb-8.2* Hct-26.8*
MCV-86 MCH-26.3 MCHC-30.6* RDW-16.8* RDWSD-51.8* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-196* UreaN-19 Creat-0.5 Na-139
K-3.8 Cl-104 HCO3-25 AnGap-14
___ 06:00AM BLOOD ALT-95* AST-92* AlkPhos-315* TotBili-4.8*
___ 06:00AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 50 mcg/h TD Q72H
2. Ondansetron 8 mg IV BID n/v
3. Oxybutynin 10 mg PO QHS
4. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
5. Thiamine 100 mg PO TID
6. LORazepam 1 mg PO Q4H:PRN anxiety
7. Famotidine 20 mg PO DAILY
8. Ondansetron 8 mg IV DAILY:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV every 24
hours Disp #*18 Intravenous Bag Refills:*0
2. Fluconazole 400 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 2 tablet(s) by mouth daily
Disp #*36 Tablet Refills:*0
3. Fentanyl Patch 100 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour 1 patch every 72 hours Disp #*5 Patch
Refills:*0
4. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 15 mg 1 tablet(s) by mouth every four hours Disp
#*60 Tablet Refills:*0
5. Famotidine 20 mg PO DAILY
6. LORazepam 1 mg PO Q4H:PRN anxiety
7. Ondansetron 8 mg IV BID n/v
RX *ondansetron HCl 2 mg/mL 8 mg IV twice a day Disp #*28 Vial
Refills:*0
8. Ondansetron 8 mg IV DAILY:PRN nausea
RX *ondansetron HCl 2 mg/mL 8 mg IV daily Disp #*14 Vial
Refills:*0
9. Oxybutynin 10 mg PO QHS
10. Pantoprazole 40 mg PO Q12H
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Thiamine 100 mg PO TID
13.Normal Saline 0.9% Solution
Sig: Please infuse 1L of IV Normal Saline over ___ hours daily.
Disp: 14 Bags of IVF
Refills: 0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Cholangitis
Hepatic abscess
R pleural effusion
Secondary:
Metastatic appendiceal carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with port and power picc // evaluate position
of picc evaluate position of picc
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. There is increasing right pleural effusion with volume loss in
the right lower lobe. No evidence of vascular congestion or acute focal
pneumonia, though in the appropriate clinical setting it would be impossible
to exclude consolidation at the right base, especially in the absence of a
lateral view.
Radiology Report
INDICATION: ___ year old woman with ? recurrent hepatic abscess // please
review ___ ct scan and evaluate for recurrent hepatic abscess,
fluid will need to be sent for cultures
COMPARISON: Outside hospital CT torso from ___.
PROCEDURE: Ultrasound-guided drainage of a right hepatic lobe collection.
OPERATORS: Dr. ___ resident, Dr. ___ fellow, and Dr.
___ radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the table. Limited preprocedure
ultrasound was performed to localize the collection. Based on the ultrasound
findings an appropriate skin entry site for the aspiration was chosen. The
site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using continuous sonographic guidance, 18G ___ needle was advanced via
trocar technique into the collection. Approximately 4 cc of thick clear
yellow fluid was aspirated and sent for microbiology evaluation. The needle
was then removed and a sterile dressing applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Monitored anesthesia care with an anesthesiologist present, per the
patient's request.
FINDINGS:
Septated fluid collection in the inferior right hepatic lobe.
IMPRESSION:
Successful US-guided aspiration of a right hepatic lobe fluid collection.
Sample was sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with pleural effusion s/p chest tube insertion
// assess chest tube location
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Right chest wall power injectable Port-A-Cath is present as well as a left
PICC line, both tips, projecting over the right atrium. A right pleural
catheter projects over the right mid/lower hemithorax. There is no
significant interval change in the moderate right pleural effusion with
adjacent atelectasis. No pneumothorax identified. The left lung is clear.
This size appearance of the cardiac silhouette is unchanged.
IMPRESSION:
Interval placement of a right chest tube which projects over the right mid to
lower hemithorax. No significant interval change in the moderate right
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: new chest tube placed ___ // evaluate position of chest tube on
morning of ___. please obtain this CXR between 5:00 and 5:45 am
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
Right base pigtail catheter is in place. There is no evident pneumothorax.
Now small right effusion has markedly decreased. No other interval change
from prior study.
Radiology Report
INDICATION: ___ year old woman with dark brown vomiting // concern for small
bowel obstruction
TECHNIQUE: Upright and supine radiograph view of the abdomen. The upright
image does not include portions of the lower abdomen or the pelvis.
COMPARISON: Abdominal radiograph dated ___.
CT torso dated ___ from an outside facility and uploaded onto PACS.
FINDINGS:
Mildly dilated air-filled loops of small bowel in the left lower and mid
abdomen persist and are similar to the prior radiograph and CT. No evidence of
pneumatosis or free air. No air fluid levels identified on limited upper
abdomen upright view. There is a right lower quadrant ileostomy. There is
moderate stool in the descending colon.
Bilateral percutaneous nephrostomy tubes appear in place. 4 biliary stents
appear unchanged. Surgical clips from cholecystectomy are unchanged.
No unexplained soft tissue calcifications or radiopaque foreign bodies.
An 1.8-cm round, sclerotic lesion appears benign, unchanged.
A right pigtail drain projects over the right lower hemithorax. Opacity and
silhouetting of the right hemidiaphragm is likely residual effusion and
atelectasis seen on prior CT. Opacities in the left lung base may be
atelectasis. A central line in the SVC probably ending near the SVC-RA
junction is partially imaged.
IMPRESSION:
Mildly dilated air-filled small bowel loops in the mid-left lower quadrant,
similar to prior CT and radiograph could be early small bowel obstruction.
Close attention on follow-up.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with metastatic appendiceal cancer and
recurrent R pleural effusion // assess for trapped lung/impaired expansion
after chest tube placement
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 33.6 cm; CTDIvol = 6.5 mGy (Body) DLP = 221.2
mGy-cm.
Total DLP (Body) = 221 mGy-cm.
COMPARISON: Chest CT ___.
FINDINGS:
Right pleural drainage tube inserted low laterally is largely curled in the
major fissure. Residual right pleural fluid volume is small, generally
dependent, some fissural. Parietal pleural thickening of the right lower
posterior pleura is smooth, slightly greater than it was on ___ when a
small nonhemorrhagic pleural effusion layered posteriorly. Pleural thickening
along the lateral costal surface, 03:25, is greater than it was previously,
associated with a loculation of non serous pleural fluid.
Supraclavicular and axillary lymph nodes are not enlarged. Specifically
excluding the breasts which require mammography for evaluation, there is no
soft tissue abnormality in the chest wall suspicious for malignancy. Edema in
the right posterior thoracoabdominal chest wall is new. Small left pleural
effusion and small pericardial effusion have also developed.
Volume of the right pneumothorax is small.
Emphysema is moderately severe. Several small regions of lung abnormality
have developed since ___, most of which are probably atelectasis, most
notably at the right lung base, but a region of peribronchial opacification in
the anterior segment of the right upper lobe, 5:157, and a smaller region in
the anterior segment of the left upper lobe, 5:143 could be pneumonia.
Nearly the entire esophagus is severely distended with fluid to the level of
the gastroesophageal junction. Assessment of swallowing function her and
exclusion of stricture or subtle mass would require fluoroscopic observation
of a contrast swallow or direct inspection. In any case, the condition puts
the patient at risk for aspiration.
CHEST CAGE, ESPECIALLY THE THORACIC SPINE, IS SEVERELY OSTEOPENIC, BUT THERE
IS NO COMPRESSION FRACTURE, PATHOLOGIC FRACTURE, OR CLEARLY DESTRUCTIVE BONE
METASTASIS.
IMPRESSION:
PERSISTENT SMALL POSSIBLY LOCULATED RIGHT PLEURAL EFFUSION SMALL PNEUMOTHORAX,
FOLLOWING INSERTION OF RIGHT PLEURAL DRAINAGE CATHETER, LARGELY FISSURAL.
MODERATE VOLUME OF RIGHT LOWER LOBE ATELECTASIS IS NEW SINCE ___.
SEVERE DISTENTION AND RETENTION OF FLUID IN OF THE ESOPHAGUS PUTS THE PATIENT
AT RISK FOR ASPIRATION.
SMALL AREAS OF LIKELY NEW PNEUMONIA.
NEW MILD ANASARCA.
EMPHYSEMA.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:20 ___, 1 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ year old woman with metastatic appendiceal carcinoma //
concern for aspiration pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest radiograph and CT scan of the chest dated ___
from earlier in the day
FINDINGS:
Right chest wall power injectable Port-A-Cath tip and left PICC line tip
project over the right atrium. A right pleural drainage tube is present.
Unchanged atelectasis at the right lung base as well as patchy airspace
opacities predominantly involving the right lung. A small right pleural
effusion is present. Trace right pneumothorax which is better evaluated on
today's CT scan of the chest.
The size the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Trace right pneumothorax ; however this was better evaluated on today's CT
scan of the chest. Otherwise there is no significant interval change since
the prior examination. .
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old woman with cholangitis // ___ request for planning
placement of PTBD history of appendiceal cancer, metastatic.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 14.9 s, 0.2 cm; CTDIvol = 253.7 mGy (Body) DLP =
50.7 mGy-cm.
3) Spiral Acquisition 7.5 s, 48.9 cm; CTDIvol = 15.8 mGy (Body) DLP = 760.8
mGy-cm.
Total DLP (Body) = 813 mGy-cm.
COMPARISON: CT abdomen pelvis with contrast ___ and ___. Chest CT ___.
FINDINGS:
LOWER CHEST: There are bilateral pleural effusions, small, right greater than
left, and patchy nodular airspace opacity in the lung bases, right middle
lobe, and lingula, better evaluated on the recent CT of the chest from ___. Again noted is opacification of the distal esophagus with
fluid.
ABDOMEN:
HEPATOBILIARY: Again seen are 4 common bile duct stents. There has been an
interval decrease in left sided intrahepatic biliary ductal dilatation
compared to ___, now with pneumobilia. Mild hyper enhancement of
the hepatic parenchymal in this region is favored to represent either
cholestatic hepatitis or cholangitis.
There is persistent intrahepatic biliary ductal dilatation in the area drained
by the right anterior biliary drain. Again seen in this region is a fluid
collection, compatible with resolving biloma/abscess. This fluid collection
measures 1.2 x 1.3 cm, and is not significantly changed from the most recent
prior studies but has decreased over serial examinations (02:28). There is a
stable 9 mm hypodensity in segment IV compatible with a cyst. An ill-defined
area of low density in hepatic segment VIII measuring 1.8 x 1.1 cm is slightly
decreased in size from ___ at which time it measured 1.8 x 1.3 cm
(04:15).
No significant intrahepatic biliary ductal dilatation is noted in the areas
drained by the other 2 right-sided biliary stents.
No new focal lesions are seen. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is similar appearance of numerous peripheral wedge shaped
perfusion defects in the spleen, compatible with splenic infarcts.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No focal renal lesions are seen. There is mild persistent right
hydronephrosis which has decreased in time since ___. Bilateral
percutaneous nephrostomy tubes are in appropriate positioning. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is collapsed. There are a few mildly dilated
loops of small bowel in the midline which contain air and fluid measuring up
to 4.8 cm, similar compared to prior studies. The patient is status post
right colectomy with anastomosis in the right upper quadrant. There is a
right lower quadrant colostomy. There is no evidence of obstruction or
parastomal hernia.
PELVIS: The bladder is thick walled which may be related to underdistention or
tumor involvement. Again seen is a lobulated mass in the posterior aspect of
the bladder with loss of the normal fat plane between the posterior bladder
wall, vagina, and rectum. There is a trace amount of free fluid in the
pelvis.
REPRODUCTIVE ORGANS: No large adnexal mass is seen.
LYMPH NODES: Again seen is prominent retroperitoneal adenopathy with a
prominent left periaortic lymph node measuring 1.4 cm, previously 1.3 cm
(04:34). There is no inguinal or pelvic 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. Again seen are four common bile duct metal stents. Compared to ___, there is decreased intrahepatic biliary ductal dilatation in the portion
of the hepatic parenchyma drained by the left biliary stent. There is also
new pneumobilia in this region. Mild hyperenhancement of the hepatic
parenchymal in this region is favored to represent either cholestatic
hepatitis or cholangitis.
2. There is persistent intrahepatic biliary ductal dilatation in the segments
drained by the right anterior stent. Again seen in this region is a resolving
biloma/abscess which is similar in size compared to ___.
3. No significant intrahepatic biliary ductal dilatation is noted in the areas
drained by the other 2 right-sided biliary stents.
4. Similar to mildly decreased size of a segment 8 hypodensity, compatible
with resolving abscess. No new hepatic lesion is seen.
5. Mild persistent right hydronephrosis is slightly decreased compared to
prior studies. There is no left hydronephrosis. The bilateral percutaneous
nephrostomy tubes are in appropriate position.
6. Similar appearance of multiple splenic hypodensities, compatible with
infarcts.
7. Diffusely thickened bladder wall may be related to under distension and
tumor involvement, however clinical correlation to exclude cystitis is
recommended.
8. Similar appearance of persistent posterior bladder mass with loss of rectal
fat plane worrisome for metastatic involvement.
9. Similar appearance of retroperitoneal lymphadenopathy.
10. Bilateral pleural effusions and patchy nodular airspace opacity in the
lung bases, right middle lobe, and lingula were better evaluated on the
dedicated CT of the chest from ___. Please see that report for
further details.
Radiology Report
INDICATION: ___ year old woman with adenocarcinoma and biliary obstruction //
PTBD
COMPARISON: CT abdomen pelvis on ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Drs. ___
were present and personally supervised the trainee during the key components
of the procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: General anesthesia
CONTRAST: 40 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 55.4 min, 171 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound guided right anterior percutaneous transhepatic bile duct
access.
3. Right anterior cholangiogram.
4. Balloon sweep of the right anterior internal metal stent.
5. Successful placement of a 8 ___ right anterior biliary drain through the
pre-existing right anterior internal metal stent
6. Ultrasound guided left percutaneous transhepatic bile duct access.
7. Left cholangiogram.
8. Balloon sweep of the left internal metal stent.
9. Successful placement of a 10 ___ left biliary drain through the
interstices of the pre existing left internal metal stent.
1. PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right and mid
abdomen was prepped and draped in the usual sterile fashion.
Under Ultrasound and Fluoroscopic guidance, a 21G Cook needle was advanced
into right anteriorbiliary system. Images of the access were stored on PACS.
Once return of bilious fluid was identified, a Nitinol wire was advanced under
fluoroscopic guidance into the peripheral right anterior duct. A skin ___ was
made over the needle and the needle was removed over the wire. An Accustick
set was advanced over the wire and the inner stiffener was withdrawn. A
contrast injection was performed to confirm biliary anatomy. The Nitinol wire
was exchanged for a Glidewire which was placed through the right anterior
internal metal stent and into the duodenum using a MPA catheter. The glidewire
was exchanged for ___ wire. A ___ sheath was advanced over the wire into
the biliary system. Next, a 6 mm x 40 mm Mustang balloon was used to balloon
sweep the right anterior internal metal stent. Cholangiogram was again
performed. A 5 ___ balloon was also used a balloon sweep the right
anterior internal metal stent.
Attention was then turned to the left sided system. Under Ultrasound and
Fluoroscopic guidance, a 21G Cook needle was advanced into the leftbiliary
system. Images of the access were stored on PACS. Once return of bilious fluid
was identified, a Nitinol wire was advanced under fluoroscopic guidance into a
peripheral left bile duct. A skin ___ was made over the needle and the needle
was removed over the wire. An Accustick set was advanced over the wire and the
inner stiffener was withdrawn. A contrast injection was performed to confirm
biliary anatomy. The Nitinol wire was exchanged for a stiff Glidewire.A ___
sheath was advanced over the wire into the biliary system. The stiff
Glidewire was replaced with a Glidewire, and the Glidewire was placed through
the the interstices of the left internal metal stent and into the duodenum
using a Kumpe catheter. The glidewire was exchanged for an Amplatz wire. Next,
a 6 mm x 40 mm Mustang balloon was used to dilate the interstices of the metal
stent and balloon sweep the left internal metal stent. Cholangiogram was again
performed.
Cholangiogram was again performed on the right sided system. The ___ wire
was replaced with an Amplatz wire. The catheters and sheath were removed. A
___ internal external biliary catheter was advanced, the wire and inner
stiffener were removed and the pigtail was formed. Contrast injection
confirmed appropriate position. The catheter was flushed with saline, secured
with stay sutures to the skin and sterile dressings were applied. The
catheter was attached to a bag.
On the left, the catheters and sheath were removed. A ___ internal external
biliary catheter was advanced, the wire and inner stiffener were removed and
the pigtail was formed. Contrast injection confirmed appropriate position.
The catheter was flushed with saline, secured with stay sutures to the skin
and sterile dressings were applied. The catheter was attached to a bag.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Right anterior cholangiogram demonstrates complete obstruction of the
right anterior internal metal stent with moderate upstream biliary dilation.
The known biloma/abscess in the right anterior liver was noted to be supplied
by this liver segment.
2. Post balloon sweep of the right anterior internal metal stent demonstrates
brisk flow through the stent.
3. Cholangiogram through the successfully placed 8 ___ internal external
biliary drain demonstrates good flow and drainage of the right anterior bile
ducts.
4. Left sided cholangiogram of an excluded duct which was utilized to access
the left biliary stent demonstrates complete obstruction of the left internal
metal stent and moderate upstream biliary dilation. Numerous excluded dilated
ducts were noted on the left sided of the liver which were successfully
drained with the new ___ internal external drain.
5. Post balloon sweep of the left internal metal stent demonstrates brisk
flow through the stent.
6. Cholangiogram through the successfully placed 10 ___ internal external
biliary drain demonstrates good flow and drainage of the left bile ducts.
IMPRESSION:
1) Successful balloon sweeps of the right anterior metallic stent
2) Successful ___ PTBD placement through the right anterior stent
3) Successful balloon sweeps of the left biliary stent
4) Successful placement of a left 10 ___ internal external biliary drain
through the interstices of the existing left internal metal stent.
RECOMMENDATION(S): Patient can remain to bag while she defervesces. After
this, she should return for a repeat cholangiogram to evaluate the stent
patency and flow. The ___ team will follow the patient.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic appendiceal carcinoma with
large right pleural effusion s/p chest tube // Any interval change? Any
interval change?
IMPRESSION:
In comparison with study of ___, there is little overall change.
Again there is a small apical pneumothorax. Little change in the atelectatic
streaks at the right base with residual effusion. Mild atelectatic changes
are seen at the left base and the central catheters are stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with Stage IV adenocarcinoma of the appendix
with right pleural effusion s/p chest tube to suction // Image requested per
IP. Any interval change?***Please perform at 3 pm on ___ Image
requested per IP. Any interval change?***Please perform at 3 pm on ___
IMPRESSION:
In comparison with the earlier study of this date, the apical pneumothorax on
the right appears to have slightly decreased. Otherwise little change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Fever, Abscess
Diagnosed with Unspecified abdominal pain, Fever, unspecified
temperature: 97.7
heartrate: 95.0
resprate: 16.0
o2sat: 95.0
sbp: 127.0
dbp: 76.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ is a ___ w/ Stage IV adenocarcinoma of the
appendix recently on cetuximab, s/p R hemicolectomy with
diverting ileostomy, complicated by chronic
partial SBO on TPN, b/l hydronephrosis s/p b/l ureteral stents
and PCNs, recent polymicrobial bacteremia and liver abscesses
s/p 6 weeks of IV antibiotics, who p/w chief complaint of fevers
and was found to have a hepatic abscess, cholangitis requiring 2
PTBDs, and progression of stage IV appendiceal cancer. The
hepatic abscess was aspirated by ___ and grew ___ and
klebsiella. She was also found to have cholangitis and had 2
PTBDs placed with ___. For the hepatic abscess and cholangitis
she was treated with ceftriaxone and fluconazole. Per ID recs
she will receive 4wks of antibiotics from PTBD placement (last
day ___ and will be followed by OPAT. PTBDs were capped prior
to discharge and further plan will be decided by ___ as an
outpatient.
She also had a CT placed for R pleural effusion which was
removed prior to discharge. Her pleural fluid analysis was
consistent with an exudate, but was negative for malignant cells
on cytology.
#Cholangitis.
She had an elevated bilirubin, fevers, and an elevated WBC
count, all consistent with cholangitis. The patient already has
4 biliary stents that were placed by ___. ERCP was attempted but
unable to be completed as there was external compression of the
pylorus, likely from progression of her malignancy, that made it
impossible to pass the scope. As a result she underwent
bilateral internal/external PTBD placement with ___ on ___ with
good drain output. There was a slight decrease in her bilirubin,
with marked improvement in her clinical status. With drain
placement and ceftriaxone her WBC went down, she was afebrile,
and her abdominal pain improved. Her bilirubin stabilized at
around 5.1 and is unlikely to drop much further given her
metastatic disease. Her PTBDs were capped, and her bilirubin
remained stable. ___ will see her as an outpatient to discuss
further management of the drains. Per ID she will continue
ceftriaxone for 4 weeks from drain placement (last day ___.
She will be followed by OPAT as an outpatient.
#Hepatic abscess
Cultures from hepatic abscess on most recent admission grew pan
sensitive Enterococcus and E.coli ___. She received Zosyn
for about 6 weeks and completed treatment ___ per chart. CT
abdomen from ___ showed a small hepatic abscess. Hepatic
abscess was aspirated ___ and grew ___ and klebsiella. She
was initially started on zosyn, but was transitioned to
ceftriaxone per ID recs with a plan to continue until ___ (per
above). She was also started on fluconazole to treat the
___. She will be followed by OPAT as an outpatient.
#R Pleural effusion.
The patient had reaccumulation of her R sided pleural effusion
so IP was consulted and placed a chest tube. The fluid analysis
was consistent with an exudate but cytology was negative for
malignancy. The chest tube was pulled a few days after
placement. She was monitored for signs of reaccumulation but did
not develop any.
#Goals of care.
There were many goals of care discussion had with the patient
and her family and friends. Before speaking with the family, the
inpatient team reached out to the patient's outpatient
oncologist, Dr. ___ her thoughts on the patients
prognosis. She informed the team that the patient had been
reluctant to have goals of care discussions in the past and
expressed that the patient may not benefit from further
therapies, may not even be able to receive them given her
current clinical condition, but that if she is able and wants
more treatment Dr. ___ will discuss options with her. She
also stated that if the patient wants hospice she feels that is
a good option today. Hospice was brought up with the patient and
her family. The family felt hospice would be a good option for
the patient, but the patient was still hesitant and was asking
about more treatment options. Ultimately the patient agreed to
go home on hospice, with the knowledge that if she does improve
clinically she has the option of coming off hospice and
receiving more treatment. Unfortunately the company that
provides her ___ services will not provide hospice services to
someone who is still receiving TPN and antibiotics. As a result
she went home resuming her prior ___ services with palliative
care with the option of readdressing hospice when she completes
her antibiotic course on ___.
#Erythema around colostomy site.
Patient states that she has had erythema and irritation around
the ostomy site for weeks. She says she was supposed to see
wound care as an outpatient but unfortunately it did not happen.
Wound care saw her here and gave her a new ostomy bag. She feels
the erythema and irritation is improving. A few days prior to
discharge she was noted to have some blood in her ostomy which
appeared to be coming from her stoma. She says this happens
intermittently at home. Her hgb was stable so there was low
concern for a GI bleed.
#Vomiting.
The patient had one day where she had dark brown emesis that was
gastroccult positive. There was a concern for a GI bleed so she
was started on a high dose pantoprazole IV BID and given a PRBC
transfusion. The next day she was still having some emesis
(which is baseline for her), but it was not dark and was
non-bloody. Her hgb was also stable, decreasing the concern for
a GI bleed. She continued to have intermittent nausea and so she
was continued on her home regimen of IV Zofran 8mg BID, with one
8mg PRN Zofran. Of note, she has a chronic malignant partial
SBO, but a CT abdomen on ___ was negative for obstruction. She
also had ostomy output throughout her admission.
#Pain.
On admission the patient was on a fentanyl patch 50mcg/hr with
oxycodone PRN. She was also given IV dilaudid while here for
breakthrough pain. Her fentanyl patch was also increased to 75
mcg/hr because of increased pain. Prior to discharge she needed
to be transitioned to PO medications so her pain medication
needs were calculated based on her PRNs. As a result her
fentanyl patch was increased to 100mcg/hr with oxycodone 15mg PO
Q4H:PRN with adequate pain control.
#Appendiceal cancer.
Followed by ___. Her chemo has been on hold given her
infection and overall clinical decline. The patient plans to see
her outpatient oncologist after discharge and wants to pursue
further treatment options.
#Severe Protein calorie malnutrition.
She was continued on her home TPN. Nutrition was consulted and
made adjustments as needed.
# Anemia
Likely secondary to antineoplastic therapy and inflammatory
blockade from
malignancy. She had a hgb drop at one point during the admission
when there was a concern for GI bleed. She was transfused at
that time, and her hgb remained stable but low after that.
#Hyperglycemia.
Had elevated glucoses during this admission. She was started on
a regular insulin sliding scale and had 10U insulin added to her
TPN. The hyperglycemia was most likely from her infection.
#Vaginal discharge.
Likely yeast infection. Patient has been on antibiotics, also
patient reports symptoms are similar to prior yeast infections.
She was being covered with the fluconazole she was getting for
the ___ that grew out of her hepatic abscess. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
EGD with banding ___
Large volume paracentesis ___
History of Present Illness:
___ year-old gentleman with alcoholic cirrhosis decompensated by
refractory ascites and encephalopathy who has been referred in
for evaluation of worsening renal function.
He was seen in ___ clinic yesterday and told to come into
the ER for admission, however he left without being seen due to
the long wait time. Hepatology would like his diuretics held and
IV albumin for the renal function.
For the last 2 weeks he has been having intermittent hematuria
which he says he has never had before. No other new urinary
symptoms (he is incontinent at baseline s/p prostatectomy and
radiation therapy; however, this is unchanged). Does not think
that he has been obstructed. No back or flank pain.
No other infectious sx/sx. No abdominal pain. No lightheadedness
/ dizziness. No f/c. No confusion. No other bleeding that he has
noticed.
In the ED:
- Initial vital signs were notable for:
T 97.0, HR 66, BP 96/68, RR 15, O2 100% RA
- Exam notable for:
Moderately distended abdomen, soft, nontender, AOx3
- Labs were notable for:
Chem 10: Na 139, Cr 2.3
CBC: WBC 6.9, Hgb 11.7, Plt 132
coags: INR 1.2
- Studies performed include:
Diagnostic tap: TNC 258
- Patient was given:
Albumin 75g
- Consults:
Hepatology "Pt with etoh cirrhosis, portal htn, ascites with new
___ in the setting of worsening refractory ascites.
Will need:
1. Full labs
2. Infectious rule out
3. Dx paracentesis
4. 1gm/kg of 25% IV albumin
5. Admit to the Liver service (attending ___
Vitals on transfer: T 98.1, HR 70, BP 97/68, RR 18, O2 100% RA
REVIEW OF SYSTEMS: Complete ROS obtained. Positive per HPI. Also
positive for R small toe pain 1 day ago that has since resolved.
Otherwise negative.
Past Medical History:
alcoholic cirrhosis,
prostate cancer s/p prostatectomy and radiation in ___,
depression s/o ECT in ___,
GERD,
radiation proctitis,
hearing loss from aminoglycosides,
essential tremor
Social History:
___
Family History:
Denies family history of liver disease or liver
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITALS: T 98.8 PO BP 93/58 HR 71 RR 18O2 94 RA
Gen: alert, NAD
HEENT: no scleral icterus, pupils equally round, OP clear, no
JVD
Lungs: CTAB
Heart: RRR, soft systolic murmur
Abdomen: soft, non-tender, quite distended with medium reducible
umbilical hernia
Ext: WWP, no edema, no toe lesions appreciated, no swelling /
erythema / warmth
Skin: no rashes noted
Neuro: Face symmetric, no dysarthria, moving all extremities
with
purpose.
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: ___ 0720 Temp: 98.0 PO BP: 109/71 HR: 66 RR: 18 O2
sat: 96% O2 delivery: RA
HEENT: no scleral icterus, pupils equally round, MMM
Lungs: CTAB, no adventitious sounds
Heart: RRR, soft systolic murmur, no rubs/gallops
Abdomen: soft, BS+, non-tender, abd distention, reducible
umbilical hernias x2
Ext: WWP, no ___ edema
Neuro: A&Ox3, moving all extremities with purpose, no asterixis
Pertinent Results:
ADMISSION LABS
================
___ 08:53PM BLOOD WBC-7.6 RBC-3.67* Hgb-11.8* Hct-36.1*
MCV-98 MCH-32.2* MCHC-32.7 RDW-14.0 RDWSD-50.9* Plt ___
___ 08:53PM BLOOD Neuts-72.3* Lymphs-13.1* Monos-11.5
Eos-2.2 Baso-0.5 Im ___ AbsNeut-5.46 AbsLymp-0.99*
AbsMono-0.87* AbsEos-0.17 AbsBaso-0.04
___ 08:53PM BLOOD Plt ___
___ 06:19PM BLOOD ___ PTT-29.9 ___
___ 08:53PM BLOOD Glucose-130* UreaN-36* Creat-2.2* Na-133*
K-4.5 Cl-94* HCO3-25 AnGap-14
___ 08:53PM BLOOD ALT-7 AST-22 AlkPhos-61 TotBili-1.3
___ 03:55PM BLOOD Lipase-54
___ 03:55PM BLOOD Albumin-3.9 Calcium-10.1 Phos-4.2 Mg-2.4
DISCHARGE LABS
===============
___ 06:40AM BLOOD WBC-5.2 RBC-3.02* Hgb-9.7* Hct-29.4*
MCV-97 MCH-32.1* MCHC-33.0 RDW-13.8 RDWSD-49.4* Plt Ct-84*
___ 06:40AM BLOOD ___ PTT-30.4 ___
___ 06:40AM BLOOD Glucose-94 UreaN-21* Creat-1.6* Na-135
K-3.9 Cl-98 HCO3-21* AnGap-16
___ 06:40AM BLOOD ALT-<5 AST-15 AlkPhos-42 TotBili-1.9*
___ 06:40AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.9
Other Pertinent Labs/Micro
============================
___ 08:37AM BLOOD ANCA-NEGATIVE
___ 08:37AM BLOOD ___
___ 07:00AM BLOOD C3-75* C4-10
___ 01:28AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:28AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 01:28AM URINE RBC-8* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-1
___ 01:28AM URINE CastHy-5*
___ 01:28AM URINE Mucous-RARE*
___ 11:18PM URINE Hours-RANDOM Creat-208 TotProt-29
Prot/Cr-0.1
___ 05:30PM ASCITES TNC-258* RBC-65* Polys-6* Lymphs-4*
Monos-61* Mesothe-16* Macroph-13* Other-0
___ 05:30PM ASCITES TotPro-3.3 Glucose-114
___ 10:15AM ASCITES TNC-120* RBC-203* Polys-5* Lymphs-42*
Monos-20* Mesothe-1* Macroph-32*
___ 5:30 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 10:15 am PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 10:15 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending):
Pertinent Imaging/Studies
==========================
Renal U/S (___)
IMPRESSION:
1. No evidence of hydronephrosis.
2. Cirrhotic liver, with large volume ascites.
EGD (___)
Findings:
-Esophagus: Normal mucosa was noted in the whole esophagus. 3
cords of large varices were seen in the distal esophagus. The
varices were not bleeding. 3 bands were applied for variceal
eradication successfully.
-Stomach: Diffuse continuous erythema and edema of the mucosa
with no bleeding was noted in the stomach body. These findings
are compatible with gastritis. Several mixed non-bleeding
polyps of benign appearance were found in the stomach body. The
polyps were inflammatory-appearing.
Impressions:
Varices in the distal esophagus (ligation)
Normal mucosa in the whole esophagus.
Inflammatory polyps in the stomach body.
Erythema and edema in the stomach body compatible with
gastritis.
Recommendations:
-Omeprazole 20 mg twice daily, Carafate 2 g twice daily for 2
weeks. Soft diet for 24 hours and then advance diet as
tolerated to regular diet.
Paracentesis (___): 6L ascitic fluid was drained
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
2. rifAXIMin 550 mg PO BID
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Escitalopram Oxalate 10 mg PO DAILY
6. Furosemide 80 mg PO DAILY
7. Lactulose 30 mL PO QHS
8. Midodrine 5 mg PO TID
9. Propranolol 10 mg PO QHS
10. Pantoprazole 40 mg PO Q24H
11. Spironolactone 200 mg PO DAILY
Discharge Medications:
1. Sucralfate 1 gm PO QID Duration: 2 Weeks
RX *sucralfate 1 gram/10 mL 1 mL by mouth four times a day Disp
#*1 Bottle Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Lactulose 30 mL PO TID
4. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*3
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. rifAXIMin 550 mg PO BID
10.Outpatient Lab Work
ICD-9 571.5
Please collect chem 10 weekly
Fax results to Dr. ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute kidney injury
SECONDARY DIAGNOSES
===================
Decompensated alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with decompensated cirrhosis, new ___, and new
hematuria // hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: No relevant prior studies available for comparison.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 11.3 cm
Left kidney: 11.5 cm
The bladder is moderately well distended and normal in appearance.
The liver demonstrates a nodular contour, compatible with known cirrhosis.
Large volume ascites is partially imaged.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Cirrhotic liver, with large volume ascites.
Gender: M
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: Abdominal distention, Abnormal labs
Abdominal distention
Diagnosed with Abdominal distension (gaseous)
Alcoholic cirrhosis of liver with ascites
temperature: 97.9
97.0
heartrate: 72.0
66.0
resprate: 16.0
15.0
o2sat: 100.0
100.0
sbp: 124.0
96.0
dbp: 74.0
68.0
level of pain: 0
0
level of acuity: 3.0
2.0 | ___ year-old gentleman with alcoholic cirrhosis decompensated by
refractory ascites and encephalopathy who referred from liver
clinic for sub-acute worsening renal function in setting of
intermittent hematuria. |
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/vomiting
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
Magnetic resonance elastography
History of Present Illness:
___ with localized unresectable neuroendocrine tumor encasing
the mesentery who developed nausea yesterday evening and was
transferred with a diagnosis of SBO from OSH. The patient has
had upset stomach off and on with gas sounds for the past few
weeks, but there was a change with nausea developing yesterday.
This morning he couldn't eat cereal because of nausea and
vomiting which was not controlled by Compazine and Zofran. He
felt weak and also couldn't tolerate oral nutritional
supplement, so wife called ambulance who took him to a local
hospital. There he had CT scan that showed SBO with dilated
proximal small bowel loops with air-fluid levels and a
transition at the level of the
ileum. NGT was placed but how much was suctioned up was not
documented.
He was transferred to ___ for surgical eval. Here surgery saw
patient and he had KUB that confirmed NGT location and signs of
SBO. Vitals 98.6 80 119/65. Surgery recommended ___
medical management.
Past Medical History:
#localized unresectable neuroendocrine tumor encasing the
mesentery
--followed by Dr. ___ with octreotide every 28d, last on ___
#Ascites requiring weekly paracentesis
#Malnutrition, weight loss
No longer requires medication for HTN, HL
Social History:
___
Family History:
Esophageal cancer and alcoholism in his father
MI in his mother
Physical ___:
ADMISSION:
___ 1127 Temp: 98.0 PO BP: 131/78 R Lying HR: 93 RR: 16 O2
sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
thin male with some temporal wasting
non toxic, aox3 fluent speech
NGT in place, capped
CTAB
RRR NMRG
soft abdomen, trace bulging flanks, hypoactive bowel sounds, no
tenderness to palpation, percussion, no appreciable organomegaly
no suprapubic tenderness
no peripheral edema
no confusion
no signs of bleeding
no asterexis
DISCHARGE
98.0 PO 125/75 78 16 95% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, mildly 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
Pertinent Results:
ADMISSION
___ 03:56AM BLOOD WBC-10.9*# RBC-4.73 Hgb-13.1* Hct-40.4
MCV-85 MCH-27.7 MCHC-32.4 RDW-14.3 RDWSD-44.4 Plt ___
___ 03:56AM BLOOD Neuts-87.9* Lymphs-4.1* Monos-6.3
Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.59*# AbsLymp-0.45*
AbsMono-0.69 AbsEos-0.02* AbsBaso-0.05
___ 03:56AM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-130*
K-7.2* Cl-95* HCO3-24 AnGap-11
___ 05:33AM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.8* Mg-2.1
DISCHARGE
___ 06:50AM BLOOD WBC-5.6 RBC-4.45* Hgb-12.1* Hct-38.9*
MCV-87 MCH-27.2 MCHC-31.1* RDW-14.3 RDWSD-45.7 Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-140
K-4.4 Cl-100 HCO3-25 AnGap-15
___ 06:50AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
CT abdomen/pelvis performed ___ at ___
moderate bilateral pleural effusions slight decrease in
mod-significant ascites stable lobulated mass lesion near root
of mesentery, 8.5x5.3x5.5cm, unchanged since ___ proximal
small bowel loops with air-fluid levels and a transition at the
level of the ileum
KUB ___
Small-bowel obstruction, likely distal
Upper endoscopy
Normal mucosa in esophagus, stomach and duodenum
MRE
IMPRESSION:
1. Evidence of unchanged distal small-bowel obstruction
secondary to the
central mesenteric mass as described above.
2. Unchanged edema and mucosal hypoenhancement of the most
distal dilated
small bowel loops proximal to the transition point concerning
for vascular
compromise. Evidence of marked luminal narrowing of the SMV and
SMA.
3. Moderate amount pleural effusions and large amount of
intra-abdominal
ascites.
4. Unchanged central mesenteric mass biopsy-proven
neuroendocrine tumor with associated mesenteric adenopathy.
5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely
evaluated and remains indeterminate. This can be followed on
subsequent imaging.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
2. Creon 12 1 CAP PO TID W/MEALS
3. Pantoprazole 40 mg PO Q24H
4. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Pancreatic neuroendocrine tumor
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with ___ w/ NGT eval for position// ___ w/ NGT eval
for position
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Outside hospital CT from ___.
FINDINGS:
Multiple air-fluid flow loops of small bowel are seen to the level of the
pelvis measuring up to 4.7 cm. The large bowel is decompressed. There is
large volume ascites.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Previously administered contrast is seen
within the bladder. An enteric tube is visualized terminating in the proximal
stomach.
IMPRESSION:
Small-bowel obstruction, likely distal as dilated loops of bowel are seen to
the level of the pelvis.
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ w/ unresectable neuroendocrine tumor in the mesentery who
presented to OSH with complaints nausea and vomiting thought to be ___ to a
SBO.// Please evaluate for bowel obstruction
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (6 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
MR ENTEROGRAPHY:
Small bowel motility appears unremarkable. There is re-demonstration of
proximally dilated small bowel loops measuring up to 4.3 cm in caliber. The
distal small bowel loops are under distended in a similar fashion when
compared to the ___ with a transition point in the right lower
quadrant (series 13, image 65) where the small-bowel loops are tethered to the
mesenteric mass. The degree of dilatation has not significantly changed.
There is mild submucosal edema of the distal most dilated small bowel loops
just proximal to the transition point, the degree of which is not changed from
the CT examination. There is also mild mucosal hypoenhancement when compared
to the remaining small bowel loops, which may indicate vascular compromise.
The draining veins of these bowel loops appear mildly engorged when compared
to the rest of the mesenteric veins.
These findings are secondary to the spiculated homogeneously enhancing mass
centered around the root of the small bowel mesentery inferior to the
pancreatic head and encircling the SMA and SMV where it causes marked luminal
narrowing. This mass collectively measures 5.9 x 7 x 9.6 cm. There are
associated enlarged mesenteric lymph nodes that have not changed in size.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
There is moderate amount of ascites that has not changed. There is an 8 mm
hypoenhancing lesion along the dome of the right hepatic lobe, incompletely
evaluated. This is too small to be seen on the previous CT. Gallbladder
appears unremarkable. Portal vein is patent. There is no splenomegaly.
There is no pancreatic ductal dilatation. The mass is inferior to the
pancreatic head. There is no hydronephrosis. Left adrenal gland appears
unremarkable. There are moderate size bilateral pleural effusions.
IMPRESSION:
1. Evidence of unchanged distal small-bowel obstruction secondary to the
central mesenteric mass as described above.
2. Unchanged edema and mucosal hypoenhancement of the most distal dilated
small bowel loops proximal to the transition point concerning for vascular
compromise. Evidence of marked luminal narrowing of the SMV and SMA.
3. Moderate amount pleural effusions and large amount of intra-abdominal
ascites.
4. Unchanged central mesenteric mass biopsy-proven neuroendocrine tumor with
associated mesenteric adenopathy.
5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely evaluated and
remains indeterminate. This can be followed on subsequent imaging.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS
INDICATION: ___ w/ unresectable neuroendocrine tumor in the mesentery who
presented to OSH with complaints nausea and vomiting thought to be ___ to a
SBO. Has had refractory ascites since cancer diagnosis requiring weekly
paracentesis, due tomorrow.// Therapeutic paracentesis. Diagnostic to
determine if truly chylous ascites (concern per pt's description). Also
serum-to-ascites albumin gradient, cell count and differential, culture, total
protein and cytology.
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Outside facility CT abdomen and pelvis ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3.5 L of blood-tinged, slightly cloudy fluid were removed.
Fluid samples were submitted to the laboratory for cell count, differential,
culture, and cytology. Please note that according to patient, the previously
drained fluid looked very 'milky or milk-shake like' and different in
appearance compared to fluid retrieved on this paracentesis.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3.5 L of thin milky pink fluid were removed. Fluid samples were submitted
to the laboratory for cell count, differential, culture, and cytology.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, SBO, Transfer
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 98.6
heartrate: 94.0
resprate: 16.0
o2sat: 96.0
sbp: 140.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | #Small bowel obstruction
#Pancreatic neuroendocrine tumor
The patient initially presented with nausea and was found to
have a small bowel obstruction secondary to his known pancreatic
neuroendocrine tumor. He was initially treated with an NG tube,
kept NPO, treated with fluids and Zofran for nausea. However, by
the second day of his admission, his symptoms were markedly
improved, his NGT was removed and his diet was advanced.
Endoscopy showed normal mucosa in esophagus, stomach and
duodenum. MRE showed evidence of unchanged distal small-bowel
obstruction secondary to the central mesenteric mass. Based on
these findings, the patient's clinical improvement, and his
ongoing ascites, surgery decided to hold off on a bypass at this
time and see him in follow up as an outpatient.
# Ascites
Per hepatology evaluation, ascites seems to be multifactorial
due to portal hypertension due to the obliteration of his portal
vein and encasement of his SMA/SMV by his tumor, as well as
obstruction of his lymph system contributing to chylous nature
of the ascites. The liver is unlikely cirrhotic given normal
LFTs,
synthetic function and non-cirrhotic appearance on OSH CT scan.
For the concern for chylous ascites (based on patient's
description) as well as overall malnutrition, he was seen by
nutrition, who recommended a low fat, sodium restricted diet
with ensure enlive supplements mixed with beneprotein and 15 mL
medium chain triglycerides oil. A triene/tetraene ratio was also
checked with results pending on discharge; if> 0.4 and s/sx of
deficiency consider parenteral fat emulsion. He had a
paracentesis on the day of discharge, both therapeutic on
schedule for his weekly tap and also diagnostic to evaluate for
chylous ascites. Also continued home Lasix 10 mg daily while
inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ female patient with history of
hypertension, diabetes, arthritis, on steroids, dementia
presenting with her son for evaluation of ongoing weakness. The
patient was seen in the ED on ___ for abdominal pain and
shortness of breath and had a negative CT scan at that time. She
was diagnosed with a UTI and discharged home. Today she returns
with worsening pain weakness and shortness of breath. The
shortness of breath is worse with exertion. She is now also
requiring oxygen as she desats to 88 or 89% on room air. Her son
is also noticed that she has had new bilateral lower extremity
swelling. She has no history of heart failure. Son denies any
nausea vomiting or diarrhea. No black or bloody stools. However
he does note that she has been having poor p.o. intake.
In the ED, initial vital signs were:
T 97.7, HR 105, BP 128/55, RR 18, 92% Ra
Exam notable for:
on 3L NC, guiac negative
Labs were notable for:
CBC: WBC 11.2, Hgb 9.8, platelets 208
Chemistry: Na 140, K 4.5, CL 99, HCO3 25, BUN, Cr 0.8
Lactate 2.2
UA: Leuk Lg, nitrates positive, WBC 97, many bacteria
proBNP 547
troponins pending
Normal LFTs
Studies performed include:
CTA Chest:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevated right hemidiaphragm is similar to before.
3. Trace left pleural effusion.
CXR:
FINDINGS:
Lung volumes are relatively low as seen previously. Elevation
the right hemidiaphragm is unchanged. Linear opacity on the
lateral view, likely localizing to the left on the frontal view
is likely atelectasis. No definite focal consolidation. No
edema or effusion. Cardiomediastinal silhouette is stable.
IMPRESSION:
No definite acute cardiopulmonary process.
Patient was given:
Ceftriaxone 1 g
Insulin 2 units
Haldol 2 mg
Consults: none
Vitals on transfer:
HR 104, BP 106/60, RR 18, 94% 3 L NC
Upon arrival to the floor, the patient was found sleeping.
History was obtained by the family. The daughter and son who
take
care of her note that she is verbal, but does not respond to
direct questioning.
The family noted that their mom began grabbing her stomach
earlier in the month. That is when they first presented to the
ED. The patient was diagnosed with a UTI and was discharged with
a 10 day course of antibiotics. She took all of the antibiotics
as scheduled, but the abdominal pain never abided. She
initially
had only been grabbing her left lower abdomen and is now
grabbing
her right lower abdomen as well. The family reports she did not
tolerate the antibiotics well and was extremely awake and active
during treatment. She denies fevers, chills. Her appetite has
been decreased. She has intermittently having some looser stools
(last on ___. She has had no vomiting. She has had
increased wet diapers. Of note she has also been placing her
hand
over her chest at times.
She is currently short of breath. This has only started in the
past week. She was not short of breath when she came to the ED
several weeks ago. The son reports she had a similar episode of
shortness of breath some time ago and was started on an
incentive
spirometer by her PCP.
The family notes that she always reports she has a headache. She
is always cold even on warm summer nights. ROS otherwise limited
as patient does not respond to direct questioning.
Past Medical History:
Stroke
Diabetes
Dementia
Osteoarthritis (RT hip pain)
Hypertension
Osteoporosis
Lower Extremity Edema
Rheumatoid arthritis
Social History:
___
Family History:
Grandmother had stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- T97.8, BP 172/67, HR 113, RR 18, 93% Ra
General: Well appearing, NAD, sleeping comfortably
HEENT: atraumatic, PERRLA, no pallor, unable to assess mouth,
neck soft, no lymphadenopathy
Cardiac: Normal S1, S2, RRR, no murmur, rubs, gallops
Abdomen: normal bowel sounds, soft, non-tender, non-distended
Extremities: warm to palpation, 1+ peripheral edema, 2+ DP
pulses
Pysch: Not responding to any questioning, not following commands
DISCHARGE PHYSICAL EXAM:
========================
General: NAD, pleasant
HEENT: MMM
PULM: Decreased breath sounds at bases of lungs bilaterally with
faint crackles
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: warm, well perfused, 2+ DP pulses, no ___ edema
Pertinent Results:
ADMISSION LABS:
===============
___ 10:12AM BLOOD WBC-11.2* RBC-3.90 Hgb-9.8* Hct-32.6*
MCV-84 MCH-25.1* MCHC-30.1* RDW-17.1* RDWSD-50.9* Plt ___
___ 10:12AM BLOOD Glucose-171* UreaN-18 Creat-0.8 Na-140
K-4.5 Cl-99 HCO3-25 AnGap-16
___ 10:12AM BLOOD ALT-7 AST-12 AlkPhos-80 TotBili-0.3
___ 10:12AM BLOOD proBNP-547
___ 10:12AM BLOOD cTropnT-<0.01
___ 10:12AM BLOOD Lipase-30
MICROBIOLOGY:
=============
___ 11:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ (MD) (___)
___.
ESCHERICHIA COLI. >100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL
MORPHOLOGIES. .
PREVIOUSLY REPORTED AS ___.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
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
DISCHARGE LABS:
===============
___ 06:55AM BLOOD WBC-8.4 RBC-3.59* Hgb-8.9* Hct-29.8*
MCV-83 MCH-24.8* MCHC-29.9* RDW-17.1* RDWSD-51.6* Plt ___
___ 05:50AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-141
K-4.1 Cl-99 HCO3-28 AnGap-14
IMAGING/STUDIES:
================
CTA CHEST ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevated right hemidiaphragm is similar to before.
3. Trace left pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
3. Lisinopril 10 mg PO DAILY
4. Mirtazapine 7.5 mg PO QHS:PRN insomnia
5. RisperiDONE 0.25 mg PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Glargine 24 Units Breakfast
Humalog 14 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Clopidogrel 75 mg PO DAILY
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
10. Cyanocobalamin 100 mcg PO DAILY
11. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
3. Citalopram 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Glargine 24 Units Breakfast
Humalog 14 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Lisinopril 10 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Mirtazapine 7.5 mg PO QHS:PRN insomnia
10. PredniSONE 5 mg PO DAILY
11. RisperiDONE 0.25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Hypoxia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with SOB, hypoxia// r/o PTX PNA
TECHNIQUE: Two portable AP views of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lung volumes are relatively low as seen previously. Elevation the right
hemidiaphragm is unchanged. Linear opacity on the lateral view, likely
localizing to the left on the frontal view is likely atelectasis. No definite
focal consolidation. No edema or effusion. Cardiomediastinal silhouette is
stable.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with ___ edema dyspnea, hypoxia// r//o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
2) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 13.8 mGy (Body) DLP = 322.1
mGy-cm.
Total DLP (Body) = 324 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Trace left pleural effusion is noted.
LUNGS/AIRWAYS: Atelectasis is mild at the bilateral lung bases. Elevation of
the right hemidiaphragm is similar to before. The airways are patent to the
level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is notable for partially
imaged 0.8 cm hypodense lesion in the spleen, unchanged compared to ___ and statistically likely a cyst or hemangioma.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevated right hemidiaphragm is similar to before.
3. Trace left pleural effusion.
Gender: F
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Abd pain, Dyspnea on exertion, Leg swelling
Diagnosed with Dyspnea, unspecified
temperature: 97.7
heartrate: 105.0
resprate: 18.0
o2sat: 92.0
sbp: 128.0
dbp: 55.0
level of pain: 4
level of acuity: 3.0 | ___ woman with history of hypertension, diabetes,
rheumatoid arthritis on steroids, dementia presented with UTI,
abdominal pain, and dyspnea/hypoxia. Treated with 5 days
ceftriaxone, etiology of hypoxia unclear but resolved
spontaneously. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ketorolac / Nalbuphine / Simvastatin / Atorvastatin / Crestor /
adhesive tape / Erythromycin Base / Green Pepper / Macrobid /
Tizanidine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of sarcoidosis presents with
worsening shortness of breath, back pain, and dehydration.
Patient is ___ days post left pharngoplasty, arytenoid adduction,
and medialization laryngoplasty and since then she reports she
has not fully recovered, with poor ability to tolerate p.o. and
worsening back pain, which is chronic for her. Denies any fever
or chills at home. Has a chronic cough, which is nonproductive.
She denies any N/V/D orthopnea, PND or sputum production.
In the ED, initial vitals were: 97.6 107 111/71 22 97% ra
Labs were significant for
CBC: 8.8 > 12.5 < 309
CHEM 7
131 95 23
-------------<355
5.2 24 0.7
Lactate:3.6
Ca: 11.0 Mg: 1.9 P: 2.3
Imaging revealed
- T spine X ray: Limited evaluation of the vertebral bodies at
the upper thoracic spine. If This remains of clinical concern,
CT is more sensitive and should be considered. Query pulmonary
nodule projecting over the right mid lung appear recommend
dedicated chest x-ray for further evaluation.
- CXR: No acute findings
The patient was given
2 L IVF 1 mg IV dilaudid x2 and tessalon perels x1
Vitals prior to transfer were:
T 97.5 82 129/69 20 98% RA
Upon arrival to the floor,
Vitals were T 98.1 BP 155/80 p 96 R 20 99% on RA
REVIEW OF SYSTEMS:
(+) Per HPI On interview on the floor she reports cough is worse
after eating and she now has worsening SOB on exertion which is
worse since her surgery on ___. She also reprots subacute gait
insability requiring a walker for ambulation x several months as
well as urinary incontinece requiring depends x ___ months.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies 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:
TBM - (Aspiration of foreign object ___ s/p intubation)
1. Sarcoidosis
2. Diabetes
3. Hypertension
4. Hyperlipidemia
5. Pancreatic disease
- s/p cholecystectomy, ___
- s/p sphincterotomy, ___
- numerous ERCP
6. Chronic abdominal/back pain with history of detox
7. Osteoarthritis
8. Osteoporosis with compression fractures
9. Peptic ulcer disease
10. Gastroesophageal reflux disease
11. Depression
.
PAST SURGICAL HISTORY:
1. Appendectomy. ___
2. Right ankle pinning, 1970s
3. Total abdominal hysterectomy, ___
4. Kyphoplasy, ___
5. Rib fracture, thought secondary to coughing (___)
6. Inguinal hernia repair
7. Left pharngoplasty, arytenoid adduction, and medialization
laryngoplasty (___)
Social History:
___
Family History:
Father: died of CVA
Mother: died of MI/COPD
Brother: died of MI (age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.1 BP 155/80 HR 96 R 20 99% on RA
General: Alert, oriented, no acute distress, initially able to
speak full sentenced but became staccato during interview with
rare transmitted upper airway wheeze
HEENT: ruddy complexion Sclera anicteric, MMM, oropharynx clear
Neck: thick neck,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rare expiratory wheeze
Abdomen: Obese, nontender
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 PHYSICAL EXAM:
Vitals: Tm 98.9, 108/65, 76, 18, 97%RA
General: Alert, oriented, NAD
HEENT: Oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Occasional transmission of upper airway sounds, otherwise
clear to auscultation, no wheezes.
Pertinent Results:
==== ADMISSION LABS ====
___ 06:10PM BLOOD WBC-8.8 RBC-4.24 Hgb-12.5 Hct-34.9*
MCV-82 MCH-29.4 MCHC-35.8* RDW-16.1* Plt ___
___ 06:10PM BLOOD Neuts-76.9* ___ Monos-4.4 Eos-0.4
Baso-0.3
___ 01:18AM BLOOD Glucose-215* UreaN-17 Creat-0.6 Na-136
K-4.5 Cl-103 HCO3-23 AnGap-15
___ 06:10PM BLOOD Calcium-11.0* Phos-2.3* Mg-1.9
==== PERTINENT LABS ====
___ 01:18AM BLOOD PTH-51
___ 01:18AM BLOOD 25VitD-21*
___ 01:18AM BLOOD VITAMIN D ___ DIHYDROXY-PND
==== IMAGING ====
CXR (___):
PA and lateral views of the chest provided. Lungs appear
grossly clear.
Subtle areas of scarring in the right mid lung not significantly
changed from recent CT. No focal consolidation concerning for
pneumonia. No effusion or pneumothorax. Cardiomediastinal
silhouette is stable. Vertebroplasty changes at the lower
thoracic spine noted. Chronic right fourth rib resection noted.
IMPRESSION: No acute findings.
T-SPINE PLAIN FILM (___):
Limited evaluation of the vertebral bodies at the upper thoracic
spine. This remains of clinical concern, CT is more sensitive
and should be considered. Query pulmonary nodule projecting over
the right mid lung appear recommend dedicated chest x-ray for
further evaluation.
VIDEO SWALLOW (___):
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is trace penetration with
thin liquids, but no gross aspiration.
IMPRESSION:
Penetration with thin liquids, but no aspiration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Tricor (fenofibrate nanocrystallized) 145 mg ORAL QAM
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. Pravastatin 40 mg PO QPM
11. PredniSONE 20 mg PO DAILY
12. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Ibuprofen 400 mg PO Q8H:PRN pain
14. Nortriptyline 75 mg PO QHS
15. Lorazepam 1 mg PO Q8H:PRN anxiety
16. Metoclopramide 10 mg PO QIDACHS
17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. Lisinopril 10 mg PO DAILY
7. Lorazepam 1 mg PO Q8H:PRN anxiety
8. Metoclopramide 10 mg PO QIDACHS
9. Nortriptyline 75 mg PO QHS
10. Omeprazole 40 mg PO BID
11. Pravastatin 40 mg PO QPM
12. PredniSONE 20 mg PO DAILY
13. Fenofibrate (fenofibrate nanocrystallized) 145 mg ORAL QAM
14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*14 Tablet Refills:*0
15. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
16. Nystatin Cream 1 Appl TP BID Duration: 5 Days
RX *nystatin 100,000 unit/gram Apply to affected area. twice a
day Refills:*0
17. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride [Ditropan XL] 5 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
18. Phosphorus 500 mg PO TID
RX *sod phos,di & mono-K phos mono [Phospha 250 Neutral] 250 mg
2 tablet(s) by mouth three times a day Disp #*90 Tablet
Refills:*0
19. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tablet(s) by mouth qday Disp
#*30 Tablet Refills:*0
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
22. Ibuprofen 400 mg PO Q8H:PRN pain
23. Outpatient Lab Work
Please draw Chem-10 panel on ___
Indication: ICD-9-CM ___
Fax results to Dr. ___ (FAX: ___
24. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Paradoxical vocal cord dysfunction
Secondary Diagnoses:
- Urinary tract 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: CHEST (PA AND LAT)
INDICATION: ___ with increased sob/doe // ?pna
COMPARISON: CT trachea dated ___.
FINDINGS:
PA and lateral views of the chest provided. Lungs appear grossly clear.
Subtle areas of scarring in the right mid lung not significantly changed from
recent CT. No focal consolidation concerning for pneumonia. No effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Vertebroplasty changes
at the lower thoracic spine noted. Chronic right fourth rib resection noted.
IMPRESSION:
No acute findings.
Radiology Report
INDICATION: History: ___ with upper thoracic spine pain // Eval for
fx/injury
TECHNIQUE: AP and lateral views of thoracic spine
COMPARISON: None.
FINDINGS:
The superior thoracic spine vertebral bodies are not well assessed on the
lateral view. The patient is status post vertebroplasty/ kyphoplasty at the
thoracolumbar junction, not well assessed on the study. Vertebral body heights
and alignment are maintained in the mid to lower thoracic spine. Chronic
appearing rib deformity involving the right fourth rib. Query pulmonary nodule
projecting over the right mid lung appear recommend dedicated chest x-ray for
further evaluation.
IMPRESSION:
Limited evaluation of the vertebral bodies at the upper thoracic spine. This
remains of clinical concern, CT is more sensitive and should be considered.
Query pulmonary nodule projecting over the right mid lung appear recommend
dedicated chest x-ray for further evaluation.
Radiology Report
EXAMINATION: VIDEO SWALLOW STUDY
INDICATION: ___ year old woman with hx of sarcoidosis, ENT surgery 1 month ago
for vocal cord paralysis, p/w worsening SOB/cough/dysphagia since operation.
// ? leak contributing to aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2.4 min.
COMPARISON: ___
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is trace penetration with thin liquids, but no gross
aspiration.
IMPRESSION:
Penetration with thin liquids, but no aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with SHORTNESS OF BREATH, HYPERCALCEMIA, DIABETES UNCOMPL JUVEN
temperature: 97.6
heartrate: 107.0
resprate: 22.0
o2sat: 97.0
sbp: 111.0
dbp: 71.0
level of pain: 8
level of acuity: 2.0 | ___ with h/o sarcoidosis, hypercalcemia and recent laryngeal
surgery for vocal cord paralysis admitted for progressive DOE
and coughing since her surgical procedure 1 month ago, as well
as expedited neurology consultation for new urinary incontinence
and gait instability.
# Dyspnea and cough without hypoxemia: Patient presented with
dyspnea and cough that had worsened since her ENT surgical
intervention 1 month ago. Appeared to be upper airway in nature.
No evidence of PNA on CXR, no elevated WBC count, EKG unchanged
from prior. Patient localized a sensation to her throat which is
worse with eating and results in coughing. Lungs were clear to
auscultation without wheezing but with occasional transmission
of upper airway sounds. ENT was consulted and declined to scope
the patient because she had been scoped the day prior to
admission without evidence of any pathology that could be
contributing to her presentation. They recommended video swallow
to rule out aspiration but otherwise no acute intervention.
Video swallow on ___ was w/o evidence of aspiration.
Differential includes paradoxical vocal cord dysfunction. Her
omeprazole was subsequently increased to 40mg BID. Despite the
patient's ongoing symptoms, there was no immediate need for
inpatient work up. She was therefore able to be discharged home
for ongoing workup as an outpatient. She will have close follow
up in pulmonary and neurology clinic. We have also recommended
referral to speech pathology for empiric treatment of
paradoxical vocal cord dysfunction.
# Hypercalcemia: Total serum calcium of 11.0 on admission which
resolved after receiving 2L IVF in the ED. Differential includes
sarcoidosis (1,25-OH-VitD pending), malignancy, and
calcium-alkali syndrome (serum bicarbonate elevated). Normal PTH
makes primary hyperparathyroidism highly unlikely. Low 25-Vit-D
(value of 21 this admission) could be consistent with
sarcoidosis or other granulomatous processes if the 1,25-Vit-D
comes back as high (currently pending). Patient's serum
phosphate was low on presentation but this is confounded by her
poor PO intake in the setting of her dysphagia. The patient is
scheduled to follow up with both pulmonology and neurology at
___, as well as her PCP, for ongoing evaluation of this issue.
1,25-OH-Vitamin D will be followed up by her pulmonologist.
# Back Pain, Urinary Incontinence, Lower Extremity Weakness /
Gait Instability: Per patient, her back pain has not changed in
years. However, her gait instability and urinary incontinence
are new/subacute in onset and raised concern for malignancy vs
neurosarcoidosis. Neurology was consulted on ___ for evaluation
of her lower extremity weakness, gait instability and urinary
incontinence. They felt that her presentation was not consistent
with neurosarcoidosis or normal pressure hydrocephalus and there
was no need for imaging studies. Their impression was that her
weakness was secondary to deconditioning and mild electrolyte
abnormalities (mild hypophosphatemia) and that they would
resolve with physical therapy and electrolyte repletion. At
discharge, the patient was prescribed potassium, phosphate and
magnesium supplements to aid in preventing electrolyte
imbalances.
# UTI: Urine culture from admission grew >100k E.coli resistant
to ampicillin, cefazolin, ceftriaxone, ciprofloxacin, tobramycin
and bactrim. It was sensitive to ampicillin/sulbactam,
ceftazidime, gentamicin, meropenam, nitrofurantoin, and zosyn.
Given the patient's allergy history and use of prednisone, she
was prescribed a 7 day course of Augmentin (___) to
complete as an outpatient.
# Diabetes: The patient's insulin sliding scale was increased at
discharge given hyperglycemia into 300s-400s during admission.
==== TRANSITIONAL ====
# 1,25-OH-Vit-D pending at discharge
- Patient has pulmonology follow up with her outpatient
provider. Please follow up the 1,25-OH-VitD sendout lab for
question of sarcoidosis as underlying cause of her hypercalcemia
# Urinary Incontinence
- 7 day Augmentin course for UTI
- Started oxybutynin 5mg PO TID
- Patient has an outpatient urologist with whom she will
schedule a follow up appointment
# Cough, SOB, possible paradoxical vocal cord dysfunction
- Pulmonary follow up appointment scheduled
- PCP follow up within 1 week: we highly recommend outpatient
speech pathology referral for empiric treatment of paradoxical
vocal cord dysfunction
# Back pain and lower extremity weakness / gait instability
- Patient will be called regarding scheduling follow up with
Neurology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Cephalosporins /
Quinolones / Bactrim / Oxycodone
Attending: ___.
Chief Complaint:
intertrochanteric hip fracture
Major Surgical or Invasive Procedure:
ORIF of hip
History of Present Illness:
___ y/o F with hx of ESRD on HD ___, HTN, moderate AS, and
bifasicular block who presents with a fall leading to R
intertrochanteric hip fracture and is transferred to the MICU
for respiratory status monitoring after general anesthesia.
Patient was home after HD and fell face forward after getting up
from the chair due to hx of imbalance and lightheadedness after
HD. No LOC, +head strike, remembers event of the fall. Family
denies any chest pain, shortness of breath, or any other recent
complaints. She was brought to OSH where she was found to have R
intertrochanteric hip fracture. CT head and c-spine were
negative. She was transferred to BI for orthopedic intervention.
She reportedly had palpitations and progressive dyspnea, and a
pre-operative TTE on ___ revealed mild/moderate aortic stenosis
with a valve area of 1.7, elevated PASP around 60mmHg, mild
mitral stenosis. She subsequently went to the OR for ORIF. She
received 1U PRBCs intraoperatively. She did not tolerate spinal
block thus the procedure was done under general anesthesia. She
was hypotensive during the case to 70/30 and was transfused 1U
PRBCs, given 1300mL IVF, and started on phenylephrine. She
remained intubated given general anesthesia and intraoperative
fluid shifts, so she is transferred to the care of the MICU team
post-op.
On arrival to the MICU, patient is intubated and sedated but
hemodynamically stable.
Past Medical History:
stage V CKD ___ htn and ischemic nephropathy
HTN
gout
osteoarthritis
sensori-neural hearing loss
mod aortic stenosis
mitral annular calcification
tricuspid regurgitation
diverticulitis s/p colostomy and subsequent takedown, ileostomy
h/o GI obstruction
vitamin D deficiency
h/o obesity
abdominal fistula
hip fracture
Social History:
___
Family History:
Father passed at ___ from MI, mother passed at ___ from "old age."
Multiple siblings passed from cancer including brother from
colon ca in ___, sister with stomach cancer, sister with throat
cancer. Another brother currently has ___ and another
sister passed from unknown causes.
Physical Exam:
Physical Exam on Admission:
GENERAL: intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally,
CV: distant heart sounds no murmurs appreciated
ABD: soft, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, right hip dressing clean with incision clean, dry, and
intact
SKIN: multiple small areas of eccymoses
NEURO: intubated and sedated, does not open eyes to voice or
noxious stimuli
Discharge Physical Exam:
Vitals: T: 98.1 BP: 101/46 P: 77 R: 18 O2: 95% RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP normal
Lungs: Clear to auscultation bilaterally with good air movement
CV: Regular rate and rhythm, normal S1 + S2, mid peaking II/VI
SEM
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema. Patient states she has chronic decreased right foot
sensation which is stable. Moves R toes to command. Incision
has surrounding ecchymosis but is c/d/i. The right hip is
moderately larger than the left hip but is not firm.
Pertinent Results:
___ 09:42PM GLUCOSE-128* UREA N-36* CREAT-4.0* SODIUM-138
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11
___ 09:42PM estGFR-Using this
___ 09:42PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.1
___ 09:42PM WBC-16.4* RBC-3.45* HGB-10.6* HCT-34.0*
MCV-99* MCH-30.6 MCHC-31.1 RDW-17.7*
___ 09:42PM NEUTS-81.3* LYMPHS-10.2* MONOS-7.0 EOS-1.0
BASOS-0.4
___ 09:42PM PLT COUNT-256
___ 09:42PM ___ PTT-29.3 ___
Discharge Labs:
___ 05:40AM BLOOD WBC-12.1* RBC-2.89* Hgb-9.1* Hct-28.2*
MCV-98 MCH-31.5 MCHC-32.2 RDW-17.4* Plt ___
___ 05:40AM BLOOD Glucose-86 UreaN-32* Creat-3.7*# Na-131*
K-3.8 Cl-93* HCO3-29 AnGap-13
___ 05:40AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
CXR:
FINDINGS: In comparison with study of ___, what appears to be
the
right-sided PICC line has its tip just outside the rib cage.
Obliquity of the patient somewhat obscures detail, though the
overall appearance of the heart and lungs is quite similar to
the prior examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Acetaminophen 1000 mg PO Q8H
4. Heparin 5000 UNIT SC TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6hrs prn
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Right Hip fracture s/p ORIF
Secondary Diagnosis:
Heart failure with preserved EF
HTN
Gout
CKD stage V on Hemodyalisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: PICC line pulled by the patient.
FINDINGS: In comparison with study of ___, what appears to be the
right-sided PICC line has its tip just outside the rib cage. Obliquity of the
patient somewhat obscures detail, though the overall appearance of the heart
and lungs is quite similar to the prior examination.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.
INDICATION: ORIF right hip.
TECHNIQUE: 51 spot fluoroscopic images obtained in the OR without radiologist
present, 134.1 seconds fluoroscopy time.
COMPARISON: Right femur radiographs ___.
FINDINGS:
The available images show open reduction internal fixation of a proximal
femoral fracture with placement of an IM nail. A dynamic hip screw is placed
through the femoral neck. Please see the operative report for further
details.
IMPRESSION:
Intraoperative images from open reduction internal fixation of a right
proximal femur fracture
Radiology Report
PORTABLE CHEST ___ WITH COMPARISON ___ RADIOGRAPH
FINDINGS: Interval placement of endotracheal tube, with tip terminating 3 cm
above the carina. Cardiomediastinal contours are stable. Interval
development of bibasilar atelectasis, left greater than right, as well as a
small left pleural effusion. No definite pneumothorax.
Radiology Report
INDICATION: ___ year old woman with 45cm right PICC out 1 cm.
TECHNIQUE: Single portable AP view of the chest was obtained.
COMPARISON: Multiple prior chest radiographs, most recently ___ 14:22
FINDINGS:
Endotracheal tube has been removed. There is interval placement of a
right-sided PICC line. The tip projects over the right paraspinal line and is
somewhat difficult to see, but likely terminates in the lower SVC. Enlargement
of the cardiac silhouette is likely in part due to technique, but remains
stable. Lungs are clear. Bibasilar atelectasis noted. There is no large
effusion or pneumothorax.
IMPRESSION:
Interval removal of endotracheal tube and placement of a right PICC with tip
likely in the lower SVC. No substantial change otherwise.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, RIGHT HIP FX, Transfer
Diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: 98.0
sbp: 127.0
dbp: 84.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ woman with h/o ESRD on HD ___, HTN,
and moderate AS who presents with a fall c/b L hip fracture and
s/p ORIF and transferred to MICU for continued intubation and
hypotension intra-operatively requiring phenylepherine.
# L Hip fracture: s/p successful ORIF by orthopedics.
Orthopedics continued to monitor patient's recovery daily during
her MICU and medicine floor stay and there were no
complications.
# Respiratory status: Pt intubated for general anesthesia
administration as patient did not tolerate spinal block. She
received 1 unit pRBC and 1.3L of fluid in the OR and remained
intubated in the event she developed flash pulmonary edema as
she does not make any urine and is on HD. Patient was
successfully extubated on ___. She had no further respitatory
distress during admission.
# Hypotension: Likely ___ multifactorial in setting of
intubation with positive pressure ventilation and likely volume
depletion given symptoms prior to fall (light-headedness ___
HD). Required phenylepherine in the OR and was then s/p 1 unit
pRBC and 1.3L as well. Patient did have a leukocytosis but no
fevers or chills and no report of any localizing source of
infection. She was weaned from phenylephrine and propofol and
pressures remained stable. Her blood pressure remained in the
85-100 Systolic range once transitioned to floor. She was
asymptomatic.
# Leukocytosis: Most likely reactive in nature, patient without
any localizing sources of infection and no fevers or chills on
presentation. Patient was given clindamycin perioperatively but
antibiotics were not continued. He leukocytosis is 12 and
downtrending at the time of discharge.
# ESRD: Anuric by report, has dialysis ___.
Patient missed HD on ___ and, on ___, patient was found to
have K 7.9 and decreased bicarb of 9. She had urgent bedside HD
and her lab abnormalities improved. Her last HD session was
___. She is scheduled for her next session on ___.
#Delirium: Pt had episodes of hypoactive delirium overnight
which improved with reorientation and during day light hours.
Attempt to minimize pain medications as possible.
# s/p fall
Per family, patient felt lightheaded as she usually does after
dialysis and unfortunately fell after standing. Family denies
patient was having any chest pain, shortness of breath. Denies
any recent cough as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
left upper extremity paresthesias and weakness
Major Surgical or Invasive Procedure:
Core needle biopsy of the thoracic spinal mass ___
History of Present Illness:
___ year old man with history of C4-C5 cervical fusion ___ years
ago), L2-L5 stenosis, DM2 and HTN, presents with left upper
extremity paresthesias and weakness. Symptoms began two months
ago. He has pain that starts in his left shoulder blade and
radiates down arm to level of elbow. From his elbow to his hand
he has paresthesias. He has lost his fine dexterity in his left
hand which feels weak. He has been using oxycodone for the pain
which helps, but recently needed to increase the dose because of
worsening symptoms. No aggravating factors. He has cervical
neck pain when flexing his chin to his chest, but not with head
rotation. He lost 20lb unintentionally over the past year.
Denies fever, chills, night sweats, blood in stool/urine. He
has recently developed a sore throat and cough, but no SOB. He
smokes ___ cig/day for the past ___ years.
His PCP ordered an MRI of the cervical spine which showed a mass
around the cervical cord. His neurosurgeon subsequently
referred him to the ED.
In the ED, initial vitals: 99.2 91 165/72 16 100% RA. He
received his home meformin 100mg, oxycodone/acetaminophen
___ x2, gabapentin 20mg. Images were uploaded into PACS.
No labs were obtained.
Upon arrival to the floor, he has mild pain in his arm and
shoulder. Feels anxious and scared. He has a supportive wife
and brother with him at the bedside.
ROS: per HPI, headache, vision changes, rhinorrhea, congestion,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
cervical fusion by Dr ___ at ___ ___ years ago
cervical fusion by Dr ___ at ___ ___ years ago
glaucoma
Type II diabetes
? HTN
severe DJD with L2-L5 lumbar stenosis
arthritis
psoriasis
right knee meniscus repair ___ years ago at ___ orthopedics
lymph node/left enlarged salivary gland resection ___ yrs ago
(benign)
Social History:
___
Family History:
father w/ psoriasis and CABG age ___, mother with OA, maternal
uncle with lung CA (smoker), no other malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION (___):
VS - 97 136/64 78 18 100%RA
GENERAL - NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclera anicteric, MMM, OP clear
NECK - supple, no LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - wheezing at bases b/l, no rhonchi or crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no axillary or inguinal LAD
SKIN - psoriatic plaques on UE b/l
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ with exception of 4+/5 with hand flexion, sensation intact
to dull and sharp touch in UE b/l
DISCHARGE PHYSICAL EXAMINATION (___):
GENERAL - NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclera anicteric, MMM, OP clear
NECK - supple, no LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/rhonchi
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - psoriatic plaques on UE b/l
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ grossly in UE and ___, sensation intact grossly in UE and ___
Pertinent Results:
ADMISSION LABS:
___ 09:05PM BLOOD WBC-5.9 RBC-3.28* Hgb-11.4* Hct-33.6*
MCV-102* MCH-34.8* MCHC-34.0 RDW-13.9 Plt Ct-71*
___ 09:05PM BLOOD Neuts-55 Bands-0 ___ Monos-7 Eos-5*
Baso-0 ___ Myelos-0
___ 09:05PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 09:05PM BLOOD ___ PTT-33.4 ___
___ 07:25AM BLOOD Ret Aut-1.6
___ 09:05PM BLOOD Glucose-105* UreaN-10 Creat-0.9 Na-137
K-4.4 Cl-102 HCO3-29 AnGap-10
___ 09:05PM BLOOD ALT-30 AST-33 LD(LDH)-128 AlkPhos-64
TotBili-0.4
___ 09:05PM BLOOD Calcium-10.0 Phos-3.0 Mg-2.1 UricAcd-3.6
___ 07:25AM BLOOD TotProt-6.8 Albumin-3.7 Globuln-3.1
Iron-76
___ 07:25AM BLOOD calTIBC-337 ___ Ferritn-95 TRF-259
___ 07:50AM BLOOD VitB12-431
___ 07:25AM BLOOD TSH-1.7
___ 07:25AM BLOOD HBsAb-NEGATIVE
___ 07:25AM BLOOD PEP-NO SPECIFI
___ 07:25AM BLOOD HCV Ab-NEGATIVE
___ 07:25AM BLOOD METHYLMALONIC ACID-PND
___ 02:00AM URINE U-PEP-NO PROTEIN
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-5.4 RBC-3.48* Hgb-12.1* Hct-36.8*
MCV-106* MCH-34.6* MCHC-32.8 RDW-14.1 Plt Ct-73*
___ 07:20AM BLOOD Glucose-117* UreaN-11 Creat-1.0 Na-138
K-4.2 Cl-101 HCO3-28 AnGap-13
IMAGING STUDIES:
CXR (___): Hardware overlies the lower cervical spine
consistent with previous cervical fusion. Lungs are relatively
well inflated without evidence of focal airspace consolidation,
pleural effusions, or pneumothorax. The interstitium is
slightly prominent, but this may reflect small airways disease,
age related changes or smoking-related changes. Clinical
correlation is advised. Overall cardiac and mediastinal
contours are within normal limits. No acute bony abnormality is
seen. Depending upon the etiology of the patient's cervical
mass, additional imaging with CT could be undertaken. Minimal
degenerative changes in the thoracic spine with no obvious
vertebral compression fractures.
CT CHEST/ABDOMEN/PELVIS with CONTRAST (___):
1. 5.6 x 6.2 cm enhancing mass arising from the upper pole of
the right
kidney suspicious for renal cell carcinoma with large mass
involving T1-T3
likely representing a metastatic focus as well as a concerning
lesion in the spleen.
2. Enlarged left subclavian lymph node may also represent
metastatic
involvement.
3. Thicking of the bilateral adrenal glands without discrete
nodule or mass may represent hyperplasia, but metastases not
excluded.
4. Cirrhosis with evidence of portal hypertension and
esophageal varices.
5. Cholelithiasis.
___ RADIOLOGY READ OF OSH C-SPINE MRI (___)
1. Large expansile mass lesion involving the posterior left
paramedial
vertebral bodies from T1 through T3 levels as described in
detail above,
causing left-sided neural foraminal narrowing at T1/T2, T2/T3
levels and also left paracentral canal narrowing and impinging
the thecal sac posteriorly, no frank evidence of spinal cord
edema is demonstrated.
2. The differential diagnosis for this lesion includes
metastatic disease,
myeloma may have similar appearance.
3. Small cystic-appearing formation noted in the posterior lobe
of the
thyroid gland on the right, there is also a small area of cystic
signal on the posterior aspect of the right parotid gland,
possibly consistent with a small intraparotid lymph node or
cystic formation.
4. The patient is status post anterior fusion and discectomy at
C5/C6 level.
PATHOLOGY:
Spinal mass cytology (___): POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic carcinoma,
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Infliximab 800 mg IV Q5WEEKS
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Gabapentin 300 mg PO HS
4. Gabapentin 200 mg PO TID
5. OxycoDONE (Immediate Release) 10 mg PO TID:PRN pain
6. Duloxetine 90 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
11. Ranitidine 150 mg PO BID
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Duloxetine 90 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Gabapentin 200 mg PO TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
hold for RR <12 or sedation
RX *oxycodone 10 mg 1 tablet(s) by mouth q4H PRN Disp #*80
Tablet Refills:*0
8. Ranitidine 150 mg PO BID
9. Simvastatin 20 mg PO DAILY
10. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Docusate Sodium 100 mg PO BID constipation
RX *Colace 100 mg 1 capsule(s) by mouth BID PRN Disp #*30 Tablet
Refills:*0
13. Nicotine Patch 14 mg TD DAILY nicotine craving
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*28 Transdermal
Patch Refills:*0
14. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
hold for RR <12 or sedation
RX *OxyContin 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*30 Tablet Refills:*0
15. Senna 1 TAB PO BID constipation
RX *senna 8.6 mg 1 tab by mouth BID PRN Disp #*60 Tablet
Refills:*0
16. Infliximab 800 mg IV Q5WEEKS
17. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic malignancy, suspected renal origin with metastases to
thoracic spine, adrenal and spleen
Thrombocytopenia
Anemia
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 FILM ___ AT 2138
CLINICAL INDICATION: ___ with new cervical mass. Evaluate for
intrathoracic malignancy.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
PA and lateral views of the chest ___ at 2138 are submitted.
IMPRESSION:
1. Hardware overlies the lower cervical spine consistent with previous
cervical fusion. Lungs are relatively well inflated without evidence of focal
airspace consolidation, pleural effusions, or pneumothorax. The interstitium
is slightly prominent, but this may reflect small airways disease, age related
changes or smoking-related changes. Clinical correlation is advised. Overall
cardiac and mediastinal contours are within normal limits. No acute bony
abnormality is seen. Depending upon the etiology of the patient's cervical
mass, additional imaging with CT could be undertaken. Minimal degenerative
changes in the thoracic spine with no obvious vertebral compression fractures.
Radiology Report
EXAM: CT torso with contrast.
INDICATION: ___ man with new T1-T3 mass with left-handed weakness and
shoulder pain. Please evaluate for other primary malignancy.
COMPARISON: MRI cervical spine from outside institution ___.
TECHNIQUE: 5-mm axial series through the chest, abdomen, and pelvis after
uneventful administration of 75 cc Omnipaque IV contrast and 900 cc Redicat
p.o. contrast. Coronal and sagittal reformats provided by technologist.
DLP: 816.97 mGy-cm.
FINDINGS:
CHEST:
In the left supraclavicular fossa, there is a 1.3-cm lymph node. No other
lower cervical or supraclavicular adenopathy is seen. Normal appearance of
the visualized thyroid. Heart size within normal limits. Atherosclerotic
coronary artery calcifications are noted. There is a 5-mm prevascular lymph
node as well as a 10-mm subcarinal lymph node.
Normal overall lung parenchymal pattern without suspicious nodule or mass
arising from the lung parenchyma. Extending from T1 to T4, there is a large
soft tissue mass which measures 5.4 x 5.8 cm in greatest axial dimension, with
cortical destruction involving the posterior and left paramedial aspect of the
vertebral bodies, the costovertebral junction, and short segments of the left
first-third ribs. The mass measures 6.3 cm in craniocaudal dimension and
involves only the superior T4 facet on the left. There is encroachment on the
spinal canal, best seen on series 2, image 9, with abutment against the spinal
cord at the T2 and T3 levels. No other thoracic lesions are identified.
ABDOMEN/PELVIS:
Cirrhotic morphology of the liver with hypertrophied caudate lobe,
recanalization of the umbilical vein, esophageal varices and gastrohepatic
varices. No hepatic lesions are identified. There is a small amount of
perihepatic fluid. There is cholelithiasis without evidence of acute
cholecystitis. The spleen contains a 14-mm ill-defined hypoenhancing lesion
(2:54) which is suspicious for metastasis. In the right kidney, there is a
5.6 x 6.2 cm heterogeneously enhancing mass arising from the upper pole which
may represent the primary tumor. There is also a cortical defect of the right
inferior renal pole which could be post-infectious or related to prior
procedure or infarct. Left kidney contains a simple-appearing 9-mm cyst which
is too small to accurately characterize with CT. There is thickening of the
medial limb of the right adrenal gland as well as slight thickening of the
left adrenal gland which could represent hyperplasia versus less likely,
metastatic involvement.
Small and large bowel are unobstructed. There is colonic diverticulosis
without evidence of acute diverticulitis. Normal appearance of the bladder.
Hepatic arterial anatomy is standard. Portal vein and splenic veins are
patent. There are prominent peripancreatic and periportal lymph nodes
measuring up to 1.5 cm in short axis, which are most likely related to
cirrhosis, however, metastasis is not excluded.
Degenerative changes of the lower lumbar spine. No additional suspicious bone
lesions are identified.
IMPRESSION:
1. 5.6 x 6.2 cm enhancing mass arising from the upper pole of the right
kidney suspicious for renal cell carcinoma with large mass involving T1-T3
likely representing a metastatic focus as well as a concerning lesion in the
spleen.
2. Enlarged left subclavian lymph node may also represent metastatic
involvement.
3. Thicking of the bilateral adrenal glands without discrete nodule or mass
may represent hyperplasia, but metastases not excluded.
4. Cirrhosis with evidence of portal hypertension and esophageal varices.
5. Cholelithiasis.
Radiology Report
INDICATION: Left hand weakness and paresthesias.
COMPARISON: MR ___ reference examination available from ___.
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the neck were obtained
following the uneventful administration of 70 cc of Omnipaque intravenous
contrast. Coronal and sagittal reformations were performed at 2-mm slice
thickness.
FINDINGS:
The patient is post anterior fusion of C5/6 (301B:55). Vertebral disc spacer
prosthesis is present. There is no acute fracture or traumatic malalignment
of the cervical spine. No prevertebral soft tissue abnormalities are seen.
Centered about the left T2 lamina is a large heterogeneously enhancing soft
tissue mass measuring up to 5.9 x 5.3 cm, better appreciated on the CT torso
examination performed on the same day (2:70), demonstrating extensive cortical
destruction of the posterior left paramedial T1, T2, and T3 vertebral bodies,
with involvement of the costovertebral junction, short segments of the left
first through third ribs, the left T2 and T3 lamina and spinous processes, and
the left T1 through 3 neural foramen. There is encroachment of the spinal
canal with abutment against the cord at the T2 and T3 levels (2:70).There is
about 50% narrowing of the spinal canal and displacement of the thecal sac to
the right.
Included views of the brain parenchyma are unremarkable. Aerosolized
secretions are seen within the maxillary sinuses, worse on the right (2:15).
The middle ear cavities and mastoid air cells are clear.
The parotid and submandibular glands are symmetric in size and appear normal.
No cervical lymphadenopathy is seen.
The thyroid is normal.
There are moderate atherosclerotic calcifications at the carotid bifurcations
(2:46).
Prominent prevascular lymph nodes and an enlarged subcarinal node (2:90) are
incompletely seen, better appreciated on the CT torso examination.
IMPRESSION:
1. Destructive soft tissue mass arising from the T2 left lamina extending to
the T1 through T3 posterior left paramedial vertebral bodies, with involvement
of the T1 through T3 costovertebral junction, towards segments of the left
first through third ribs, and left T1 through T3 neural foramen.
2. Encroachment of the mass into the spinal cord at the T2 and T3 levels,
with abutment against the cord.
3. No cervical lymphadenopathy.
4. Moderate maxillary sinusitis with acute features.
5. Post C5/6 anterior cervical fusion.
Radiology Report
EXAM: CT-guided soft tissue biopsy.
COMPARISON: CT Torso, ___.
MEDICATIONS: Fentanyl 100 mcg, Versed 2 mg, 10ml 1% Lidocaine.
Moderate sedation was provided by administering divided doses of fentanyl and
Versed throughout the total intraservice time of 20 minutes during which the
patient's hemodynamic parameters were continuously monitored.
PHYSICIANS: Dr. ___ Dr. ___.
TECHNIQUE: Informed consent was obtained. A final timeout was performed.
The patient was scanned in prone position in the area of interest. The area
over the planned tract was prepped and draped. The skin and tract were
anesthetized using 1% lidocaine. An 18-gauge ___ needle was advanced to
the lesion, and using a 17-gauge Bard biopsy device, two samples were
obtained. These were deemed adequate by cytology onsite. The needle and
trocar were removed. Manual pressure was used for hemostasis. The patient
tolerated the procedure well without complication.
Complications: None
Sample: Core Biopsy (2)
IMPRESSION:
Successful thoracic mass biopsy.
Radiology Report
STUDY: MRI of the cervical spine, second opinion readout.
CLINICAL INDICATION: ___ man with history of low back pain,
presurgical evaluation.
COMPARISON: Prior CT of the neck and torso dated ___.
TECHNIQUE: This examination was performed on ___ at an outside
institution (Shields MRI, ___ MRI and CT Center).
Sagittal T1, T2 and proton density images were submitted for interpretation
and also axial 3D T2, axial T2-weighted images.
FINDINGS: The left parotid gland is not clearly identified, however, appears
present in the CT of the neck dated ___. The visualized elements of
the posterior fossa and the craniocervical junction are grossly unremarkable.
Small rounded hyperintense area is noted in the posterior aspect of the right
parotid gland, likely consistent with a small intraparotid nodule (image #23,
series #8). The signal intensity throughout the cervical and upper thoracic
spinal cord appears normal with no evidence of focal or diffuse lesions to
indicate the spinal cord edema. The patient is status post anterior fusion
from C4/C5 through C6/C7 levels. The fixation hardware is causing significant
susceptibility artifacts, however, there is no evidence of significant spinal
canal stenosis at the surgical site.
At C2/C3 level, both neural foramina are patent and there is no evidence of
spinal canal stenosis.
At C3/C4, there is a mild posterior osteophytic disc bulge complex formation,
causing minimal anterior thecal sac deformity as well as mild bilateral neural
foraminal narrowing (image #28, series #7).
At C4/C5, there is mild posterior disc bulging and bilateral uncinate process
hypertrophy, causing mild bilateral neural foraminal narrowing, there is no
evidence of central spinal canal stenosis.
At C5/C6 level, the patient is status post fusion and discectomy, significant
metallic artifact obscures the anatomical details, there is mild left and
moderate right neural foraminal narrowing, and there is no evidence of
significant spinal canal stenosis.
At C6/C7 level, the patient is status post anterior fusion, metal artifact
also obscures the anatomical details, however, it is possible to identify mild
bilateral uncovertebral hypertrophy, causing mild bilateral neural foraminal
narrowing (image #13, series #7).
At C7/T1 level, there is no evidence of neural foraminal narrowing or spinal
canal stenosis.
There is mild-to-moderate posterior epidural lipomatosis visualized from C7
throughout the upper thoracic spine.
In comparison with the CT of the neck dated ___, again a large expansile
mass lesion arising from the T2 left lamina and extending to T1 through T3
levels is identified. This lesion demonstrates an intermediate T1 and T2
isointense signal with some areas with heterogeneous signal and is causing
significant narrowing of the left T1, T2, and T2/T3 neural foramina. This
lesion is also causing canal compromise and is displacing the thecal sac
towards the right (image #1, series #8). No frank evidence of edema is noted
within the cervical or thoracic spinal cord.
There is no evidence of lymphadenopathy or enlarged lymph nodes by
radiological criteria. A small T2 hyperintense focus is demonstrated in the
posterior margin of the right thyroid lobe (image #12, series #8), measuring
approximately 5 x 4 mm in size.
IMPRESSION:
1. Large expansile mass lesion involving the posterior left paramedial
vertebral bodies from T1 through T3 levels as described in detail above,
causing left-sided neural foraminal narrowing at T1/T2, T2/T3 levels and also
left paracentral canal narrowing and impinging the thecal sac posteriorly, no
frank evidence of spinal cord edema is demonstrated.
2. The differential diagnosis for this lesion includes metastatic disease,
myeloma may have similar appearance.
2. Small cystic-appearing formation noted in the posterior lobe of the
thyroid gland on the right, there is also a small area of cystic signal on the
posterior aspect of the right parotid gland, possibly consistent with a small
intraparotid lymph node or cystic formation.
3. The patient is status post anterior fusion and discectomy at C5/C6 level.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL MRI
Diagnosed with BONE & CARTILAGE DIS NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 99.2
heartrate: 91.0
resprate: 16.0
o2sat: 100.0
sbp: 165.0
dbp: 72.0
level of pain: 5
level of acuity: 3.0 | ___ year old man with history of C4-C5 cervical fusion ___ years
ago), L2-L5 stenosis, DM2 and HTN, who presented with left upper
extremity paresthesias and weakness. His PCP completed ___ spinal
MRI which showed a new T1-T3 mass without current cord
compression per our radiology second read. He was admitted for
expedited work up and biopsy. CT torso showed right renal mass
with likely metastases to adrenal gland and spleen. He received
a biopsy of the T1-T3 mass by interventional radiology on
___. Preliminary pathology on discharge showed likely
metastatic clear cell carcinoma, although final stains are
pending. He was seen by oncology who will continue to see the
patient upon discharge. He had significant left shoulder and
arm pain that improved with addition of oxycontin and oxycodone
for break through pain.
CT torso also showed cirrhosis suspected due to prior liver
injury from methotrexate treatment for his psoriasis. He will
be evaluated by hepatology as an outpatient prior to
chemotherapy initiation.
Work up for thrombocytopenia and anemia inclding normal iron
panel, normal B12, SPEP/UPEP negative, and reticulocyte count
low at 0.8. Poor production may be due to his malignancy or
other primary bone marrow process.
Patient's other health issues were managed during the hospital
stay per home regimens (hypertension, GERD, glaucoma).
Metformin was held during hospitalization and resumed on
discharge for diabetes mellitus.
Patient was FULL CODE throughout hospital stay. We conducted
several family meetings including the patient, his wife, and
their daughter, during his hospitalization to discuss the
medical plan and results as they were obtained. The patient was
aware of the malignant cells on his cytology, and the suspicion
for a renal origin as the primary, pending further pathologic
results. The patient also expressed understanding that further
diagnostic steps, discussion of the pathology results, and
eventually determination of a treatment plan and prognosis would
be forthcoming as he met with the oncology team as an
outpatient. |